This is the current release of the guideline.

Injury associated with violence

Prevention

Emergency Medicine
Family Practice
Obstetrics and Gynecology
Pediatrics
Preventive Medicine

Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Managed Care Organizations
Nurses
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Public Health Departments
Social Workers

• To assess scientific evidence concerning the effectiveness of early childhood home visitation in preventing violence by the visited child against others or self (i.e., suicidal behavior), violence against the child (i.e., maltreatment [abuse or neglect]), violence by the visited parent, and intimate partner violence
• To present recommendations regarding early childhood home visitation in preventing violence

Populations and families believed to benefit from home visitation during the child’s first 2 years of life (e.g., teenage parents; single mothers; families of low socioeconomic status; families with very low birthweight infants; parents previously investigated for child maltreatment; and parents with alcohol, drug, or mental health problems)

Home visitations* including (but not limited to) one or more of the following components:

1. training of parent(s) on prenatal and infant care
2. training on parenting
3. child abuse and neglect prevention
4. developmental interaction with infants or toddlers
5. family planning assistance
6. development of problem-solving skills and life skills
7. educational and work opportunities
8. linkage with community services

Services in addition to home visitations (multicomponent):

1. day care
2. parent group meetings for support, instruction, or both
3. advocacy
4. transportation
5. other services

*Definition: A program that includes visitation of parents and children in their home by trained personnel who convey information, offer support, provide training, or perform a combination of these activities.

• Child maltreatment
  • Direct measures include child abuse and neglect (e.g., child protective services reports, parent reports, visitor reports, clinic reports). Proxy measures include emergency room visits for injury or ingestion; injury, trauma; out-of-home placement
• Violence by visited children
  • Direct measures include reported or observed violence and violent crime. Proxy measures include delinquency (with violence), conduct disorder, externalizing behavior, arrests, convictions)
• Violence by visited parents
  • Direct measures include reported or observed violence and violence crime. Proxy measures include arrests, convictions
• Intimate partner violence
  • Direct measures include reported or observed partner victimization. Proxy measures include arrests, convictions for partner assault
• Benefits, costs, and applicability of recommended interventions, and barriers to implementation

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Electronic searches for intervention studies were conducted in MEDLINE, EMBASE, ERIC, National Technical Information Service (NTIS), PsycINFO, Sociological Abstracts, National Criminal Justice Reference Service (NCJRS), and CINAHL. Also reviewed were the references listed in all retrieved articles as well as additional reports as identified by the team, the consultants, and specialists in the field. Journal articles, government reports, books, and book chapters were included in the review.

Inclusion Criteria

To be included in the review of effectiveness, studies had to:

1. be primary investigations of the intervention selected for evaluation rather than, for example, guidelines or reviews
2. provide information on at least one outcome of interest from the list of violent outcomes preselected by the team
3. be conducted in Established Market Economies
4. compare outcomes in groups of persons exposed to the intervention with outcomes in groups of persons not exposed or less exposed to the intervention (whether the comparison was concurrent between groups or before-and-after within the same group).

The search covered any research published before July 2001.

• Effects of early childhood home visitation on violence by visited children: Four studies
• Effectiveness of early childhood home visitation in preventing violence by visited parents (other than child abuse): One study
• Effectiveness of early childhood home visitation in preventing intimate partner violence in visited families: One study
• Effects of early childhood home visitation on child maltreatment: Twenty-one studies

Weighting According to a Rating Scheme (Scheme Given)

On the basis of the number of threats to validity, studies were characterized as having good, fair, or limited quality of execution. Results on each outcome of interest were obtained from each study that had good or fair execution.

The strength of the body of evidence of effectiveness was characterized as strong, sufficient, or insufficient on the basis of the number of available studies, suitability of study designs for evaluating effectiveness, quality of execution of the studies, consistency of the results, and effect size.

Systematic Review with Evidence Tables

Each study that met the inclusion criteria was evaluated by using standardized abstraction criteria and was assessed for suitability of the study design and threats to validity. On the basis of the number of threats to validity, studies were characterized as having good, fair, or limited execution. Results on each outcome of interest were obtained from each study that had good or fair execution. Measures adjusted for the effects of potential confounders were used in preference to crude effect measures. A median was calculated as a summary effect measure for outcomes of interest. For bodies of evidence consisting of seven or more studies, an interquartile range was presented as an index of variability. Unless otherwise noted, the results of each study were represented as a point estimate for the relative change in the violent outcome rate associated with the intervention. Percentage changes were calculated by using the following formulas:

• For studies with before-and-after measurements and concurrent comparison groups:

  Effect size = [(Ipost/Ipre)/(Cpost/Cpre)] – 1

  where Ipost = last reported outcome rate in the intervention group after the intervention; Ipre = reported outcome rate in the intervention group before the intervention; Cpost = last reported outcome rate in the comparison group after the intervention; and Cpre = reported outcome rate in the comparison group before the intervention.

• For studies with post measurements only and concurrent comparison groups:

  Effect size = (Ipost – Cpost)/Cpost

• For studies with before-and-after measurements but no concurrent comparison:

  Effect size = (Ipost – Ipre)/Ipre

Other

Task Force recommendations are based primarily on the effectiveness of interventions as determined by the systematic literature review process. In making recommendations, the Task Force balances information about the effectiveness of an intervention with information about other potential benefits and potential harms. To determine how widely a recommendation should apply, the Task Force also considers the applicability of the intervention in various settings and populations. Finally, the Task Force reviews economic analyses of those interventions found to be effective and summarizes applicable barriers to intervention implementation. Economic information is provided to assist the reader with decision making but generally does not affect the Task Force’s recommendation.

Recommendations regarding interventions reflect the strength of the evidence of effectiveness (i.e., sufficient or strong evidence of effectiveness). Other types of evidence can also affect a recommendation. For example, evidence of harms resulting from an intervention might lead to a recommendation that the intervention not be used if adverse effects outweigh improved outcomes.

A finding of insufficient evidence to determine effectiveness should not be interpreted as evidence of ineffectiveness but rather as an indicator that additional research is needed before the effectiveness of the intervention can be determined. In contrast, sufficient or strong evidence of harmful effect(s) or of ineffectiveness leads to a recommendation that the intervention not be used.

Strength of Evidence of Effectiveness = Strength of Recommendation

The strength of each recommendation is based on the evidence of effectiveness (i.e., an intervention is recommended on the basis of either strong or sufficient evidence of effectiveness).

If insufficient evidence to determine effectiveness is found, this means that it was not possible to determine whether or not the intervention works based on the available evidence.

The only available cost-benefit analysis of a nurse home visitation program to reduce child maltreatment was based on a limited, government perspective (i.e., including only those costs and benefits incurred by the government). In the whole study sample, costs exceeded economic benefits directly attributable to reduced child maltreatment services by $3,000 per family. Including benefits beyond those of the government, such as averted health-care costs, productivity losses, and other costs to the victim, is likely to result in greater net benefits. Program cost estimates --- largely dependent upon frequency of home visits and program duration --- ranged from $958 to $8,000 per family (in 1997 dollars). In the study subsample of low-income mothers, the analysis showed a net benefit of $350 per family (in 1997 dollars). Differences in costs may be due to differences in duration and frequency of visits, and items included in estimates.

External Peer Review
Internal Peer Review

The guideline was submitted for extensive peer review, including review at various stages by a "consultant team," an external team of subject matter and methodologic experts, and peer review of the finished product by agencies and professional groups.

The relationship between the strength of evidence of effectiveness and the strength of the recommendation is defined at the end of the "Major Recommendations" field.

On the basis of strong evidence of effectiveness, the Task Force recommends early childhood home visitation for prevention of child abuse and neglect in families at risk for maltreatment, including disadvantaged populations and families with low-birthweight infants.

Evidence was insufficient to determine the effectiveness of early childhood home visitation in preventing violence by visited children. The studies also yielded insufficient evidence to determine the effectiveness of early childhood home visitation in preventing violence by visited parents (other than child abuse and neglect) or intimate partner violence in visited families.

Definitions:

Strength of Evidence of Effectiveness = Strength of Recommendation

The strength of each recommendation is based on the evidence of effectiveness (i.e., an intervention is recommended on the basis of either strong or sufficient evidence of effectiveness).

If insufficient evidence to determine effectiveness is found, this means that it was not possible to determine whether or not the intervention works based on the available evidence.

None provided

The recommendations are based on qualifying studies, all of which had good or fair execution quality. In general, the strength of evidence of effectiveness corresponds directly to the strength of recommendations (see the "Major Recommendations" field).

Overall Potential Benefits

Home visitation programs, reviewed in this guideline, might be useful in reaching several objectives of Healthy People 2010, the disease prevention and health promotion agenda for the United States. These objectives identify major preventable threats to health and focus the efforts of public health systems, legislators, and law enforcement officials in addressing those threats. Many of the Healthy People objectives in Chapter 15, "Injury and Violence Prevention," relate to home visitation and its proposed effects on violence-related outcomes.

Specific Potential Benefits

• Compared with controls, the median effect size of home visitation programs was a reduction of approximately 40% in child abuse or neglect. Benefit was found whether the outcome was directly assessed in terms of reported abuse or neglect or indirectly assessed as reported injury.
• Programs delivered by professional visitors (nurses or mental health workers [with either post--high school education or experience in child development]) yielded more beneficial effects than did those delivered by paraprofessionals. Programs delivered by nurses demonstrated a median reduction in child abuse of 48.7% (interquartile range: 24.6–89.0%); programs delivered by mental health workers demonstrated a median reduction in child abuse of 44.5% (interquartile range not calculable). However, programs of two or more years duration delivered by paraprofessionals were also effective.

Not stated

• The independent, nonfederal Task Force on Community Preventive Services (the Task Force) is developing the Guide to Community Preventive Services (the Community Guide) with the support of the U.S. Department of Health and Human Services (DHHS) in collaboration with public and private partners. Although The Centers for Disease Control and Prevention (CDC) provides staff support to the Task Force for development of the Community Guide, the recommendations presented in this report were developed by the Task Force and are not necessarily the recommendations of U.S. Department of Health and Human Services or the Centers for Disease Control and Prevention.
• Recommendations regarding interventions reflect the strength of the evidence of effectiveness (i.e., sufficient or strong evidence of effectiveness). Other types of evidence can also affect a recommendation. For example, evidence of harms resulting from an intervention might lead to a recommendation that the intervention not be used if adverse effects outweigh improved outcomes. When interventions are determined to be effective, their costs and cost effectiveness are evaluated, insofar as relevant information is available.
• Although the option exists, the Task Force has not yet used economic information to modify recommendations. A finding of insufficient evidence to determine effectiveness should not be interpreted as evidence of ineffectiveness but rather as an indicator that additional research is needed before the effectiveness of the intervention can be determined. In contrast, sufficient or strong evidence of harmful effect(s) or of ineffectiveness leads to a recommendation that the intervention not be used.

Use of the Recommendation in States and Communities

Given the substantial burden of child maltreatment in the United States and the importance of this problem both from public health and societal perspectives, the Task Force saw the need to specifically review the effectiveness of home visitation programs in reducing this and other forms of violence. The finding that these programs are effective in reducing child abuse and neglect should be relevant and useful in various settings.

The Task Force recommendation supporting early childhood home visitation interventions for prevention of child abuse and neglect in families at risk of maltreatment can be used to support, expand, and improve existing home visitation programs, and to initiate new ones. In selecting and implementing interventions, communities should carefully assess the need for such programs (e.g., the burden of child maltreatment) and clearly define the target populations. Home visitation programs included in this review were generally directed to those populations and families believed to benefit most from common program components, such as support in parenting and life skills, prenatal care, and case management. Target populations included teenage parents; single mothers; families of low socioeconomic status; families with very low birthweight infants; parents previously investigated for child maltreatment; and parents with alcohol, drug, or mental health problems. The population that might benefit is large. For example, in 1999, approximately 33% of the 4 million births in the United States were to single mothers, 12.2% were to women aged <20 years, and 22% were to mothers with less than a high school education; 43% of births --- approximately 1.7 million --- were to mothers with at least one of these characteristics (B. Hamilton, National Center for Health Statistics, CDC, personal communication, 2002).

Studies included in this review were conducted in a variety of geographic locations in the United States and Canada and in populations with various ethnic and cultural backgrounds. The available evidence on the effectiveness of home visiting programs of sufficient duration indicates benefit for population subgroups in greatest need, provided that appropriate care is taken to tailor programs to local circumstances. Because no study reviewed assessed the effectiveness of home visitation in preventing violence in the general population, the broader applicability of these programs (e.g., to the general population) is uncertain.

Public health professionals and policy makers should carefully consider the attributes and characteristics of the particular program to be chosen for implementation. Given the heterogeneity of home visitation programs in the United States, which differ in focus, curricula, duration, visitor qualifications, and target populations, no single optimal, effective, and cost-effective approach could be defined for the multiplicity of possible outcomes, settings, and target populations. However, the robust findings across a spectrum of program characteristics increase confidence that these programs can be effective in a range of circumstances and reduce concern that effectiveness hinges on particular characteristics of one intervention or one context.

The Task Force found insufficient evidence to determine the effectiveness of early childhood home visitation in preventing violence by visited children and between adults. This conclusion does not imply that the intervention is ineffective in preventing these outcomes. Rather, the finding reflects a lack of enough high-quality studies with long enough follow-up periods to make a determination. These areas merit further research.

This review considered only studies that evaluated violent outcomes. Home visiting may also affect other outcomes. Other studies have reported many other desirable outcomes of early home visitation, including health benefits for premature, low birthweight infants and for disabled and chronically ill children as well as long-term benefits, including reductions in need for public support of visited mothers, particularly single mothers of low socioeconomic status. However, all home visiting programs are not equal. Some are narrowly focused, oriented, for example, only toward improving vaccination coverage. Others might influence a broader range of outcomes. Program selection and design should consider the range of options relevant to the particular communities. To meet local objectives, recommendations and other evidence provided in the Community Guide should be used in the context of local information --- resource availability; administrative structures; and the economic and social environments of communities, neighborhoods, and health-care systems.

In conclusion, this review should prove a useful and powerful tool for public health policy makers, for program planners and implementers, and for researchers. It may help to secure interest, resources, and commitment for implementing these interventions, and will provide direction and scientific questions for additional empirical research in this area, which will further improve the effectiveness and efficiency of these programs.

Staying Healthy

Effectiveness
Patient-centeredness

Not applicable: The guideline was not adapted from another source.

2003 Oct 3

Task Force on Community Preventive Services - Independent Expert Panel

U.S. Department of Health and Human Services; Centers for Disease Control and Prevention (CDC)

Task Force on Community Preventive Services

Task Force: Chair: Jonathan E. Fielding, M.D., M.P.H., M.B.A.), Los Angeles Department of Health Services, Los Angeles, California Vice-Chair: Patricia Dolan Mullen, Dr.P.H., University of Texas-Houston School of Public Health, Houston, Texas

Members: Ross C. Brownson, Ph.D., St. Louis University School of Public Health, St. Louis, Missouri; John Clymer, Partnership for Prevention, Washington, D.C.; Jane L. Delgado, Ph.D., M.S., National Alliance for Hispanic Health, Washington, D.C.; Mindy Thompson Fullilove, M.D., New York State Psychiatric Institute and Columbia University, New York, New York; Alan R. Hinman, M.D., M.P.H., Task Force for Child Survival and Development, Atlanta, Georgia; George J. Isham, M.D., HealthPartners, Minneapolis, Minnesota; Garland H. Land, M.P.H., Center for Health Information Management and Epidemiology, Missouri Department of Health, Jefferson City, Missouri; Patricia A. Nolan, M.D., M.P.H., Rhode Island Department of Health, Providence, Rhode Island; Dennis E. Richling, M.D., Union Pacific Railroad, Omaha, Nebraska; Susan C. Scrimshaw, Ph.D., School of Public Health, University of Illinois, Chicago, Illinois; Steven M. Teutsch, M.D., M.P.H., Merck & Company, Inc., West Point, Pennsylvania; Robert S. Thompson, M.D., Department of Preventive Care, Group Health Cooperative of Puget Sound, Seattle, Washington

Consultants: Robert S. Lawrence, M.D., Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland; J. Michael McGinnis, M.D., Robert Wood Johnson Foundation, Princeton, New Jersey; Lloyd F. Novick, M.D., M.P.H., Onondaga County Department of Health, Syracuse, New York

Research conducted by: Robert A. Hahn, PhD, Division of Prevention Research and Analytic Methods, Epidemiology Program Office; Oleg O. Bilukha, MD, PhD, Division of Prevention Research and Analytic Methods, Epidemiology Program Office; Alex Crosby, MD, Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia; Mindy T. Fullilove, MD, New York State Psychiatric Institute, Columbia University, New York, New York; Akiva Liberman, PhD, National Institute of Justice, U.S. Department of Justice, Washington, DC; Eve K. Moscicki, ScD, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland; Susan Snyder, PhD, Division of Prevention Research and Analytic Methods, Epidemiology Program Office; Farris Tuma, ScD, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland; Amanda Schofield, MPH, Division of Prevention Research and Analytic Methods, Epidemiology Program Office; Phaedra S. Corso, PhD, Division of Prevention Research and Analytic Methods, Epidemiology Program Office; Peter Briss, MD, Division of Prevention Research and Analytic Methods, Epidemiology Program Office

Not stated

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on May 28, 2004. The information was verified by the guideline developer on July 9, 2004.

No copyright restrictions apply.