Home-visiting support during pregnancy or soon after the birth of an infant can be advantageous for maternal well-being and infant development. The best results have been identified when home visitors are professionals, especially nurses, and if a theoretically driven curriculum is followed with fidelity. Some suggest that disadvantaged families, who may avoid professional services, respond well to support from community volunteers, but there is less evidence about their impact. This study identified potentially vulnerable mothers during pregnancy in randomly allocated neighbourhoods where local volunteer home-visiting schemes agreed to offer proactive volunteer support and control areas where the local home-visiting schemes did not offer this proactive service. Taking demographic, child, and family factors into account, there were no significant differences in infant cognitive development at 12 months of age between families who had been supported by a volunteer and those who had not. Better cognitive development was predicted by less reported parenting stress when infants were 2 months and a more stimulating and responsive home environment at 12 months. The results suggest that unstructured proactive volunteer support for potentially vulnerable families is not likely to enhance infant development. Limitations of the cluster-randomised design are discussed.
Based on evidence from studies of early brain development (e.g., [
There is some evidence that effects of different elements of interventions can be additive. For instance, the Early Head Start intervention randomly assigned families to receive home-visiting support and child educational services in a group, or only one of these. Children and parents in families receiving both home-visiting and centre-based child care showed most improvement, while centre care alone led to more improvement for children, and home visiting had more impact on parenting and the home environment [
Timing of support may be important. A review of early interventions concluded that support might be particularly useful when the first contact is made during pregnancy, providing a means of establishing positive relationships between families and service providers in the community [
There has been debate regarding whether professionals should offer support to parents or whether the same impact could be achieved by (less expensive) paraprofessionals, and results are contradictory [
The question of whether or not visits are structured, following a clear curriculum, is also relevant. There is a range of evidence that professional home visiting using structured materials can significantly improve parenting and child outcomes. The most rigorously evaluated home-visiting intervention, the Nurse Family Partnership Programme [
It has been found that “community mothers” who are not health professionals can be effective in delivering a structured programme originally intended for use by professionals. A randomised trial in Dublin assessed the impact of the Bristol Child Development Programme for families with new-born infants living in disadvantaged neighbourhoods when delivered by community mothers, finding significant benefits for mothers and children [
Home-Start support is offered widely in the UK and provides visits by local volunteer parents who receive some preparation about how to be supportive but generally decide on the content of visits and their frequency with the family [
Ethical approval was obtained from the NHS Multi-Centre Research Ethics Committee (MREC) and all relevant local Research Ethics Committees.
The Home-Start national organisation agreed to participate in the study only if randomisation was at the scheme level and only if research home visits were initiated after the home visiting had been established and the families had been given time to settle into a routine following the birth of their new babies. Of 237 Home-Start schemes in England, at the time 161 (68%) were eligible and approached, and 41 (24%) agreed to be randomised. Ineligibility was because their catchment area was also a Sure Start Local Programme area (
Recruitment took place in waiting areas during routine antenatal clinics. Mothers were told that the study was designed to find out if offering home-visiting volunteer support to families made a difference. All completed a brief screening measure to determine eligibility and gave initial consent so that they could be contacted once their infant was born. They were told that further contact from the researchers, when their infants were 2 months and 12 months of age, would depend on background characteristics collected at recruitment. In areas randomised to provide the intervention, women were also told that they might be contacted by Home-Start before their baby was born to offer volunteer support; those in the control areas were told that the support was not available in their area.
Eligibility criteria for inclusion were living in the geographical areas covered by the Home-Start scheme; mother at least 18 years; able to understand spoken English; infant birth weight ≥2500 grams; ≤5 days in Special Care Baby Unit; a score of 9 or more on a modified version of the social disadvantage screening index (SDI) [
In pregnancy, 1,007 mothers-to-be agreed to be involved, 541 in intervention neighbourhoods, and 466 in control neighbourhoods. Just over half the families in intervention and control areas were eligible (intervention areas 274/541, 51%; control areas 253/466, 54%). The mean SDI of eligible families in the intervention areas was higher than that of the families in control areas (mean SDI: intervention 11.3, s.d. 1.9; control 10.9, s.d. 1.8;
Names and contact details of eligible families in the intervention areas were passed to their local Home-Start scheme. Of the 274 eligible intervention families, 96 received Home-Start support, defined as more than one visit while 178 did not. Of the 178 unsupported intervention families, three quarters declined the offer either following telephone contact by Home-Start (73, 41%) or after the initial visit by the Home-Start scheme coordinator (60, 34%) [
Consort diagram.
The extent to which families in the Home-Start areas were not receiving the service only became evident part-way through the study, and contact was then made with unsupported intervention families to gain their agreement for research visits. It was possible to contact 130 and 97 (75%) agreed. For some, their infants were older than 2 months, but the 2-month home visits were completed for 73 and 90 had a visit when their infants were 12 months of age, with completed visits at both time points for 66 (see Figure
Just over three quarters (196/253, 77%) of eligible families recruited in the control areas agreed to research visit when recontacted after their child’s birth. Those who did not agree (
Detailed information about family demographics, child, and family characteristics was collected during two research home visits completed when infants were 2 and 12 months of age. Thus, there is little true “baseline” information apart from general family vulnerability. A
Home-Start offers a service intended to complement the role of professionals by improving the support available to families who may not want or be identified as requiring on-going professional help. Emphasising the befriending nature of the support, volunteers are mainly parents themselves who aim to remove any stigma attached to receiving help, responding to families with flexibility, openness, and encouragement so that parents’ capacity to cope is enhanced. There are national guidelines for volunteer preparation and general guidelines about the nature of the support offered to families [
After an initial visit from the local Home-Start scheme coordinator to decide if the family wanted support and to discuss their needs, a volunteer was identified matched as closely as possible to the family. Subsequently, volunteers and families jointly decided on needs, on the frequency of visits, and how long the support should continue. They may engage in a number of different activities, providing company, assistance with childcare or other household tasks, going out on joint trips to local facilities, or giving parenting advice (see [
Families in the control group and those in intervention areas offered but not receiving Home-Start received existing services provided by the UK National Health Service (NHS) free of charge to all mothers and infants, that is, home visits from a midwife are routine during pregnancy, and for two weeks after the birth, home visits are routine from a health visitor after the child’s birth; there is on-going availability of their general practitioner (GP) and, when referred by the GP, from any of the specialist mental health services [
Maternal depression symptoms in the previous seven days were assessed with the Edinburgh Postnatal Depression Scale (EPDS), [
The parenting stress index short form (PSI/SF, 36 items; [
The Infant/Toddler version of the Home observation for measurement of the environment (HOME) inventory [
Infant difficult temperament was measured when infants were 2 and 12 months old using the Infant Characteristics Questionnaire (ICQ) [
The Bayley Scales of Infant Development [
Only those families with complete data when infants were both 2 and 12 months of age were included in analyses. Using SPSS version, 18 comparisons were made between the Home-Start-supported group and both comparison groups (matched control group, unsupported intervention group) of their SDI scores, demographic characteristics, and all characteristics assessed at 2 and 12 months, using chi-square for categorical variables and
Families were referred to Home-Start during pregnancy, but there was a substantial range in the average age in which the support started, reflecting different local capacity and the availability of suitable volunteers. On average, support started just after birth at 0.2 months (s.d. 1.7 months), but this ranged from three months before the infant’s birth to 4 months after the birth. More than half of the support (56%) had started by the infant’s birth, and almost all families (93%) were receiving support when the first research home visit was made and when infants were 2 months old meaning that the family characteristics such as reported stress, the home environment, and maternal depression and child characteristics such as difficult temperament may have been influenced by the support. The frequency and duration of support were determined by the volunteer and family jointly, and the research team could not influence this. Support did not extend through the whole first year for most families, the average number of visits was 15.1 (s.d. 11.9, range from 2 to 50), and average of months of support was 5.5 (s.d. 3.6, range from 1 to 14).
Given the difference in mean SDI scores between the total intervention and control groups, the scores of families taking part in the research visits were compared, and there was only one difference. The total control group (
The mean SDI of the intervention group families supported by Home-Start and completing both research visits (
Comparisons between groups in demographic characteristics of families seen at both research visits, when infants were 2 and 12 months of age (standard deviations or percentages in brackets).
Intervention group: supported |
Intervention group: not supported |
Total control group |
Matched control group |
|
---|---|---|---|---|
Mean maternal age (years) | 29.0 (5.7) | 28.6 (5.9) | 28.1 (6.1) | 29.0 (5.8) |
Mean number of children in family |
2.3 (1.1) | 2.2 (1.3) | 2.1 (1.1) | 2.1 (0.8) |
New baby male | 48 (52.2) | 35 (53.0) | 87 (48.9) | 47 (51.1) |
Biological father in the home | 73 (79.3) | 51 (77.3) | 142 (79.8) | 76 (82.6) |
Mother white2 | 76 (82.6) | 48 (72.7) | 161 (90.4) | 79 (85.9) |
Family structure | ||||
Mother single | 17 (18.5) | 13 (19.7) | 30 (16.9) | 13 (14.1) |
Living with partner | 27 (29.3) | 22 (33.3) | 71 (39.9) | 40 (43.5) |
Married | 48 (52.2) | 31 (47.0) | 77 (43.3) | 39 (42.4) |
Mother’s highest qualification3 | ||||
Degree/higher degree | 19 (20.7) | 7 (10.6) | 10 (5.6) | 10 (10.9) |
Advanced level (age 18) | 8 (8.9) | 5 (7.6) | 22 (12.4) | 11 (12.0) |
General certificate of secondary education (age 16) | 26 (28.3) | 19 (28.0) | 65 (36.5) | 26 (28.3) |
Other qualification | 32 (34.8) | 28 (42.4) | 63 (35.4) | 38 (41.3) |
None | 7 (7.6) | 7 (10.6) | 18 (10.1) | 7 (7.6) |
Mother’s occupation4 | ||||
Professional | 9 (9.8) | 4 (6.1) | 17 (9.6) | 10 (10.9) |
Intermediate/small employer | 17 (18.5) | 14 (21.2) | 41 (23.0) | 21 (22.8) |
Lower supervisory/technical/semiroutine/routine | 21 (22.8) | 24 (36.4) | 63 (35.4) | 19 (20.7) |
Unemployed or student | 45 (48.9) | 24 (36.4) | 57 (32.0) | 42 (45.7) |
Father’s highest qualification | ||||
Degree/higher degree | 14 (17.7) | 7 (13.7) | 11 (6.8) | 8 (9.5) |
Advanced level (age 18) | 7 (8.9) | 4 (7.8) | 16 (9.9) | 11 (13.1) |
General certificate of secondary education (age 16) | 28 (35.4) | 18 (35.3) | 65 (40.4) | 34 (40.5) |
Other qualification | 18 (22.8) | 18 (35.3) | 48 (29.8) | 25 (29.8) |
None | 12 (15.2) | 4 (7.8) | 21 (13.0) | 6 (7.1) |
Father’s occupation | ||||
Professional | 9 (10.8) | 6 (10.2) | 11 (6.7) | 5 (5.8) |
Intermediate/small employer | 21 (25.3) | 10 (16.9) | 32 (19.4) | 21 (24.4) |
Lower supervisory/technical/semiroutine/routine | 43 (51.8) | 37 (62.7) | 107 (64.8) | 52 (60.5) |
Unemployed or student | 10 (12.0) | 6 (10.2) | 15 (9.1) | 8 (9.3) |
1Mean higher for intervention supported group (
2Proportion lower in intervention-supported group (
3Significant difference between intervention-supported group (
4Significant difference between intervention-supported group (
Comparisons of child and family characteristics indicated that, despite matching, there was one difference between the supported group and the matched controls, with intervention mothers reporting more parenting stress when their infants were 2 months old than the matched controls. Consequently, this was controlled for in regression analyses, as these were all other indicators with significant correlation coefficients with the Bayley MDI (see Table
Comparisons between groups in mean characteristics of the children, mothers, and the home environment of families seen at both research visits, when infants were 2 and 12 months of age (standard deviations or percentages in brackets).
Correlation coefficient with 12-month Bayley MDI |
Intervention group: supported mean |
Intervention group: not supported mean |
Matched control group mean |
Intervention supported versus |
Intervention- | |
---|---|---|---|---|---|---|
Infant 2 months old | ||||||
| ||||||
Mean maternal depression (EPDS)1 | −.14* | 8.2 (5.8) | 7.9 (5.7) | 6.8 (4.9) |
|
|
Mean parenting distress (PSI)2 | −.22** | 72.6 (16.4) | 70.8 (15.9) | 67.5 (15.6) |
|
|
Mean HOME3 environment | .14* | 32.3 (5.1) | 31.8 (5.5) | 33.2 (5.6) |
|
|
Mean child difficult temperament (ICQ)4 | −.15* | 2.9 (.76) | 2.7 (.78) | 2.7 (.72) |
|
|
| ||||||
Infant 12 months old | ||||||
| ||||||
Mean maternal depression (EPDS) | −.08 | 7.0 (5.9) | 6.8 (5.0) | 6.3 (5.4) |
|
|
Mean parenting distress (PSI) | −.16* | 66.5 (14.4) | 66.9 (15.6) | 66.9 (17.7) |
|
|
Mean HOME environment | .33** | 38.4 (5.0) | 38.3 (4.5) | 39.6 (3.9) |
|
|
Mean child difficult temperament (ICQ) | −.07 | 2.8 (.73) | 2.9 (.68) | 2.8 (.64) |
|
|
*Correlation coefficient is significant at
1Edinburgh postnatal depression scale [
2Parenting stress index [
3Home observation for measurement of the environment [
4Infant characteristics questionnaire [
In uncontrolled comparisons, infants in the matched control group had a significantly higher mean Bayley MDI score than the children in families supported by Home-Start (mean MDI: control group 93.3, s.d. 10.9; supported group 89.0, s.d. 11.2;
Multiple regression analyses were conducted first to include the supported and matched controls and then the supported and nonsupported families from the intervention areas, taking into account all 2- and 12-month characteristics significantly associated with the Bayley MDI (see Tables
Results of multiple regression to predict the Bayley Mental Developmental Index, comparing Home-Start-supported families and matched controls.
Unstandardized coefficients | Standardized coefficients |
|
Sig. | ||
---|---|---|---|---|---|
|
Std. error | Beta | |||
EPDS1 total score 2 months | .076 | .181 | .037 | .422 | .674 |
PSI2 total score 2 months | −.149 | .073 | −.215 | −2.049 | .042 |
HOME3 total score 2 months | −.199 | .179 | −.095 | −1.112 | .268 |
ICQ4 mean item score 2 months | −.092 | 1.262 | −.006 | −.073 | .942 |
HOME total score 12 months | .785 | .208 | .312 | 3.779 | .000 |
PSI total score 12 months | −.025 | .060 | −.036 | −.420 | .675 |
Matched control group | 2.656 | 1.584 | .119 | 1.677 | .095 |
1Edinburgh postnatal depression scale [
2Parenting stress index [
3Home observation for measurement of the environment [
4Infant characteristics questionnaire [
Results of multiple regression to predict the Bayley Mental Developmental Index, comparing Home-Start-supported families and intervention area families not receiving support.
Unstandardized coefficients | Standardized coefficients |
|
Sig. | ||
---|---|---|---|---|---|
B | Std. error | Beta | |||
EPDS1 total score 2 months | .171 | .176 | .093 | .973 | .332 |
PSI2 total score 2 months | .019 | .077 | .029 | .244 | .808 |
HOME3 total score 2 months | −.194 | .206 | −.094 | −.939 | .349 |
ICQ4 mean item score 2 months | −1.369 | 1.211 | −.100 | −1.130 | .260 |
HOME total score 12 months | .874 | .205 | .398 | 4.267 | .000 |
PSI total score 12 months | −.122 | .074 | −.168 | −1.662 | .099 |
Intervention, not supported | 2.998 | 1.669 | .138 | 1.796 | .075 |
1Edinburgh postnatal depression scale [
2Parenting stress index [
3Home observation for measurement of the environment [
4Infant characteristics questionnaire [
This study reflects a challenge that faces many researchers to attempt a rigorous study design in a real-world setting. The intervention providers imposed restrictions which weakened the study. Cluster randomisation of areas rather than families led to a control group that was less vulnerable based on the screening instrument. Possibly in the intervention areas, more families with some problems thought that taking part in the study would be a good idea, whereas in the control areas, they would not receive support, so this was not a factor influencing involvement. A trial with randomisation of families within each area would have been preferable. However, the eventual supported and control groups receiving both research visits did not have significantly different scores on the screening instrument, principally because the most vulnerable of the control group families declined to take part in the research. A second issue was the low rate at which the support was taken up by families whose names had been passed to Home-Start organisers, which was probably a reflection of the fact that this study referred families to them based on risk factors, whereas their more usual practice was to receive referrals of families with identifiable problems. Nevertheless, once this issue came to the research team’s notice, a second “no treatment” control group could be included which proved useful since they did not differ from the supported group in any way.
A further restriction imposed by the voluntary organisation was that research visits should not start until families had become “settled” following their new baby’s birth, with two months of age being the agreed first research contact. This information then could not be considered a baseline since for almost all the supported families visits had been initiated, some several months earlier and before the birth. Supported families reported experiencing more stress in their parenting at that first visit than the control families. This could mean that the matching failed to take into account sufficient factors and that they did have more stress, despite similar demographic characteristics. There may also be other aspects of the families that the study did not measure. The families who agreed to the support may have been hoping to meet someone who could share their problems and have had greater concern about their ability to cope with their infants. It could also mean that the introduction of a volunteer had led them to talk about and contemplate their difficulties more openly as a first stage of dealing with them, so they were more likely to report problems on a questionnaire. This might be the case since the only impact of the support on parenting identified for these families was that the parenting stress reported by mothers in the supported group started higher but was reduced significantly more than the stress reported by the control group [
The level of parenting stress reported at two months was a significant predictor of a lower MDI score when infants were 12 months old, but receipt of support was not significant. Perceiving parenting as stressful when infants are in their first few weeks may leave mothers less able to be responsive and stimulating, and it was this aspect of the home environment when infants were 12 months of age that was a significant predictor of Bayley MDI scores in both regression analyses. This suggests that home visiting, whether from a volunteer or from a professional, may be more effective in promoting child development if parents are given strategies to enable them to be more responsive, focussing on promoting positive parent-child interactions rather than concentrating on stress. A qualitative study exploring the nature of Home-Start support [
This study did not show that volunteer support of an indeterminate nature offered proactively in pregnancy was likely to enhance child cognitive development at the end of the child’s first year, and this appears to be a reasonable robust result, despite the study limitations since it was shown with two different comparison groups. In addition, it reflects the findings of the only other randomised study of this particular volunteer support which found no impact on children’s socioemotional development [
To enhance child cognitive development, it is probably necessary either to intervene directly with children or to work with parents specifically on ways to promote infant development, as occurs in the Nurse Family Partnership programme [
The study was funded by a Grant from the Health Foundation (no. 16665/608) awarded to the author as a Principal Investigator and to Dr. Rob Senior as a Coinvestigator. The study would not have been possible without the close cooperation and involvement of the Home-Start national office, the local Home-Start schemes, and the many professionals throughout the country in antenatal and well-baby clinics who assisted with the recruitment. In addition, the study would not have been possible without the families who took time to welcome the researchers into their homes and talked openly about their lives and families. Thanks are also due to the dedicated research team who conducted the interviews, with particular thanks to Dr. Kristen MacPherson for coordinating the trial.