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Home Visiting Evidence of Effectiveness Review: Executive Summary. Washington, DC: U.S. Department of Health and Human Services, Administration for Children and Families, Office of Planning, Research and Evaluation

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This executive summary provides an overview of the Home Visiting Evidence of Effectiveness review process, a summary of the review results, and a link to more detailed information. Overall, the review identified impact studies with high or moderate ratings for seven home visiting models: Early Head Start—Home Visiting, Family Check-Up, Healthy Families America, Healthy Steps, Home Instruction for Parents of Preschool Youngsters, Nurse Family Partnership, and Parents as Teachers.
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Home Visiting Evidence of
Effectiveness Review:
Executive Summary
November 2010
Contract Number:
HHSP23320095642WC/HHSP23337007T
Mathematica Reference Number:
06686-608
Submitted to:
Lauren Supplee, Project Officer
Office of Planning, Research and
Evaluation
Administration for Children and Families
U.S. Department of Health and Human
Services
Submitted by:
Project Director: Diane Paulsell
Mathematica Policy Research
P.O. Box 2393
Princeton, NJ 08543-2393
Telephone: (609) 799-3535
Facsimile: (609) 799-0005
Home Visiting Evidence of
Effectiveness Review:
Executive Summary
November 15, 2010
Diane Paulsell
Sarah Avellar
Emily Sama Martin
Patricia Del Grosso
This report is in the public domain. Permission to reproduce is not necessary. Suggested citation: Paulsell, D., Avellar, S., Sama
Martin, E., & Del Grosso, P. (2010). Home Visiting Evidence of Effectiveness Review: Executive Summary. Office of Planning,
Research and Evaluation, Administration for Children and Families, U.S. Department of Health and Human Services. Washington,
DC.
Disclaimer: The views expressed in this publication do not necessarily reflect the views or policies of the Office of Planning,
Research and Evaluation, the Administration for Children and Families, or the U.S. Department of Health and Human Services.
This report and other reports sponsored by the Office of Planning, Research and Evaluation are available at
http://www.acf.hhs.gov/programs/opre/index.html.
1
HOMVEE EXECUTIVE SUMMARY
Home Visiting Evidence of Effectiveness (HomVEE) was launched in fall 2009 to conduct a
thorough and transparent review of the home visiting research literature and provide an assessment
of the evidence of effectiveness for home visiting program models that serve families with pregnant
women and children from birth to age 5. The HomVEE review was conducted by Mathematica
Policy Research under the guidance of a Department of Health and Human Services (HHS)
interagency working group composed of representatives from:
The Office of Planning, Research, and Evaluation (OPRE), Administration for Children
and Families (ACF)
The Children’s Bureau, ACF
The Centers for Disease Control and Prevention (CDC)
The Health Resources and Services Administration (HRSA)
The Office of the Assistant Secretary for Planning and Evaluation (ASPE)
The Patient Protection and Affordable Care Act established a Maternal, Infant, and Early
Childhood Home Visiting Program (MIECHV) that provides $1.5 billion over five years to states to
establish home visiting program models for at-risk pregnant women and children from birth to
age 5. The Act stipulates that 75 percent of the funds must be used for home visiting programs with
evidence of effectiveness based on rigorous evaluation research. The HomVEE review provides
information about which home visiting program models have evidence of effectiveness as required
by the legislation and defined by HHS, as well as detailed information about the samples of families
who participated in the research, the outcomes measured in each study, and the implementation
guidelines for each model.
This executive summary provides an overview of the HomVEE review process, a summary of
the review results, and a link to the HomVEE website for more detailed information.
Review Process
To conduct a thorough and transparent review of the home visiting research literature,
HomVEE performed seven main activities:
1. Conducted a broad literature search.
2. Screened studies for relevance.
3. Prioritized program models for the review.
4. Rated the quality of impact studies with eligible designs.
5. Assessed the evidence of effectiveness for each model.
6. Reviewed implementation information for each model.
7. Addressed potential conflicts of interest.
2
Literature Search
The HomVEE team conducted a broad search for literature on home visiting program models
serving pregnant women or families with children from birth to age 5.
1
1. Child health
The team limited the search
to research on models that used home visiting as the primary service delivery strategy and offered
home visits to most or all participants. Program models that provide services primarily in centers
with supplemental home visits were excluded. The search was also limited to research on home
visiting models that aimed to improve outcomes in at least one of the following eight domains
specified in the legislation:
2. Child development and school readiness
3. Family economic self-sufficiency
4. Linkages and referrals
5. Maternal health
6. Positive parenting practices
7. Reductions in child maltreatment
8. Reductions in juvenile delinquency, family violence, and crime
HomVEE’s literature search included four main activities:
1. Database Searches. The HomVEE team searched on relevant key words in a range of
research databases. Key words included terms related to the service delivery approach,
target population, and outcome domains of interest. The initial search was limited to
studies published since 1989; a more focused search on prioritized program models
included studies published since 1979 (see Prioritizing Programs below).
2. Website Searches. The HomVEE team used a custom Google search engine to search
more than 50 relevant government, university, research, and nonprofit websites for
unpublished reports and papers.
3. Call for Studies. In November 2009, HomVEE issued a call for studies and sent it to
approximately 40 relevant listservs for dissemination.
4. Review of Existing Literature Reviews and Meta-Analyses. The HomVEE team
checked search results against the bibliographies of recent literature reviews and meta-
analyses of home visiting models and added relevant missing citations to the search
results.
1
For the purposes of the MIECHV, home visiting program models have been defined as programs or initiatives in
which home visiting is a primary service delivery strategy and in which services are offered on a voluntary basis to
pregnant women, expectant fathers, and parents and caregivers of children from birth to kindergarten entry, targeting
participant outcomes that may include improved maternal and child health; prevention of child injuries, child abuse, or
maltreatment, and reduction of emergency department visits; improvement in school readiness and achievement;
reduction in crime or domestic violence; improvements in family economic self-sufficiency; improvements in the
coordination and referrals for other community resources and supports; or improvements in parenting skills related to
child development.
3
The literature search yielded approximately 8,200 unduplicated citations, including 150 articles
submitted through the HomVEE call for studies.
Screening Studies
The HomVEE review team screened all citations identified through the literature search for
relevance. The team screened out studies for the following reasons:
Home visiting was not the primary service delivery strategy.
The study did not use an eligible design (randomized controlled trial, quasi-experimental
design, or implementation study).
The program did not include an eligible target population (pregnant women and families
with children from birth to age 5).
The study did not examine any outcomes in the eight eligible outcome domains (child
development and school readiness; child health; family economic self-sufficiency;
linkages and referrals; maternal health; positive parenting practices; reductions in child
maltreatment; and reductions in juvenile delinquency, family violence, and crime).
The study did not examine a named home visiting program model.
The study was not published in English.
The study was published before 1989 for the initial search or 1979 for the focused
search on prioritized program models.
Prioritizing Home Visiting Program Models for the Review
After screening, the initial search yielded studies on more than 250 home visiting program
models. To prioritize home visiting models for inclusion in the review, the HomVEE team created a
point system for ranking models. This point system was developed as a means of ranking models by
the extent of rigorous research evidence available on their effectiveness. Points were assigned to
models based on:
The number and design of impact studies (three points for each randomized controlled
trial and two points for each quasi-experimental design)
Sample sizes of impact studies (one point for each study with a sample size of 50 or
more)
HomVEE staff did not include models that had no information about implementation, were
implemented only in a developing-world context, or were no longer in operation and provided no
support for implementation.
To be useful to the home visiting field, the review should include information about the most
prevalent home visiting program models currently funded and implemented. Some frequently used
program models, however, may not have a sufficient number of causal studies to receive priority for
4
review. To ensure that the review included the most prevalent models, we compared the prioritized
list of models to an objective data source on the prevalence of implementation.
2
Through this process, the team prioritized 11 program models for the review. These models
were among those with the highest rankings based on HomVEE’s point system; models that ranked
below these 11 typically had only one or two impact studies of their effectiveness. Moreover, the
prioritized program models include the most widely used home visiting models and those that have
been most rigorously and extensively evaluated. They are:
We identified one
highly prevalent program model not on our prioritized list and added it in consultation with HHS.
1. Early Head Start–Home Visiting
2. Family Check-Up
3. Healthy Families America (HFA)
4. Healthy Start–Home Visiting
5. Healthy Steps
6. Home Instruction for Parents of Preschool Youngsters (HIPPY)
7. Nurse Family Partnership (NFP)
8. Parent-Child Home Program
9. Parents as Teachers (PAT)
10. Resource Mothers Program
11. SafeCare
HomVEE reviewed 162 impact studies and 122 implementation studies about these 11 models.
Rating the Quality of Impact Studies
For each of the 11 prioritized models, HomVEE reviewed impact studies with two types of
designs: randomized controlled trials and quasi-experimental designs
3
In brief, the high rating is reserved for random assignment studies with low attrition of sample
members and no reassignment of sample members after the original random assignment, and single
case and regression discontinuity designs that meet What Works Clearinghouse (WWC) design
(including matched
comparison group designs, single case designs, and regression discontinuity designs). Trained
reviewers assessed the research design and methodology of each study using a standard review
protocol. Each study was assigned a rating of high, moderate, or low to provide an indication of the
study design’s capacity to provide unbiased estimates of program impacts.
2
Stoltzfus, E & Lynch, K. (2009). Home visitation for families with young children. Washington, DC:
Congressional Research Service..
3
HomVEE defines a quasi-experimental design as a study design in which sample members (children, parents, or
families) are selected for the program and comparison conditions in a nonrandom way.
5
standards (Table 1).
4
Assessing Evidence of Effectiveness
The moderate rating applies to random assignment studies that, due to flaws in
the study design, execution, or analysis (for example, high sample attrition), do not meet all the
criteria for the high rating; matched comparison group designs that establish baseline equivalence on
selected measures; and single case and regression discontinuity designs that meet WWC design
standards with reservations. Studies that do not meet all of the criteria for either the high or
moderate ratings are assigned the low rating.
After completing all impact study reviews for a model, the HomVEE team evaluated the
evidence across all studies of the program models that received a high or moderate rating and
measured outcomes in at least one of the eligible outcome domains. To meet HHS’ criteria for an
“evidence-based early childhood home visiting service delivery model,” program models must meet
at least one of the following criteria:
At least one high- or moderate-quality impact study of the model finds favorable,
statistically significant impacts in two or more of the eight outcome domains; or
At least two high- or moderate-quality impact studies of the model using non-
overlapping analytic study samples find one or more favorable, statistically significant
impacts in the same domain.
In both cases, the impacts considered must either (1) be found for the full sample or (2) if
found for subgroups but not for the full sample, be replicated in the same domain in two or more
studies using non-overlapping analytic study samples. Additionally, following the legislation, if the
model meets the above criteria based on findings from randomized controlled trial(s) only, then one
or more favorable, statistically significant impacts must be sustained for at least one year after
program enrollment, and one or more favorable, statistically significant impacts must be reported in
a peer-reviewed journal.
5
In addition to assessing whether each model met the HHS criteria for an evidence-based early
childhood home visiting service delivery model, the HomVEE team examined and reported other
aspects of the evidence for each model based on all high- and moderate-quality studies available,
including the following:
Quality of Outcome Measures. HomVEE classified outcome measures as primary if
data were collected through direct observation, direct assessment, or administrative
records; or if self-reported data were collected using a standardized (normed)
instrument. Other self-reported measures are classified as secondary.
Duration of Impacts. HomVEE classified impacts as lasting if they were measured at
least one year after program services ended.
4
The What Works Clearinghouse (WWC), established by the Institute for Education Sciences in the U.S.
Department of Education, reviews education research.
5
Section 511 (d)(3)(A)(i)(I)
6
Table 1. Summary of Study Rating Criteria for the HomVEE Review
HomVEE Research Design and Criteria
Quasi-Experimental Designs
HomVEE Study
Rating
Matched Comparison
Group
Single Case Design
b
Regression Discontinuity
Design
b
High - Random assignment
- Meets WWC standards for
acceptable rates of overall and
differential attrition
a
- No reassignment; analysis must
be based on original assignment
to study arms
- No confounding factors; must
have at least two participants in
each study arm and no
systematic differences in data
Not applicable
- Timing of intervention is
systematically
manipulated
- Outcomes meet WWC
standards for
interassessor agreement
- At least three attempts to
demonstrate an effect
- At least five data points
in relevant phases
- Integrity of forcing variable
is maintained
- Meets WWC standards for
low overall and differential
attrition
- The relationship between
the outcome and the
forcing variable is
continuous
- Meets WWC standards for
functional form and
bandwidth
Moderate - Reassignment OR unacceptable
rates of overall or differential
attrition
a
- Baseline equivalence established
on selected measures
- No confounding factors; must
have at least two participants in
each study arm and no
systematic differences in data
collection methods
- Baseline equivalence
established on selected
measures
- No confounding factors;
must have at least two
participants in each
study arm and no
systematic differences in
data collection methods
- Timing of intervention is
systematically
manipulated
- Outcomes meet WWC
standards for
interassessor agreement
- At least three attempts to
demonstrate an effect
- At least three data points
in relevant phases
- Integrity of forcing variable
is maintained
- Meets WWC standards for
low attrition
- Meets WWC standards for
functional form and
bandwidth
Low
Studies that do not meet the requirements for a high or moderate rating
Note: “Or” implies that one of the criteria must be present to result in the specified rating.
a
The What Works Clearinghouse (WWC), established by the Institute for Education Sciences in the U.S. Department of Education, reviews education
research (http://ies.ed.gov/ncee/wwc/). The WWC standard for attrition is transparent and statistically based, taking into account both overall
attrition (the percentage of study participants lost in the total study sample) and differential attrition (the differences in attrition rates between
treatment and control groups).
b
For ease of presentation, some of the criteria are described very broadly. Additional details about standards are available for single case designs
(
http://ies.ed.gov/ncee/wwc/pdf/wwc_scd.pdf) and regression discontinuity designs (http://ies.ed.gov/ncee/wwc/pdf/wwc_rd.pdf).
7
Replication of Impacts. HomVEE classified impacts as replicated if favorable,
statistically significant impacts were shown in the same outcome domain in at least two
non-overlapping analytic study samples.
Subgroup Findings. HomVEE reported subgroup findings if the findings were
replicated in the same outcome domain in at least two studies using different samples.
Unfavorable or Ambiguous Impacts. In addition to favorable impacts, HomVEE
reported unfavorable or ambiguous, statistically significant impacts on full sample and
subgroup findings. While some outcomes are clearly unfavorable (such as an increase in
children’s behavior problems), others are ambiguous. For example, an increase in the
number of days mothers are hospitalized could indicate an increase in health problems
or increased access to needed health care due to participation in a home visiting
program.
Evaluator Independence. HomVEE reported the funding source for each study and
whether any of the study authors were program model developers.
Magnitude of Impacts. HomVEE reported effect sizes when possible, either those
calculated by the study authors or HomVEE computed findings.
Implementation Reviews
The HomVEE team collected information about implementation of the 11 prioritized models
from all impact studies with a high or moderate rating and from stand-alone implementation studies.
In addition, staff conducted internet searches to find implementation materials and guidance
available from home visiting program developers and national program offices. The HomVEE team
used this information to develop detailed implementation profiles for each model that include an
overview of the program model and information about prerequisites for implementation, materials
and forms, estimated costs, and program contact information. National program offices were invited
to review and comment on the profiles. The team also extracted information about implementation
experiences from the studies reviewed, including the characteristics of program participants, location
and setting, staffing and supervision, program model components, program model adaptations or
enhancements, dosage, fidelity measurement, costs, and lessons learned.
Addressing Conflicts of Interest
All members of the HomVEE team signed a conflict of interest statement in which they
declared any financial or personal connections to developers, studies, or products being reviewed
and confirmed their understanding of the process by which they must inform the project director if
such conflicts arise. The HomVEE review team’s project director assembled signed conflict of
interest forms for all project staff and subcontractors and monitored for possible conflicts over
time. If a team member was found to have a potential conflict of interest concerning a particular
home visiting model being reviewed, that team member was excluded from the review process for
the studies of that model. In addition, reviews for two program models previously evaluated by
Mathematica Policy Research were conducted by contracted reviewers who were not Mathematica
employees.
8
Summary of Review Results
The HomVEE review produced assessments of the evidence of effectiveness for each home
visiting model and outcome domain, as well as a description of each model’s implementation
guidelines. This section provides a summary of evidence of effectiveness by model and outcome
domain, a summary of implementation guidelines for program models with evidence of
effectiveness, and a discussion of gaps in the home visiting research literature.
Evidence of Effectiveness by Program Model
Overall, HomVEE identified impact studies with high or moderate ratings for seven home
visiting models: (1) Early Head Start-Home Visiting, (2) Family Check-Up, (3) Healthy Families
America (HFA), (4) Healthy Steps, (5) Home Instruction for Parents of Preschool Youngsters
(HIPPY), (6) Nurse Family Partnership (NFP), and (7) Parents as Teachers (PAT).
All seven of these models meet the HHS criteria for an evidence-based early childhood home
visiting service delivery model. All of them have at least one high- or moderate-quality study with at
least two favorable, statistically significant impacts in two different domains or two or more high- or
moderate-quality studies using non-overlapping analytic study samples with one or more statistically
significant, favorable impacts in the same domain.
Based on the available high- or moderate-quality studies, findings by program model are as
follows (Table 2):
Early Head StartHome Visiting had favorable impacts in three domains (child
development and school readiness, family economic self-sufficiency, and positive
parenting practices) and at least one favorable impact in all three domains was sustained
for at least one year after program inception and lasted for at least one year after
program completion. The available evidence indicated two unfavorable or ambiguous
impacts in the family economic self-sufficiency domain. The available evidence did not
indicate any of the findings were replicated in a second study sample.
Family Check-Up had favorable impacts in three domains (child development and
school readiness, maternal health, and positive parenting practices) and impacts on
positive parenting practices were replicated in at least one other study sample. The
available evidence indicated that at least one favorable impact was sustained for at least
one year after program inception but did not indicate that any of the impacts lasted for
at least one year post program completion.
Healthy Families America (HFA) had favorable impacts in seven domains (child
development and school readiness; child health; family economic self-sufficiency;
linkages and referrals; positive parenting practices; reductions in child maltreatment; and
reductions in juvenile delinquency, family violence, and crime). The findings in child
development and school readiness, child health, positive parenting practices, and
reductions in child maltreatment were replicated in at least one other study sample. The
available evidence indicated HFA had at least one unfavorable or ambiguous finding in
child health, family economic self-sufficiency, and linkages and referrals. The available
evidence indicated that at least one favorable impact in all seven domains was sustained
for at least one year after program inception but did not indicate any of the impacts
lasted for at least one year post program completion.
9
Table 2. Home Visiting Evidence Dimensions
High or
Moderate
Quality
Impact
Study?
Number of
Favorable
Impacts on
Primary
Outcome
Measures
a
Number of
Favorable
Impacts on
Secondary
Outcome
Measures
a
Sustained?
b
Lasting?
c
Replicated?
d
Favorable
Impacts
Limited to
Subgroups?
Number of
Unfavorable or
Ambiguous
Impacts
e
Early Head Start
Home Visiting
Yes*
4*
24*
Yes*
Yes*
No
No*
2**
Family Check-Up
Yes*
5*
1*
Yes*
No
Yes*
No*
0
Healthy Families
America
Yes*
10*
21*
Yes*
No
Yes*
No*
4**
Healthy Steps
Yes*
2*
3*
Yes*
No
No
No*
0
HIPPY
Yes*
4*
4*
Yes*
Yes*
Yes*
No*
0
Nurse Family
Partnership
Yes*
26*
39*
Yes*
Yes*
Yes*
No*
6**
Parents as
Teachers
Yes*
5*
0
Yes*
No
Yes*
No*
7**
a
In the full sample only. Primary measures were defined as outcomes measured through direct observation, direct assessment, administrative data,
or self-reported data collected using a standardized (normed) instrument. Secondary measures included other self-reported measures.
b
Yes, if favorable impacts were sustained for at least one year post program inception.
c
Yes, if favorable impacts lasted for at least one year after the program ended.
d
Yes, if favorable impacts (whether sustained or not) were replicated on at least one measure in the same outcome domain in either a high- or
moderate-quality study.
e
This number includes unfavorable or ambiguous impacts on both primary and secondary measures in the full sample. Unfavorable findings should
be interpreted with caution because there is subjectivity involved in interpreting some outcomes; for some outcomes, it is not always clear in
which direction it is desirable to move the outcome. Readers are encouraged to use the HomVEE website, specifically the reports by program
model and by outcome domain, to obtain more detail about unfavorable findings.
*Green-shaded table cell = favorable dimension of the study.
**Red-shaded table cell = unfavorable or ambiguous impact.
10
Healthy Steps had favorable impacts in two domains (child health and positive
parenting practices). The available evidence indicated that at least one favorable impact
in positive parenting practices was sustained for at least one year after program
inception, but none of the impacts lasted for at least one year post program completion
or was replicated in a second study sample.
Home Instruction for Parents of Preschool Youngsters (HIPPY) had favorable
impacts in two domains (child development and school readiness and positive parenting
practices), and both of these impacts were replicated in at least one other study sample.
The available evidence indicated that at least one favorable impact in both domains was
sustained for at least one year post program inception and at least one favorable impact
in child development and school readiness lasted for one year or more post program
completion.
Nurse Family Partnership (NFP) had favorable impacts in seven domains (child
development and school readiness; child health; family economic self-sufficiency;
maternal health; positive parenting practices; reductions in child maltreatment; and
reductions in juvenile delinquency, family violence, and crime). At least one impact in all
seven domains was replicated in another study sample, was sustained at least one year
post program inception, and lasted for at least one year post completion. The evidence
indicated that NFP had unfavorable or ambiguous findings in five of the domains (child
development and school readiness; child health; linkages and referrals; positive
parenting practices; and reductions in juvenile delinquency, family violence, and crime).
Parents as Teachers (PAT) had favorable impacts in two domains (child development
and school readiness and positive parenting practices). Favorable impacts in child
development and school readiness were replicated in at least one other study sample.
The evidence indicated that PAT had unfavorable or ambiguous findings in three
domains (child development and school readiness, family economic self-sufficiency, and
positive parenting practices). The evidence available indicated that favorable impacts in
child development and school readiness and positive parenting practices were sustained
for at least one year post program inception but did not indicate any of the impacts
lasted for at least one year post program completion.
In addition to the seven home visiting models described above, HomVEE reviewed four other
home visiting program models: (1) Healthy StartHome Visiting, (2) Parent-Child Home Program,
(3) Resource Mothers Program, and (4) SafeCare. No high- or moderate-quality studies were
identified for these models, however, and consequently HomVEE was unable to assess their
effectiveness.
Evidence of Effectiveness by Outcome Domain
In seven of the eight outcome domains, at least one of the home visiting models had favorable
impacts on a primary measure (Table 3). None of the models, however, show impacts on reductions
in juvenile delinquency, family violence, and crime, using a primary outcome measure. All models
except Healthy Steps had favorable impacts on primary measures of child development and school
readiness and positive parenting practices. Nurse Family Partnership had the greatest breadth of
favorable findings, with favorable impacts on primary measures in six outcome domains.
11
Table 3. Number of Favorable Impacts on Primary Measures, by Outcome Domain
Child
Health
Maternal
Health
Child
Development
and School
Readiness
Reductions
in Child
Maltreatment
Reductions
in Juvenile
Delinquency,
Family
Violence,
and Crime
Positive
Parenting
Practices
Family
Economic
Self-
Sufficiency
Early Head
StartHome
Visiting
0
0
1
0
Not
measured
3
0
Family Check-
Up
Not
measured
0
3
Not
measured
Not
measured
2
Not
measured
Healthy
Families
America
1
0
7
0
0
1
0
Healthy Steps
2
0
0
0
Not
measured
0
Not
measured
HIPPY Not
measured
Not
measured
3
Not
measured
Not
measured
1
Not
measured
Nurse Family
Partnership
4
3
5
7
0
5
2
Parents as
Teachers
0
0
2
Not
measured
Not
measured
3
0
Summary of Implementation Guidelines for Models with Evidence of Effectiveness
The MIECHV legislation specifies a number of program model implementation requirements.
6
6
Section 511(d)(3)(A)(i)(I). These variables include, “the model has been in existence for at least 3 years and is
research-based, grounded in relevant empirically-based knowledge, linked to program determined outcomes, associated
with a national organization or institution of higher education that has comprehensive home visitation program
standards that ensure high quality service delivery and continuous quality improvement…”
The review of information about implementation identified a number of requirements for
implementing home visiting models included in the review (Table 4). All programs in the HomVEE
review with evidence of effectiveness had been in existence for at least three years prior to the start
of the review, are associated with a national program office that provides training and support to
local program sites, and have minimum requirements for the frequency of home visits and for home
visitor supervision. In addition, most have pre-service training requirements, implementation fidelity
standards, a system for monitoring fidelity, and specified content and activities for the home visits.
Only three programsFamily Check-Up, Healthy Steps, and Nurse Family Partnershiphave
specific educational requirements for home visitors.
12
Table 4. Overview of the Implementation Guidelines for the Home Visiting Models with Evidence of Effectiveness
Model
Has Been
in
Existence
for 3
Years
a
Model Is
Associated
with
National
Organization
or
Institution of
Higher
Education
a
Model Has
Specified
Minimum
Requirements
for Frequency
of Visits
Model Has
Minimum
Education
Requirements
for Home
Visiting Staff
a
Model Has
Supervision
Requirements
for Home
Visitors
a
Model Has
Specific Pre-
Service
Training
Requirements
for Home
Visiting Staff
a
Model Has
Fidelity
Standards
Local
Implementing
Agencies
Must Follow
a
Model Has
System for
Monitoring
Fidelity
a
Model
Has
Specified
Content
and
Activities
for
Home
Visits
Early Head
StartHome
Visiting
Yes*
Yes*
Yes*
No
Yes*
No
Yes*
Yes*
No
Family
Check-Up
Yes*
Yes*
Yes*
Yes*
Yes*
Yes*
No
No
Yes*
Healthy
Families
America
Yes*
Yes*
Yes*
No
Yes*
Yes*
Yes*
Yes*
No
Healthy Steps
Yes*
Yes*
Yes*
Yes*
Yes*
Yes*
No
No
Yes*
HIPPY
Yes*
Yes*
Yes*
No
Yes*
Yes*
Yes*
Yes*
Yes*
Nurse Family
Partnership
Yes*
Yes*
Yes*
Yes*
Yes*
Yes*
Yes*
Yes*
Yes*
Parents as
Teachers
Yes*
Yes*
Yes*
No
Yes*
Yes*
Yes*
Yes*
Yes*
Source: HomVEE implementation profiles.
a
Included in legislation.
*Blue-shaded table cell = in compliance with implementation guidelines.
13
Gaps in the Research
The HomVEE review identified several gaps in the existing research literature on home visiting
models that limit its usefulness for matching program models to community needs. First, research
evidence of program effectiveness is limited. As noted earlier, many models do not have high- or
moderate-quality studies of their effectiveness; thus, policymakers and program administrators
cannot determine whether those models are effective. Other models have only a few high- or
moderate-quality studies, indicating that additional research on those models may be needed.
Second, more evidence is needed about the effectiveness of home visiting models for different
types of families with a range of characteristics. Overall, the studies included in the HomVEE
review had fairly diverse study samples in terms of race/ethnicity and income. However, sample
sizes in these studies are not typically large enough to allow for analysis of findings separately by
subgroup. Moreover, HomVEE found little or no research on the effectiveness of home visiting
program models for families from American Indian tribes, immigrant families that have diverse
cultural backgrounds or may not speak English as a first language, or military families.
For More Information
The HomVEE website (http://www.acf.hhs.gov/programs/opre/homvee) provides detailed
information about the review process and the review results, including the following:
Reports on the evidence of effectiveness for each program model
Reports on the evidence of effectiveness across models for each outcome domain
Implementation profiles and information on implementation experiences for each
program model
A searchable reference list that provides the disposition of each study considered for the
11 models reviewed
Details about the review process and a glossary of terms
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... Some home visiting programs are made available to all parents, while others target subgroups of families, such as first-time parents, teen mothers, and families with children with chronic health conditions or other special needs (Supplee, 2016). Outcomes for parents and children targeted by home visiting models include both proximal outcomes, such as improvements in parenting practices, maternal mental health, and child health and development and reductions in child abuse and neglect, and more distal outcomes, such as reduced juvenile delinquency and increased family economic self-sufficiency (Gomby et al., 1999;Sama-Miller et al., 2018). Evaluations of home visiting models have shown mixed results but generally conclude that home visiting is an effective methodology for delivering support to at-risk families (Gomby et al., 1999;Howard & Brooks-Gunn, 2009;Sama-Miller et al., 2018). ...
... Outcomes for parents and children targeted by home visiting models include both proximal outcomes, such as improvements in parenting practices, maternal mental health, and child health and development and reductions in child abuse and neglect, and more distal outcomes, such as reduced juvenile delinquency and increased family economic self-sufficiency (Gomby et al., 1999;Sama-Miller et al., 2018). Evaluations of home visiting models have shown mixed results but generally conclude that home visiting is an effective methodology for delivering support to at-risk families (Gomby et al., 1999;Howard & Brooks-Gunn, 2009;Sama-Miller et al., 2018). Two home visiting models, Healthy Families America (HFA) and Nurse-Family Partnership (NFP), have been found to have the most positive impacts across targeted outcomes (Sama-Miller et al., 2018). ...
... Evaluations of home visiting models have shown mixed results but generally conclude that home visiting is an effective methodology for delivering support to at-risk families (Gomby et al., 1999;Howard & Brooks-Gunn, 2009;Sama-Miller et al., 2018). Two home visiting models, Healthy Families America (HFA) and Nurse-Family Partnership (NFP), have been found to have the most positive impacts across targeted outcomes (Sama-Miller et al., 2018). Both models are among those that receive support for implementation in states, tribes, and territories through the federally funded Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. ...
Chapter
Exposure to severe, chronic, and cumulative adversity during sensitive periods of development such as early childhood places children at immediate risk of harm and has been linked to many of the most common physical and mental health problems later in adulthood. However, recent advances in neuroscience, developmental psychology, social work, and related fields demonstrate that early childhood is also a period of great opportunity for promoting resilience in development, as early life experiences have a strong influence on young children’s brain development, gene expression, social and emotional well-being, and learning. This chapter provides an overview of resilience theory and related frameworks for understanding competence in the face of adversity and provides examples of evidence-based interventions and protective factors that are aligned with this approach. Extrapolating from the scientific literature to date, we discuss implications for nurturing resilience among young children and their families and related implications for policymakers, practitioners, and researchers. Finally, we consider next steps for growth in the field.
... The program is designed to empower families via home visiting for at-risk pregnant women and parents of young children. It builds upon research showing that home visits by trained professionals during pregnancy and early childhood can improve the lives of children and families (Avellar & Supplee, 2013;Paulsell et al., 2010). Most programs aim to promote positive parenting, maternal and child health, and child development and school readiness. ...
... Many of the models identified as effective (and therefore eligible for federal funding through MIECHV) have been shown to significantly reduce use of physical punishment (e.g., DuMont et al., 2008;Fergusson et al., 2005Fergusson et al., , 2013Olds et al., 1986;Roggman & Cook, 2010). In contrast, other programs have little evidence of their effectiveness in this regard (Avellar & Supplee, 2013;Paulsell et al., 2010). ...
... There is a continued need to build the evidence base on and extend the reach of interventions to reduce, and ideally prevent, physical punishment and abuse. Broad prevention programs, such as those involving home visiting, have reported long-term benefits, but vary in the extent to which they address physical punishment, and many studies of home visiting programs have not evaluated their impact on parent-child physical aggression (Avellar & Supplee, 2013;Paulsell et al., 2010). ...
Article
Full-text available
Parent-child physical aggression, including both physical punishment and abuse, remains a prevalent problem in the United States. In this paper, we briefly review the prevalence and harms of parent-child aggression and discuss changes in social norms and policies over the past several decades. Then, we discuss broad social policies influencing risk for parent-child physical aggression, policies relevant to reducing and preventing physical abuse, and policies relevant to reducing and preventing physical punishment. We close by considering future directions to strengthen research and evaluation and accelerate progress toward ending parent-child physical aggression.
... A recent review of 21 parenting interventions in developing countries aimed at enhancing early child development found medium-sized effects (0.42 SD) from parenting interventions on cognitive development while the 18 nutrition interventions were less effective in this domain (0.09 SD), see Figure 4.3. To assess the evidence on parenting interventions, we considered 11 reviews that spanned developing countries (Britto et al. 2017;Aboud et al. 2015;Rao et al. 2014;Grantham-McGregor et al. 2014;Baker-Henningham et al. 2010;Engle et al. 2011;and Walker et al. 2011), developed countries (Filene et al. 2013;Pontoppidan et al. 2016;and Avellar et al. 2017) and both (Nores and Barnett, 2010). See Annex 1 for a short summary of each review. ...
... The existing evidence on large-scale parenting interventions is very limited, and there is no guarantee that interventions that are effective in small efficacy trials will continue to be so when scaled up. In terms of large-scale programs, in the USA, evidence-based large-scale evaluations of parenting interventions such as the Nurse Family Partnership Program 12 have found that these programs had a positive impact on children's development (Avellar et al. 2017). In developing countries, Peru's "Cuna Mas" parenting program improved child development (cognition and language skills) and Niger's parenting program improved socio-emotional development but not cognition or language skills (Araujo et al. 2016 andPremand et al. 2016). ...
... 12 The Nurse Family Partnership programs is one of the most evaluated and well-known parenting interventions in the US. It operates in 32 states and has been identified as a successful model by the Home Visiting Evidence of Effectiveness review launched by the Department of Health and Human Services in the United States (Avellar et al. 2017). This is a free, voluntary program that partners low-income, first-time mothers with a registered nurse home visitor. ...
... While there are many benefits to technology and the use of digital tools within family services, a drawback is that the most vulnerable families are least likely to have regular access to the internet or digital tools (OECD, 2020 [13]; European Commission, 2020 [51]). Family support services users face many barriers to using digital technologies, including the lack of internet access, affordability of digital tools, as well as lack of basic and digital literacy and a lack of familiarity or trust in the protection of family privacy (Schmida et al., 2017[52]; UNESCO, 2018 [53]; Riding, 2020 [40]). Practitioners can advocate for families and raise awareness of barriers and accessibility by ensuring vulnerable families have access to assistive technologies including text-to-speech software, tablets or promote digital inclusion toolkits which include information on where to find free WiFi in the community, basic information about internet and data providers, programmes that are working to provide low-cost devices and technology as well as programmes that offer digital learning such as digital literacy and online educations (City of South Bend Indiana, 2020 [54]). ...
... Practitioners can advocate for families and raise awareness of barriers and accessibility by ensuring vulnerable families have access to assistive technologies including text-to-speech software, tablets or promote digital inclusion toolkits which include information on where to find free WiFi in the community, basic information about internet and data providers, programmes that are working to provide low-cost devices and technology as well as programmes that offer digital learning such as digital literacy and online educations (City of South Bend Indiana, 2020 [54]). Resource sharing models such as community tool libraries can also be used to create technology libraries where anyone in need can borrow laptops and other assistive technology (Hamilton, 2020[55]; Riding, 2020 [40]). ...
Preprint
Full-text available
This paper provides an overview of the nature and key priorities of family support services operating in OECD countries to inform on the factors that contribute to their quality and delivery effectiveness. The evidence collated in this paper draws from the responses to Questionnaires answered by delegates to the OECD Working Party on Social Policy and by around 170 family service providers from OECD countries. The report discusses policy options to help countries develop and sustain the effective delivery of family support services throughout childhood, improve their quality, and to make better use of digital tools to enhance service delivery.
... MIECHV provides funding to states and territories to implement models that have undergone rigorous evaluation (Adirim & Supplee, 2013). To date, 20 models have met criteria for evidence of effectiveness and several other models are currently being evaluated (Sama-Miller et al., 2019). In some states and localities in the US, EBHV is offered universally or is at least widely available. ...
Article
Full-text available
Evidence-based maternal and early childhood home visiting (EBHV) may support health and well-being among families headed by a caregiver with an intellectual disability or other learning difference. Little is known about tools EBHV staff can use to identify caregivers with learning differences and inform service delivery strategies. Investigators used a two-step stakeholder-engaged approach to identify screening tools that are feasible, acceptable, and useful in the EBHV context. In the first step, authors conducted a scoping review to identify validated screening tools. Data describing the studies and tools were extracted and synthesized. In the second step, an established Stakeholder Advisory Group gave two rounds of feedback on the feasibility, acceptability, and usefulness of each tool for the EBHV context. Most identified tools were verbal or written questionnaires developed outside the United States. Only one tool was developed for parents or other caregivers. Overall, tools had limited psychometric evidence. Stakeholders expressed concerns about potentially stigmatizing language of some items within tools, suggesting that adaptations may be needed for tools to be acceptable in the EBHV context. Investigators concluded that there are few valid and reliable screening tools to identify learning differences that are brief and can be used by paraprofessionals with no prior expertise. Additional research is needed to further validate, adapt, or develop a tool that is feasible, acceptable, and useful for the EBHV context.
... The necessity of visiting services to improve the health of these vulnerable people is suggested. Since the visiting service is said to be effective for family and maternal health [24], it will be necessary to develop and apply an effective health management program for individualized health management of the vulnerable. By expanding the scope and scale of the currently implemented government-based visiting service, it is necessary to pay attention to the health management of the vulnerable. ...
Article
Purpose: This study aimed to explore and understand the health promoting behaviors of low-income overweight and obese women in Korea. Methods: Data were collected from 10 low-income overweight and obese women working at a community self-sufficiency center through semi-structured in-depth interviews. Individual interviews were conducted and transcribed. Deductive content analysis was done, using the MAXQDA program. Results: The health promoting behaviors practiced by low-income overweight and obese women were affected by intrapersonal, interpersonal, and organizational/community factors. Six categories were identified and two category clusters were derived that could best describe their health promoting experiences. As main category clusters, despite "feeling that the body and mind are not healthy" participants noted "difficulty maintaining a healthy lifestyle." Overall, the participants had poor nutritional status, lacked physical activity, experienced much stress in intrapersonal level, and faced intrapersonal-level barriers to health promoting behaviors. Moreover, participants had a lack of personal will, and lack of specific information to practice health promoting behaviors, a lack of time, and too many overall burdens to earn a living for their family while trying to maintain health promotion behaviors. Conclusion: Lifestyle interventions for nutrition management, encouragement of physical activity, and stress management are needed for overweight and obese low-income women. In addition, social support and policies are needed to improve their living environment.
... Many interventions are available to support families at risk for intergenerational transmission of maltreatment, including early home visiting programs with varying strategies for service delivery, home visitor qualifications, and target populations (Sama-Miller et al., 2018). Given the lasting and complex effects of childhood experiences of maltreatment on parenting, however, it is unclear whether and how these interventions might help mitigate family cycles of childhood maltreatment. ...
Article
Background: Racism is a significant source of toxic stress and a root cause of health inequities. Emerging evidence suggests that exposure to vicarious racism (i.e., racism experienced by a caregiver) is associated with poor child health and development, but associations with biological indicators of toxic stress have not been well studied. It is also unknown whether two-generation interventions, such as early home visiting programs, may help to mitigate the harmful effects of vicarious racism. Objective: The purpose of this study was to examine associations between maternal experiences of racial discrimination and child indicators of toxic stress and to test whether relationships are moderated by prior participation in Minding the Baby (MTB), an attachment-based early home visiting intervention. Methods: Ninety-seven maternal-child dyads (n = 43 intervention dyads, n = 54 control dyads) enrolled in the MTB Early School Age follow-up study. Mothers reported on racial discrimination using the Experiences of Discrimination Scale. Child indicators of toxic stress included salivary biomarkers of inflammation (e.g., C-reactive protein, panel of pro-inflammatory cytokines), body mass index, and maternally reported child behavioral problems. We used linear regression to examine associations between maternal experiences of racial discrimination and child indicators of toxic stress and included an interaction term between experiences of discrimination and MTB group assignment (intervention vs. control) to test moderating effects of the MTB intervention. Results: Mothers identified as Black/African American (33%) and Hispanic/Latina (64%). In adjusted models, maternal experiences of racial discrimination were associated with elevated salivary interleukin-6 and tumor necrosis factor-α levels in children, but not child body mass index or behavior. Prior participation in the MTB intervention moderated the relationship between maternal experiences of discrimination and child interleukin-6 levels. Discussion: Results of this study suggest that racism may contribute to the biological embedding of early adversity through influences on inflammation, but additional research with serum markers is needed to better understand this relationship. Improved understanding of the relationships among vicarious racism, protective factors, and childhood toxic stress is necessary to inform family and systemic-level intervention.
... Many interventions are available to support families at risk for intergenerational transmission of maltreatment, including early home visiting programs with varying strategies for service delivery, home visitor qualifications, and target populations (Sama-Miller et al., 2018). Given the lasting and complex effects of childhood experiences of maltreatment on parenting, however, it is unclear whether and how these interventions might help mitigate family cycles of childhood maltreatment. ...
Article
Research is needed to better understand how childhood maltreatment history affects parental reflective capacities, and whether early childhood interventions help mitigate these effects. We examined associations between childhood maltreatment and current parenting (parental reflective functioning, parenting behaviors) among mothers who participated in a follow-up study ( N = 97) of the Minding the Baby® (MTB) randomized control trial. MTB is a home visiting program that aims to help mothers understand their child’s mental states (feelings, intentions, needs) by promoting parental reflective functioning. Mothers retrospectively reported childhood maltreatment using the Childhood Trauma Questionnaire. Endorsing a higher number of childhood maltreatment subtypes was associated with less supportive/engaged parenting and higher pre-mentalizing modes, or difficulty with appropriately reflecting on the child’s mental states. These relationships were not moderated by participation in the MTB intervention. However, exploratory analyses of individual maltreatment subtypes revealed that participation in MTB may mitigate the harmful effects of childhood emotional abuse on pre-mentalizing modes, specifically. Further research is needed to understand the mechanisms through which early childhood interventions may prevent intergenerational cycles of maltreatment.
Chapter
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Growing up under conditions of major stress and poverty in the first 3 years of life exacerbates children’s development more deeply than any other developmental period. Just as early childhood can be a period of vulnerabilities due to a multitude of risk factors (Evans et al., Psychological Bulletin, 139(6), 1342–1396: 2013), there is also evidence that early interventions provide a buffer against early adversity. This chapter illustrates the Istanbul95 initiative, an example of an integrated early childhood intervention model in Istanbul, the largest metropolitan area in Turkey. The Istanbul95 initiative is piloted in four district municipalities in Istanbul and includes (1) neighborhood mapping to display services for children and families, (2) a home visitation model for parent coaching, and (3) public space transformations into family-friendly urban systems. Preliminary findings on participating families’ feedback obtained in focus groups are presented in this chapter. Recommendations for policymakers are also provided as the Istanbul95 program points to the fact that a comprehensive approach is needed to promote the development of young children who live under disadvantaged conditions.
Article
The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program, administered by the Health Resources and Service Administration in collaboration with the Administration for Children and Families, provides evidence-based home visiting services across 50 states, the District of Columbia, and five U.S. territories. MIECHV invests in comprehensive technical assistance (TA) to support and build the capacity of awardees to conduct rigorous evaluations of their programs. Throughout the course of the evaluation process, awardees received TA from the Design Options for Home Visiting Evaluation project. Between 2011 and 2020, over 173 state-led evaluations have been conducted. Individual technical assistance (TA) modalities included conference calls, emails, interactive and individualized webinars, developing and sharing resources, and involvement of content experts. When issues and challenges were identified across multiple awardees, Design Options for Home Visiting Evaluation (DOHVE) delivered targeted group TA to awardees with common needs that may benefit from peer-to-peer learning. When cross-cutting issues and challenges were identified, DOHVE used universal approaches such as webinars and guidance documents that were made available to all awardees.Through the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program, efforts have been taken to promote awardee capacity by targeting all phases of the evaluation process, including planning, implementing, and disseminating findings and providing TA that is responsive and tailored to meet awardee-specific needs. This approach enabled DOHVE to support MIECHV awardees in expanding knowledge of their programs and the evidence base on home visiting. Lessons learned from TA provision highlight the importance of developing feasible plans and providing ongoing support during implementation.
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