Journal Issue: Home Visiting: Recent Program Evaluations Volume 9 Number 1 Spring/Summer 1999
The winter 1993 issue of The Future of Children examined the practice, policy, and research underlying home visiting programs for families with young children. At that time, we estimated that as many as 200,000 children and families were enrolled in home visiting programs whose primary goals were preventive in nature (for example, to prevent preterm or low birth weight births, to promote healthy child development or school readiness, or to prevent child abuse). We cautioned that the research on home visiting programs was limited in scope and findings were mixed, but concluded that results were promising enough to suggest that the expansion of home visiting was warranted.
Since 1993, home visiting programs have blossomed, watered by a flow of millions of public and private dollars from sources as varied as the federal Office of Juvenile Justice and Delinquency Prevention, Maternal and Child Health Bureau, Early Head Start, Title I, and Temporary Assistance to Needy Families; state Children's Trust Funds; and foundations. Buoyed by research about the importance of the earliest years of children's lives,2 by a recognition that home visiting can offer unique benefits as a service strategy,3 and by preliminary positive research findings for some home visiting program models,4 home visiting programs now number in the thousands. Counting only the six program models profiled in this journal issue, as many as 550,000 children may be enrolled in home visiting programs for pregnant women and families with young children.
The programs have diverse goals, but they share a focus on the importance of children's early years and on the pivotal role parents play in shaping children's lives, and by the sense that one of the best ways to reach families with young children is by bringing services to them, rather than expecting them to seek assistance in their communities. Home visitors can see the environments in which families live, gain a better understanding of the families' needs, and therefore tailor services to meet those needs. The relationships forged between home visitors and parents can break through loneliness and isolation and serve as the first step in linking families to their communities.
Since 1993, research regarding home visiting programs has blossomed as well. Several demonstration projects have been conducted during the past half-decade, which have shed increased light on the strengths and weaknesses of home visiting programs. This journal issue provides a summary of some of the key studies. Specifically, it summarizes the results of evaluations of six home visiting models that are being, or have been, implemented nationally:
- The Nurse Home Visitation Program (NHVP), developed as a university-based demonstration program in Elmira, New York, studied again in Memphis, Tennessee, and Denver, Colorado, and now being replicated nationally;
- Hawaii's Healthy Start, a home visiting program that serves families identified through screening at birth as highly stressed and/or at risk for child abuse;
- Parents as Teachers (PAT), a program that began in Missouri and now operates at more than 2,000 sites across the country to promote the development of children from birth to age three;
- The Home Instruction Program for Preschool Youngsters (HIPPY), which seeks to prepare three- to five-year-olds for kindergarten and first grade;
- The Comprehensive Child Development Program (CCDP), a five-year federal demonstration program that worked with poor families in 24 sites to promote children's development, parents' ability to parent, and family self-sufficiency; and
- Healthy Families America (HFA), a child abuse prevention program that evolved from Hawaii's Healthy Start and is now the subject of a pioneering, multisite research network.
These model programs fairly represent the home visiting programs across the country that seek to help parents provide children with the best start in life.5 Four of these programs have national headquarters to help new programs begin, to train new home visitors, to hone curricula, to maintain the quality of the programs across the nation, and to conduct research. (See Appendices A through D in this journal issue for descriptions of the HFA, PAT, NHVP, and HIPPY programs and the activities of their national headquarters.)
These six home visiting programs are among the best studied, and they are among the relatively few that have been evaluated in rigorous randomized trials. In many cases, the evaluations summarized in this journal issue are not the only ones that have been conducted of these programs, and the articles have reported the highlights but not all of the findings derived from these evaluations. For the reader's convenience, therefore, this journal issue includes tables that report detailed results of relevant studies of these programs. (See Appendix B, Appendix E, and the article by Daro and Harding in this journal issue.)
This analysis relies primarily upon the findings of the evaluations included in the main articles in this journal issue. These findings are sobering. In most of the studies described, programs struggled to enroll, engage, and retain families. When program benefits were demonstrated, they usually accrued only to a subset of the families originally enrolled in the programs, they rarely occurred for all of a program's goals, and the benefits were often quite modest in magnitude.
This analysis begins with a discussion of home visiting programs generally and a description of the program models reviewed in this journal issue. Then, results of the studies that are presented in this journal issue are summarized for each of the key domains identified as areas of change for home visiting programs: parents' attitudes, knowledge, and behavior as parents; children's health and development; child abuse and neglect; and mothers' life course (for example, deferral of subsequent pregnancies and maternal education, employment, and income).
The analysis then explores the meaning of these findings. Many links in a fairly long chain must be in place before positive results can be observed, including a well-implemented program and accurate assessment in a well-designed study. This analysis discusses which links in that long chain seem particularly strong or weak. We recommend that any new expansion of home visiting programs be reassessed in light of the findings presented in this journal issue. We further urge that existing programs focus on program improvement, that practitioners and policymakers recognize the inherent limitations in home visiting programs and embrace more modest expectations for their success, and that home visiting services are best funded as part of a broad set of services for families and young children.