ZERO TO THREE strongly urges policymakers to continue supporting the expansion of evidence-based home visitation programs, so the diversity of families who need support can access it in a culturally appropriate manner.
Any new parent will likely tell you that parenting is the most rewarding, while also the most difficult, thing they have ever done. Especially during the first years of a child’s life, parents play the most active and influential role in their baby’s healthy growth and development. Parenting is difficult even in the best of circumstances, and when coupled with other stressful life events, it becomes even more challenging. During these times, support from others is critical. Unfortunately, many parents face obstacles—such as those caused by stress, language barriers, geographic and social isolation, poverty, and their own adverse childhood experiences that leave them without a positive parenting model—that impacts their ability to fully support their baby’s development during these critical years.
Home visiting has been demonstrated to be an effective method of supporting families, particularly as part of a comprehensive and coordinated system of high-quality, affordable early care and education, health and mental health, and family support services for families of children from the prenatal through the pre-kindergarten stages. These voluntary programs tailor services to meet the needs of individual families and offer information, guidance, and support directly in the home environment. While home visiting programs vary in goals and content of services, in general, they combine parenting and health care education, child abuse prevention, and early intervention and education services for young children and their families.
48 states, the District of Columbia, and 5 U.S. territories are currently operating home visiting programs through interagency planning efforts.
ZERO TO THREE strongly urges policymakers to continue supporting the expansion of evidence-based home visitation programs, so the diversity of families who need support can access it in a culturally appropriate manner. ZERO TO THREE also encourages the development of infrastructure to sustain the growing network of programs across the country. The infrastructure would ensure that programs are high quality, true to their intended model, and linked to other critical early childhood systems, thereby creating a seamless and holistic network of support for at risk families.
New Federal Support for Home Visitation
Home visiting received an unprecedented boost in 2010 through the passage of the Patient Protection and Affordable Care Act, which established the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. This program provides $1.5 billion over 5 years to states to establish evidence-based home visiting programs for at-risk pregnant and parenting women, children from birth to age 5, and their families. The majority of the funding is used by states to implement program models that have demonstrated their effectiveness based on rigorous evaluation findings. The remaining portion of funds is distributed through states to “promising approaches” that have not yet demonstrated their efficacy with evidence that meets the level of rigor required by federal mandates, but must be evaluated if implemented through MIECHV. These significant new resources have led to the addition and expansion of home visiting programs in communities across the country. In addition, resources are being allocated to expand new infrastructure-building initiatives to bolster the field of home visiting and better integrate home visiting services into a broad system of early childhood supports. The evaluation component of the MIECHV initiative, which includes all competitive and promising approach awards, will also contribute new understanding of home visiting implementation among the diverse populations it aims to support.
Home Visiting Infographic
A trusted face at the front door can bring parents the support they need to nurture their young child’s healthy development. Home visiting reaches families where they live by delivering parent support and child development services directly in the home environment.
1. Support the development and expansion of evidence-based home visiting models endorsed by MIECHV and other promising high-quality programs with a proven track record of success.
In planning for MIECHV, Mathematica Policy Research, Inc., in partnership with key federal agencies under the Administration for Children and Families (ACF), launched Home Visiting Evidence of Effectiveness (HomVEE) to conduct a transparent and extensive review of home visiting research and assess the quality and rigor of the evidence. This assessment determined which home visiting models are considered evidence-based and thus could be selected and implemented by the states with federal MIECHV dollars. HomVEE has also established an ongoing process to review new research literature that may be in the evaluation pipeline. See http://homvee.acf.hhs.gov/ for more information. While the growth of the approved program models will lead to more parents receiving this critical support during their child’s early years, many families will still not have access to high-quality research-based programs. Current MIECHV implementation data shows that new funding reaches 15% of U.S. counties. Policymakers should continue to expand access and funding for parent support and child development services delivered through home visiting, paying attention to resources that not only support the delivery of home visiting services but also support the rigorous evaluation of current evidence-based models and promising approaches in operation across the country.
2. Develop a continuum of care for young children and their families by coordinating home visiting efforts with other child development and family services in the community.
Connecting home visiting efforts, particularly those focused on children’s well-being and healthy development, with other child and family services in communities will help to ensure that young children and parents have the comprehensive support they need. In instances when parents and children have needs beyond those addressed by the home visiting program in which they are enrolled, they should be linked to additional resources available in their community, such as high-quality child care programs and comprehensive early childhood programs such as Early Head Start, early intervention programs, health assistance programs, and mental health services.
Every state has created a comprehensive child find and referral system under Part C of the Individuals With Disabilities Education Act, and there are explicit requirements for states to coordinate early identification efforts between health, social service, and educational systems. Similar coordination efforts are required under the Health Resources and Services Administration (HRSA) Maternal and Child Health Early Childhood Comprehensive Systems (ECCS) grant program. ECCS grants help states and communities to build and integrate early childhood service systems in the areas of a) access to health care and medical homes, b) social-emotional development and mental health, c) early care and education, d) parenting education, and e) family support. State efforts to expand home visiting should formally integrate these services and ensure that families are being appropriately matched with available home visiting and other early childhood services.
However, in many communities, high-quality clinical intervention services (i.e., substance abuse treatment and mental health) are neither available nor accessible to parents with very young children. State leadership that encourages the development of the continuum of care is critical to the success of home visiting. This leadership can take the form of gubernatorial initiatives, interagency planning groups, or system changes to provide universal access to services.
3. Build state systems for home visitation and integrate home visiting infrastructure into broader early childhood systems.
As states and communities establish and expand home visiting services, the need for state-level infrastructure to support program development becomes essential. Such system work includes developing state-supported and coordinated efforts in the areas of professional development, cross-model standards, data collection and evaluation, continuous quality improvement, and processes to deliver high-quality technical assistance. Home visiting initiatives at the state level should seek to coordinate across all home visiting programs being implemented within the state (whether federally funded or not), while also embedding home visiting within a broader state early childhood system. Federal regulations for related programs create opportunities for collaborative state and community planning. For example, home visits are included with family training and counseling as part of the definition of early intervention services under Part C and, according to the most recent data reports, approximately 87% of all Part C services for infants and toddlers with developmental delays or disabilities are provided in home settings.
Representatives of home visiting programs should participate in community and statewide collaborative groups to improve the coordination of services for young children and their families across agencies and programs. In addition, governors should appoint home visiting representatives to the State Advisory Councils on Early Childhood Education and Care and other state-specific early childhood oversight boards. MIECHV has supported the development of home visiting systems through the availability of competitive grants that reward program expansion and encourage the development of system infrastructure components.
4. Ensure that home visiting services are culturally competent, responsive, and language appropriate.
Home visiting programs serve an ethnically diverse population including immigrant and refugee families. In this country, 63% of infants and toddlers (under age 3) with immigrant parents—1.3 million—live in low-income families. In addition, Black, American Indian, and Hispanic children represent a disproportionate share of the low-income population under age 3 (55%). Home visiting services have been found to reduce the language and cultural barriers faced by families and ensure that parents receive the support and resources they need to promote their child’s healthy development, despite the obstacles presented by poverty. Policymakers and program administrators should ensure that services delivered through home visiting programs are culturally appropriate and consider the barriers that families endure in today’s society and economy. In order to engage, retain, and support diverse populations, home visiting programs must integrate cultural competency and responsiveness into every aspect of the design and implementation of the program.
5. Ensure that all home visiting initiatives incorporate known elements of effectiveness and best practices.
There is growing consensus on the list of key elements of effective home visiting models that are most likely to achieve outcomes for young children and their families. This list includes: solid internal consistency that links specific program elements to specific outcomes, well-trained and competent staff, high-quality reflective supervision that includes observation of the provider and participant, strong leadership and organizational capacity, linkages to other community resources and supports, and consistent implementation of program components. Policymakers should ensure that new home visiting initiatives utilize models that incorporate these key elements and are focused on high-quality service design and delivery. In addition, as services are expanded within states, policymakers should ensure that program models are implemented with commitment to fidelity so that key elements are not diluted as the programs expand.
6. Support rigorous, ongoing evaluation and continuous quality improvement efforts for home visiting programs.
Program evaluation allows home visitors, supervisors, funders, families, and policymakers to know whether a program is being implemented as designed and how closely it is meeting its objectives. This information can be used to continually refine and improve service delivery for young children and their families, as well as provide an evidence-based rationale for the expansion of home visiting programs. When financing home visiting programs, policymakers should ensure that adequate time and funding are included for thorough evaluation.
7. Ensure that home visiting services address the distinct needs of high-risk families, including those coping with the challenges of domestic violence, substance abuse, and mental health issues.
Home visiting programs report that families are experiencing higher risk issues over time, with many participants experiencing multiple risk factors simultaneously. Domestic violence, maternal depression, and addiction plague many home visiting participants, which often makes effective intervention with those families challenging for home visiting professionals. Home visiting and other early childhood programs are evolving to meet these high-risk needs, and effective models are emerging to assist these populations. Services to high-risk families can either be integrated into the home visiting programs themselves or connected via community linkages and referral systems. Policymakers and administrators should direct attention to these emerging models and continue to build support for this difficult work.
Home Visiting Evaluation and MIECHV
MIECHV has launched an array of efforts to strengthen and facilitate states’ efforts in tracking benchmark data, strengthening evaluation efforts, developing data systems, and implementing quality assurance systems. The body of evaluation findings that will emerge through MIECHV at both the state and national levels will be a tremendous asset to the further evolution of the home visiting field. As of the publication of this issue brief, 12 programs have been deemed “evidence-based” by the MIECHV initiative through the HomVEE assessment. Those models include: Child FIRST, Early Head Start-Home Visiting, Early Intervention Program for Adolescent Mothers (EIP), Early Start (New Zealand), Family Check-Up, Healthy Families America (HFA), Healthy Steps, Home Instruction for Parents of Preschool Youngsters (HIPPY), Nurse Family Partnership (NFP), Oklahoma’s Community-Based Family Resource and Support (CBFRS) Program, Parents as Teachers (PAT), Play and Learning Strategies (PALS) Infant6, and SafeCare Augmented. For more information on model specifics, see: http://homvee.acf.hhs.gov/Default.aspx. The federal home visiting evaluation efforts include:
Mother and Infant Home Visiting Program Evaluation (MIHOPE)
MIHOPE is sponsored by the U.S. Department of Health and Human Services, ACF, and HRSA. This evaluation, mandated by the Patient Protection and Affordable Care Act of 2010 (P.L. 111-148), is designed to build knowledge for policymakers and practitioners about the effectiveness of the MIECHV program in improving outcomes for at-risk children and families. The study includes: an analysis of the state needs assessments that were provided in the state MIECHV applications and an effectiveness study that includes an impact analysis to measure what difference home visiting programs make for the at-risk families they serve in areas such as prenatal, maternal, and newborn health; child development; parenting; domestic violence; and referrals and service coordination. The effectiveness study will also include an implementation analysis that will examine how the program models operate in their local and state contexts and describe the families who participate; and an economic analysis that will examine the financial costs of operating the programs.
A special goal of this study is the linking of implementation strategies to program impacts, thus informing the field about the types of program features or strategies that might lead to even greater impacts on families. For example, understanding how, and at what level, the average family participates in the program will provide context to any variation in impacts we find in the health of families. The primary data used in the study are expected to be collected by the research team through surveys, review of administrative records, interviews, observations, and staff logs. The study will be conducted by a team of organizations: MDRC (the lead), James Bell Associates, Johns Hopkins University, Mathematica Policy Research, and the University of Georgia.
Design Options for Home Visiting Evaluation (DOHVE)
The DOHVE project provides research- and evaluation-related technical assistance (TA) to MIECHV program grantees. Specifically, the DOHVE TA team assists state, territory, and tribal grantees with:
- developing plans for collecting data on benchmarks;
- designing and strengthening evaluations of promising programs and evaluations being done as part of competitive grant projects;
- selecting, adapting, and developing data collection tools and measures;
- developing and adapting data systems to facilitate tracking and reporting on federal benchmarks;
- designing and implementing continuous quality improvement (CQI) systems; and,
- establishing data protection and privacy policies and procedures.
This TA is provided through webinars, facilitated group calls with multiple grantees, technical assistance resource documents, and individual grantee calls, meetings, and written feedback.
The DOHVE project is funded by ACF and HRSA, and the work is performed under a contract awarded to MDRC, James Bell Associates, and Cincinnati Children’s Hospital Medical Center. For more information about DOHVE and links to the TA resources it has created, please see www.mdrc.org/dohve/dohve_resources.html.
Tribal Home Visiting Evaluation Institute (TEI)
The ACF Office of Planning, Research and Evaluation (OPRE) awarded the TEI contract to provide technical assistance, leadership, and support to promote excellence in community-based research and evaluation of MIECHV initiatives that serve American Indian and Alaska Native (AIAN) children and families through the Tribal Maternal, Infant, and Early Childhood Home Visiting program. The TEI will engage in activities that support tribal home visiting grantees in the identification and development of effective practices and systems for integrated services for home visiting in tribal communities. Examples of focal areas include: developing and implementing a rigorous evaluation of home visiting; selecting, adapting, and developing culturally appropriate data collection tools and measures; tracking and measuring benchmarks; developing and modifying existing data systems; continuous quality improvement; data protection and privacy; and ethical dissemination and translation of evaluation findings derived from research with AIAN to external audiences.
The staffing of the TEI reflects an understanding and sensitivity to issues of conducting an evaluation in a tribal setting and includes researchers who have a history of working with AIAN communities on the evaluation of home visiting. In FY11 the contractor has been funded to provide individualized, grantee-specific guidance around research and evaluation topics; begin analyzing and synthesizing challenges faced by grantees around research and evaluation; develop comprehensive, user-friendly synthesis of guidance for tribal grantees; and work with grantees on efforts to disseminate and share the knowledge they are building regarding effective home visiting in tribal communities. These activities will continue for the full 4-year contract. The award was made to MDRC, James Bell Associates, Johns Hopkins University, and University of Colorado at Denver.
A growing body of research demonstrates that home visiting can be an effective method of delivering family support and child development services. While home visiting programs share similar overall goals of enhancing child well-being and family health, they vary in their program structure, specific intended outcomes, content of services, and targeted populations. Over time, however, certain key cross-model outcome areas have emerged, including positive impacts on:
- school readiness,
- child health and development,
- child abuse and neglect,
- parenting practices,
- family economic self-sufficiency, and
- maternal health.
The following presents a sampling of research from the home visitation field. Full literature reviews and study details are available at http://homvee.acf.hhs.gov/Default.aspx.
High-quality home visiting programs can increase children’s readiness for school.
The first 3 years of life are a period of intense intellectual development during which the brain forms a foundation for later learning and development. High-quality home visiting programs can be an effective service delivery method to support early learning in these years, ensuring that children succeed in school and beyond. When compared to control group counterparts in randomized trials, infants and toddlers who participated in high-quality home visiting programs were shown to have more favorable scores for cognitive development and behavior, higher IQs and language scores, higher grade point averages and math and reading achievement test scores at age 9, and higher graduation rates from high school. One 7-year followup study showed that children enrolled in a high-quality home visiting program were more likely to participate in a gifted program and less likely to receive special education services or report skipping school than were children in the control group. In addition, two studies using stratified random sampling found that a high-quality home visiting program positively impacted school readiness through better parenting practices, increased reading to children at home, and a greater likelihood of enrollment in preschool programs.
High-quality home visiting programs can improve child health and development.
The domains of development are inextricably linked during the early years of life, and children need support for their physical, cognitive, and social-emotional development to thrive. Randomized trial research demonstrates that high-quality home visiting programs can be effective supports for children’s healthy development. Compared to control groups, babies of parents enrolled prenatally in home visiting programs had better birth outcomes, and the programs were found to have a positive impact on breastfeeding and immunization rates., In other randomized trials, participating children were found to have a reduction in language delays at 21 months, reductions in mental health problems, fewer behavior problems, and increased mental development. In addition, when compared to control groups, children of teen mothers who participated in a home visiting program showed gains in cognitive development.
High-quality home visiting programs can reduce child abuse and neglect.
Infants and toddlers need safe and nurturing surroundings in which they can develop and grow. By working with parents in their own environments, home visiting programs can reduce child abuse and neglect. In a randomized trial, a home visiting program reduced physical and psychological abuse after 1 year of participation and had the greatest impact on first-time and psychologically vulnerable mothers after 2 years of participation. In addition, compared to control groups, teen mothers who participated in a home visiting program and received comprehensive case management had fewer opened cases of child abuse or neglect. Finally, another randomized control trial at 7 years followup showed an 80% reduction in the average number of acts of serious physical abuse.
High-quality home visiting programs can enhance parents’ abilities to support their children’s overall development.
To ensure that babies grow up healthy and ready to learn, parents need resources and tools to help them fully support their child’s development. In randomized trials, home visiting programs were found to be effective methods for delivering these essential parent support services. When compared to control group counterparts, parents with very low incomes who participated in a home visiting program were more likely to read aloud, tell stories, say nursery rhymes, and sing with their child. Participants in home visiting programs also created more developmentally stimulating home environments, had more responsive interactions with their children, and knew more about child development. One high-quality program found that mothers were more likely to use appropriate limit-setting and parenting strategies that stimulated the child’s cognitive skills and to report using nonviolent discipline strategies.
High-quality home visiting programs can improve family economic self-sufficiency.
Economic security is vital for families with young children, yet a large percentage of families across our country continually struggle with attaining financial self-sufficiency and stability. Close to 15 million children in the United States (21% of all children) live in families with incomes below the federal poverty level. Poverty negatively impacts children’s physical, social, and emotional development and can impede their ability to learn. The risks are exacerbated for children who experience poverty when they are very young. Home visitation programs can counteract the negative consequences of economic insecurity and encourage success not only at home but also in school and at work. Home visitation programs help parents enroll in educational and training programs and pursue employment opportunities. In a series of randomized controlled trials of a nurse home visitation program serving unmarried low-income women, 82% more participants worked compared to the control group in the period up until their child turned 4. In another trial of the same program, participants were twice as likely to be employed as the control group at their child’s second birthday. A randomized controlled trial of another program demonstrated high participation in school or training compared to the rate of the control group; a particular benefit of this program was the setting of concrete goals with the mothers for their education and professional development. Finally, a 5-year followup study of another home visitation program found higher monthly income for study participants.
High-quality home visiting programs can improve maternal health.
The physical and mental transformations a woman goes through during pregnancy and after are significant and life changing. Home visitation programs often connect pregnant women to prenatal services to ensure a safe labor and delivery outcome for both the newborn and the mother. Home visitation programs also support the mother’s ongoing physical and mental health during the post-partum period as she navigates the changes that come her way. A series of randomized control trials of a nurse home visitation program show a range of positive effects on maternal health, including decreases in prenatal cigarette smoking, fewer hypertensive disorders in pregnancy, and fewer closely spaced subsequent pregnancies., A randomized control study of another program that works with a particularly high-risk population found that participant mothers showed significantly lower depressive symptoms than those in the control group and were less likely to report feeling stressed a year after participation. Finally, a randomized control study showed significantly less use of alcohol at 6-month and 1-year followups of a home visiting program.
Early childhood home visitation has a promising future that builds on its successful history serving vulnerable families across our nation. The new federal investments in home visiting augment a variety of existing state and private funding sources and provide an unprecedented opportunity to advance the field and positively impact a diverse array of the children and families most in need.
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