Employment, Social Affairs & Inclusion

VoorZorg

Evidence level:
 
Evidence of effectiveness:
? - 0 + ++
Transferability:
? - 0 + ++
Enduring impact:
? - 0 +

Project overview

VoorZorg is a home visitation programme in the Netherlands which has been adapted for the Dutch health context from the Nurse Family Partnership (NFP) programme in the United States (Olds et al. 1986). It is designed to assist young pregnant women of low socio-economic status in reducing risk factors for foetal and child development as well as reduce risk of child abuse. The programme consists of approximately 10 home visits of 60-90 minutes delivered to the young mothers during pregnancy, 20 visits during the child’s first year of life and 20 visits during the child’s second year of life. Home visits are delivered by a specially trained and certified VoorZorg nurse.

Practice category

  • Supporting Parenting and Assisting with Childcare
  • Helping Vulnerable Children

Recommendation pillars

  • Enhance family support and the quality of alternative care settings
  • Improve the responsiveness of health systems to address the needs of disadvantaged children
  • Provide children with a safe, adequate housing and living environment

Countries that have implemented practice

  • Netherlands

Age groups

  • Prenatal (before birth)
  • Young Children (age 0 to 5)

Target groups

  • Low-income Families
  • Mothers
  • Children

Years in operation

  • 2004  - still operating

Scope of practice

Not available

Type of organisation implementing practice

  • Private Health Care Organisation
  • Other Private Organisation

Rationale of the practice

During the home visits, the nurses discuss the following topics with the young mother: the health status of the mother; the child’s health and safety; housing assistance; financial independence; the personal development of the mother; the mother’s relationship with her partner, family, and friends; and utilization of health care organizations. The nurses also discuss exposure to passive (second-hand) cigarette smoking and deliver the Smoking Cessation Counseling by Midwives (V-MIS, also reviewed for the EPIC website, see link) smoking cessation counselling strategy (de Vries, et al., 2006) for reducing cigarette smoking during pregnancy and in the first six weeks after birth. VoorZorg nurses also encourage and help find solutions for breastfeeding. Finally, the nurses discussed the Power and Control Wheel (Domestic Abuse Intervention Project, 1984) which describes eight tactics commonly used by abusers strategies for emotional regulation and communication, and the consequences of intimate partner violence (IPV) for children.

The VoorZorg programme model was developed in Dutch in three manuals intended for implementation by trained VoorZorg nurses. Programme developers included representatives from the Netherlands Youth Institute, the Youth Health Care organization Evean, the Dutch Societies for Midwives, Obstetricians, and General Practitioners, as well as NFP managers trained in Denver, CO, USA by NFP. The portions of NFP that were culturally adapted or adjusted were reviewed by Dr. David Olds, the original developer of NFP. VoorZorg is in the process of being rolled out nationally in the Netherlands.

Mode of delivery

  • Face-to-face
  • Individual sessions

Delivery dosage

  • Frequency: 10 visits during pregnancy, 20 visits during the child’s first year of life and 20 visits during the child’s second year of life. 
  • Duration: More than 1 hour sessions

The programme consists of approximately 10 home visits of 60-90 minutes delivered to the young mothers during pregnancy, 20 visits during the child’s first year of life and 20 visits during the child’s second year of life. 

Location of practice

  • Home/ Family based

Evidence of effectiveness

A randomized controlled trial found that mothers participating in VoorZorg smoked less and more had quit smoking two months after the birth of their child than in the control group. More mothers in VoorZorg were breastfeeding six months after the birth of their child. The home environment of intervention group participants was rated better when the child was two years old and at three years old, and children whose mothers participated in VoorZorg had fewer Child Protection Services (CPS) reports on file by the time the child was three years old. Additionally, when their child was two years old, fewer women in the programme perpetrated intimate partner violence than in the control group.

Evaluation 1

Mejdoubi, J., van den Heijkant, S., van Leerdam, F., Heymans, M., Hirasing, R., & Crijnen, A. (2013). Effect of Nurse Home Visits vs. Usual Care on Reducing Intimate Partner Violence in Young High-Risk Pregnant Women: A Randomized Controlled Trial. PLoS ONE 8 (10).

This evaluation assessed intimate partner violence (IPV) and other outcomes (see Evaluation 2 and Evaluation 3), collecting various data from participants at intake, 32 weeks of pregnancy, 6 months after birth, 18 months, and 24 months. A random sample of 460 eligible disadvantaged women <26 years, with no previous live births, was randomized. Women in the control group (n=223) received usual care; women in the intervention group (n=237) received usual care plus nurse home visits. IPV reports were assessed using the Conflicts Tactics Scale (CTS2). The programme was undertaken over a 2.5 year period from 2007 to 2009 in 20 Dutch municipalities.

At 32 weeks of pregnancy, women in the intervention group self-reported significantly less IPV victimization and perpetration than women in the control group. At 24 months after birth, IPV victimization was significantly lower in the intervention group for level 1 physical assault (C: 44% vs. I: 26%), and IPV perpetration was significantly lower for level 1 sexual assault (C: 18% vs. I: 3%). The table below summarises improvement within groups across time; we can see that while physical assault by mother was significantly less frequent in the intervention group at the study end, it actually decreased at the same rate over time in both groups. On the contrary, psychological aggression by mother was reduced more in the treatment than in the control group over time, although the resulting rates were not significantly different due to the intervention group having slightly higher prevalence of psychological aggression.

 Summary of Results for Evaluation 1

Outcome: Change in share of mothers reporting event from 32 weeks of pregnancy to 24 months after birth (in percentage points)

 

Treatment Group

Control Group

 

32 weeks of pregnancy

24 months after birth

32 weeks of pregnancy

24 months after birth

Outcomes improved (statistically significant)

Psychological aggression by mother (level )

89%

76%

87%

80%

Sexual coercion by mother (level 1)

7%

3%

6%

18%

Outcomes with no effect

Psychological aggression toward mother (level 1)

100%

74

100%

73%

Physical assault of mother (level 2)

28%

14%

33%

25%

Sexual coercion of mother (level 1)

8%

8%

16%

15%

Injury to mother (level 1)

16%

16%

26%

23%

Physical assault by mother (level 1)

52%

33%

65%

48%

Injury caused by mother (level 1)

17%

17%

27%

24%

Evaluation 2

Mejdoubi, J., van den Heijkant, S., van Leerdam, F., Heymans, M., Crijnen, A., & Hirasing, R. (2015). The Effect of VoorZorg, the Dutch Nurse-Family Partnership, on Child Maltreatment and Development: A Randomized Controlled Trial. PLoS ONE 10(4).

This study used the same treatment and control group participants, the same intervention, as well as methodology as Evaluation 1, but focused on outcomes related to home atmosphere and child development. The questionnaires used were the Home Observation Measurement of the Environment (IT-HOME) and the Child Behaviour Checklist 1.5–5 years (CBCL/1.5–5). This evaluation also collected CPS reports of suspected child abuse from Dutch Child Protection Services in most of the regions where participants lived.

Three years after birth, 19% and 11% of the children in the control and treatment groups, respectively, had a CPS report, showing significantly better results for the treatment group. At 24 months after birth, the intervention group scored significantly better on the IT-HOME score. No statistically significant improvement was shown at 6 and 18 months after birth.

Summary of Results for Evaluation 2

Outcome: mean test score

Treatment Group

Control Group

Outcomes improved (statistically significant)

IT-HOME (24 months)

38.3

36.4

CBCL-Internalizing behaviour* (24 months)

40

69

Number of CPS reports of suspected
child abuse*(36 months)

18

31

Outcomes with no effect

IT-HOME (6 months)

33.4

33.0

IT-HOME (18 months)

36.0

36.8

CBCL-Externalizing behaviour* (24 months)

59

78

*Lower is better

Evaluation 3

Mejdoubi, J., ven den Heijkant, S., van Leerdam, F., Crone, M., Crijnen, A., & Hirasing, R. (2014). Effects of a nurse home visitation on cigarette smoking, pregnancy outcomes and breastfeeding: A randomized controlled trial. Midwifery 30 pp. 688-695.

This study used the same treatment and control group participants, the same intervention, as well as methodology as Evaluations 1 and 2, but focused on outcomes related to smoking (prevalence and frequency), breastfeeding, and pregnancy outcomes (birth weight, weeks of gestation, prematurity).

The percentage of smokers was significantly lower in the intervention group compared to the control group at two months post birth. Mothers in the intervention group also smoked 50% fewer cigarettes compared to the control group after birth and did not smoke near the baby. Birth weight and gestational age were similar in both groups. Significantly more women in the intervention group were still breast feeding their baby at six months post-birth.

Summary of Results for Evaluation 3

Outcome: number of cigarettes or share of mothers

Treatment Group

Control Group

Outcomes improved (statistically significant)

Current smoker (2 months)

48%

65%

Average number of cigarettes per day (2 months)

4

8

Average number of cigarettes per day near baby (2 months)

0

2

Breastfeeding (6 months)

13%

6%

Outcomes with no effect

Current smoker (32 weeks of pregnancy)

33%

35%

Average number of cigarettes per day (32 weeks of pregnancy)

2

5

Low birth weight (<2500g)

12.3%

11.3%

Preterm gestation (<37 weeks)

8.6%

7.0%

Initiated breastfeeding

82%

78%

Transferability

The VoorZorg programme is a Dutch-language programme based on the Nurse-Family Partnership programme from the United States. VoorZorg integrates with an anti-smoking programme developed for the Netherlands and the Dutch midwife system. These adaptations of the programme make it unclear whether VoorZorg would be as effective in other national or cultural contexts.

Practice Materials

  • Practice materials are not available 

Cost information

Over the course of the RCT evaluation, researcher and project manager Klaas Kooijman estimated the cost to be 13,000 euros per expectant mother enrolled in VoorZorg over the two and a half year participation period.

Enduring impact

There was no follow-up study at least 2 years after the programme end so enduring impact cannot be assessed. Notwithstanding that, the intervention was conducted over the span of several years and, as described below, showed positive results mainly in the long term. Specifically, by the time the children were two years old, the study found that there were significantly fewer reports of child abuse in the intervention group and fewer incidences of domestic violence.

Evaluation details

Evaluation 1

From 2007 to 2009, 460 pregnant Dutch women across 20 municipalities were recruited for the RCT based on a sample size calculation. The women were 25 or younger, with no advanced education, were no more than 28 weeks of gestational age, had no previous live birth, and who spoke Dutch. Participants were also required to have one of the following risk factors: single mother, history or current exposure to domestic violence, psychosocial symptoms, unwanted pregnancy, financial problems, housing difficulties, no employment, no education, alcohol or drug use. All eligible women were randomized into the control or intervention group after stratification by region and ethnicity (Dutch, Surinamese/Antillean, Turkish, Moroccan, Cape Verdean or other).
Trained VoorZorg midwives carried out the home visitations with the 237 women who had been assigned to the intervention group, while the control group received usual midwife or other care. Trained female interviewers conducted interviews with the participating mothers in their homes, in private, at 16-28 weeks of pregnancy, 32 weeks of pregnancy, 2 months after birth, 6 months after birth, 18 months after birth, and 24 months after birth. Interviewers assessed the Conflicts Tactics Scale (CTS2; Straus, et al., 1996) to the women to record their self-reports of intimate partner violence.

The RCT measured the following outcomes:

•    Maternal cigarette smoking at 16-28 weeks and 32 weeks of pregnancy and two months after birth as well as maternal smoking near the child;
•    Adverse pregnancy outcomes, birth weight and gestational age;
•    Child development at six months, 18 months and 24 months of age, measured with, among others, the Home Observation for Measurement of the Environment, and the Child Behavior Checklist;
•    Child abuse reports;
•    Intimate Partner Violence.

The authors worked with 223/237 women at the study start. Throughout the study, 54/30 (control group/intervention group) were lost to follow-up, 25/20 women declined the assessment, 21/34 were inaccessible due to design constraints, and 3/7 moved outside of the region.

Evaluation 2

This evaluation used the same sample as Evaluation 1, but assessed additional questionnaires. Interviewers assessed the Home Observation Measurement of the Environment (IT-HOME) at the last three observation dates and asked the Child Behaviour Checklist 1.5-5 years (CBCL/1.5-5) at 24 months after birth. In some regions, the Dutch Child Protection Services agency provided a list of reports of suspected child abuse at 36 months after birth.

Evaluation 3

This evaluation used the same sample as Evaluation 1, but assessed additional questionnaires and medical outcomes. Interviewers asked about women’s smoking habits at baseline, 32 weeks gestational age, and two months after birth. Interviewers asked about breastfeeding at six months after birth. Pregnancy and new-born health outcomes were collected from the databases of the Dutch Youth Health Care Organization.

Issues to consider

David Olds, the programme developer of Nurse-Family Partnership (NFP), a programme in the United States, stipulated that VoorZorg be evaluated using an RCT trial as part of his role in assisting the development of the Dutch version of the NFP programme. NFP was also adapted for the United Kingdom, however an RCT evaluation of the Nurse-Family Partnership UK found no significant outcomes from their programme aimed at teenage mothers (Robling, et al., 2016). VoorZorg is different from the other two programmes because of its emphasis on recognizing and addressing domestic abuse and the integration of a Dutch anti-smoking programme, Smoking Cessation Counselling by Midwives. Another difference is that the Netherlands has a midwife system as part of the national health care model and VoorZorg complements the usual midwife care routine. The evaluation by Mejdoubi, et al., was funded by the Netherlands Organization for Health Research and Development (ZonMw) and run by the VU University Medical Center. A smaller master’s thesis evaluation of VoorZorg was carried out previously (Woolthuis, 2008) which suffered from small sample size and low response rate.

Available resources

https://www.ncj.nl/programma-s-producten/voorzorg

Training for VoorZorg nurses and accompanying materials are available from the Dutch NCJ, in Dutch.

Bibliography

  • Mejdoubi, J., van den Heijkant, S., van Leerdam, F., Heymans, M., Hirasing, R., & Crijnen, A. (2013). Effect of Nurse Home Visits vs. Usual Care on Reducing Intimate Partner Violence in Young High-Risk Pregnant Women: A Randomized Controlled Trial. PLoS ONE 8(10).
  • Mejdoubi, J., van den Heijkant, S., van Leerdam, F., Heymans, M., Crijnen, A., & Hirasing, R. (2015). The Effect of VoorZorg, the Dutch Nurse-Family Partnership, on Child Maltreatment and Development: A Randomized Controlled Trial. PLoS ONE 10(4).
  • Mejdoubi, J., ven den Heijkant, S., van Leerdam, F., Crone, M., Crijnen, A., & Hirasing, R. (2014). Effects of a nurse home visitation on cigarette smoking, pregnancy outcomes and breastfeeding: A randomized controlled trial. Midwifery 30 pp. 688-695.
  • Woolthuis, A. (2008). Postnatale Depressie en Angst; Het effect van VoorZorg op jonge zwangere vrouwen [Translated: Postnatal depression and anxiety; The effect of VoorZorg on young pregnant women]. Master’s thesis, Universiteit Utrecht. [In Dutch]
  • Olds, D. L., et al. (1986). Preventing child abuse and neglect: a randomized trial of nurse home visitation. Pediatrics 78(1): 65-78.
  • Robling, M., et al. (2016). Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomized controlled trial. Lancet 2016, 387: 146-155.

Last updated

June 2019

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