Jane Barlow, Claire Burns, Hilton Davis, Patricia Jarrett, Sue Kirkpatrick, Carole Mockford, Sarah S

1
Randomised controlled trial of an intensive home
visiting programme

• Jane Barlow, Claire Burns, Hilton Davis, Patricia
  Jarrett, Sue Kirkpatrick, Carole Mockford, Sarah
  Stewart-Brown

2
Home Visiting Programmes

• Widespread visiting of pregnant women and new
  mothers at home by public health nurses in many
  countries
• This trend is based on a recognition of the
  importance of the early years in both preventing
  adverse outcomes and promoting optimal mental and
  physical health outcomes in later life

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• a significant proportion of some of the most
  difficult and costly problems faced by young
  children and parents today, are a direct
  consequence of adverse maternal health related
  behaviours during pregnancy, dysfunctional infant
  care-giving, and stressful environmental
  conditions that interfere with parental and
  family functioning (Olds, 1993)

4
What are home visiting programmes?

• Effective way of reaching hard to reach or very
  vulnerable groups of parents
• Structured programme of visits
• Delivered by professionals or volunteers
• Usually provided to parents with specific needs
• Provided in the home on a one-to-one basis for an
  extended period of time (e.g. 2-3 years)

5
Home Visiting in the UK

• Universal home visiting - health visiting and
  midwifery services
• Structured and targeted home visiting programmes
• Professionally delivered programmes
• - Child Development Programme
• - First Parent Visitor Programme
• Volunteer delivered programmes
• - Community Mothers Programme
• - Home Start

6
Home Visiting ProgrammesCurrent Evidence

• HDA review of reviews of home visiting programmes
  (Bull et al., 2004)
• Improved parenting and child behavioural
  problems better cognitive development reduced
  accidental injury improved detection and
  management of PND
• Inconclusive evidence regarding other outcomes
  including child abuse uptake of immunisation
  hospital admissions maternal participation in
  education or workforce
• A need for more UK trials of home visiting which
  address the methodological limitations
  identified (Bull et al., 2004)

7
Recent UK evaluations of the effectiveness of
Home Visiting programmes

• Community postnatal support workers - (Morrell et
  al., 2000) - HTA
• HOME Start (McAuley et al., 2004) - JRF
• Health Visiting (Wiggins, Oakley, et al 2004) -
  HTA
• Oxfordshire Home Visiting study (Barlow et al.,
  forthcoming) DH, Nuffield Foundation

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The New Service

• Began in January 2001 in 40 GP practices
• Developed as part of a research study (RCT with
  economic evaluation)
• A weekly home visiting service delivered to women
  identified by midwives as vulnerable at the
  booking-in visit
• Began during the second trimester for a period of
  18 months in total
• Delivered by health visitors who had received
  training in the Family Partnership Model combined
  with strategies for enhancing parent-infant
  interaction

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Key features of the Intervention

• Parents children make sense of their worlds by
  developing constructs - change requires
  exploration modification of constructs
• Focus on the relationship building between helper
  and client
• Need for helper to have effective communication
  skills
• Helping process is based on a partnership model
  of working
• Helper needs to demonstrate particular qualities
  and attitudes e.g. warmth, respect,
  genuinessness, empathy

10
Methods of promoting mother-infant interaction

• Four methods of enhancing parent-infant
  relationship
• Infant
  massage
• Modified Brazelton (PIPPIN) -
  Touchpoints
• Dialogical Baby Dance
• Songs music
• Increasing sensitivity of
  parents to infant
• Improving ability to
  empathise thus to think
• about infant in more
  positive ways
• Increasing repertoire of
  skills in responding
• positively to infant

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Training the health visitors

• 8 day training programme over 8 weeks
• -Needs of parents, children and
  families
• - Aims and processes of helping parents
• - Parent-professional relationship
• - Helper qualities and skills
• - Exploring notion of construing
• - Aetiology of abuse and neglect
• - Methods of enhancing early
  parent/infant
• interaction
• Regular supervision by psychodynamically trained
  supervisors

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Prenatal Programme

• Building a relationship with the mother
• Exploring the mothers constructs of pregnancy,
  her baby, herself, and her wider family and
  social situation
• Preparation for parenting by promoting healthy
• realistic attitudes toward pregnancy,
  childbirth, and child rearing

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Postnatal programme

• Understanding their infant and developing
  realistic expectations
• Facilitating interaction between mother and
  infant enhancing mothers sensitivity to
  infants signals etc
• Strengthening support networks e.g. toddler
  parenting groups
• Developing mothers self-esteem and self-efficacy
• Dealing with parents emotional problems e.g.
  depression
• Dealing with issues such as parental conflict,
  domestic violence, financial problems, and
  housing difficulties

14
Evaluation of the new service
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Main inclusion criteria

• Substance misuse/addiction
• Major current parenting difficulties
• Child on CP register
• Domestic violence
• Social work involvement relating to children
• Non specific serious concern expressed by midwife

• Homelessness/moved more than twice in last 12
  months
• Severe debt/financial hardship
• Absence of support networks
• Aged 17 or under
• Serious mental illness needing treatment
• Moderate learning disabilities

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Recruitment Process (I)
STAGE ONE Assessment by community midwives
attached to 40 GP practices in Oxfordshire and
Buckinghamshire Booking clinic visit at 12-16
weeks Screening checklist to identify
vulnerable pregnant women



Referral of vulnerable women to trial researcher
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STAGE TWO First visit by researcher Screening
checklist completed by researcher Oral and
written information given to all potential
participants and the issue of consent
discussed Second visit by researcher Obtain
consent Collect baseline data from all
participants Carry out telephone
randomisation Set in process appropriate services
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Uptake and loss

• 433 Referrals 120 non-contactable 151
  ineligible
• 162 invited to take part 31 refused (interview
  data published in Children and Society)
• 131 consented 68 HV and 63 control group
• HV group
• 6-month n61 (93) 12-month n64 (97)
• Control group
• 6-month n59 (94) 12-month FU n58 (92)

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Primary Outcomes

• Maternal
• Mental health (GHQ)
• Parenting competence (PSOC)
• Parenting stress (PSI)
• Parenting attitudes (AAPI)
• Infant
• Home environment (HOME Inventory)
• Mental development (Bayley scales)
• Social and emotional development (BITSEA)
• Mother-Infant
• Maternal sensitivity and infant cooperativeness
  (CARE-Index)

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Secondary Outcomes

• Maternal
• Relationship with partner (GRIMS)
• Self efficacy (SEQ)
• Feelings about being a parent (WBPB)
• Use of GP, HV, Community services (e.g.
  family/day centres, toddler groups, parenting
  groups), Social services, Sure Start, AE etc.
• Infant
• Infant temperament
• Use of services
• Case conferences, Child Protection Register,
  removal from home, visits to AE, admissions to
  hospital, legal orders, injuries, non-organic
  failure to thrive etc.

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Qualitative data

• In-depth interviews with 20 participating women
• In-depth interviews and focus groups with 33 of
  the 40 participating home visitors
• Aim
• To explore process issues such as compliance and
  satisfaction
• To examine user and provider perceptions
  concerning the impact of the intervention on
  womens lives

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The results

• A tale of two cities
• In-depth interviews with first twenty women to
  complete the intervention provides moving
  testimony to the success of the intervention
• Standardised measures show little impact

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Number of visits
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Sample characteristics
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Birth Data
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Qualitative data - Focus groups with
participating home visitors

• Describe important changes in their practice
• Preventive model as opposed to crisis
  management
• More in-depth knowledge as opposed to skimming
  the surface permitting better monitoring of
  lives of high babies
• Working holistically, client-centred and less
  directive
• Focus on developing relationships and on helping
  the mothers to get to know their babies
• Range of benefits described

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she managed to chuck her partner out. He was
violent towards her and he was getting the older
sibling to beat up the study infantthe fact
that there was a constant source of support there
and I was listening to her side of the story gave
her the confidence to do that
her mental health was very low. I guess about
10 days after the baby was born, and at one point
she did say I cant care for this baby, I want
this baby fostered. She didnt really think
that she could do it, and the relationship that
she has with her son is just wonderful to see
now, which is a sense of satisfaction. She is a
really good mum, she is really responsive to him.
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In-depth interviews with participating women

• Considerable hostility towards and mistrust at
  the outset of professionals generally and health
  visitors specifically
• Despite this, most got to like and trust their
  home visitor, and many described opening up for
  the first time
• Considerable evidence about the effects of the
  partnership model of working and being helped to
  feel that they were in control
• Multiple benefits described including better
  relationship with the baby more confidence as a
  parent improved mental health less domestic
  violence more use of other services changed
  views about professionals Changed views about
  professionals

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Perceptions about home visitors
Very very friendly, relaxed, brilliant and she
is easy to get on as with well which is good
Warm and friendly. Easy to talk to, willing to
listen
I would say she was helpful, she was.really
friendly and a good friend really  
Sympathetic, very caring, she listens just
generally a very nice person
Bubbly person, she has got a great
personalityshe is a good listener.. she could
become a best friend, you could tell her
anything.
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Developing Trust
I felt as the months rolled on it got more and
more comfortableit seemed, you know, I was
talking a lot more.and it got more and more
comfortable and more relaxed.
I was very defensive at first, but gradually
began to open up and whatnot. It did help seeing
her every week.and towards the end she was just
a godsend to be there for me.
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Opening up
you know, she was interested in not just
infant but me, and I found I was able to open
up to her, whereas Im a very closed sort of
person normally but she sort of made me feel
comfortable to be able to sort of say little bits
whereas I couldnt to friends, like personal
family problems that I had and I think it
fair surprised me that I did open up at all, but
I certainly wouldnt have done that going to
health centre
It was easier to talk with her because after a
while she got to know me and know when I was
hiding something from her she would always
know when something was wrong.
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Working in partnership
She always made me feel that what I was doing
was right and they were my views, and if I said
something she never disagreed with me. She never
sort of said I should do it this way or whatever.
She always made me feel I was in control.
you know, she talks to you like a human being,
she doesnt treat you like you dont know
anything.
She didnt ever opinionate either. I didnt feel
as if she would say you should be doing this,
you should be doing that
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The Benefits

• Better relationship and interactions with baby
• Feeling supported and helped
• Increased confidence to parent
• Improved mental health
• Improved child behaviour problems
• Improvement in relationship problems including
  domestic violence
• More use of other services
• Changed views about professionals

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The social baby
I have learned quite a few things with Home
Visitor like doing baby dancethat I had never
heard of before and she used to love it. We do
the movements and we sit and you know she
encourages you to turn the telly off and read to
her which I do, and some other things, play with
her and interact with her, that I would never
have thought of doing..she really likes books so
I do make the effort to read to her most
days.but again, that is not something I would
have thought to do.
putting it on a plate and shoving it in her gob
its about playing, making a meal a happy time
and fun time
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Developing confidence as a parent
I think I feel a bit more confident in myself as
a parent.I looked forward to her coming round,
because sometimes I would just sit and tell her a
load of stuff, just stuff that I needed to get
off my chest that may not have been even relevant
to infant, but it helped in how I was feeling
about myself I suppose the way I feel about
myself helps around the children
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and improved mental health
I would say it helped me change because I was
more confident.I felt a lot more confident
because obviously when I had depression I wasnt
confident at all. I wouldnt even go out. I
feel a lot more confident when I do go outeven
some of my friends say that I have changed very
much. Before I wouldnt go out unless he
husband was with me. I wouldnt do anything
unless he was there. Now I can do it all and I
dont need him here.
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Postnatal depression 2 month follow-up
   
 
 
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Infant outcomes reported at 6 months postnatal
   
 


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Outcomes at 6- and 12-month post-natal follow-up

• Parent-report
• Mental health social support self-esteem
  self-efficacy attitudes parenting competence
  and stress infant emotional and social
  adjustment infant temperament not significant
• Independent Observations
• Bayley scales not significant
• Home Inventory not significant
• CARE-Index Maternal sensitivity 0.024
• Infant cooperativeness
  0.011

 
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Risk of Intentional Injury
 
 
 
 
 
 
 
 
 
   
   
 
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Conclusions

• Qualitative data
• Health visitors new ways of working and
  important changes in families
• Participating womenTrusting and supportive
  relationships moving testimony to benefits for
  themselves and their babies
• Quantitative data
• No difference on any parent report outcomes or
  two sets of independent observations
• Improved maternal sensitivity and infant
  cooperativeness (independent assessment)
• Improved recognition of risk of injury and need
  for removal from home
• Further follow-up at 3 years being undertaken