CG GLOBAL REPORT 6:
HEALTH HOME VISITING TO SUPPORT EARLY CHILDHOOD DEVELOPMENT IN THE CEE/CIS REGION

CG GLOBAL REPORT 6:

HEALTH HOME VISITING TO SUPPORT EARLY CHILDHOOD DEVELOPMENT IN THE CEE/CIS REGION

BETTINA SCHWETHELM AND DEEPA GROVER (UNICEF Regional Office For Central and Eastern Europe/Commonwealth of Independent States)

While the strategic importance of synergetic, multisectoral interventions for holistic child development has long been recognized, early childhood programmes are typically associated with early education and parenting programmes organized by a variety of providers. This has resulted in horizontal and vertical discontinuities, varying notions of accountability and programmes that end with a particular project. To address this issue, UNICEF is working with national governments in the Central and Eastern Europe (CEE)/Commonwealth of Independent States (CIS) region1 to employ a systems-based approach to early childhood development (ECD) in the health sector. The approach promotes the survival, development, protection and well-being of young children, their caregivers and pregnant women, particularly from the most disadvantaged populations.

The effort aims to transform existing health home visiting systems so that home visitors, in addition to their health-related responsibilities, are enabled to partner with families to promote ECD, recognize and address potential or manifest risks
in the home environment, provide guidance and psychosocial support, and link families and young children to other services as needed. While home visitors are being trained for these additional tasks, simultaneous efforts are underway to ensure an enabling environment within the health sector. These efforts include redefining health and education policies, reforming institutional arrangements and intersectoral linkages, and establishing adequate and appropriate legal and budgetary provisions as well as new standards of quality. Founded on global evidence and the support of a Technical Advisory Group (TAG) composed of international experts, this approach is expected to be sustainable and result in positive outcomes for children and families now and in the future.

Photo: UNICEF/John McConnico

Background and Context

THE IMPORTANCE OF EARLY CHILDHOOD DEVELOPMENT

Research has provided robust evidence of what young children need for their optimal development: conditions that ensure good health and nutrition, attuned and nurturing caregivers, and a safe and stimulating environment. There is an abundance of evidence from biological, behavioural and neurological science on the long-term consequences of factors such as early childhood nutrition status,2 physical and mental health of caregivers,3 brain development and the impact of toxic stress,4 and adverse childhood experiences.5 A variety of interventions can address these factors independently.6 The more difficult task, however, is bringing these interventions together to mediate ‘risk and protective factors’7 in a symbiotic and comprehensive way for each child, family and community. Creating this kind of synergy between and across interventions remains a major challenge for ECD programmes.8

THE SITUATION OF YOUNG CHILDREN IN CEE/CIS

Many countries in the CEE/CIS region are middle or upper-income countries, but by no means does this guarantee equity or quality in ECD services. Much remains to be done in this region to improve the well-being of young children and, by extension, their lifelong chances for physical and mental health, achievement and productivity. Social determinants . such as high levels of child poverty, discrimination against ethnic minorities, ignored and untreated perinatal mental illness, undiagnosed and thus invisible young children with developmental difficulties, and tolerance of harsh discipline even for young children . exacerbate inequities in child outcomes within and across countries. Specifically, the following obstacles to equitable opportunities for ECD have been found in the CEE/CIS region:

    • Child mortality: With improvements in perinatal care, more high-risk newborns (such as children with extremely low birth weight) are surviving, but systems are not in place to provide them with sustained follow-up.
    • Child poverty: Significant numbers of children in CEE/CIS survive below minimum living standards, experience stunting (a sign of inadequate nutrition), are not immunized, and do not have access to quality education and health care services. Fiscal constraints related to the global financial crisis have made it more difficult for countries to meet their obligations to promote children’s rights.9
    • Violence against children: According to UNICEF’s Multiple Indicator Cluster Surveys (MICS), between 38% and 84% of children aged 2 to 4 in 11 CEE/CIS countries experience psychological aggression or physical punishment.10 Younger children are also experiencing more physical punishment than older children. In some countries children aged 2 to 4 are almost twice as likely to experience ‘minor to moderate’ physical punishment than are children aged 10 to 14.
    • Lack of parental support for learning: In the same 11 countries, the MICS found that between 26% and 61% of children under the age of 2 receive inadequate support for learning, as measured by the number of times an adult has engaged in early learning activities (such as reading, counting or singing) with the child in the last 3 days.11
    • Equity gaps in services and programmes: While services and programmes for children have expanded, equity gaps have stagnated and even increased in some countries.12
    • Low capacity for early identification and intervention: The region has limited skills and experience using standardized tools to monitor child development in both home and clinic settings. The region suffers from a widespread lack of specialists available to conduct child and parental assessments and provide intervention. Children identified as experiencing developmental difficulties are treated with a medical and ‘defectology’ approach rather than a family-centred psychosocial approach.
    • Children in residential care: In 2010, 42% of all children in institutional care globally lived in the CEE/CIS region.13 While this number has since decreased, in 2012 there were still over half a million children were living in residential institutions in the region.

Progress in addressing these issues may also be hindered by a lack of awareness. The critical importance of the early childhood years . including the damage caused by adverse childhood experiences and the impact of parenting and the home environment . is not well understood in the region by families or the professionals who support them.

Health Home Visiting as an Entry Point for ECD

In the CEE/CIS region, the health sector is in universal and regular contact with pregnant women and families of young children, as evidenced by high rates of participation in antenatal care, deliveries with trained providers, immunization coverage and utilization of child health services at the primary care level. Additionally, many countries have retained their maternal and child health (MCH) home visiting services established during the pre-transition period. Few changes have been made to this service, and its potential for providing families of young children with information, guidance and support, as well as its ability to reach vulnerable families who are not accessing facility-based services, has remained unrecognized and underutilized.

Within this context, from 2010 to 2013 UNICEF partnered with national governments to conduct a series of assessments aimed at gauging the feasibility of using health home visiting as an entry point for comprehensive ECD, and to identify existing gaps in support to families that might be addressed through home visits. Additionally, two regional surveys contributed to a better understanding of home visiting content and quality, as well as equity gaps in access.

It was found that 17 countries in the CEE/CIS region had retained some form of MCH home visiting services. Of those that had retained the service, some countries . notably Serbia and Croatia . had moved towards a more comprehensive role for the home visiting professional. For the most part, however, only incremental improvements had been made in home visiting services, such as providing training in infant and young child feeding (IYCF). Countries that had introduced family medicine often assumed that some form of home visiting would still take place, but at best visits occurred only sporadically.

With regard to the content of home visits, UNICEF’s regional surveys revealed that in most countries home visitors tend to provide traditional health services and do not routinely identify or give support to the most vulnerable women and children. For example, the majority of countries reported that home visitors provided IYCF counselling, breastfeeding support, child growth monitoring, parenting education and prenatal care (see Figure 1). A much small number of countries reported that home visitors screened for developmental milestones or provided early childhood intervention (ECI) services for developmental delays; provided counselling on substance abuse or maternal depression; identified child protection issues; or assessed speech and language development.

FIGURE 1: TOPICS COVERED BY HEALTH HOME VISITS IN CEE/CIS COUNTRIES

In large part, this was due to the fact that home visitors had not been trained in such skills as identification of risk, use of standardized measurement tools, or active case management and counselling (see Figure 2), and because this was not a part of their job requirements.

FIGURE 2: SELF-REPORTED SKILLS OF HEALTH HOME VISITORS IN CEE/CIS COUNTRIES

Notably, the findings also indicated that home visitors are trusted by families and that their services are valued. Unlike some other social services, the support of health care providers is not considered stigmatizing. Another positive feature of the service is that home visitors tend to continue to work in the same communities and thus provide a continuum of care to families in their charge. These results suggest that health home visitors have extensive reach, especially among marginalized populations, and, with appropriate training and support, are poised to make a significant impact on ECD in the CEE/CIS region.

Why Home Visiting? The Global Evidence

The home is the child’s first important environment. During the critical early years of life, the family is the primary mediator of child health and development outcomes. Home visitors meet the family in its own environment, which provides a unique insight into challenges and coping strategies. Because of this specialized access, home visiting has the potential to mitigate the many different issues that can derail young children’s development, and to enhance the conditions that will contribute to their long-term health and well-being.

IMPACT OF HOME VISITING

National and global reviews of home visiting programmes have shown that programmes vary widely in terms of staff qualifications and competencies, staffing levels and target populations, as well as delivery methodology, content, intensity, frequency and duration. Despite these differences, overall evidence suggests that home visiting programmes most likely have a positive impact on:14

      • Parental well-being, including fewer and better-spaced pregnancies, reduced maternal depression and increased maternal employability;
      • Parenting skills and behaviours, such as improved breastfeeding and responsive feeding, greater positive responsiveness to the infant, reduced use of harsh discipline, and more stimulating and safer home environments; and
      • Child outcomes, including improved health and nutrition, and greater infant sociability, exploration and cognitive growth.

There also is strong evidence that home visiting can reduce the risk factors for child maltreatment, and some programmes have shown effectiveness in preventing maltreatment.15

Positive outcomes tend to be stronger when home visiting is provided by well-trained professionals, is sustained over time, and ‘when home visitation services are co-joined with additional support programmes’.16

Because home visiting for pregnant women, parents and young children is provided during the period of greatest vulnerability, it can achieve significant financial returns. For example, in 2012 the State of Washington in the USA conducted a cost.benefit analysis of an intensive home visiting programme that sends nurses to the homes of low-income families during a woman’s pregnancy and the first two years of a child’s life. In monetary terms, the total benefits of the programme – to participants (mother and child), tax-payers and society as a whole – were estimated at almost $23,000 per family, versus a cost of less than $10,000 per family for the 2-year programme.17

Home visiting has the potential to address equity issues, as home visitors can reach pregnant mothers, parents and children who are most in need and most likely to fall through the cracks because they are not accessing other services. Unfortunately, however, home visiting programmes often do not reach the most marginalized and vulnerable families. While these families have been labelled as ‘hard-to-reach’, it has been argued that it is the health system and providers that find it hard to engage and retain these families.18 Approaches such as using trained individuals from the same cultural group (e.g. Roma mediators in several countries of south-eastern Europe) or sensitizing providers to social determinants (i.e. gender, income, education) have been developed to remove such barriers and build a much-needed bridge between clinical health services and families previously referred to as hard-to-reach. Once in contact with the health system, these families can also be referred to other services as needed.

APPROACHES TO HOME VISITING

Countries around the world have chosen different approaches to utilize home visiting services for strengthening parenting capacity and supporting families experiencing challenges.

The targeted approach (used notably in the USA) prioritizes high-risk or vulnerable families and children, based on such indicators as poverty, teenage parenthood and risk of child maltreatment or domestic violence. This approach has been popular in countries that are looking at home visiting as a way of reducing equity gaps and increasing school readiness in children from ‘sub-optimal homes’.

The universal approach, which provides services to the entire population, rests on the premise that a large population exposed to low or moderate levels of risk may actually contribute more cases (i.e. people in need of individualized services) than a small, high-risk population.19 In addition, it is argued that universal programmes provide a more acceptable and less stigmatizing platform for delivering needs-based enhanced services. This argument has been supported by research on child abuse which indicates that a significant number of families would be missed if a targeted approach were used.20

The universal progressive approach, also known as ‘proportionate universalism’, is a blended universal and targeted approach which proposes to shift the whole population gradient towards greater equity. In this model, all families receive health home visiting services, which are used in part to identify families in need of more enhanced or intensive services. Services become more complex and targeted in proportion to a family’s needs.

Because of its potential to reduce inequities, the universal progressive approach is the model chosen for the CEE/CIS effort to support ECD through home visiting services.

FIGURE 3: A MODEL FOR PROPORTIONATE UNIVERSALISM IN HOME VISITING

Universal Progressive Home Visiting in CEE/CIS

Based on the findings of qualitative and quantitative assessments in the CEE/CIS region, in 2012 a consensus-building process was initiated around home visiting for ECD. The process first identified existing assets . the still prevalent and mostly universal MCH home visiting services in the region . as well as the constraints, namely a lack of awareness of the potential of home visiting to support overall child well-being and development.

UNICEF is not an implementing agency in this process but rather a facilitator. The organization works with diverse stakeholders with differing priorities, political will and budgets for home visiting, and differing levels of human resources capacities. Its efforts focus on advocacy, technical assistance to system reforms, human resources capacity-building and modelling of good practices. UNICEF’s main activities in this process are providing technical support to governments to reform existing systems, setting up and testing demonstration models, and helping governments utilize the available workforce and resources with greater efficiency and effectiveness.

A reform that is perceived as being imposed from the outside will not be sustainable; therefore at all times it remains vital for UNICEF to ensure full stakeholder ownership. With this in mind, the option of importing proven, ready-made models from other countries was deliberately eschewed. As a result, start-up was slow, but progress has been substantial over the past three years. With the assistance of a Technical Advisory Group of international experts, a number of countries have started to introduce new and improved universal progressive home visiting services.

UNICEF and its partners have used four main approaches to help countries build home visiting capacities: 1) bringing the best evidence into the region, 2) contributing to home visitation system development and standards, 3) preparing training modules to build home visitor knowledge and skills to support ECD and child protection, and 4) promoting inter-country exchanges.

BEST EVIDENCE

Reforming home visiting services requires the input of different disciplines and specialties, including child development, health policy, health systems, public health, finance, communication, monitoring and evaluation (M&E), child protection and early childhood intervention. To facilitate this input, a Technical Advisory Group was established in 2012 with over 30 international experts. The TAG has made and continues to make significant contributions at all levels.

Over the past three years, the TAG has acted as a think tank and source of expertise, as well as motivational force helping to propel the reform processes forward. The international experts have gained an excellent understanding of the specific challenges of the CEE/CIS region; provided technical support for country-level advocacy, evaluations, costing studies and capacity building; and become a sounding board and source of advice. Annual TAG meetings have served to infuse new knowledge, exchange ideas, develop action plans and review regional and country products and progress.

SYSTEM DEVELOPMENT AND STANDARDS

Regional guidance documents were drafted to support an organized road map for home visiting reforms. These include general recommendations for the role of home visitors; a step-wise approach to the assessment, development and/or reform of home visiting within the context of the primary health care system; recommendations for professional practice; home visiting content; and an M&E framework. The recommendations promote a significant shift in the role of the home visitor from expert who monitors family health status and competencies to a partner who recognizes family strengths and supports the building of confidence, competence and resilience in child-rearing. This living and evolving set of documents is in active use in the region and is being integrated into new policies and implementation approaches.

TRAINING MODULES

In partnership with the International Step by Step Association (ISSA) and international and regional experts, UNICEF drafted 14 resource modules to complement the current medical focus of pre-service and in-service training of home visitors. The topics cover:

      • The science of early child development
      • The changed role of home visitors
      • Attachment
      • Interacting with young children: love, play, talk, read
      • Common parenting issues
      • Engaging fathers
      • Parental well-being
      • Home environment and safety
      • Children who develop differently
      • Developmental monitoring and screening
      • Preventing child abuse, neglect and abandonment
      • Communication
      • Working against stigma and discrimination
      • Working with other sectors

In 2014 some modules were piloted in an online and in-person training format at a consultative meeting in Belgrade for national experts, trainers and experienced home visitors from Belarus, Bosnia and Herzegovina, Croatia, Georgia, Serbia, the former Yugoslav Republic of Macedonia, Turkmenistan and the UK. The modules were subsequently refined to address the work situation of home visitors more directly and strengthen their motivation to improve professional knowledge, attitudes and practices and engage families more actively in partnership. A training for experienced national trainers from 13 countries was completed in late 2015. The participants in this training have started to adapt and contextualize the materials for national use in pre-service and in-service training.

INTER-COUNTRY EXCHANGE

National capacities are also being built through ongoing inter-country exchanges. Study tours within and outside the region, site visits and collaboration in the dissemination and capacity-building of new screening, planning, costing and M&E tools have become routine. In some cases it has been found that the actual experience of participating in a home visit is more powerful than a conference with expert presentations. Observing an experienced home visitor interact with a family . her respect shown in interactions with caregivers from the moment she rings the doorbell and asks to be allowed into the family’s home; her encouragement of family strengths and gentle coaching; her questions to check for understanding and concerns; and her appreciation for the family’s time . can become a strong motivational force to improve the service in one’s own country or context. Similarly, hearing first-hand about challenges encountered in setting up a new service and engaging in joint problem-solving for persistent bottlenecks can help neighbouring countries learn from each other and adapt shared innovations and changes.

EMERGING RESULTS

While the process of transforming the home visiting system in the CEE/CIS region is still underway, early achievements are promising. Two countries that had discontinued home visiting are in the process of reintroducing the service. Of these, Bulgaria is already in the process of replicating a demonstration project, with the government interested in a national scale-up. Kosovo21 utilized the regional roadmap to conduct a systematic system assessment, worked on consensus-building and adaptation of the home visiting standards with a national working group, and is piloting in several municipalities.

Several countries (Serbia, Croatia, the former Yugoslav Republic of Macedonia, Kazakhstan and Turkmenistan) are focusing on strengthening the enhanced components of their existing home visiting systems. Some countries (Serbia, Bosnia and Herzegovina, Croatia and the former Yugoslav Republic of Macedonia) are also strengthening provider knowledge on developmental difficulties.

Bosnia and Herzegovina also conducted the very first quasi-experimental impact assessment of its pilot, providing the first evidence of results for children.

LOOKING AHEAD

There are indications (e.g. from evaluations and assessments in Bosnia and Herzegovina and the former Yugoslav Republic of Macedonia) that retooling health home visiting systems and personnel increases provider and family satisfaction. These results, as well outcomes for children and families, need to be tracked over time, and variables that contribute to greater child well-being, particularly for vulnerable children, need to be identified. National programmes must move from coding activities, such as measuring the number of families visited, to assessing successful referrals and outcomes for children. Similarly, rigorously designed, local cost-effectiveness and cost.benefit analyses are essential.

This will be a challenge moving forward. The process of building capacity for universal progressive home visiting is country-led and thus moves in line with national priorities, available resources and the vagaries of the socio-political context. Interest in establishing strong monitoring, evaluation and research frameworks remains low, and the complexity of arriving at agreed-upon indicators for measurement, particularly ECD outcome measures, continues to be a concern. While proxy measures such as parental well-being, the home environment, nutritional status and the use of disciplinary methods are established predictors of child development and well-being, very few of these measures are standardized, translated or validated for the region.

Support for international research partnerships and exchange with other regions . such as Latin America and the Caribbean . that are promoting home visiting services is likely to be beneficial in advancing this agenda in CEE/CIS. There are many shared challenges and questions that are globally applicable, such as:

        • How to finance home visiting services;
        • How to scale up pilot projects while retaining quality and fidelity to the original model;
        • How to track progress and measure outcomes for children and families; and
        • How to measure costs and benefits for society.

Learning from each other and benefitting from new tools and innovations could serve to enrich both regions and contribute to further investments in young children for lifelong health, well-being and productivity.

        1. According to UNICEF’s parameters, the CEE/CIS region includes Albania, Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, Croatia, Georgia, Kazakhstan, Kosovo (under UN Security Council Resolution 1244), Kyrgyzstan, Moldova, Montenegro, Romania, Serbia, Tajikistan, the former Yugoslav Republic of Macedonia, Turkey, Turkmenistan, Ukraine and Uzbekistan.
        2. See the The Lancet’s Maternal and Child Undernutrition Series (Lancet, 2008).
        3. Fisher et al., 2012; Howard et al., 2014; Jones et al., 2014; Stein et al., 2014.
        4. Shonkoff et al., 2009.
        5. Felitti et al., 1998; Mair et al., 2012; Liu et al., 2012.
        6. Denboba et al., 2014.
        7. Walker et al., 2011.
        8. Shonkoff, 2010.
        9. UNICEF, 2013; UNICEF, n.d.
        10. UNICEF, 2008.
        11. Ibid.
        12. UNICEF, 2015.
        13. UNICEF, 2010.
        14. Cowley et al., 2013; Gomby, 2005; Moore et al., 2012; Paulsell, Avellar et al., 2010; Paulsell, Boller et al., 2010.
        15. WHO, 2013.
        16. Astuto and Allen, 2009, p. 14; Browne et al., 2006.
        17. Karoly et al, 2005; Washington State Institute for Public Policy, 2012.
        18. Slee, 2006.
        19. Khaw and Marmot, 2008.
        20. Browne et al, 2006.
        21. Under UNSC Resolution 1244.

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