The Future of Children

European countries have a long history of providing home health visiting services. These services contrast in many ways with the services of those programs in the United States described by Douglas Powell in this journal issue. Most notably, the European programs are typically universal in that they are offered to all families. In describing the European programs, Sheila Kamerman and Alfred Kahn give special focus to programs in Denmark and Great Britain. Universal home health visiting has been in place in these countries for decades and is widely accepted as a valuable and effective service, although formal research on its effectiveness has been limited. The authors conclude that home health visiting programs have been successful, in part, because these countries have a comprehensive maternal and child health system (both to finance and to deliver services), and home visiting is well integrated into this broader system of care and support for all families. Home visiting programs for very young children and their families are not a uniform intervention. As discussed in the article by Powell in this journal issue, these programs vary in their content, goals, and staffing. This article focuses on European home visiting programs in which public health nurses visit homes following the birth of a child. Special attention is given to describing these programs in Great Britain (England, Scotland, and Wales) and Denmark. The experience of these countries can guide U.S. policymakers as they consider expanding home visiting programs in this country. This article will (1) provide an overview of home health visiting in Europe, (2) address some questions Americans typically ask about these programs, and (3) discuss some implications of this experience for the United States. As a prelude to this discussion, however, it is important to note that the transferability of lessons from Europe to the United States may be complicated. Very different perspectives and premises affect policymaking in the United States compared with most European countries. In Europe, home visiting programs have existed for more than a century; they are a well-accepted part of life that is integrated into broad government-funded health and social services systems. Despite growing concern about limited resources to expend on social programs in many European countries, their home visiting programs continue to be universal (available to all families), popular, generously supported, and viewed as effective. Generally, Europeans have not thought it necessary to evaluate formally these programs to prove their effectiveness and defend their existence. In contrast, the United States does not have a similar tradition of broad, universal The Future of Children HOME VISITING Vol. 3 • No. 3 Winter 1993 Sheila B. Kamerman, D.S.W., is professor of social policy and planning at the School of Social Work, Columbia University, and codirector of the CrossNational Studies Research Program at Columbia. Alfred J. Kahn, D.S.W., is professor emeritus at the School of Social Work, Columbia University, and co-director of the Cross-National Studies Research Program at Columbia. Kamerman and Kahn have conducted research on child and family policy and programs in the United States and European countries for more than 20 years. 40 THE FUTURE OF CHILDREN WINTER 1993 supports for families. Debate here about whether to expand home visiting programs often begins with questions about their proven effectiveness with specific targeted populations, questions simply not asked in Europe’s history with these programs. Despite these differences, familiarity with the structure and characteristics of these European programs is important. At a minimum, the extensive European experience suggests criteria for success which U.S. policymakers should carefully consider when planning home visiting programs. Each of these countries believes that HHV programs are but one piece of an essential network of economic and social supports provided by the government to families. Because of the lack of written evaluation and analysis of home visiting programs in Europe, much of the following discussion is based on our more than 20 years of research in these countries, visiting and studying these and other child and family programs, and interviewing policymakers responsible for them. Our current research, which gives special attention to maternal and child health and home visiting—in the context of a general focus on children under age three—has been in six countries: Denmark, England, Finland, France, Germany, and Italy. Overview of the European Experience Home health visiting (HHV) exists to some extent in all of the northern and western European countries as part of their national, universal systems of health care. These countries include Denmark, Finland, France, Germany, Great Britain, Ireland, Italy, the Netherlands, Norway, and Sweden.1 All the HHV services are voluntary, free, and not income-tested. Each of these countries believes that HHV programs are but one piece of an essential network of economic and social supports provided by the government to families. There is strong conviction that achievement of child health goals requires not only health services, but also cash and noncash benefits, housing supports, child care services, and social services as needed by the family. In essence, child health policies and programs are viewed as an integral component and interdependent with the other elements of social policy for children and their families. A firm social infrastructure provides the foundation and building blocks for supplementary interventions for those children and families with special needs. In all countries, home visiting programs are carried out by professionals, typically registered nurses. In Denmark, home visitors also have pediatric hospital experience. In the Netherlands, paraprofessionals supplement the nurses’ role. Where HHV occurs in Germany, social workers are the visitors and encourage regular checkup visits to private physicians or public health clinics. Often these professionals have supplemental public health training. Home visitors in each of these countries provide health education, preventive care, and social support services to very young children and their parents. Home visitors may be assigned to families according to geographic boundaries or, in some countries, according to the general practitioner physician the family sees. In all countries, home visiting services are supplemented by more comprehensive health services available to children through a system of maternal and child health clinics or through private doctors under a universal health insurance system, or through both. Every country focuses its home visiting programs on children under the age of three. All see the home locus as essential at the start. Visiting in the home allows the home visitor to meet other siblings and fathers, and provides a better opportunity to view mother-child interactions in a natural setting and to establish a close relationship with the mother on a oneto-one basis. However, European HHV programs vary along other indicia: whether special focus is given to specially identified families, whether a family is visited only after the birth of their first child, whether visits begin prenatally, and whether the visits are supplemented with center-based support groups and care. In addition, these programs also vary in frequency of the visits. For example, in DenHome Health Visiting in Europe 41 mark, Great Britain, Ireland, and the Netherlands, nearly all newborns and their mothers are visited at home by a public health nurse at least several times during the first year. In contrast, Finland, France, Germany, and Italy offer only one or two postbirth visits, with additional visits on a discretionary basis as needed. No matter what the frequency of visits, home visiting in each of these countries links the family, as needed, to social services, income maintenance, housing, and other government programs. Home visiting programs are often located within, or in close proximity to, the offices for broader social services. Regardless of location, they typically enjoy coordinated or integrated relationships with these other programs. Home visitors also help with early identification of risk of child abuse or neglect, developmental lags, or postpartum depression; they offer treatment or referral as appropriate for children, mothers, or other family members. The most comprehensive HHV programs are those in Denmark and Great Britain. These programs are discussed in more detail in the following section. A Closer Look at Great Britain and Denmark When and why did HHV services first begin? Home health visiting began in Great Britain in the mid-nineteenth century, in Denmark in the 1930s, and in most other European countries in the period immediately following World War II. The British system has been especially influential crossnationally, and its history is instructive.