Supplementation of urban home visitation with a series of group meetings for parents and infants: results of a “real-world” randomized, controlled trial

Abstract

Objective: Home visitation has been shown to be effective in reducing rates of child maltreatment and in enhancing psychosocial outcomes in children and their parents. Even when available, however, it is underutilized by parents in some urban settings. We tested a supplemental 10-session group intervention for its ability to increase active participation in home visitation, enhance the quality of caregiving behavior of parents, and improve social developmental outcome in children.

Method: A randomized controlled design was utilized, involving two separate cohorts of parents of 3- to 18-month old infants, totaling 148 parent-child dyads. The intervention focused on practical experience in promoting parent-infant attachment relationships.

Results: At 6 months follow-up, there was a substantial increase in the proportion of intervention group parents participating in home visitation, compared to parents in the control group (Fisher’s exact p = .008). Parents in the intervention group exhibited a trend for improvement in their capacity to appropriately interpret infants’ emotional cues (p = .08), independent of the effects of home visitation itself. Attrition in both the treatment and control groups was inversely associated with income and level of education.

Conclusions: Group meetings may constitute an effective means of engaging stressed urban families in home visitation.

Résumé

Objectif: Les visites á rèduire le taux des mauvais traitements et améliorent les conditions psychosociales des enfants et de leurs parents. Toutefois, même lorsque disponibles, elles demeurent sous-utilisées dans certains milieux urbains. Les auteurs ont testé une intervention de groupe comprenant 10 sessions pour voir si cela pouvait accroı̂tre la participation des visites à domicile, améliorer la qualité des soins parentaux et favoriser les conditions du développement social des enfants.

Méthode: On á élaboré un design aléatoire contrôlé, comprenant deux groupes de parents d’enfants âgés de 3–18 mois. En tout, ii y avait 148 dyades parents-enfants. L’intervention cibla l’attachement parent-enfant dans le contexte d’expériences pratiques.

Résultats: Un suivi au bout de 6 mois révèle que les parents participant au programme de groupe utilisent les visites à domicile beaucoup plus que les parents du groupe contrôle (p exacte de Fisher = .008). Les parents du premier groupe démontrent une tendance à améliorer leur compétences lorsqu’ifs s’agit d’interpréter les signes émotionnels de leurs enfant (p = .08), indépendamment des visites à domiciles en soi. Les effets des interventions, tant dans le groupe de traitement que le groupe contrôle, sont inversement liés au revenu et au niveau de scolarité.

Conclusions: Les sessions en groupe pourraient constituer un moyen efficace d’obtenir la participation au programme de visites à domicile des families urbaines stressées.

Resumen

Objetivo: Los programas de “educación familiar” han mostrado ser efectivos para reducir las tasas de maltrato infantil y mejorar aspectos psicosociales en los niños y sus padres. Sin embargo, incluso cuando son accesibles, estos programas suelen ser infrautilizados por los padres en algunos ambientes urbanos. Esta investigación evaluó la eficacia de un programa de intervención grupal de 10 sesiones para aumentar la participación activa en los programas de “educación familiar,” mejorar la calidad de la conducta parental de cuidado de los niños y mejorar el desarrollo social de los niños/as.

Método: Se utilizó un diseño experimental con grupo control de selección al azar en el que se implicaba a dos grupos de padres de niños/as de entre 3 y 18 meses, totalizando 148 dı́adas padres-niños. La intervención se focalizó en experiencias prácticas dirigidas a promover las relaciones de apego padres-hijos.

Resultados: A los seis meses de seguimiento se observó un aumento sustancial en el grupo de tratamiento, en comparación con el grupo control, en la proporción de padres que participaron en el programa de “educación familiar.” Los padres del grupo de intervención mostraron una tendencia para mejorar en su capacidad de interpretar correctamente las señales emocionales de los niños/as, independientemente de los efectos del programa de “educación familiar.” Tanto en el grupo control como en el grupo de tratamiento, la atribución estaba inversamente asociada con los ingresos y el nivel educativo.

Conclusiones: Las reuniones de grupo pueden constituir un sistema efectivo para implicar a familias urbanas con elevados niveles de estrés en programas de “educación familiar.”

Introduction

Previous research has demonstrated the efficacy of home visitation as a public health intervention capable of reducing rates of child abuse and neglect Gomby et al 1999, Olds et al 1997, as well as improving long-term social developmental outcome in children (Olds, Henderson, Cole, Eckenrode, Kitzman, Luckey, Pettitt, Sidoria, Morris, & Powers, 1998). Two important characteristics of successful demonstration projects involving home visitation have been (1) low attrition rates and (2) intervention effects that appear stronger for disadvantaged families than for middle and upper class families. Attempts have now been made to implement home visitation on a larger (public health) scale, but it has been the experience in many urban settings that disadvantaged parents are reluctant to utilize this service Duggan et al 2000, Gomby et al 1999, even when they are entitled to it by law. If such underutilization involves families who would have been particularly likely to benefit from the intervention, this could seriously erode treatment effects of large-scale programs.

We undertook this study to determine whether engaging parents in a nonthreatening group experience would (1) improve the likelihood of their enrollment and active participation in an ongoing home visitation program, and (2) confer benefits to parents and infants independent of the effects of home visitation itself. Incentives for participation in the intervention were limited to meals and modest provision of household goods (made available by existing resources in the community), to preserve, as much as possible, the applicability of the program (and its results) to “real-world” public health efforts. The group sessions were designed to promote parents’ practical understanding of children’s earliest social (attachment) relationships, and to emphasize the centrality of the role of parents in cultivating those relationships. This approach was taken because research on attachment has suggested a significant association between insecure parent-infant attachment and child abuse (Carlson, Cichetti, Barnett, & Braunwald, 1989). In addition, review and meta-analysis of previous prospective and quasi-longitudinal studies of attachment have shown that insecure attachment doubles the relative risk of developing clinically significant abnormalities in social behavior over the course of childhood and adolescence (Constantino, 1995). We hypothesized that an intervention to promote parent-infant attachment might be of interest to parents, would provide a forum for engaging parents in the prospect of home visitation, and might have beneficial effects of its own.