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Growing Support
6. Professional home visiting
Unlike education programmes there is considerably more information regarding the effectiveness of support for individual vulnerable parents. Often support programmes involve professionals or volunteers offering advice and support to parents (mothers) in their own homes, in contrast to family centres and parent education, which are mainly based on group activity or learning away from home. All families should receive this to some extent through routine midwifery and health visiting, but parenting support is more frequent and intensive. Most often the support is offered to particular types of family (in practice mothers), but occasionally intensive support is offered on a wider basis in a local area.
Targeted intensive programmes
A number of schemes have been established and evaluated where health visitors (or their equivalents in other countries) offer intensive help to mothers identified to have one or more high-risk factors as regards the quality of child care. These factors include low birth-weight and mental health problems, as well as suspected or proven child abuse ( see section 10). The intensive support usually entails more frequent contact, easier availability out of normal office hours and, as a result, readier access to other services.
It has been well documented that vulnerable mothers are more likely to have low birth-weight babies as a result of poor diet and unfavourable environmental factors, and as a consequence these children are more at risk from developmental delays. A study using an experimental design illustrated the effectiveness of a programme that provided social support to women with a history of low birth-weight babies. One randomly selected group of women received the intervention and another group (the control group) received traditional ante-natal care. The intervention group received a range of additional support and were able to contact a midwife at any time of the day or night. The study showed that birth weight for the intervention group was slightly higher than the control group, and 41 per cent of the intervention group, as opposed to 52 per cent of the control group were admitted to hospital (Oakley et al 1996). In addition differences between the two groups continued throughout the follow-up period of the study. Oakley reported that at 7 years, children of the intervention group demonstrated fewer behavioural problems, and anxiety amongst the mothers in the group was less than those in the control group.
Parental mental illness has been identified as a significant risk factor for children and families. A study carried out by Holden et al (1989) in Edinburgh identified 60 mothers with post-natal depression through a screening process at 6 weeks post partum and a more specific psychiatric interview at 13 weeks. Women who were identified as depressed were randomly allocated to either a normal treatment programme or a programme of eight weekly counselling sessions carried out by specially trained health visitors. A total of five women chose not to participate in the study and another five dropped out. Based on follow-up interviews and a self-report scale, the findings showed that 69 per cent of the 26 women in the treatment group had fully recovered compared with only 38 per cent of the 24 women in the control group. The researchers thus concluded that the intervention provided by trained health visitors in the study was effective in managing non-psychotic post-natal depression.
Wider intensive programmes
A widely acknowledged social support initiative also involving health visitors is the Child Development Programme. This provides monthly visits by a health visitor, primarily to new parents, antenatally and for the first year of life. However, it does also provide visits to parents with more than one child who are experiencing particularly difficult problems in coping with their children. The programme aims to provide support for mothers, not just in their role as a mother but as women in their own right. The visits focus on health, development, diet (children and parent's), and self-esteem. Tasks are set around these areas, which the parent/s work on in the month following the visit. The evaluation reported that families who were part of the programme scored more highly on most of the main outcome measures compared with non-programme families, even though these were considerably less disadvantaged (Macdonald and Roberts 1998).
Research overviews of home visiting programmes
Recently two systematic reviews have been undertaken to examine the effectiveness of home visiting programmes (Hodnett and Roberts 1998, Kendrick et al 2000). The former looked at the effectiveness of programmes offering additional home-based support for recent mothers who are socially disadvantaged. The latter looked at the effectiveness of home visiting programmes on parenting and the quality of the home environment. Whist the second analysis did not specifically focus on disadvantaged families, most of the studies included in the review were concerned with this group.
The review by Hodnett and Roberts includes a total of 11 studies, all of which adhered to the following inclusion criteria:
- experimental or quasi-experimental design;
- one or more post-natal home visits; and
- additional home-based support compared to usual care.
The authors noted that the majority of studies had methodological limitations, but they nonetheless assembled evidence that socially disadvantaged mothers did benefit. Bearing in mind the design issues, the authors did not reach firm conclusions about the effectiveness of intensive home visiting for the target group. They did conclude, however, that it had no risks and may lead to improvements for disadvantaged mothers.
The review carried out by Kendrick et al (2000) examined the effectiveness of home visiting programmes on parenting and quality of the home environment. A total of 34 studies were included in the review and 12 were entered into a meta-analysis. Of the 34 studies 26 were with participants considered to be at risk of adverse maternal or child health outcomes; two used pre-term or low birth weight infants and two used infants with 'failure to thrive'. Eight used participants not considered at risk.
The criteria for inclusion into the review were:
- use of experimental or quasi-experimental designs;
- home visiting programmes, which included at least one post-natal visit;
- the programmes included tasks that were within the remit of British health visiting; 6 and
- the studies reported outcomes relevant to British health visiting.
The studies in the review used several outcome measures to examine parenting and the quality of the home environment. Seventeen used the Home Observation for Measurement of the Environment (HOME) (see Kendrick et al 2000 for more detail), 27 used other outcome measures and a further 10 used both the HOME and other measures. Of these studies only 12 were included in the meta-analysis, and these were all studies using the HOME. Five studies that used the HOME were excluded from the meta-analysis as they did not report certain key statistics.
Results of the meta-analysis and the systematic review showed that home visiting programmes were effective, producing improvements in HOME scores and other outcome measures were evident. However, the authors of this review were clear in considering the limitations of the studies. In addition Kendrick et al suggest that due to the lack of theoretical frameworks in most of the studies it is difficult to assess exactly which elements of the interventions produced the improvements.
In terms of UK health visiting the study reported that it was difficult to extrapolate directly the results as only four of the studies under review concerned UK health visitors. It was also indicated that these studies were targeted at particularly high-risk families, whereas health visiting in the UK is a universal service. Nevertheless the results were positive in showing that home visiting programmes can improve parenting and the quality of the home environment.
Combining support groups and home visiting
The Parents in Partnership: Parent Infant Network (PIPPIN) is based on a sequence of connected education and support, using both individual and group methods. Parents attend ante-natal classes, then receive home visits by trained facilitators before and after the birth, with partners seen separately. A comparison was carried out between 49 families involved in the programme and 57 unwilling or unable to attend. The programme couples were shown to be have greater confidence and less anxiety than the comparison group. They also appeared more 'child-centred' in their attitudes, but the research measures detected no difference between the two groups in their actual parenting behaviour (Little and Mount 1999).
Perceptions of routine health visiting interventions
Whilst there appears to be little experimental evidence to indicate the effectiveness of home visiting in the UK, there have been a number of non-experimental studies carried out to examine user views of health visiting. The following section focuses on this aspect. Although the evidence does not clearly indicate impact of the service, it does provide interesting material concerning the perceptions of those receiving services from health visitors.
Young single mothers have been identified as a particularly vulnerable group who are often in need of additional support in parenting their children. A study by Knott et al (1999) sought to examine the views of unsupported young mothers with children aged 9 to 21 months about their needs and the support they received from health visitors. This study was qualitative in nature and used semi-structured interviews to elicit the views of a sample of 12 young mothers. The study identified four main areas of concern to young mothers, which have been illuminated by other research too.
First, participants felt that health visitors were not concerned with the health and welfare of mothers, but concentrated on the children. The mothers felt uncomfortable initiating a discussion about their own problems or worries, so they all raised questions only about their chid's health or development. The authors indicate that this perception was not in keeping with the health visitors' own perception of their role. Other writers have suggested that it is important for clients to be aware of the health visitor role and what they can expect from them. When this is clear, communication and satisfaction with the service is enhanced (Watson 1986). When engaging with this particularly vulnerable group it has been suggested that professionals need to focus on environmental and social needs just as much as on the baby (Luker and Chalmers 1990).
Similarly a lack of communication and unclear understanding of the role of the health visitor resulted in missed opportunities for mothers to see health visitors when they attended clinics. As far as they were concerned, the clinic was for getting your baby weighed, and although health visitors were on hand at the clinic, mothers were not aware of this. Previous research has also shown that mothers perceive health visitor clinics as for weighing babies (Sefi and Macfarlane 1985, Watson 1986, Sherratt et al 1991, Sharpe and Lowenthal 1992). Mothers in this study also indicated that clinics lacked privacy and they found it was often difficult to explain a problem to someone in a crowded noisy situation, whereas if the health visitor came to their house it was much easier to do this. These findings reflected those from previous studies (Sharpe and Lowenthal, Machen 1996, Folkes-Skinner and Meredith 1997).
Young single mothers are often particularly vulnerable, and this was evident in the study conducted by Knott et al. Young mothers believed they were treated differently by health visitors because they were young and single. Comments made by health visitors regarding young mothers' inability to parent effectively were reported by several of the participants, which made them feel stigmatised and demoralised. The majority of those in the study lacked confidence and self-esteem. They felt that the health visitors did little to boost either of these. Previous studies (Clark 1984, Mayall and Grossmith 1985, Foster and Mayall 1990) also reported that health visitors' attitudes towards this group were somewhat judgemental. Simms and Smith (1984) indicate that a more positive type of approach in line with that of health promotion (Tones and Tilford 1994) would enable young mothers to develop autonomy and self-efficacy, which gives people the ability to change their behaviour. This approach also empowers vulnerable groups to take control over their own lives.
The final area identified by the Knott et al study was the level of help provided by health visitors. Seven out of the 12 mothers indicated that they had experienced specific problems with their babies, for which they had sought help from the health visitor. Only one reported that the help received was useful. In addition to this type of help eight of the respondents had also asked for general advice about the child, five of whom found it useful. These negative findings indicate a problem, but should not be generalised too far. Contrary to these results, other studies that did not focus on such vulnerable disadvantaged groups found much greater satisfaction with the help received from health visitors. Cowpe et al (1994) showed that 78 per cent of their sample were satisfied with the help they received from health visitors and in another study by Machen (1996) 19 out of 20 participants were largely positive about their health visitors.
Thus, the evidence is that health visitors are generally well regarded, but young single mothers tend to feel they are treated more negatively. Many mothers do not have a clear idea of health visitors' roles, especially in the clinic setting. The findings suggest that the training and practice of health visitors should take more account of the social and economic disadvantage of this group, as well as their feelings of vulnerability.
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