CLINICALLY APPRAISED TOPIC (CAT): What nursing-led intervention has been proven to help protect vulnerable Kiwi children?
CLINICAL BOTTOM LINE:
Home visitation programmes are associated with about one third reduction in unintentional injury, halving of harsh physical punishment rates, and with improvements in parenting competence and child behaviour.
As a community nurse, you are aware that child abuse is a prominent issue in society. With New Zealand having one of the highest rates of child abuse in the developed world, you know that interventions need to be implemented in order to address this problem. You look to the literature for how your role as a nurse can help play a part in reducing child abuse.
In New Zealand families, do home visitation programmes help reduce child abuse in comparison to families receiving no home visit?
PubMed Clinical Queries – (therapy, broad): Child abuse
Boden J, Fergusson D, Horwood J. Nine-Year Follow-up of a Home Visitation Program: A Randomized Trial. Pediatrics 2013;131(2):297-303. doi: 10.1542/peds.2012-1612
Two-arm, parallel group, randomised control trial with families recruited from Christchurch over a 19-month period beginning in January 2000. Families were screened by Plunket nurses using a screening tool that covered parent age, social support, whether pregnancy was planned, parental substance use, financial situation, and history of family violence. Exposure to two or more risk factors led to referral. Plunket nurses were also asked to refer any family where they had serious concerns about the family’s capacity to care for the child. 4523 families were screened; 3935 families were not eligible, and 145 declined to participate. 443 families were randomised. Scheduled intensive home visits occurred for the Early Start families, and for both groups, assessments were made at baseline, six months, annually from one year to six years, and at nine years. Data was gathered through structured client interviews, medical records and school teacher questionnaires. Families in the control group were offered $50 for each data collection visit.
Intervention (n=220): Of the 220 families randomised, 14 families declined support after the first month. Trained support workers (qualified nurses) provided intensive home visits throughout the study. Each support worker had a caseload of 10-20 families. The intervention was based on the social learning model and involved  assessments of family needs, issues, strengths and resources  developing a positive partnership between family and support worker  collaborative problem solving  provision of support, mentoring, and advice to mobilise strengths, and involvement with family throughout pre-school years.
Control (n=223): Of the 223 families allocated to the control group, two families declined participation after the first month. These families were not provided with intensive home visits.
Outcomes: A broad range of outcome measures were included in the trial – e.g. reduction in child abuse, improvements in child health, parental physical and mental health, family relationships, and material wellbeing. Measures reported in this nine-year follow-up included hospital attendance for unintentional injury, harsh punishment/parental use of physical punishment, parenting competence, child behaviour, maternal depression, parental substance use, family violence, life stress, and economic circumstances.
Randomisation occurred at point of referral to the trial, with families being randomised based on a computer-generated series of random numbers. Allocation concealment was not reported. There was complete follow up of 86 per cent of the study participants at nine years (78 per cent in Early Start and 89 per cent in control). Intention to treat – the primary analysis used data from “completers” only. Two sensitivity tests were done to test effect of missing data – data was first imputed assuming Early Start had no effect on baseline variables and then the data was imputed assuming Early Start had same effect on missing families as on those followed up at nine years. These analyses showed the effects varied little from the “completers” analysis. Blinding was not possible in this study, and apart from the intervention, no differences in treatment were likely. The control and intervention groups were similar at baseline.
Mean maternal age was 24.5 years at baseline, in 81 per cent the pregnancy was unplanned, about two-thirds were single parent families or lacked educational qualifications, and about one third had been assaulted by their current partner at baseline. There were reduced rates of child abuse in those families enrolled in the Early Start programme, parentally reported harsh punishment, and physical punishment scores. Average parenting scores were higher in the Early Start programme. There were no statistically significant differences in depression symptoms, cigarette smoking, alcohol problems, illicit drug use, intimate partner violence, welfare dependence, or level of debt.
Positive effects on child health, including unintentional injury, were reported earlier (Fergusson DM et al. Pediatrics 2005;116:e803). This longer term report confirms earlier findings.
Important to note that child-related benefits are apparent, although programme failed to produce change in parental and family circumstances.
Cost effectiveness of the Early Start programme has not been reported.
Reviewers: Sarah Menzies, 3rd year student nurse, and Andrew Jull, Associate Professor, School of Nursing, University of Auckland
Table: Outcomes to the 9 year follow up
Outcome Early Start
(n=199) RR (95%CI)* P value
Attending hospital for unintentional injury 50
Parent-reported harsh punishment 17
Physical punishment score ‡ 1.29 1.44 P<0.05
Parenting competence score ‡ 10.13 9.88 P<0.01
Parent reported behaviour score ‡ 9.91 10.08 P<0.05