Effect of a Community Agency–Administered Nurse Home Visitation Program on Program Use and Maternal and Infant Health Outcomes: A Randomized Clinical Trial | Child Abuse | JAMA Network Open | JAMA Network
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    1 Comment for this article
    Preventing child abuse
    Frederick Rivara, MD, MPH | University of Washington
    Child abuse is a problem in all societies and its causes are complex and multifactorial. This terrific study by Dodge and colleagues however shows that prevention is possible at the community level by the simple intervention of a nurse home visitation program. Other studies have shown the cost-effectiveness of this program as well. To me the big question is--why don't we have it available in all communities?
    CONFLICT OF INTEREST: Editor in Chief, JAMA Network Open
    Original Investigation
    November 1, 2019

    Effect of a Community Agency–Administered Nurse Home Visitation Program on Program Use and Maternal and Infant Health Outcomes: A Randomized Clinical Trial

    Author Affiliations
    • 1Sanford School of Public Policy, Duke University, Durham, North Carolina
    • 2Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina
    JAMA Netw Open. 2019;2(11):e1914522. doi:10.1001/jamanetworkopen.2019.14522
    Key Points español 中文 (chinese)

    Question  What is the effect of a nurse home visitation program for families with newborns implemented in a community setting on program penetration and fidelity and family outcomes?

    Findings  This community-based randomized clinical trial found that the visitation program was implemented with 76% penetration and 90% adherence to the protocol, leading nurses to address minor problems for 52% of families and connect an additional 42% to community resources. Analyses of interviews and administrative records indicated that families assigned to the intervention had more community connections, fewer cases of maternal anxiety or depression, and fewer investigations for child abuse.

    Meaning  This study demonstrates successful implementation and decreased child abuse investigations among participants in a postnatal nurse home visitation program implemented at scale in a community setting.


    Importance  Postnatal home visitation to support parenting and infant healthy development is becoming increasingly common based on university efficacy studies, but effectiveness when disseminated by communities is not clear.

    Objective  To test implementation and impact of the Family Connects (FC) program when administered by a community agency.

    Design, Setting, and Participants  In this randomized clinical trial, births were randomly assigned to receive FC or treatment as usual. Independent evaluation was conducted through parent interviews and review of health and child protective services records. Interviewers were blind to the experimental condition of participants, and participants were blind about the purpose of the interview as an intervention evaluation. A total of 936 consecutive residential births at Duke University Hospital from January 1, 2014, through June 30, 2014, were included. Data were analyzed preliminarily for reporting to funders in early 2015 before all birth-record covariates were scored and were analyzed more comprehensively in mid-2019 after administrative birth and child protective service records became available.

    Interventions  The goals of the FC brief universal program were to assess family-specific needs, complete brief interventions, and connect families with community resources. Community agencies and families were aligned through an electronic data system.

    Main Outcomes and Measures  Case records documented program penetration and quality. The primary outcome was child protective services investigations for maltreatment. Secondary outcomes were the number of sustained community connections, maternal mental health, parenting behavior, infant well-child care visits and maternal postpartum care compliance, and emergency health care utilization.

    Results  Of 936 births, 451 infants (48.2%) were female and 433 (46.3%) were from racial/ethnic minority groups. In all, 456 births (46.5%) were randomized to the intervention and 480 (53.5%) were randomized to the control. All analyses were based on intention to treat. The impact analysis included 158 intervention families and 158 control families. Intervention penetration was 76%, adherence to the protocol was 90%, and independent agreement in scoring (κ) was 0.75. Nurses identified and addressed minor problems for 52% of families and connected an additional 42% to community resources. Analysis of the primary outcome of child abuse investigations revealed a mean (SD) of 0.10 (0.30) investigations for the intervention group vs 0.18 (0.56) investigations for the control group (b = −0.09; 90% CI, −0.01 to −0.12; 95% CI, −0.18 to 0.01; P = .07). The intervention group’s rate of possible maternal anxiety or depression was 18.2% vs 25.9% for the control group (b = −7.70; 90% CI, −15.2 to −0.1; 95% CI, −16.6 to 1.3; P = .09).

    Conclusions and Relevance  This study indicates that a nurse home visitation program for families of newborns can be implemented by a community agency with high penetration and quality. Other communities could benefit from wider dissemination of the program provided that quality remains strong and evaluation continues.

    Trial Registration  ClinicalTrials.gov identifier: NCT01843036