Revisiting Home Visitation: The Promise and Limitations of Home-Visiting Programs
The following article was featured as the Special Report in the March 2010 issue of OCD's newsletter Developments. To download a PDF of the issue, click here.

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 service delivery.

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 cognitive development.

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
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.

Variations Among Programs
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 self-sufficiency.

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 services.

Effectiveness Of Home-Visiting Programs
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 Neglect
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.

The Nurse-Family 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.

Harsh Parenting Behaviors
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.

The Nurse-Family 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 nurturing behaviors.

Parent 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 Environment
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 Safety
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.

The Nurse-Family 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.

Cognitive Development
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
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.

Policy And Practice
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.

Key Program Features
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.

Integrated 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.


References

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.

This Special Report is based on the above-referenced publications. It is not intended to be an original work but a summary for the convenience of our readers. References noted in the text follow:

1 National Center for Children in Poverty. (2007). Basic Facts About Low-Income Children: Birth to Age 6. New York, NY: Columbia University, Mailman School of Public Health.

2 Olds, D.L., Eckenrode, J., Henderson, C.R. Jr., Kitzman, H., Powers, J., Cole, R., Sidora, K., Morris, P., Pettitt, L.M., & Luckey, D. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect. Fifteen-year follow-up of a randomized trial. Journal of the American Medical Association, 278, 637-643.

3 DuMont, K., Mitchell-Herzfeld, S., Greene, R., Lee, E., Lowenfels, A., Rodriguez, M., & Dorabawila, V. (2008). Healthy Families New York (HFNY) randomized trial: Effects on early child abuse and neglect. Child Abuse and Neglect, 32, 295-315.

4 Fergusson, D.M., Grant, H., Horwood, L.J., & Ridder, E.M. (2005). Randomized trial of the Early Head Start Program of Home Visitation. Pediatrics, 116(6), 803-809.

5 Brooks-Gunn, J., Berlin, L.J., Fuligni, A.S., & Leventhal, T. (2000). Depending on the kindness of strangers: Current national data initiatives and developmental research. Child Development, 71, 257-268.

6 Fergusson, Grant, Horwood, & Ridder, op. cit.

7 van Doesum, K.T.M., Riksen-Walraven, J.M., Hosman, C.M.H., & Hoefnagels, C. (2008). A randomized controlled trial of home-visiting intervention aimed at preventing relationship problems in depressed mothers and their infants. Child Development, 79(3), 547-561.

8 St. Pierre, R.G., & Layzer, J.I. (1999). Using home visits for multiple purposes: The Comprehensive Child Development Program. The Future of Children 9, 134-150.

9 Olds, D.L., Robinson, J., O’Brien, R., Luckey, D. W., Pettitt, L. M., Henderson Jr., C. R., Ng, R. K., Sheff, K. L., Korfmacher, J., Hiatt, S., & Talmi, A. (2002). Home visiting by paraprofessionals and by nurses: A randomized, controlled study. Pediatrics 110(3), 486-496.

10 Olds, D. L., Kitzman. H., Hanks, C., Cole, R., Anson, E., Sidora-Arcoleo, K., Luckey, D.W., Henderson, C.R. Jr., Holmberg, J., Tutt, R.A., Stevenson, A.J., & Bondy, J. (2007). Effects of nurse home visiting on maternal and child functioning: Age 9 follow-up of a randomized trial. Pediatrics, 120(4), 832-835.

11 Duggan, A., Rodriguez, K., Burell, L., Shea, S., & Rohde, C. (2005). Evaluation of Healthy Families Alaska program: Final report: January 21, 2005. Anchorage: Alaska Department of Health and Social Services.

12 Infant Health and Development Program (1990). Enhancing the outcomes of low-birth-weight, premature infants: A multisite, randomized trial. Journal of the American Medical Association, 263(22), 3035-3042.

13 Karoly, L. A., Greenwood, P., Everingham, S., Hoube, J., Kilburn, M.R., Rydell, C., Sanders, M., & Chiesa, J. (1998). Investing in Our Children: What We know and Don’t Know about the Costs and Benefits of Early Childhood Interventions. Santa Monica, CA: RAND Corporation.

14 Aos, S., Lieb, R., Mayfield, J., Miller, M., & Pennucci, A. (2004). Benefits and Costs of Prevention and Early Intervention Programs for Youth. Olympia, WA.: Washington State Institute for Public Policy.

15 Duggan, A., McFarlane E., Fuddy, L., Burrell L., Higmana, S. M., Windham, A., & Sia C. (2004). Randomized trial of a statewide home visiting program: Impact in preventing child abuse and neglect. Child Abuse and Neglect, 28(6), 597-622.

16 Brooks-Gunn, Berlin, Fuligni, & Leventhal, op. cit.

17 Brookes, S. Summers, J.A., Thornburg, K. R., Ispa, J. M., & Lane, V.J. (2006). Building successful home visitor-mother relation- ships and reaching program goals in two Early Head Start Programs: A qualitative look at contributing factors. Early Childhood Research Quarterly, 21, 25-45.

18 Administration for Children and Families (2001). Building Their Futures: How Early Head Start Programs Are Enhancing the Lives of Infant and Toddlers in Low-Income Families. Washington, DC: U.S. Department of Health and Human Services.

19 Tandon, S. D., Parillo, K. M., Jenkins, C. & Duggan, A. K. (2005). Formative evaluation of home visitors’ role in addressing poor mental health, domestic violence, and substance abuse among low-income pregnant and parenting women. Maternal & Child Health Journal, 9(3), 273-283.