Vol. 1, No. 4
Summer 1996

Does Home Health Visiting Have a Future in the United States?

When social workers and other child advocates are asked what the ideal child welfare system might look like, many talk about universal support services that are not aimed at particular classes of citizens and that prevent problems rather than address crisis.

One strategy often mentioned in these discussions is postpartum home health visiting (HHV). This type of home visiting is common in European countries; many believe that if it were instituted in a comprehensive way in this country, potential abuse and neglect problem could be solved before they became serious.

However, the issue may not be as simple as mandating these services. Sheila Kamerman and Alfred Kahn have studied family policy in this country and abroad for many years and recently published an article reviewing HHV in Europe and discussing implications for United States policy.

HHV in Europe

HHV services exist in all northern and western European countries. All services are free, participation is voluntary, and there is no particular income level one must fall below to qualify.

However, Kamerman and Kahn report that models of home health visiting vary from country to country. All home visitors are professionals, but some are nurses and some are social workers. Some services are provided by geographic region, while others depend on the family's primary physician.

All programs focus on small children, providing health education, preventive care, and social support to parents of children under three.

There is great variety in other aspects. Some countries provide visiting following the birth of every child in a family while others concentrate only on the first child's birth. In some places, visiting begins during pregnancy, along with support groups and other services.

The frequency of visits also differs. In Italy, one or two visits follow the birth of a child, whereas in Scandinavian countries, children are seen multiple times in their first year.

But Does It Work?

There has been very little formal evaluation as to the effectiveness of HHV programs in preventing child abuse and neglect. However, there is widespread acceptance of these services throughout these countries and a strong belief that they are necessary and effective at preventing problems. Kamerman and Kahn cite several British studies documenting lower rates of sudden infant death syndrome (SIDS), postpartum depression, and accidents in the home.

Implementing widespread HHV in the United States, while not impossible, would be challenging, according to Kamerman and Kahn. All of the countries described have central, government-based, comprehensive health systems. HHV is part of those systems. In contrast, the U.S. has multiple health care providers who are both privately and publicly funded. Significant cost benefits would have to exist in order to persuade private insurers to provide regular home health visiting services.

Hawaii's Healthy Start

Home health visiting already exists in America, however. Hawaii, as part of a statewide comprehensive health service, has implemented HHV services through its Healthy Start program.

Wallach and Lister provide an overview of this effort in their 1995 article, Stages in the Delivery of Home-Based Services to Parents at Risk of Child Abuse: A Healthy Start Experience. In 1995 the program was serving 52% of the families with newborns in Hawaii.

Unlike the European models, Hawaii uses paraprofessionals as visitors. They are supervised by professional nurses and social workers and go through an extensive training program and probation period.

Children at risk for abuse and neglect are identified and offered services for up to five years. Caseloads are kept between 15 and 25 families, depending on the intensity of services being provided. While there are no long-term or experimental studies at this time, early reports show decreases in abuse and neglect reports, higher immunization rates of two-year-olds, and high connections with regular primary care providers.

References

Kamerman, S. B., & Kahn, A. J. (1993). Home health visiting in Europe. The Future of Children, 3(3), 39-52.

Wallach, V. A., & Lister, L. (1995). Stages in the delivery of home-based services to parents at risk of child abuse: A healthy start experience. Scholarly Inquiry for Nursing Practice: An International Journal, 9(2), 159-173.