Journal Issue: Preventing Child Maltreatment Volume 19 Number 2 Fall 2009
Review of Home-Visiting Programs
The best known home-visiting program is the Nurse-Family Partnership, developed by David Olds and colleagues in Elmira, New York.15 Evaluations have been conducted in Elmira, Memphis, and Denver. Another popular home-visiting program is Hawaii Healthy Start,16 on which other home-visiting programs have been modeled. Most notably, Healthy Families America was originally based on the Hawaii model and offers services to families in many states around the country. Results have been published based on the outcomes of Healthy Families evaluations conducted in San Diego,17 Alaska,18 and New York state.19
We also review three programs in which home visiting is a key component, though not the only method of service delivery. Early Head Start20 and the Infant Health and Development Program21 had center-based components, and the Comprehensive Child Development Program included home visiting in addition to case management services.22 Finally, we review three smaller-scale home-visiting programs from abroad that have used rigorous evaluation methods and provide important insights into home visiting. The three are Early Start in New Zealand,23 a program for at-risk families in Queensland, Australia,24 and one for depressed mothers in the Netherlands.25 Table 1 shows the characteristics of the nine home-visiting programs included in this review.
Nurse-Family Partnership (NFP)
The NFP is the most well developed home-visiting program in the United States. Home visits are conducted by registered nurses who are specially trained to provide the visits to low-income, first-time mothers, beginning prenatally and continuing through the child’s second birthday. The NFP curriculum focuses on encouraging healthful behaviors during pregnancy, teaching developmentally appropriate parenting skills, and improving the maternal life course by reducing subsequent births and increasing the interval between pregnancies. During the first month prenatal visits are weekly, then taper to biweekly until the child is born. After the birth, weekly visits resume for the first six weeks, and then biweekly visits continue until the child is approximately twenty months old. The final four visits leading up to the child’s second birthday occur monthly.26
The program originally developed in Elmira served primarily white, rural adolescent mothers (400 mothers, divided into four different treatment groups) for whom data are available through the child’s fifteenth birthday.27 It was replicated in Memphis with an urban sample of 1,139 predominantly African American adolescent mothers and their children who have been followed through age nine28 and in Denver with an ethnically diverse sample of 735 low-income mothers and their children who have been followed through age four.29 Beginning in 1996, NFP programs began expanding to other states using a mix of private, local, and federal funds. Today the Nurse-Family Partnership operates well over one hundred sites in twenty-six states across the country. Four states (Colorado, Louisiana, Oklahoma, and Pennsylvania) have statewide initiatives, with families being served in every county. As of 2006, it was estimated that the NFP serves more than 20,000 families each year. The NFP plans to scale up services around the country to reach as many as 100,000 families by 2017.30
Hawaii Healthy Start Program (HSP)
Around the same time that the NFP program was getting under way in Elmira, the Hawaii Healthy Start program began in 1975 in a single site on the island of Oahu with the goal of preventing child abuse through early identification of family risks and the provision of home-based supports by trained paraprofessionals. After gaining support from state funding organizations, it expanded to the other Hawaiian islands during the mid-1980s.31 Since 2004, it has operated ten sites within Hawaii. Families of newborns are screened for their risk of child abuse and neglect and offered services if they meet eligibility criteria. The home-visiting program is long term and takes place over the first three to five years of the child’s life. In-home parent training is provided by paraprofessionals who have received at least five weeks of intensive training in topics such as parenting skills, child development, recognizing the signs of child abuse or neglect, problem solving, and domestic violence. In addition to teaching parents specific skills, home visitors also connect families with additional resources that are available in their communities.32 Hawaii’s Healthy Start Program continues to be a statewide program that provides early identification and home-visiting services to families.
The major evaluation of HSP took place on Oahu, the home of the majority of the state’s residents as well as of six HSP sites. In addition to measuring baseline characteristics of families in the treatment and control groups and conducting follow-up assessments at one, two, and three years, evaluators collected data on the implementation of the program. In particular, evaluators assessed the process of home visiting by measuring the dose of service given to each family, such other elements of implementation as staff recruitment and training, and how well home visiting was integrated with other services in the community. In addition, home visitors’ notes were evaluated to assess the degree to which they recognized and responded to the needs of individual families.33
Healthy Families America (HFA)
Based in large part on the model developed for the Hawaii Healthy Start project, Healthy Families America began as a similar program with similar goals in the continental United States in 1993. With support from Prevent Child Abuse America and the Ronald McDonald Foundation, HFA also provides home-based support for disadvantaged mothers beginning prenatally or just after the child’s birth and continuing for three to five years. Healthy Families America uses trained paraprofessionals to provide in-home support for disadvantaged mothers to promote parenting skills, support optimal child development, and improve maternal self-sufficiency. Preventing child abuse and neglect is a specific goal of the program. HFA programs have been implemented in twenty-two states and the District of Columbia, and most have included some sort of evaluation component. Of these, only three have conducted rigorous randomized controlled trials: San Diego, Alaska, and New York.34
The Healthy Families San Diego (HFSD) evaluation was conducted from 1999 to 2000 and included 489 families who were randomly assigned either to receive home visiting from Healthy Families staff or to serve as controls. The evaluation consisted of a baseline assessment before enrollment in the program, as well as in-home interviews at twelve, twenty-four, and thirty-six months. Brief phone interviews every four months ensured more frequent contact with program families.35 In Alaska, the evaluation of Healthy Families took place on a statewide basis from 2000 to 2003. The total sample consisted of 316 families who were eligible for enrollment in one of the state’s six program sites. Families were assessed before randomization and again when the child was twenty-four months old. Every eight months, the research staff made contact with the families to maintain current records.36
Most recently, the state of New York has undertaken an evaluation of its Healthy Families program. The assessment took place in three of the most developed sites in the state representing diverse communities and included more than 1,000 participants. A unique feature of the HFNY program was its emphasis on recruiting mothers prenatally instead of after the birth of the child.
Prenatal recruitment among first-time mothers ensures that the program offers primary prevention. That is, the program is able to prevent child abuse before it ever happens. Recruiting mothers who have already given birth or those with other children may mean that some families have already engaged in child maltreatment; for these families, the program provides what is called secondary prevention.37
Comprehensive Child Development Program (CCDP)
During the early 1990s the CCDP was the most prominent early intervention in the country. As a federally funded program aimed to enhance the development of children in low-income families while providing support to parents, it provided services to 4,410 families and children in twenty-two states across the country. Although home visiting was the primary method of service delivery, the CCDP was not conceptualized as a home-visiting program because it provided comprehensive case management services to families while linking them to community resources in addition to delivering home-based parenting skills training. Families received hour-long home visits at least twice a month beginning in the child’s first year of life and continuing until school entry. The evaluation of CCDP consisted of annual assessments on the child’s second through fifth birthdays and smaller assessments at eighteen and thirty months.38
Infant Health and Development Program (IHDP)
The Infant Health and Development Program began in 1985 as a follow-up to the Abecedarian Project that was specifically geared to premature infants with low or very low birth weight. The program recruited 985 families in hospitals and assigned them randomly to the intervention group or controls. In both groups babies received developmental checkups from a physician, but the intervention group received additional services for the first three years of the child’s life. Home visits took place weekly during the first year and then biweekly during the second and third years. In the second and third years, children in the treatment group also received high-quality full-day child care, and parents were invited to participate in bimonthly parent group meetings. Although most outcomes were reviewed at program completion to observe the effects of a high-intensity comprehensive treatment program for low-birth-weight infants,39 certain outcomes were examined after the first year and provide a test of the home-visiting component on its own.40
Early Head Start (EHS)
Early Head Start, a federally funded two-generation program that includes parent education and quality early care and education for children, began in 1995 as a precursor to today’s national Head Start program for families with children from birth to age three. The national evaluation of EHS was planned from its inception and included randomized controlled trials of different aspects of the program. Although home visiting was a major component of the service delivery model, EHS also used center-based child care or a mix of home- and center-based services (seven of the seventeen sites provided home visiting only).41 Because EHS sites used either home visits, center-based child care, or a combination of both, an empirical test of the effectiveness of home visiting was built into the evaluation. Families were recruited during pregnancy or within the first year of the child’s life and were eligible based on low family income. The evaluation included 3,001 families at seventeen sites nationwide and consisted of baseline assessments as well as follow-up assessments when children were fourteen, twenty-four, and thirty-six months old.42
Early Start is a home-based family support program that offers services to 443 families in Christchurch, New Zealand. It is part of a larger network of home-visiting services that are provided in thirty-two sites around the country. Early Start follows the Healthy Families America model of providing home-based supportive services to vulnerable families on the basis of risk screening. Families become eligible for services after being determined to be at an elevated risk for adverse outcomes including child maltreatment. The goals of the program are to assess the strengths and needs of the families served, to develop positive relationships, to improve family problem solving, and to provide support, mentoring, and assistance in helping families connect to their own resource networks. The goals are attained through sustained contact that occurs from shortly after the child is born through the preschool years.43
The frequency of home visits depends on a family’s level of risk. Those who are considered to be at highest risk are visited up to two and a half hours every three months for up to two years. Home visits are conducted by family support workers who have degrees in either nursing or social work and have received five weeks of additional training specific to the goals and procedures surrounding the Early Start Program. The program has been evaluated with a randomized trial, and outcomes have been examined at six, twelve, twenty-four, and thirty-six months after program entry.44
The Queensland, Australia, home-visiting program has been evaluated by K. L. Armstrong and colleagues and by J. A. Fraser and colleagues.45 Its goals were to build trusting relationships among family members, improve parenting self-esteem and parenting efficacy, provide information about child health and development, and link families to other resources in the community. The program was offered to 181 mothers who were considered at risk for poor parenting. Participants were recruited in the hospital after the birth of a child. Those who were randomly assigned to the treatment group received weekly nurse visits for six weeks, biweekly visits for the next three months, and then monthly visits until the child was six months old. Outcomes were assessed at six weeks, at twenty-five weeks, and again at twelve months.46
Karin van Doesum and colleagues evaluated a home-visiting program in the Netherlands that was aimed at preventing relationship problems between depressed mothers and their infants. All seventy-one mothers in the treatment and control groups were receiving treatment for their depressive symptoms. In addition, the treatment group received eight to ten home visits lasting sixty to ninety minutes over a period of three to four months. Mothers were visited in their homes by one of fourteen master’s-level psychologists or social psychiatrists who had also received additional graduate or postgraduate training in prevention or health education. The evaluation consisted of a baseline assessment and two follow-up assessments—one within two weeks of program completion and another six months later.47
Because these nine programs differed widely in their targets, method of service delivery, intensity, and content, it is not surprising that their outcomes also often differed substantially as well. The result is a body of research that is somewhat conflicted regarding essentially every outcome under study. Next we turn to a discussion of the outcomes of home-visiting programs, with a focus on those outcomes that are most relevant to preventing child abuse and neglect.