Are home visiting programs more effective than the standard of care at preventing injury in children who are at risk for injury?

The question for this issue's column was posed by Jan Pratt, the nursing director of the Primary Care Program at the Royal Children's Hospital and Health Service District in Queensland, Australia. Jan's primary research interest focuses on injuries in children younger than the age of one year. There is good evidence to suggest that home visiting programs versus standard community support lower the incidence of childhood injuries (1) (Grade of recommendation: A, based on systematic review of randomized controlled trials [Table 1])(2). For example, in their systematic review of eight randomized controlled trials conducted between 1977 and 1995 Roberts et al (1) found that home visiting programs are effective for reducing the rate of childhood injuries. However, the authors caution the generalization of their findings for several reasons. First, they point out that the home visiting programs investigated in the eight trials may have been more intense than programs that are typically provided by health visitors. Thus, home visiting programs implemented in the ‘real world’ need to be assessed before assuming that they will achieve the effects of the programs investigated in this review. Second, all but one trial investigated the effectiveness of home visits in a population of children who were at risk of adverse health outcomes (eg, children of single or teenage mothers, or children who recently visited the emergency department for an injury). Therefore the results do not address whether these programs are effective for children who are not at risk. Finally, the authors point out that most of the trials reviewed used non-professional home visitors; consequently the effectiveness of professional home visitors remains unknown. Levels of evidence and grades of recommendations Data from reference 2. RCT Randomized controlled trial; SR Systematic review Levels of evidence and grades of recommendations Data from reference 2. RCT Randomized controlled trial; SR Systematic review Evidence from randomized controlled trials published after Roberts et al's (1) review provides additional support for the use of home visiting programs to reduce the occurrence of childhood injuries (3,4). For instance, in their randomised controlled trial of the effectiveness of a home visit to prevent childhood injuries, King et al (3) found that home visits reduced the occurrence of injuries in at risk children. However, as in Roberts et al's (1) systematic review, the findings of the King trial (3) cannot be applied to other home visiting programs or to children who are not at-risk because the program investigated may have been more intense than standard home visiting programs, and was only tested in children who were at risk for an injury. Overall, there is evidence to suggest that home visiting programs are effective at decreasing the occurrence of injury in children who are at risk. However, given the variety of home visiting programs available, the variety of settings in which they can be delivered, and the range of individuals to whom they can be delivered, it is important for program developers to evaluate each program within the appropriate population before its implementation.

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