To conduct a systematic review of the effectiveness and cost-effectiveness of home visiting by health visitors.

MEDLINE from 1966 to July 1997, CINAHL from 1982 to July 1997, and EMBASE from 1980 to October 1997, were searched using an extensive list of search terms. Additional studies were located by searching via the Internet and the Cochrane Library, handsearching the journal 'Health Visitor' from 1982 to 1997, and by examining the reference lists of 17 review articles. The Index to Theses was searched from 1980 to 1997, and references to PhD theses in other articles were followed-up; potentially relevant PhDs cited in other PhD theses were also retrieved. Further information was also gained by contacting key individuals and organisations, and through advertisements placed in a number of journals.

Study designs of evaluations included in the review

Studies including a comparison group, i.e. randomised controlled trials (RCTs), non-RCTs, and controlled before-and-after comparisons.

Specific interventions included in the review

Home visiting programmes. At least one postnatal home visit had to be undertaken as part of the programmes, in order for studies to be considered. Studies were only included if the personnel involved in the programme undertook responsibilities within the remit of British health visitors, and were not members of a professional group other than health visiting, e.g. community psychiatric nursing and midwifery.

Participants included in the review

The authors did not specify any disease or participant inclusion or exclusion criteria.

Outcomes assessed in the review

Outcomes relevant to the objectives of British health visitors were assessed, namely: increasing rates of uptake of appropriate health and community services; reducing rates of child abuse and unintentional injury in childhood; changing behaviours, attitudes and beliefs; and improving client satisfaction.

How were decisions on the relevance of primary studies made?

The authors do not state how the papers were selected for the review, or how many of the reviewers performed the selection.

The studies were assessed for quality using a modified version of the Reisch quality rating scale (see Other Publications of Related Interest no.1) Three team members applied the Reisch scale to the articles and were masked to authors, title, journal (where possible) and study results. The correlation between pairs of raters was thought to be satisfactory and the main scoring was then continued using the adapted scale.

The authors do not state how the data were extracted for the review, or how many of the reviewers performed the data extraction. The authors state that data were extracted from each study according to an agreed procedure. Categories of data extracted included author, year, quality score and study design, interveners, participants, interventions (number of participants), content, implementation and outcomes.

How were the studies combined?

Where appropriate, quantitative data were entered into a meta-analysis. When outcomes were similar, studies were combined using Hedges' method (see Other Publications of Related Interest no.2) or Peto's method (see Other Publications of Related Interest no.3), and where there was a mixture of effect types, Fisher's method was used (see Other Publications of Related Interest nos.2 and 4). Data were also discussed in a narrative manner. Publication bias was not assessed.

How were differences between studies investigated?

Formal statistical tests for heterogeneity were carried out using a chi-squared test.

One hundred and two studies evaluating 86 home visiting programmes met the inclusion criteria. Eleven of the home visiting programmes were described in more than one study; 1 was described in 4 different studies, 1 in 5 different studies, and 9 in 2 different studies each. These home visiting programmes were treated as a single study.

The studies were divided into two sections: those assessing the outcome of home visiting to parents and young children, and those assessing the outcome to elderly people and their carers.

Parents and young children (34 studies).

There was evidence to suggest that home visiting was associated with improvements in parenting skills and in the quality of the home environment; amelioration of several child behavioural problems including sleeping behaviour; improved intellectual development among children especially among children with a low birth weight or failure to thrive; a reduction in the frequency of unintentional injury as well as a reduction in the prevalence of home hazards; improvements in the detection and management of postnatal depression; enhancement of the quality of social support to mothers; and improved rates of breast-feeding.

A meta-analysis of 4 RCTs indicated that intervention group mothers were significantly less likely to report problems with their child's sleeping behaviour (odds ratio, OR 0.48; 95% confidence interval, CI: 0.30, 0.76). A meta-analysis of 8 RCTs suggested that home visiting has some effect in improving Bayley mental development scores (Hedges' g 0.17, 95% CI: 0.06, 0.28). A meta-analysis of 6 studies showed that children in the intervention group gained a score approximately five IQ points higher than children in the control group (Hedges' g 0.32, 95% CI: 0.146, 0.48). When restricting the analysis to RCTs, similar results were produced (Hedges' g 0.27, 95% CI: 0.12, 0.45). Four studies reported prevalence of hazards from which ORs could be calculated. Of 33 effect sizes, 23 had an OR of greater than one, indicating a reduction in prevalence of the hazard after intervention, whilst 8 had an OR less than 1. There was significant heterogeneity of the effect sizes.

There was insufficient evidence to show an effect of home visiting on the following outcomes because of the small number of studies available (at most 4 studies): physical development, i.e. weight and height; the incidence of child illness; mothers' use of informal community resources, or the size of their informal support network; children's diet; mothers' return to education, participation in the workforce, or use of public assistance; family size or number of subsequent pregnancies.

There was no evidence to suggest that home visiting was effective in improving children's motor development; increasing the uptake of immunisation; increasing the uptake of other preventive child health services; reducing the use of emergency medical services; or reducing hospital admission rates.

In view of the problem of surveillance bias, no conclusions could be drawn concerning the effectiveness of home visiting in reducing the incidence of child abuse and neglect.

Elderly people (17 studies).

There was evidence to suggest that home visiting was associated with reduced mortality among the general elderly population and frail 'at risk' elderly people; and reduced admission to long-term institutional care among the frail 'at risk' elderly population.

A meta-analysis of 6 RCTs demonstrated a significant effect of home visiting in reducing mortality among the general elderly population (OR 0.75, 95% CI: 0.63, 0.89). A meta-analysis of 5 studies also showed a significant effect of home visiting on mortality among elderly people who were at risk of adverse outcomes (OR 0.75, 95% CI: 0.57, 0.98). A meta-analysis of 3 controlled trials suggested that home visiting was successful in reducing admissions to long-term institutional care in 'at risk' elderly people (OR 0.58, 95% CI: 0.37, 0.92).

There was insufficient evidence to show an effect of home visiting on the outcomes of duration of elderly people's stay in hospital and physical health, because of the small number of studies available (at most 4 studies).

There was no evidence that home visiting was effective in reducing admission to hospital; reducing admission to long-term institutional care among the general elderly population; improving functional status; improving psychological symptoms; enhancing elderly people's well-being or their quality of life.

The findings from the limited number of studies assessing cost-effectiveness indicate that there is a potential for home visits to parents and their children, and to elderly people and their carers, to produce net cost-savings, in particular hospital cost-savings.

The authors conclude that home visiting by itself can be insufficient to bring about radical improvements in health and social outcomes. The evidence suggests that home visiting interventions that are restricted to the pursuit of only a narrow range of outcomes are less effective than more broadly based interventions in which the multiple needs of individuals and families are addressed. There is a need for more studies with rigorous experimental designs to evaluate the effectiveness of home visiting by British health visitors. The authors also concluded that there is a need to undertake further studies comparing the effectiveness and cost-effectiveness of professional and non-professional home visitors. In addition, they suggest that there is a need for a full economic evaluation of home visiting by health visitors using a RCT design.

The review question was clearly stated and well-supported by the inclusion criteria. The literature search was adequate but did not identify unpublished literature, and the authors did not specify whether or not the search was restricted to English language publications. The validity assessment of primary studies was carried out using a modification of an existing scale. The data were pooled appropriately using both quantitative and narrative syntheses, and heterogeneity was investigated. Publication bias, however, was not assessed. Some details explaining the review process were given, whereas others were not. The authors' conclusions appear to follow from the findings, but should be viewed in light of the mentioned limitations.

Practice: The authors did not state any implications for further practice.

Research: The authors state that there is a need for more studies with rigorous experimental designs to evaluate the effectiveness of home visiting by British health visitors. Such studies will require sufficient power to detect effects, random assignment to treatment groups, and standardised measures of outcome wherever possible. Results must be presented in sufficient detail to enable their inclusion in a meta-analysis. The rationale and objectives of the study should be clearly stated, and measures of outcomes chosen carefully to reflect these. The content of the intervention should always be described.

There is also a need to undertake further studies comparing the effectiveness and cost-effectiveness of professional and non-professional home visitors, and for a full economic evaluation of home visiting by health visitors using an RCT design.

NHS R&D Health Technology Assessment (HTA) Programme, project number 94/36/04.

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This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.