Home Visitation: Looking Closely at What Works

There are significant differences between the various health care reform bills currently moving through the House and Senate, but here’s one thing they all have in common: each would provide a substantial infusion of federal funding for home visitation programs that provide information to pregnant women and disadvantaged or first-time mothers about how to keep their babies healthy and safe.

Advocates cheer this potential expansion, pointing to the decades of research showing the effects of the Nurse Family Partnership program, started in 1977 in Elmira, N.Y., and now available in at least 26 states. But NFP is hardly the only model of home visitation programs out there, nor is it the only one that the new federal program would support. Do other models have strong research evidence showing they produce positive outcomes for children and mothers? What exactly are those outcomes? Are some models of home visitation more or less cost-effective than others?

Two new research reports show that the answers aren’t as clean-cut as advocates suggest. Kimberly S. Howard and Jeanne Brooks-Gunn, writing in the latest issue of The Future of Children, review the body of literature on various home visiting programs from across the United States and abroad and find mixed results. And a SRCD Social Policy Report by Jennifer Astuto and La Rue Allen of New York University provides a historical overview of home visitation programs and an analysis of research findings.

Howard and Brooks-Gunn’s article, “The Role of Home Visiting Programs in Preventing Child Abuse and Neglect,” reviews the literature on nine home visiting programs: the Nurse-Family Partnership (NFP); Hawaii Healthy Start; Healthy Families America; the Comprehensive Child Development Program; Early Head Start; the Infant Health and Development Program; the Early Start Program in New Zealand; a program in Queensland, Australia; and a program in the Netherlands. Each program uses slightly different means to arrive at slightly different ends. The NFP program and the Queensland program, for example, employ registered nurses. Many of the others use trained paraprofessionals instead. Researchers evaluating the programs also focused on slightly different outcome indicators, including effects on child abuse, child health and safety, home environment, parenting sensitivity and responsiveness, parenting harshness, depression and parenting stress, and child cognition. Most studies looked at only some of these indicators.

The results, not surprisingly, are mixed. (Howard and Brooks-Gunn summarize the results in this helpful grid.) The NFP program in Elmira reduced child abuse, improved child health and safety, and improved parenting practices, but didn’t seem to affect parenting stress or depression and had mixed results for child cognition. By contrast, Healthy Families in San Diego reduced harsh parenting practices and reports of child abuse and neglect, but had no impact on child health and safety or the home environment. And the differences between those two programs are just two examples among many.

Astuto and Allen’s report is titled “Home Visitation and Young Children: An Approach Worth Investing in?” And that question mark reflects continuing uncertainties about what exactly works when it comes to home visitation. The article reviews major studies of programs in the United States and highlights areas that are ripe for future research, such as how to scale up programs without losing critical elements that made them effective. But, the authors argue, simply relying on home visitation is not the answer. Rather, “Movement away from the notion that home visitation alone is a panacea for addressing the ills of poverty towards a more integrated, system-level approach to intervention and prevention is an idea whose time has arrived.”

There’s wisdom in that admission. A better scenario is to imagine a robust and well-coordinated system connecting many different high-quality services that offer parents choices depending on their family’s needs. The proposed federal Early Learning Challenge Grants should help stimulate state efforts to create or improve that coordination. Thus it’s good timing that Congress is addressing both pieces of legislation now.

At Early Ed Watch, we see ambiguities in the literature on the effectiveness of home visiting programs not as an indictment of those programs but as an important reason for states to carefully scrutinize the home visitation programs they and other entities within their borders already fund. This will be all the more important as new federal funds come into the states for home visiting.

For example, the home visitation program in the Senate Finance Committee’s health reform bill would require states to measure the effectiveness of home visiting programs and track progress in six areas: maternal and child health, childhood injury prevention, school readiness, juvenile delinquency, family economic factors, and coordination with community resources. If states fail to show improvement in at least four of these areas after the third year of the grants, they would be required to receive technical assistance.

Clear definitions for what qualifies as “effective” will be important, given how many variations in outcomes already apparent in the current research.

Done right, new federal investments in home visiting could have the potential not just to expand funding for home visitation, but also to encourage states to focus existing funds on models that produce the greatest bang for the buck.

Note: The Society for Research in Child Development has also published a series of policy briefs on home visitation, including how to implement evidence-based programs and how to reach disadvantaged families.