Early Childhood Home Visiting
Abstract and Keywords
This chapter provides an overview of early-childhood home-visiting programs and offers a brief summary of the research, policy, and practice issues. The first section defines home visiting and the funding available to support it. The next section summarizes common characteristics of home-visiting programs and describes the features of several evidence-based home-visiting programs. The outcomes from home visiting for parents and children, including relevant cost-benefit studies, are briefly reviewed. The chapter concludes with implementation issues and future directions for home visiting.
Defining Home Visiting
Home visiting as a strategy for delivering services has a long history, dating back to the 1850s, when home health services were focused on hygiene and sanitation in Great Britain. Home visiting is now more commonly viewed as a method of service delivery for families. The concept of home visitors expanded to include child-abuse prevention in the early 1900s (Guterman, 2001), however, the services provided by the home visitors varied greatly. Home visiting has been identified as a promising approach for preventing child maltreatment (National Research Council, 1993; U.S. Advisory Board on Child Abuse and Neglect, 1991). In the mid-1970s, the Child Abuse Prevention and Treatment Act (CAPTA) was passed, and home-visiting programs that were specifically focused on child-maltreatment prevention began to emerge. These home-visiting programs differ from previous services delivered in the home in that they are guided by specific goals, in the frequency and duration of home visits, in the population served, and in the training of home visitors. Typically a home visitor, who may be a nurse, social worker, other professional, or paraprofessional visits the home to provide direct services, which usually includes parenting and child-development services for new and expectant parents, as well as for other caregivers with children. Many programs also offer counseling, support, and linkages or referrals to other health, mental health, and social services that may be needed by the family. Often the home-visiting programs target pregnant women or new parents to reach families during the critical period around the birth of a child in order to provide the supportive services needed to promote positive outcomes (Johnson, 2009; Stoltzfus & Lynch, 2009).
Although there is considerable overlap of the core elements of early-childhood home-visiting programs, there are unique attributes that distinguish the models from one another. The common thread among all models is the belief that the early years are critical and that providing services to caregivers in a home setting can have a positive impact on the trajectory of children and families. The short-term and intermediate outcomes for programs include facilitating changes in parent knowledge and behavior, decreasing stress, increasing social support, improving family functioning, and providing access and referral to needed services, including mental health assessment and treatment services. Long-term outcomes generally include improved maternal and child health and developmental outcomes, social and emotional support for the families, increased parenting capacity, and decreased injuries and maltreatment (Gomby, 2005; Howard & Brooks-Gunn, 2009). Models vary with respect to the age of the child served, family risk factors, range of services offered, intensity and frequency, curriculum used, and home-visitor characteristics (Howard and Brooks-Gunn, 2009).
Federal Funding Sources for Home Visiting
Until recently, federal funding authorized home visiting as an allowable activity but did not specify dosage, type of program, or other criteria for the use of grant funds. Home visiting was funded as a venue for service delivery rather than as a focused strategy of evidence-based programs with a proven track record to promote positive outcomes for children and families. Title II of CAPTA (P.L. 111-320), for example, provides Community-Based Grants for the Prevention of Child Abuse and Neglect (CBCAP) to states. This legislation emphasizes community-based efforts to strengthen families and prevent abuse. Activities authorized under CBCAP include comprehensive supports for parents, parenting-skills training, improved access to formal and informal resources, support services for parents with disabilities (for example, respite care), referrals for early health and development services, and meaningful parent leadership. Home visiting is one of the core CBCAP-funded services (Children’s Bureau, 2012).
In 2008, the Children’s Bureau (CB) within the Administration for Children and Families (ACF) at the U.S. Department of Health and Human Services (HHS) funded the Supporting Evidence-Based Home Visiting (EBHV) Program to support the infrastructure needed for the scale-up of evidence-based home-visiting programs that prevent child maltreatment (Children’s Bureau, 2008). Seventeen grantees were funded to design home-visiting systems to implement and sustain home-visiting models with fidelity. A national cross-site evaluation was funded to generate knowledge about the use of evidence-based home-visiting programs to prevent child maltreatment, including obstacles and opportunities for their wider implementation. In 2011, the EBHV grant program was formally incorporated into the Maternal, Infant, and Early Childhood Home Visiting program, described below.
The first designated source of funding for evidence-based home-visiting programs was signed into legislation on March 23, 2010, by President Barack Obama as part of the Patient Protection and Affordable Care Act (ACA) (P.L. 11-148). The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program, within ACA, provides more than $1.5 billion over five years to states, territories, and tribes to implement evidence-based programs within a high-quality, early-childhood comprehensive system. MIECHV is administered by the Administration in partnership with the Administration for Children and Families (ACF).
Three goals comprise MIECHV: (a) strengthen and improve programs and activities carried out under Title V of the Social Security Act, (b) improve coordination of services for at-risk communities, and (c) identify and provide comprehensive services to improve outcomes for families who reside in at-risk communities. Distinguishing features of this legislation are that 75% of the funding must be directed to programs with evidence on effectiveness according to rigorous research standards (U.S. Department of Health and Human Services [HHS], 2013). The home-visiting programs that meet the rigorous research standards and are considered evidence-based are described later in this entry.
In addition to selecting evidence-based models, grantees must conduct continuous quality improvement, incorporate home visiting into a larger early-childhood system, and design a data-collection system to report on six benchmarks. The benchmarks include improved maternal and newborn health, prevention of child injuries and maltreatment, improvement in school readiness and achievement, reduction in crime or domestic violence, improvements in family economic self-sufficiency, and improvement in coordination and referrals (Health Resources and Services Administration, 2010).
Characteristics of Home-Visiting Programs
Although the program goals of home-visiting models differ somewhat, most programs seek to prevent child maltreatment; improve parents’ knowledge, beliefs, and actions regarding raising children; promote children’s health and development; and enrich mothers’ lives through social support and reducing stress, among others (Gomby, 2005). Other similarities of home-visiting programs relate to the service-delivery strategy and resources provided. Overall, a majority of programs focus on offering social support, education on parenting practices and child development, and providing concrete assistance ranging from case management to community referrals.
Even though there are numerous home-visiting models available, not all of these programs are effective or high quality. Given the wide array of home-visiting programs, service providers, funders, and families need access to effective models. In the early twenty-first century, research on existing home-visiting programs proliferated and raised the standards for a program to be considered evidence-based. This section explains the standards for determining high-quality home-visiting programs and explores the commonalities and differences between evidence-based home-visiting programs.
Since the 1970s, various studies have been conducted to examine the quality and effectiveness of home-visiting programs. Meta-analyses and systematic reviews offer invaluable research syntheses regarding the large volume of evidence on home-visiting programs. Child Trends and Home Visiting Evidence of Effectiveness (HomVEE) provide primary sources of information for this review on effective home-visiting programs (HHS, 2013; Kahn & Moore, 2010). In the Child Trends’ literature synthesis, Kahn and Moore (2010) included home-visiting programs in their review if the research implemented random assignment and used home visiting as a program component. Kahn and Moore’s review separates the findings into the categories: “Not proven to work,” “Mixed findings,” and “Found to work” (2010, p. 2). Only “Found to work” home-visiting models are considered in this review (see Table 1). Within this context, programs that are found to “work” are programs that have demonstrated positive outcomes for the participants in the program.
Table 1 Descriptions of Evidence-based Home Visiting Program Models
Intensity of Services
Population: Pregnant women & families of children 0–6 coping with w/multiple risks
Lessen emotional and behavioral disturbance, learning problems, and child maltreatment
Home visits (HV) 1/wk for 14 weeks, including:
Team: Mental health clinician (Master’s), care coordinator (Associate’s), clinical supervisor (Master’s)
-parent-child mental health intervention
Caseload: 14–18 families
Population: First-time, low-income mothers of newborns
Increase mothers’ self-esteem and health outcomes for children
-HV 1/mo for 12 months
Team: Public health nurse, volunteer home visitor (mother)
-Nurse visits at birth & 6 wks
Caseload: 5–15 families
Early Head Start (home-based)*
Population: low-income pregnant women & families of children 0–3
Enhance child development and strengthen families
-HV 1/wk for >48 weeks (90 min)
Team: Home visitor, director, early childhood consultants
-22 group activities 2/mo
Caseload: 10–12 families
Early Intervention Program for Adolescent Mothers*
Population: Underserved, first-time pregnant women, age 14–19 w/in 26 weeks gestation
Help mothers gain internal and external social competence
-HV (90 min)
Team: Health department nurse (Bachelor’s)
2 prenatal HV
Until 6 wks: 3 HV
Until 12 mo: 10 HV
-4 motherhood classes
Early Start (New Zealand)*
Population: At-risk families of children 0–5
Improve child health, parenting skills, parents’ health and social support, families’ economic well-being; and reduce child abuse
Team: Home visitors, general manager, clinical manager, clinical supervisors
High need: HV (3 hrs/wk)
Mod need: HV (3 hrs/2 wks)
Caseload: Based on service level
Low need: HV (1 hr/mo)
Graduate: Contact (1 hr/3 mos)
*All levels continue until child’s 5th birthday
Population: Families of children 2–17
Prevent and address the challenges associated with young children
3 initial and feedback sessions
Team: Parent consultant (Master’s or Doctorate recommended)
Population: Families of children 0–17 w/serious behavioral problems
Decrease children’s behavioral problems
HV 15hr/wk for 6 wks
Team: Family specialist (Associate’s), supervisor
Caseload: 10–12 families
Healthy Families America*
Population: At risk pregnant mothers or families of children 0–5
Help families deal with daily challenges by building strengths
Team: Family support worker, family assessment worker, supervisor (Bachelor’s)
-HV 1/wk for 6 mos and then less frequently as needed (1 hr)
Caseload: 15–25 families
Population: Families of children 0–3 served by a medical practice
Support child development by improving the relationship b/w healthcare providers & parents
Team: Specialist (Bachelor’s), physician or pediatric nurse practitioner
-Family health checkups
Caseload: 150–300 families
High need: 5+ HV
Mod need: 3+ HV
Low need: 1+ HV
*All levels continue until child’s 3rd birthday
High/Scope Perry Preschool + (Schweinhart et al., 1993)
Population: 3– 4-year-old African American children living in poverty
Support cognitive and social development
-Preschool 2.5 hrs/weekday
-HV 2/wk (90 min)
Caseload: 5.7 students
Home Instruction for Parents of Preschool Youngsters*
Population: Families of children 3–5 who want help preparing children for school
Promote school readiness
-HV 1/wk (1 hr)
Team: Coordinator (Bachelor’s), peer home visitor
-Group mtgs 6/yr (2 hrs)
*Services for 2–3 years
Caseload: 10–25 families
Population: Mothers w/anxious attachment to child of 12 months
Promote secure attachment
-HV 1/wk (90 min)
Team: Intervener (Master’s), supervising faculty
-Phone call 1/mo
*Ends after child reaches 24 months
Caseload: 25 families
In-home Cognitive Behavioral Therapy (Ammerman et al., 2005)
Population: High-risk, first-time, depressed pregnant mothers before 28 weeks gestation
-Decrease maternal depression, stress
-HV 1/wk for 15 weeks (60 min)
Team: Home visitor, therapist, supervising clinician (PhD)
-Increase coping, social support, and views of motherhood
Nurse Family Partnership*
Population: First-time, low-income mothers w/in 28 weeks of gestation to age 2
Promote health during pregnancy, personal growth, and care of child.
HV (1 hr):
Team: Nurse home visitor (Bachelor’s), nurse supervisor (Master’s), administrative assistant, other staff
1st month: 1/wk
Until birth: 2/mo
Until 6th week: 1/wk
Until 20th month: 2/mo
Caseload: <25 families
Oklahoma’s Community-Based Family Resource & Support Program*
Population: First-time mothers from rural areas w/in 28 wks of gestation to age 1
Increase mothers’ and children’s health and development
HV (1 hr):
Team: Child development specialist (Bachelor’s), administrator (Master’s)
1st month: 1/wk
Until birth: 2/mo
Until 3rd month: 1/wk
Until 12th month: 2/mo
Caseload: No information
Parents as Teachers*
Population: At-risk pregnant mothers and families 0–5
Increase parent’s knowledge of child development and offer parenting support
Team: Parent educator (GED); Supervisors
-10–24 HV a year based on need (1hr)
Caseload: <48–60 visits/month
Play and Learning Strategies (Infant)*
Population: Children 5 months to 12 months
Promote parent-child attachment, parenting skills, and child development
HV 1/wk for 10 weeks (90 min)
Team: Parent educator (Associate’s), Supervisor (Bachelor’s)
Project 12-Ways/SafeCare Augmented*
Population: At-risk, rural families of children 0–5
Prevent child maltreatment
-HV 1/wk or 2/mo for 18–22 weeks (90 min)
Team: Home visitor, coach
Caseload: 10–12 families
Population: Low-birth weight infants w/in 37 weeks gestation
Improve relationship b/w mother and child
4 months: HV 1/wk (90 min)
5 months: HV 2/mo
3 months: HV 1/mo
Population: Pregnant mothers in 3rd trimester and newborns living in poverty w/o social support receiving prenatal care
Promote parent-child attachment, child development; address mothers’ depression and anxiety
-Parent-child group 1/wk
Team: Mental health professional
Until 12 months: 1/wk
Until 24 months: 2/mo
*Ends after child reaches 24 months
Population: Dutch families of children 1–3 w/externalizing behaviors
Encourage maternal parenting techniques associated with favorable development
4 HV 1/mo (90 min)
Team: Intervener (Bachelor’s)
2 HV 1/bimonthly
Caseload: 15–25 families
(*) U.S. Department of Health and Human Services. (2013). Program model reports. Home Visiting Evidence of Effectiveness. http://homvee.acf.hhs.gov/programs.aspx. Only programs that meet HHS’s standards are included. Models must have one or more moderate-quality impact study with two or more positive, statistically significant outcomes from the eight target outcomes. One or more impact must come from a RCT published in a peer-reviewed journal.
(+) Kahn, J., & Moore, K. A. (2010). What works for home visiting programs: Lessons from experimental evaluations of programs and interventions. Child Trends Fact Sheet, Publication #2010 20008. Washington, DC: Child Trends. This article reviews studies that use random assignment to evaluate programs for 0–17 year olds. The table reports on home-visiting models with positive and statistically significant (p < .05) impacts on at least one child outcome, for example, health, development, parent-child attachment, or child maltreatment. To qualify as a “found to work” model, programs had 3+ measures of a construct or assessed one outcome 3+ times.
To qualify as an “evidenced-based early childhood home visiting program,” research on the program must possess at least one high- or moderate-quality study with positive, statistically significant findings in at least two of eight outcome areas, or at least two high- or moderate-quality studies with positive, statistically significant findings in the same outcome area. Here, “high quality” refers to studies with random assignment, low attrition, no sample reassignment, and analyses that meet What Works Clearinghouse (WWC) design standards. Moderate-quality studies also employ random assignment, but they may have higher attrition or contain other concerns regarding design or analysis (HHS, 2013). Research reviewed for this article adopts most of HHS’s standards and addresses the target population of pregnant mothers and families of children ages infant to five to children ages infant to 17. Although home-visiting programs share commonalities, these programs also exhibit differences regarding goals, service intensity, staffing, and target populations (see Table 1). While some programs seek to improve parenting practices or prevent child maltreatment in general, others target specific outcomes, such as addressing maternal depression. Home-visiting programs also differ by service type, duration, and intensity. Several programs begin during pregnancy and continue for two to four years, while others begin at birth and last only one year. Home-visiting programs also vary by the number of home visits, ranging from once a month to once a week for 60 to 90 minutes. Some programs require home visitors to possess certain educational backgrounds (for example, nursing), or to have more education (for example, a master’s degree), while others rely on paraprofessionals without any educational requirements. Other programs prefer workers to represent the participants they serve and to speak the native language of families served. Finally, the remaining difference in home-visiting programs relates to the target populations. A few programs offer universal services, while the majority are more specific and target at-risk families, pregnant mothers, or mothers who may have mental health problems.
Outcomes are as varied as the component parts of home-visiting program. The next section summarizes key outcomes from meta-analyses, as well as outcomes that are specific to certain evidence-based models. The outcomes for parents and caregivers are reviewed first, followed by outcomes for children. For each section, a general description of the outcome domain is provided, followed by highlights from the research studies.
Outcomes for Parents and Caregivers
Parenting Knowledge, Attitudes, and Behavior
Most home-visiting programs seek to strengthen parents’ skills and attitudes towards parenting, knowledge of child development, views of parenting, and the relationship between parent and child. Outcome measures used include observational measures of parent-child interactions or the home environment. For some measures, parent-child interactions are videotaped, and other studies also use outcome measures based on parent self-reports of parenting attitudes and practices (HHS, 2013).
Available meta-analyses, systematic reviews, and randomized-control trials suggest that home visiting improves parenting knowledge, attitudes, and behavior. Although most of these effects are small (ES = 0.14–0.25), gains in parenting knowledge relate to categories of developed norms and expectations, substance use, discipline, and responsiveness, sensitivity, and nurturing (Filene, Kaminski, Valle, & Cachat, 2013); mother-child interactions, emotional responsiveness, less punishment (Bull, McCormick, Swann, & Mulvill, 2004); and higher efficacy and scores on the Home Observation for Measurement of the Environment (HOME). The HOME measures emotional and verbal responsiveness, parental involvement with and acceptance of the child, and availability of toys and games (Caldera et al., 2007); and parenting knowledge and skills in general (Elkan et al., 2000; Layzer, Goodson, Bernstein, & Price, 2001; MacLeod & Nelson, 2000; Nievar, Van Egeren, & Pollard, 2010; Sweet & Appelbaum, 2004). Likewise, in a meta-analysis of 43 studies, Geeraert, Van den Noorgate, Grietens, and Onghena (2004) found that home visiting has a moderate, positive, and statistically significant effect on atmosphere (for example, attachment, warmth) (ES = 0.30), family functioning (ES = 0.33), and parental management (for example, reaction to child, use of play) (ES = 0.36).
Maternal Life Course
Maternal life course is a general term that refers to long-range outcomes such as socioeconomic status, education, employment, and the spacing of pregnancies throughout the mother’s lifespan (Bull et al., 2004). Measures for this domain include using administrative data, or parent or staff self-reports (HHS, 2013). In a recent meta-analysis of 52 studies, Filene and colleagues (2013) found that home visiting has a small, positive, and statistically significant effect on maternal life course overall, without significant effects on specific-life course domains, such as family planning (ES = 0.20). Although other studies indicate a positive effect of home visiting on maternal life course (see Ciliska et al., 1996; Olds et al., 1994, 1997; Kitzman et al., 1997), Elkan and colleagues (2000) did not find significant differences between the treatment and comparison groups in their meta-analysis. Likewise, another extensive literature review of home-visiting programs did not find significant impacts on maternal life course (Gomby, 2005). In addition, Bilukha and colleagues (2005) reported that results are inconclusive concerning the effect of home visiting on maternal arrest records and intimate-partner violence.
Primary Caregiver’s Self-Sufficiency
Throughout the literature, parental self-sufficiency often refers to employment, education, and reliance on public welfare programs such as food stamps. Outcomes are typically measured for public-assistance receipt based on government administrative data or parent self-reports of service receipt and economic outcomes (HHS, 2013). In a meta-analysis of 43 studies, Geeraert and colleagues (2004) found that home visiting has a moderate, positive, and statistically significant effect on a family’s socioeconomic context (ES = 0.38). The Nurse-Family Partnership (NFP) program also provides promising support for the impact of home visiting on economic self-sufficiency. During the NFP randomized control trial in Elmira, New York, poor single mothers who received home visits spent 60 months on welfare or food stamps as opposed to the control group’s 90 months (Olds et al., 1999). Another NFP trial, in Memphis, Tennessee, however, did not result in differences in employment or welfare (Olds et al., 1999).
Other meta-analyses and systematic reviews provide mixed support for the relationship between home visiting and economic self-sufficiency. In a systematic review of 34 studies, Elkan and colleagues (2000) found insufficient evidence for the relationship between home visiting and use of community resources, or participation with the workforce, education, or public assistance. Although Layzer and colleagues’ (2001) meta-analysis also found small gains in a family’s economic self-sufficiency (ES = 0.01–0.39), Sweet and Appelbaum’s (2004) meta-analysis did not. Sweet and Appelbaum (2004), however, found that home visiting has a positive effect on educational attainment (ES = 0.13). Another study, however, has not found benefits in maternal self-sufficiency. In Early Head Start, for example, teens who received home visiting were less likely to achieve educational gains, spend time in job training, and be employed. In fact, the participants were just as likely as the comparison group to use welfare, food stamps, and Medicaid (Love et al., 2001). Finally, an international meta-analysis by Layzer and colleagues (2001) concluded that home visiting has little effect on employment and welfare receipt, and found inconclusive evidence regarding education.
Primary Caregiver’s Stress and Social Support
Although several studies provide support for the role of home visiting in improving caregiver stress and social support overall, the results are mixed. Self-report measures are most commonly used for this domain (HHS, 2013). Several meta-analyses report that home visiting has small to moderate impacts on caregiver stress and social support (ES = 0.09–0.33) (Dagenais, Begin, Bouchard, & Fortin, 2004; Elkan et al., 2000; Geeraert and colleagues, 2004; Layzer et al., 2001). In particular, Elkan and colleagues’ (2000) study provided some support for an increase in mothers’ use of social support networks because of home visiting.
Home visiting also improves outcomes related to caregiver stress and social support. In a meta-analysis of 43 studies, Geeraert and colleagues (2004) found that home visiting moderately improves caregivers’ personal functioning (ES = 0.33). In a meta-analysis of 27 home-visiting programs for families at risk for child removal, Dagenais and colleagues (2004) found that 17 of the programs had a positive effect on the family’s functioning and overall environment. Other studies, however, did not find a relationship between home visiting and caregiver stress or social support outcomes (Daro & Harding, 1999; Elkan et al., 2000; Sweet & Applebaum, 2004). In particular, Bull and colleagues (2004) concluded that evidence is lacking concerning the relationship between home visiting and social support.
Parental Mental Health
Over the last few years, many home-visiting programs have examined the impact of providing support to caregivers and its impact on a range of parent outcomes, including parental depression (Ammerman et al., 2009; Chazan-Cohen, Ayoub, Pan, Roggman, Raikes, McKelvey, & Whiteside et al., 2007). Self-report measures are most commonly used for this domain (HHS, 2013). Ammerman et al. (2010) conducted a systematic review of the research on maternal depression in home-visiting programs. The review focused on previous studies that examined maternal depression and its impact on several nationally recognized home-visiting programs, such as the Nurse Family Partnership and Healthy Families America. Depression was common among parents receiving home visiting; from one quarter (28%) to almost two-thirds (61%) of participants had high levels of depressive symptoms at the start of the programs and one-quarter continued to exhibit high levels at later time points (Ammerman et al., 2010).
As of 2013, there were a number of efforts under way across the country to enhance the efforts of home visiting by addressing the mental health needs of the family (Ammerman et al., 2009; Ammerman et al., 2005). Ammerman and colleagues (2005) tested adding in-home cognitive behavior therapy to prevent mental health problems, and specifically, found that levels of depression symptoms were significantly decreased from baseline to the post-intervention. In 2013, this study was being replicated in other home-visiting programs in Connecticut (Connecticut Children’s Trust Fund, 2009). The Nurse Family Partnership program has started to test the impact of mental health consultation on their program. In this model, nurses have the opportunity to speak with a mental health consultant for clinical advice on working with parents with mental health programs. Several implementing agencies saw the added benefit of this approach and began rigorously testing the impact (Boris et al., 2006). Early Head Start programs are working on ways to address the high rates of parental depression in their program participants. Although the national evaluation did not find program impacts on depression, a later follow-up study found that there were program impacts on maternal depression two years later (Chazan-Cohen et al., 2007).
Finally, several studies found that the presence of caregiver problems associated with mental health, substance abuse, and domestic violence have moderated the impact of home-visiting programs and are critical issues that must be addressed by these programs (Chaffin, 2004; Howard & Brooks-Gunn, 2009). Several studies of home-visiting programs have found that the presence of domestic violence attenuates the impact of the program on parent and child outcomes (Chazan-Cohen et al, 2007; Eckenrode et al, 2000; Stevens, Ammerman, Putnam, & Van Ginkel, 2002).
Despite the promise of home visiting as an effective strategy for delivering services to new and expectant parents and their young children, the overall results from programs have been small to modest. There is modest evidence that home-visiting programs can produce positive impacts and promote improvements in parenting capacity. Home-visiting programs also have had small impacts on improving overall maternal health. Numerous studies point to mixed results in improving parenting stress, social support, and mental health. It is important to note that each home-visiting program may target different outcomes, and it is clear that no one program can address all the outcomes of interest. The next section highlights key outcomes for children served by various home-visiting programs.
Outcomes for Children
Birth and Child Health Outcomes
Child health and development are primary outcomes that most early childhood home-visiting programs strive to improve. Some home-visiting programs focus during the prenatal period and work with the mother during her pregnancy to ensure access to prenatal care and work toward a healthy delivery for newborns. These programs work to prevent an infant’s premature delivery and low birth weight by providing education and support to a mother during her pregnancy. Once the baby is born, home-visiting programs continue to work with caregivers to ensure they have access to all the recommended well-baby visits, pediatric care, timely immunizations, and other health care needed to promote optimal growth and development. Home-visiting programs also emphasize proper care and nutrition for young children. In general, the programs focus on helping caregivers increase their knowledge and access to services to ensure adequate care to raise healthy children.
The outcomes in this domain are assessed primarily through birth outcomes (including gestational age at delivery, birth weight, etc.), and also from medical records. It is important to note that some home-visiting programs only serve parents after birth, so it is unlikely for those programs to have an impact on birth outcomes. Parents’ self-reports about children’s health and use of health care services are also collected as additional outcome measures. Some of the outcomes measures also include the number of hospital days or other interactions with the health care system (HHS, 2013).
Available research indicates that home visiting offers many benefits for child health and development. In particular, the Nurse Family Partnership program found that participants in its programs gave birth to heavier babies than babies born to comparison group mothers (Stoltzfus & Lynch, 2009). Parents enrolled in the Healthy Families America program are more likely to have health insurance than caregivers in the comparison group (Stoltzfus & Lynch, 2009). The Early Intervention Program for Adolescent Mothers prevented additional days of re-hospitalization for infants within their first six weeks of life (HHS, 2013). Filene’s home-visiting meta-analysis (2012) found that the effect sizes for the child-birth and child-health outcomes were significantly larger for the treatment versus the control groups across all the studies that they reviewed.
Child Development and School Readiness
Promoting child development and school readiness is another primary outcome domain for early childhood home-visiting programs. Programs incorporate specific curricula or structured activities that are designed to support parents with fostering optimum child development and functioning across various areas. Home visitors often provide education to parents about the critical stages of child development and what to expect in terms of child behavior and activities at each stage. During the infancy stage, the focus is primarily on bonding and attachment, care, and soothing. As infants move into toddler and early-childhood stage, programs may focus on promoting positive parent-child interactions and positive discipline, and fostering early literacy skills. In some cases, programs may also facilitate linkages and connections to early-childhood education and preschool programs to promote school readiness.
Primary outcome measures in this domain include direct child assessments, reviews of school records, direct observations of children’s behavior, and parent and teacher self-reports of behavior on standardized measures. Other outcome measures include parent and teacher reports on measures that may not be standardized (HHS, 2013). For example, children who participated in the ChildFirst program had fewer language and behavior problems than children in the comparison groups (HHS, 2013). In addition, research on the Parents as Teachers program found that participants engage in more literacy promoting behaviors than comparison-group caregivers (HHS, 2013). Parents who received Healthy Families America home visiting reported fewer problem behaviors from their children and had more positive features in their home environment, which supports child development (Stoltzfus & Lynch, 2009). Likewise, the Nurse Family Partnership participants were found with more home environments that facilitated learning than the comparison group (Stoltzfus & Lynch, 2009). Studies on the Early Head Start program found stronger effects on school readiness for participants who received both the home-based and the center-based programs (HHS, 2013). Finally, Filene et al (2013) found larger effect sizes for home-visiting programs that emphasized children’s cognitive development and language skills.
Child Safety and Prevention of Injury and Maltreatment
Child safety and preventing injury or maltreatment are critical outcome areas that many home-visiting programs try to address. For example, home-visiting programs often provide education and support around appropriate supervision and discipline practices. For parents with infants, this may include strategies for soothing crying and helping parents ensure that the home is a safe environment for children. For parents with toddlers and older children, home visitors may work with parents to reduce stressors or other negative elements that may increase possibilities of child injury or maltreatment. In some situations, this may include efforts to address the negative impact of substance abuse, domestic violence, or other adverse environmental conditions that may increase the likelihood for negative outcomes for children.
The primary outcome measures used for these areas include substantiations of child maltreatment from CPS administrative records and counts taken from medical records of encounters with health care providers for injuries or ingestions. It is important to note that the child-maltreatment outcome domain may be susceptible to surveillance bias because the home visitor is in the home and may be more likely to see instances of suspected child abuse. In addition, parents in home-visiting programs may be encouraged to use health care services more often, such as for well-child-care visits. Information from medical records is considered a primary outcome measure, and parent reports of visits with the health care system are considered secondary outcome measures. Several studies of home-visiting-program models also use the Conflicts Tactics Scale-Parent Child (CTS-PC), a measure that assesses neglectful, psychologically aggressive, and abusive parenting behavior, as a measure of child maltreatment (HHS, 2013).
Participants in the Nurse Family Partnership program had fewer emergency room visits for their children than control-group parents. In the longitudinal study of Nurse Family Partnership, participants were found to have 80% fewer verified cases of child abuse and neglect versus their control group (Donelan-McCall, Eckenrode, & Olds, 2009). A study of Healthy Families New York found that first-time mothers who received the program were less likely to engage in harsh parenting or minor physical aggression than women in the control group (DuMont et al., 2008). A study of SafeCare with a rural population found no subsequent maltreatment reports, and also favorable outcomes related to positive disciplinary practices for parents who participated in the program (Silovsky et al., 2011). Other studies, however, found inconsistent results with respect to the impact of home visiting on child maltreatment and injury prevention (HHS, 2013; Filene et al, 2013).
The previous sections underscored the general finding that home-visiting programs can be an effective approach to addressing a variety of needs from the parent and child’s perspective. Home-visiting programs were able to impact child development and school readiness, and to facilitate improved health outcomes for children. Mixed results were still evident in efforts to prevent injuries or child maltreatment, however. Similar to outcomes for parents, some of the child outcomes varied depending on the specific home-visiting program and the core focus of the particular program.
Despite the small and moderate impacts, early-childhood programs, and specifically home visiting, have gained prominence as a cost-effective prevention strategy since the turn of the twenty-first century. Early childhood home-visiting programs have long-term benefits in outcomes related to academic achievement, behavior, educational attainment, crime and delinquency, and employment. Karoly, Killburn, and Cannon (2005) conducted a study that included home visiting and early care and education programs and found that well-designed and well-implemented programs can result in monetary benefits to society of anywhere from $1.80 to $17.07 for each dollar invested in these programs.
The Washington Institute for Public Policy has conducted cost-benefit studies of child and youth programs for a number of years. In a 2012 analysis, it reported that the Nurse Family Partnership Program for low-income families has a benefit cost ratio of $13,181, which means that the benefits for the program are much higher than the actual costs to society. Although Parents as Teachers demonstrates positive benefits, the benefit-cost ratio is much lower ($765). Conversely, this analysis found that Healthy Families America has a negative cost-benefit ratio of $2,011, meaning that the program costs more than the benefits received by the participants and society. In another cost-benefit study, benefits to society for the Nurse Family Partnership Program were determined to be $81,656 and the per case cost $8,580, which yields a benefit cost ratio of 9.5 to 1 (Miller, 2012). Other work is under way through the Supporting Evidence-Based Home Visiting cross-site evaluation, as well as the MIECHV Maternal and Infant Home Visiting Program Evaluation (MIHOPE), evaluation to better understand the actual costs of the program on a per-family basis and also to identify specific activities that are undertaken by home-visiting programs. Both evaluations include a detailed cost study of home-visiting services (Burwick et al., 2012; Knox et al., 2011).
An emerging body of research has found that implementation quality moderates the outcomes of programs (Durlak & DuPre, 2008; Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F., 2005). That is, the quality of the implementation matters for all programs and is a critical factor for ensuring the outcomes expected for evidence-based programs. Focusing on quality-assurance and quality-improvement efforts are important strategies used by many of the evidence-based home-visiting programs. The critical areas to address are discussed in the following sections.
A fundamental aspect of replication among evidence-based home-visiting programs is ensuring that replications are implemented as intended by the original program. Replicating with model fidelity is viewed as a necessary, if not sufficient, condition for ensuring that programs yield the range of outcomes observed in clinical trials of these efforts. Carroll and colleagues (2007) identified five elements of implementation fidelity: (a) adherence to the service model as specified by the developer, (b) service exposure or dosage, (c) the quality or manner in which services are delivered, (d) participants’ response or engagement, and (e) the understanding of essential program elements not subject to adaptation or variation. Most evidence-based programs strive to identify implementation agencies that have the skills and capacity to support the work and that direct service providers are well trained in the model and receive strong supervision. These programs take the time to develop detailed program manuals. Although funding agencies and local officials often document the number of families reached with a given strategy, program developers often assume primary responsibility for working with local implementing agencies (IAs) and providers to ensure ongoing quality and model fidelity. In the area of prenatal and early-childhood home visiting, several evidence-based home-visiting programs (including Nurse Family Partnership, Healthy Families America, and Parents as Teachers) have followed this pattern, establishing extensive training programs and, in the case of one model, a detailed management information system (Daro, Hart, Boller, & Bradley 2012).
The evaluation of MIECHV, in the planning stages as of 2013, will examine the capacity of the implementing organization to provide an array of additional supports for staff as well as participants (Duggan & Supplee, 2012; Knox et al., 2011). According to that evidence framework, the capacity of the organization delivering the service and the guidelines for the program provide a more comprehensive set of those factors that may determine the quality of the implementation.
Home-Visiting Workforce and Supervision
Assessing organizational readiness for an evidence-based program and developing a supportive environment for home visitors can be a decisive factor in successful program implementation and retention of home visitors. A fundamental aspect of this readiness involves ensuring that home visitors have the skills and resources they need in order to work with families. In addition, many implementing agencies have nutrition, mental health, or other specialists within their organization whom home visitors could consult when challenges arose with clients (Coffee-Borden & Paulsell, 2010).
Programs with well-trained home visitors and supervisors are more likely to experience more positive outcomes (Coffee-Borden & Paulsell, 2010). Agencies that were part of the ACF’s EBHV program were asked about the types of supports and unique workforce aspects of their program. The EBHV programs’ supervision requirements differed substantially from its agencies’ typical approach to supervision for other programs. For example, there were more hours dedicated to supervision, because supervision occurred more frequently, allowing more time for reflection and discussion. The managers of the programs described this process as helping to develop a more supportive agency culture. One benefit is that home visitors feel supported in their work with families, which may improve job satisfaction and promote retention of home visitors. Supervision also kept home visitors informed of families’ challenges, goals, and progress, meaning they could identify problems or needs more proactively and offer assistance to home visitors (Coffee-Borden & Paulsell, 2010).
Parent Engagement and Retention
For home-visiting programs to be effective, home visitors need to have the qualifications and competence to meet the needs of families, and families need to participate in the program long enough to realize some benefits (Gomby, 2005). Ammerman and colleagues (2006) conducted a longitudinal study of early engagement of first-time mothers in home visiting. The researchers considered the contribution of agency variability because the women received services from several different agencies. The dependent variables of engagement in the first year are defined as duration (number of days between first and most-recent visit), quantity (number of visits received), and consistency (number of days between visits). More than one third (34.6%) of the mothers remained in the program after the first visit, which reflects a universal challenge to retain parents in home-visiting programs over the long term. In addition, mothers who reported the presence of more risk factors at the initial family assessment are more likely to receive more home visits in the first year compared to mothers with more psychosocial resources. The strongest predictors for engagement are mental health, substance abuse, low levels of support, increased stress, and race (that is, being Caucasian) (Ammerman et al., 2006). Stevens and associates (2002) also confirmed that mental health and substance-abuse problems, as well as low levels of support and increased stress, are factors that predicted parent engagement in home-visiting programs.
Daro, McCurdy, Falconnier, and Stojanovic (2003) reviewed factors associated with retaining parents in home-visiting programs. Parent characteristics that predicted longer service duration are older, unemployed, and had earlier enrollment in the program. Hispanic and African American parents are more likely to stay in the program for longer periods and receive more home visits than white participants. At the program level, the home visitor’s age and average caseload were the only significant predictors. That is, younger home visitors and those with smaller caseloads were associated with higher levels of participation for parents.
Stevens, Ammerman, Putnam, Gannon, and Van Ginkel (2005) conducted a qualitative study to analyze factors that contribute to home-visiting engagement for mothers, home visitors, and supervisors. Home visitors and supervisors emphasized that the mental health problems of the mother often cause challenges in providing services, because mothers with these problems often do not want to engage in services. LeCroy and Whitaker (2005) conducted a similar study that focused specifically on assessing the most difficult situations that faced home visitors in their efforts to provide services to families. Home visitors identified the following situations as the most difficult: families with limited resources, substance use in the home, families who are unmotivated, and the presence of family mental illness.
Despite the broad support for home visiting, the body of evidence presents a more complex and nuanced picture regarding the types of families who may benefit the most from these services. Unfortunately, parents with more complex risk factors related to problems associated with mental health, substance abuse, domestic violence, and child maltreatment still do not universally benefit from home visiting. More work is needed to ensure that high-quality services are available for families that need this additional support. Additional research is also needed to provide more answers to questions around what programs work best and for whom, and given a particular agency’s organizational capacity. The focus on high-quality implementation and sustainability of these home-visiting programs will require that attention be paid to several key issues.
Prior to implementation of MIECHV, 46 states were implementing home-visiting programs (Johnson, 2009). These states were estimated to spend between $500 million and $750 million annually on home-visiting programs (Stoltzfus & Lynch, 2009), some of which were evidence-based and hybrid models, while most were home-grown programs developed to address locally identified needs (Wasserman, 2006). The infusion of federal dollars has led to the development of state home-visiting programs, comprising a continuum of evidence-based models to serve a range of needs. To build on and sustain federal investments, some states have been implementing state policies that direct funding to evidence-based or evidence-informed models. For example, Iowa passed legislation requiring that by 2016, 90% of state funding for family-support programs be directed to programs that meet the MIECHV definitions of evidence-based or promising-practice programs. Maryland and Michigan passed similar legislation and aligned state outcomes with federal outcomes (Strader, Counts, Filene, & Margie, 2013). More work is needed to assess the long-term and cumulative impact of these new policy mandates across the country that are increasing attention and funding toward evidence-based home visiting.
In addition to the expansion of home-visiting research being conducted by individual models, the MIECHV national evaluation (Mother and Infant Home Visiting Program Evaluation MIHOPE) will play a substantial role in contributing to the field. The evaluation will focus on four models: Early Head Start-Home Visiting, Health Families America, Nurse Family Partnership, and Parents as Teachers. The random-assignment design will include approximately 12 states, 85 local implementing agencies, and more than 5,000 pregnant women or families with infants less than six months old. The study design includes impact, implementation, and cost study (Supplee, Harwood, Margie, & Meyer, 2013). Additionally, the Centers for Medicare and Medicaid Services, Administration for Children and Families, and Health Resources and Services Administration were, in 2013, partnering on the MIHOPE-Strong Start evaluation to examine the effectiveness of home-visiting programs to improve maternal and child health outcomes. This study’s sample includes 20,000 pregnant women and also uses a random-assignment design (Supplee et al., 2013).
MIECHV legislation also includes funding to increase knowledge about what works in home visiting. The Home Visiting Research Network (HVRN) is tasked with support and infrastructure for collaborative efforts on home visiting, and three investigators initiated research to advance knowledge about home-visiting implementation and effectiveness (Health Resources and Services Administration, 2012). Finally, the final evaluation report from the Supporting Evidence-based Home-visiting programs to Prevent Child Maltreatment will provide additional detail regarding the factors that facilitated or hindered efforts in 17 projects that were trying to build the infrastructure to support high-quality implementation and sustainability of five different evidence-based home-visiting models (Paulsell, Hargreaves, Coffee-Borden, & Boller, 2012). The challenge for future researchers will be ensuring that findings from these new studies and initiatives will be translated in an accessible way that program planners and practitioners can use in direct practice.
Performance Monitoring and Continuous Quality Improvement
MIECHV includes a requirement for states to track and monitor key benchmarks that include maternal and infant health (including maternal depression), family self-sufficiency, the prevention of injuries and child maltreatment, school readiness, domestic violence or crime, and referrals and coordination. Legislation requires grantees to improve in four of the six benchmark domains (Health Resources and Services Administration, 2010. The legislative requirements have prompted states to select common measures across programs to enable progress monitoring. Many states did not have the capacity to collect and track data on such a large scale. Performance-management systems vary by state with some using centralized databases, others using platforms to link data sources, and still others using spreadsheets to collect on the program level and then aggregating (Strader et al., 2013).
MIECHV requires states to develop state home-visiting programs, which may be comprised of several models, each of which has varying fidelity and quality assurance measures. To facilitate improvement in the overall state program, grantees are required to develop a Continuous Quality Improvement (CQI) plan. Grantees are encouraged to identify a few improvement priorities, design a method to collect data on these priorities, and then develop a mechanism to tweak the program based on data (Health Resources and Services Administration, 2010). CQI is an iterative cycle that enables home-visiting programs to maximize optimize outcomes, implement targeted adaptions or enhancements while preserving core elements, and disseminate best practices (Ammerman & Knox, 2012). The promise of CQI is in the infancy stages as states grapple with how best to utilize the large volume of data they are collecting for the MIECHV benchmarks reporting for their own decision-making.
Building Early Childhood Systems
In the second decade of the twenty-first century, every state in the country is in the midst of wide-scale implementation of various evidence-based and promising home-visiting programs (Health Resources Services Administration, 2010. The guidance for this grant program indicates that “home visiting should be viewed as one of several service strategies embedded in a comprehensive, high-quality early childhood system that promotes maternal, infant, and early childhood health, safety, and development, as well as strong parent-child relationships” (Health Resources Services Administration, 2010, p. 2). Funds are provided to states to implement high-quality, evidence-based home-visiting programs that are integrated within an early-childhood system for promoting health and well-being for pregnant women, children through age eight, and their families. Some of the fundamental implementation issues that home-visiting programs must address are how to effectively identify, prevent, and respond to parent needs and promote children’s optimal health and development. State must also build and sustain the infrastructure needed to support high-quality implementation and to recruit and retain the workforce needed to deliver these services. There is now a tremendous opportunity to use the lessons learned from the prior research to build systems that will ensure that parents with young children at greatest risk for adverse childhood experiences are better served through a more targeted, effective, data-informed, and responsive service-delivery system.
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