Evidence-based home visiting to enhance child health and child development and to support families
By Lauren Supplee, PhD and Terry Adirim, MD
Home visiting is a service and support delivery strategy for families that has been around for over a century but gained prominence in the 1960s (Weiss, 1993). Home visiting can be an effective mechanism to reach the highest risk families. Prior to 2010, there were estimates that states spent between 500 and 750 million dollars annually on home visiting programs (Stoltzfus & Lynch, 2009). Through a provision of the Affordable Care Act, home visiting has been greatly expanded with $1.5 billion over 5 years to be provided to states, territories and tribes to establish evidence-based home visiting programs for at-risk pregnant women and children from birth to age five. This provision created the Maternal, Infant and Early Childhood Home Visiting Program (MIECHV) to respond to the needs of children and families in communities at risk. The Health Resources and Services Administration (HRSA) and the Administration for Children and Families (ACF) collaborate to implement MIECHV. Home visiting should be viewed as one of several service strategies embedded in a comprehensive, high-quality early childhood system that promotes maternal, infant and early childhood health, safety and development; strong parent-child relationships;and responsible parenting among mothers and fathers. Together, HRSA and ACF envision high-quality, evidence-based home visiting programs as part of an early childhood systemfor promoting health and well-being for pregnant women, children through age 5, and their families. MIECHV provides anunprecedented opportunity for collaboration and partnership at the federal, state, and community levels. Through collaborativeefforts with partners, this program has the opportunity to effect changes that will improve the health and well-being of vulnerablepopulations by addressing child development within the framework of life course development and a socioecological perspective.
The legislation specifies that MIECHV must target communities at-risk. The legislation defined communities at-risk as those with high concentrations of: premature birth, low-birth-weight infants and infant mortality, including infant death due to neglect or other indicators of at-risk prenatal, maternal, newborn or child health; poverty; crime; domestic violence; high rates of high-school dropouts; substance abuse; unemployment; or child maltreatment. In addition, the legislation specifies priority for specific high-risk populations including those: living in a community at-risk, low income, pregnant women younger than 21 years, families with a history of child abuse or neglect, families with a history of substance abuse, families with tobacco users, families with children with low student achievement or developmental delays and military families. The MIECHV program is unique as one of the first evidence-based policy initiatives. The program reserves 75 percent of funding for the implementation of one or more evidence-based home visiting models. In addition, the legislation support scontinued innovation by allowing for up to 25 percent of funding supporting promising approaches and rigorous evaluation of those approaches. To inform the execution of the MIECHV program, the Home Visiting Evidence of Effectiveness (HomVEE) project was launched to conduct a thorough and transparent systematic review of the home visiting research literature.
Home visiting evidence of effectiveness systematic review
HomVEE provides 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 review includes a broad literature search, an assessment of the quality of the study design to produce unbiased impact estimates, and a determination of whether the model meets the HHS criteria for evidence of effectiveness. The HomVEE website summarizes which models were found to have evidence of effectiveness, 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. To date, 22 models have been reviewed and nine meet the HHS criteria for evidence of effectiveness: Child FIRST, EarlyHead Start-Home Visiting, Early Intervention Program for Adolescent Mothers, Family Check-Up, Healthy Families America, Healthy Steps, Home Instruction for Parents of Preschool Youngsters (HIPPY), Nurse Family Partnership and Parents as Teachers. The following is a brief summary of the evidence from rigorous research available for primary measures (e.g. direct observation, direct assessment, administrative records or self-report on a normed, standardized measure). Most of the nine evidence-based models had favorable impacts on child development or school readiness and positive parenting. Three of the nine models had impacts on maternal health, five of the nine models had impacts in child health and three of the nine had impacts in child maltreatment. However, the review highlighted areas where more research is needed. For example, few of the reviewed models had impacts, using primary measures, on crime or family violence, family economic self-sufficiency, or coordination of resources and referrals. For more information on the review results see the executive summary (PDF, 280KB) and for more information about lessons learned, gaps in the research literature, and suggestions for strengthening future research in this area see the lessons learned (PDF, 308KB) document.
Research and evaluation
The MIECHV program has an exceptional focus on research and evaluation. First, the legislation requires a national evaluation of this new program. The Mother and Infant Home Visiting Program Evaluation (MIHOPE) will include approximately 12 states, 85 local implementing agencies and 5,100 pregnant women or families with infants less than 6 months of age to examine the efficacy of MIECHV, the efficacy of MIECHV by variations in programs and populations, and the potential for MIECHV to reduce costs and create efficiencies. This evaluation includes examining impacts across all of the domains in the legislation as well as a detailed cost and implementation study. The intent of the design will be to link features of programs, for example the training of staff in specific outcomes like child health, to impacts, such as impacts in child health. More information about this study can be found at the HHS website.
The legislation also calls for a continuous program of research to increase knowledge about implementation and effectiveness of home visiting programs. The first two Funding Opportunity Announcements have been announced: one to create an interdisciplinary research forum on home visiting research and the second to support applied research relating to home visiting services which show promise of advancing knowledge about the implementation and effectiveness to improve life outcomes among mothers, infants and young children. Information about these activities can be found at the HHS website or the grants website.
Third, if a grantee chooses to implement a promising approach, that approach must be rigorously evaluated and that design must meet HomVEE standards for study design quality. In addition, in FY11 competitive grants were also awarded to some grantees and the activities under those grants to expand services or enhance existing services were required to be rigorously evaluated. Many states are partnering with academic researchers to study activities such as: scale up of evidence-based homevisiting, the efficacy of enhancements on home visiting models or the efficacy of infrastructure supports such as state- or county-level centralized intake systems.
Finally, the legislation requires grantees to collect regular benchmark data on a range of domains and demonstrateimprovement in those domains within three years. The domains include maternal and child health, child development andschool readiness, child maltreatment, family economic self-sufficiency, crime or domestic violence and increases incoordination of resources and referrals. Building from the legislatively mandated benchmark data collection, grantees havebeen required to establish continuous quality improvement (CQI) plans to specify the processes and outcomes of the grantee’s MIECHV program through regular data collection, the use of data to inform administration, and monitoring the application of changes to improve performance. It is anticipated the use of CQI methods in the MIECHV Program will result in more effective program implementation and improved participant outcomes.
The MIECHV program provides an unprecedented opportunity to reach families and communities at-risk for health disparities. To date, approximately 40 percent of the grantees anticipate service to rural communities, reaching some of the children and familiesleast able to access other services. Evidence-based home visiting models address physiological, social, psychological, economic, family and other factors that influence children’s health and development. The grounding of this program inevidenced-based policy recognizes the importance of using rigorous evidence of effectiveness to inform decision-making. Coordination of these services, including partnerships with clinicians and researchers working towards improving services andoutcomes for children and families, is critical to MIECHV’s success. We look forward to promoting collaborative activities that are essential for effective, comprehensive home visiting and early childhood systems.
Lauren H. Supplee, PhD, is a senior social science research analyst within the Division of Child and Family Development in the Office of Planning, Research and Evaluation for the Administration for Children and Families. She is the home visiting research team lead and co-leads the OPRE Dissemination & Implementation workgroup. Her research interests include evidence-based policy, social-emotional development in early childhood, parenting, prevention/intervention programs for children-at-risk and implementation research.
Terry Adirim is the director of the Office of Special Health Affairs (OSHA) of the Health Resources and Services Administration (HRSA) in the U.S. Department of Health and Human Services. She is also the lead for the Affordable Care Act Maternal, Infant and Early Childhood Home Visiting Program, which is a five year, $1.5 billion dollar program that provides funding to states, territories and tribal communities to provide evidence-based home visiting services to at-risk families.
Stoltzfus, E., & Lynch, K. (2009). Home visitation for families with young children. Washington, DC: Congressional Research Service.
Weiss, H.B. (1993). Home Visits: Necessary but Not Sufficient. The Future of Children, 3, 113-128.