The use of home visitors to
deliver services designed to improve the well-being of children and their
families has drawn the increasing interest of policymakers, including President
Barack Obama, who last year proposed a federal investment of more than $8 billion
over the next 10 years in programs that use home visitation as a method of
Meanwhile, debate continues
over the effects that home-visiting programs have on parenting behaviors,
parent-child relationships, child health, cognitive development, child abuse
and neglect, and other important domains. In almost every domain, studies
document positive outcomes in some programs but not in others. In many cases,
reported effects are restricted to certain subgroups of families, meaning that those
do not occur for the entire population of families who were served.
While the reported results
are clearly mixed, the picture is not that simple. Comparing the results of
home-visiting programs is complicated by differences in program goals, populations
served, models used, the skill and training of staff, the degree to which
individual programs adhere to the theoretical model on which they are based,
and other factors.
Researchers have made
considerable progress in under- standing home-visiting programs in the past two
decades. Although questions remain, the body of evidence suggests home-visiting
programs can provide parents and children with important benefits, such as
improvements in parenting practices, home environment, and, to some extent, children’s
Whether they actually do
produce these benefits depends on several characteristics, including whether
home visitation is more effective when joined with additional support programs
as part of an integrated, system-level approach toward improving the well-being
of at-risk children and families.
Home visitation is a method
of service delivery used to reach at-risk children and families with a wide
range of supports. In the United States, it is estimated that home-visiting
programs serve between 400,000 and 500,000 children, about 5 percent of the
estimated 10.2 million American children under the age of 6 years who are
living in low-income families.
Several programs, national
in scope, that use home visitation as a means of delivering services have been
developed over the past three decades, including the Nurse-Family Partnership,
Healthy Start, Healthy Families America, the Comprehensive Child Development
Program, Early Head Start, and the Infant Health and Development Program.
The general goals of
programs that use home visitation include providing parents with information,
emotional support, access to other services, and direct instruction on parenting
practices. Although many programs share these goals and the same general method
of service delivery, there are many variations among them.
Home-visiting programs come
in many shapes and s. They vary in their program models, the age of the
children they serve, the risk status of families, the range of services
offered, the content of curriculum used, and the intensity of the intervention
as measured by how often and how long home-visiting services are provided to a
family. Programs also vary in terms of how effectively the program is implemented
and the range of outcomes they achieve.
Another area of variation
is found in who provides the home-visiting services. Typically, programs employ
paraprofessionals or nurses to deliver services. Their specific roles, however,
may vary. In some cases, the home visitor may be primarily used as a source of
social support, while in other programs their role may be that of a liaison to
provide families with referrals to mental health, domestic violence, and other community resources. They often serve as in-home
literary teachers, parenting coaches, role models, and experts on topics
related to parent and child health and well-being. Nurses, in particular,
provide information and services designed to encourage healthy pregnancy,
infant care, and family planning.
More specifically, the
Nurse-Family Partnership, for example, employs registered nurses who are
specially trained to provide home visits to low-income, first-time mothers
beginning during pregnancy and continuing through the child’s second birthday.
The program, which operates in Pennsylvania and 25 other states, uses a
curriculum that includes among its goals encouraging healthful behaviors during
pregnancy and teaching developmentally appropriate parenting skills.
Healthy Families America,
another large and well- established program, employs trained paraprofessionals
who provide in-home services to disadvantaged mothers that are designed to
promote parenting skills and optimal child development and improve a mother’s
Home visiting is a major
component of Early Head Start, a federally funded program that includes parent
education and quality early care and education. However, Early Head Start sites
may also use center-based childcare or a mix of home-based and center-based
Given the substantial
variation in program goals and procedures, it is not surprising that the
benefits of such programs are similarly mixed. However, certain
well-established home-visiting programs in the United States have been widely
studied to determine their effectiveness, and many of the programs developed
over the past three decades use sophisticated evaluation methods.
Most of the programs with
the strongest reputations have been evaluated using randomized clinical trials,
which are widely viewed as offering the highest level of confidence in
measuring program outcomes. However, results from even the most carefully
executed evaluations can hinge on program design and implementation.
Differences in how programs are implemented, in particular, can result in
conflicting findings, even among sites using the same model.
Mixed outcomes have
produced lingering questions about the program’s short- and long-term benefits.
But many theorists and policymakers believe home visitation can be both a
beneficial and cost-effective strategy for providing services to at-risk
children and families. The research offers evidence of benefits across several
domains while also exposing the limitations of home visitation.
Child Abuse And
Few home-visiting programs
measure child abuse and neglect as outcomes and even fewer have been able to
document that home visitation has a significant impact on child maltreatment.
Researchers suggest such shortcomings are largely due to several issues that
make measuring effects on child abuse and neglect problematic, including low
reporting rates, the difficulty of identifying substantiating cases, and the
fact that the definition of abuse and neglect may vary from state to state.
Partnership was found to reduce child maltreatment based on an evaluation of an
Elmira, N.Y., site. That study reported a 48 percent decline in rates of child
abuse and neglect at the time of the 15-year follow up among low-income
families who had participated in the program.
Conversely, studies that
examined reports of abuse and neglect gathered by child protective services
agencies have found low prevalence rates among families in home-visiting
programs. However, little difference in abuse and neglect rates was reported
between families in the programs and those in the control groups who did not
receive the intervention. For example, Healthy Families America in New York
found that 6 percent of control families and 8 percent of those in the program
had substantiated reports of abuse or neglect at one year. At two years, the
rates were around 5 percent for both groups.
No meaningful differences
child abuse and neglect rates were reported between families in Early Head
Start and families in a control group. In a study that examined both child
protection services reports and substantiated cases of abuse and neglect, 21
percent of control families had contact with child protection agencies compared
to 20 percent of program families.
Another outcome examined in
some studies is harsh parenting behavior, a less-severe form of abusive
behavior that includes spanking, slapping, or pinching a child. The impacts
home-visiting programs have on such behaviors tend to be more encouraging than those
related to child abuse.
An evaluation of Healthy
Families of New York, for example, found evidence that families in the program
showed fewer harsh parenting behaviors than families in the control group.
First-time mothers in the program and mothers who joined the program during
their pregnancies were much less likely to report harsh behaviors than mothers
who were not enrolled in the program.
Partnership documented reducing harsh parenting behaviors among adolescent
mothers. Early Head Start and the Infant Health and Development Program are
among programs that report results that include mothers spanking their children
less often. And among 13 home-visiting program evaluations that examined
mother-child interactions, 11 reported having positive effects on encouraging
Responsibility And Sensitivity
Home-visiting programs have
been found in several studies to improve the responsiveness and sensitivity
parents show their children. One Early Head Start study, for example, found
that families in the program developed higher positive parenting attitudes,
were more likely to adopt non-punitive attitudes, and had more favorable
overall parenting scores than families who were not involved in the program.
Another example is reported
in an evaluation of a program in the Netherlands, whose primary goal was to
improve maternal sensitivity. The study found that mothers who received home
visits were more sensitive in their interactions with their infants and were
more skilled in structuring activities for the child than mothers who had not
participated in the intervention.
Quality Of Home
Several, but not all, of the
home-visiting programs studied have been found to improve the quality of
children’s home environment, which is measured by factors ranging from how
responsive and involved parents are with their children to learning materials
and stimulation found in home. The quality of a child’s home environment has
been widely used as an outcome in evaluations of home-visiting programs.
Programs with home-visiting
components that improved the quality of the child’s home environment include
Healthy Families America and Early Head Start. However, the national
Comprehensive Child Development Program did not have a significant impact on
the home environment or any measured aspects of parenting.
Studies of three
Nurse-Family Partnership sites also report contradictory evidence of the impact
of home visitation on the home environment. At a site in Denver, mothers who
received home visits had more sensitive interactions with their infants and
higher Home Observation for Measurement of the Environment (HOME) Inventory
scores than mothers who did not receive home visits. At sites in New York and
Tennessee, however, home visits had no significant impact on home environment.
Researchers suggest the ages of the mothers may have contributed to the
differences. Most of the New York and Tennessee mothers were adolescents, while
the Denver mothers were more diverse in age.
Child Health And
Several evaluations of
home-visiting programs have examined factors that provide insight into
children’s health and safety, including the number of injuries and hospital
admissions, immunizations, and doctor and dental visits.
Partnership, for example, looked at injuries and hospital admissions as part of
the evaluations of two sites. In one, children of low-income, unmarried mothers
in the program had fewer emergency room visits than children of mothers who did
not participate in the program. In the other site, children of mothers in the
program had fewer emergency room visits. Program families also had a lower
child mortality rate: one child in the program families died compared to 10 in
the control group.
Several studies have looked
at the impact home-visiting programs have on children’s immunizations. Only
Early Head Start was found to improve the immunization of children, but because
center-based services were also offered, the impact was not exclusive to
families who received home visits.
Mixed findings have also
been reported in evaluations that examined the cognitive development of
children in programs that provide home visits.
One study, for example,
reported children in a Healthy Families America program in Alaska had higher
scores at age 2 than children in the control group on the Bayley Scales of
Infant and Toddler Development, which measures motor, language, and cognitive
development in young children. According to the study, 58 percent of program
children scored in the normal range compared to 48 percent of children who were
not in the program.
However, some home-visiting
programs, including the Comprehensive Child Development Program, reported no
cognitive benefits for children and others were found to have limited impact on
cognitive development. For example, studies of Nurse-Family Partnership
programs reported some cognitive gains among children, but most were concentrated
within specific subgroups, such as children of mothers with low psychological
resources. The Infant Health and Development Program identified significant
gains in cognitive development among children at 24 and 36 months, but not at
12 months, leading researchers to conclude the effects could not be attributed
solely to services delivered by home visitors.
Cost-benefit analysis is
another measure of effectiveness; unfortunately, few have been applied to
home-visiting programs. However, studies that examined economic benefits have
reported the programs resulted in a positive return on investment.
Two studies of the Elmira,
N.Y., Nurse-Family Partnership program, for example, reported that each dollar
invested in higher-risk families returned $5.70, and each dollar invested in
services to lower-risk families returned $1.26. The savings were largely the
result of higher tax revenues from more mothers gaining employment, lower use
of welfare assistance, reduced spending for health and other services, and
decreased involvement in the criminal justice system.
In 1993, the Future of Children
published a comprehensive review of home-visiting programs for young children
that reported the mixed findings among the major programs operating in the
United States, many of which were relatively new at the time. In addition,
recommendations were offered, including the need for stakeholders to recognize
the limitations of the programs and for the programs themselves to focus on
improving implementation and service quality.
Much has been learned from
the research undertaken since that report was published. More recently, the
focus on evaluation and quality assurance, cross-collaborations, and
dissemination has signaled a new era of home visitation, particularly as a
service that appears to be most effective as part of a systematic approach to
early childhood intervention.
Studies of effective prevention
programs have identified several features apparently critical to their success:
1) a theoretical basis, 2) comprehensive programming, 3) a variety of teaching
methods, 4) fostering of positive relationships, 5) treatment timed for
prevention, 6) dosage of treatment tailored to the nature of the problem, 7)
staff who are well trained and culturally sensitive, and 8) rigorous methods of
evaluation are used and meaningful outcomes are examined.
Research suggests that many
home-visiting programs lack at least one of those features.
Specifically, among home-visiting
programs, the credentials of home visitors have been found to influence their
effectiveness. The expertise of nurses is seen as critical to the success of
some programs. One goal of the Nurse-Family Partnership is to improve pregnancy
outcomes and promote child health, which public health nurses are particularly
well suited to help bring about.
Programs that use social
workers and trained paraprofessionals as home visitors have also experienced
successful outcomes. Only about one-third of the paraprofessionals used as home
visitors in the Healthy Families America program in New York had college
degrees, and the program reduced child abuse and neglect and harsh parenting
behaviors among the families it served.
Staff training and whether
home visitors are familiar with the goals of a program also influence outcomes.
The Healthy Start program in Hawaii had little impact on child abuse and
neglect, which it was designed to prevent. But home visitors rarely referred
families to additional community services, even for suspected child abuse and
domestic violence, and they neglected to do so despite the fact that linking
families to such services was a key program goal.
Studies also suggest the
targets of intervention may account for some of the differences in outcomes.
For example, the Nurse-Family Partnership was more effective in preventing child
abuse and neglect at two sites where most of the women in the program were
first-time adolescent mothers than at a third site where the age-range of the
mothers was more diverse.
Service delivery factors
also play an important role in program outcomes. Families who receive the
highest dosage of an intervention tend to benefit the most. Researchers suggest
one of the reasons some home-visiting programs have limited impact is that a
fairly high percentage of their families receive little treatment.
The quality of the
relationship between home visitors and participants is a strong predictor of
parent involvement in home visitation services and the benefits they realized
from the services. Several factors play a role in shaping that relationship,
including family stress factors, available social supports, and a parent’s
personality, health, and other characteristics. Program characteristics, such
as the conscientiousness of home visitors, efforts to build program loyalty,
and how well home visitors and parents match up in terms of personality and
personal history also influence the quality of relationships.
Studies also suggest that using
a theoretically based curriculum is critical to optimal results. Several
home-visiting programs focus on addressing the needs of individual families
and, as a result, the content of home visits may vary from family to family.
Such variation likely contributes to the inconsistent findings of evaluations
of these programs. Initially, the Nurse-Family Partnership used a curriculum
with less formal structure. More recently, program content has become more
specific and replicable, likely contributing to its success.
System Of Care
Research suggests that the
potential of home-visiting programs may best be exploited as part of an
integrated system that coordinates early childhood interventions across programs
and agencies to provide seamless access to a variety of necessary services.
Developing a comprehensive,
integrated system of care for families will have to overcome the barriers
imposed by the categorical funding of home-visiting programs. Defining eligible
target populations, requirements for staffing and program design and other criteria
require home-visiting programs to seek funds from a range of sources. The most
common federal sources include Medicaid, the State Children’s Health Insurance
Program, Temporary Assistance for Needy Families, and the Maternal and Child
Health Block Grant.
Evidence of the success of
embedding home-visiting programs
in an integrated system of care appears promising. For example, Early Head
Start recipients enrolled in programs with a combination of home visitation and
center-based services show the greatest positive gains in parenting behavior.
Studies also suggest home-visiting programs should consider including community
coalitions as part of their program goals as a way of streamlining the services
and supports available in communities.
For several decades,
researchers have examined the effectiveness of home visitation. Overall, the
results have been mixed. However, several well-established programs have
demonstrated important benefits for children and families, both in human and
economic terms. Perhaps more importantly, studies identify characteristics that
improve the chances of home-visiting programs realizing their full potential,
including the use of well-trained professional staff whose credentials are
consistent with program goals, intervening prenatally with at-risk families,
and implementing programs in a manner that is true to their theoretical models.
Howard, K., &
Brooks-Gunn, J. (2009). The role of home-visiting programs in preventing child
abuse and neglect. The Future of Children, 19(2), 119-146.
Astuto, J., & Allen, L.
(2009). Home visitation and young children: An approach worth investing in? Social
Policy Report, 23(4), 3-23.
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