Home and Community Care Digest

Home and Community Care Digest December 2002 : 0-0

Study cautions against the replacement of nurses with para-professionals to deliver home care services


This research calls for caution when designing early intervention programs for maternal and child health if the practitioners lack professional training. This study compared effectiveness of home visiting by paraprofessionals and by nurses. Nurse visits resulted in significant maternal and child outcome effects, while visits by para-professionals produced small effects that rarely achieved statistical or clinical significance.
Background: Home visiting has been promoted by the American Academy of Pediatrics as an important complement to office visits that can improve pregnancy outcomes, reduce rates of child abuse and neglect, and help low-income families become self-sufficient. In previous studies of paraprofessional home visits, only small effects have been documented. However these studies did not determine whether small effect was attributable to lack of professional training or to an underdeveloped program. This study was designed to address this question.

Method: This RCT of a maternal and child health home visiting program was conducted in a large US city. 735 women were randomized to 3 groups: a control group (no visits); paraprofessional visits; and nurse visits. The program was carefully developed and both para-professionals and nurses were provided with well-structured guidelines, training and supervision. Extensive efforts were made to ensure that paraprofessionals were well suited for this work: agencies were asked to send their best paraprofessionals for this experimental program, para-professionals were paid more for their visits during the experiment and were provided twice the level of supervision as nurses. Paraprofessionals were matched to families who shared many of the same social characteristics in order to enhance empathy and trust and increase the probability of positive outcomes. Over the course of the pregnancy, the outcomes studied were changes in women's urine cotinine levels, women's use of ancillary services, subsequent pregnancy and births, educational achievement, workforce participation, and use of welfare. Up to 2 years after birth, the outcomes studied were mother-infant responsive interactions, families' home environments, infants' response to fear, joy and anger stimuli, children's language and mental development, and children's temperament and behaviour problems.

Findings: Compared to the control group, the only statistically significant effect attributable to paraprofessionals was improvement of mother-child interaction for mothers with low psychological resources (99.45% vs. 97.54%). Compared to the control, nurse visits resulted in several significant effects. Nurse-visited smokers had greater reductions in cotinine levels during pregnancy. By the 2nd year, nurse-visited women had fewer subsequent pregnancies (29% vs. 41%) and births (12% vs. 19%), they delayed subsequent pregnancies for longer intervals, and during the 2nd year, they worked more (6.83 vs 5.65 months).

Conclusions: Nurse visits produced many clinically and statistically significant effects on a wide range of maternal and child outcomes, while paraprofessional visits did not. In explanation the researchers point to nurses' "natural legitimacy" as honest and ethical professionals, which appears to give nurses the power to engage parents and influence health behaviours. This research calls for caution when designing early intervention programs for maternal and child health if the practitioners lack professional training.

Reference: Olds D, Robinson J, O'Brien R, Luckey D, Petitt L, Henderson C, Ng R, Sheff K, Korfmacher J, Hiatt S, Talmi A. Home visiting by para-professionals and by nurses: A randomized controlled trial. Pediatrics 2002; 110 (3): 486-496.


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