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Home Visitation in 2005: Outcomes for Children and Parents

Home Visitation in 2005: Outcomes for Children and Parents. Deanna S. Gomby, Ph.D., M.S. Deanna Gomby Consulting (408) 736-8450 eleganttern@earthlink.net Invest in Kids Working Group Washington, D.C. September 19, 2005. Home Visiting Programs in This Review.

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Home Visitation in 2005: Outcomes for Children and Parents

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  1. Home Visitation in 2005: Outcomes for Children and Parents Deanna S. Gomby, Ph.D., M.S. Deanna Gomby Consulting (408) 736-8450 eleganttern@earthlink.net Invest in Kids Working Group Washington, D.C. September 19, 2005

  2. Home Visiting Programs in This Review • Primary prevention programs that provide ongoing home visiting services, focusing on families with children ages prenatal/birth to 3 or 5 years. Examples: • Parents as Teachers • Early Head Start (some sites) • Nurse-Family Partnership • Home Instruction for Parents of Preschool Youngsters • Parent-Child Home Program • 400,000 or more families served annually in thousands of programs in the U.S.

  3. Home Visiting Studies • Hundreds of studies; many literature reviews and meta-analyses • Mixed results, depending on inclusion criteria: • Study methods • US only or international • Programs differ • Home visiting alone or in combination with other services • Few longitudinal studies • Few cost-benefit analyses • Programs evolve, but studies are static

  4. Main Points • Popularity driven by results of a few studies • Most studies show varied results across program goals, program models, sites, and families. • Most studies demonstrate benefits of about .1 - .2 standard deviation in effect size. • Bolstering quality would probably improve effectiveness. • Home visiting is most effective for families where initial need is greatest and/or where parents see the need for change. • Home visiting plus center-based early childhood programs: larger, longer-lasting effects, especially for children’s cognitive development or school achievement outcomes

  5. Logic Model for Typical Home Visiting Program

  6. Program Variation • Goals • Populations served • Onset, duration, and intensity of services • Staffing • Curricula

  7. Outcomes to Expect:Best Case for Home Visiting Services • Nurse Family Partnership -- Elmira, New York • Decreases in preterm births and low birth weight births (only very young teens, smokers) • Decreases in arrests, convictions, smoking, drinking, sexual partners (age 15) • Fewer substantiated reports of child maltreatment over 15 years; fewer hospital visits for injuries/ingestions • For the mothers: less welfare, greater deferral of second births • Over 15 years, 4:1 savings to government, primarily through decreases in welfare costs and crime, and only if delivered to high-risk families

  8. Home Visiting Services: Typical Results • Variability across goals, across program models, across program sites implementing the same model, and across families at a single site • Modest in magnitude • Struggles with implementation issues

  9. Home Visiting Services: Typical Results by Goal Area • Parents • Parenting skills: knowledge, attitudes, behavior • Mothers’ lives • Stress, social support, mental health • Economic self-sufficiency: deferral of pregnancies, education, employment, income

  10. Home Visiting Services: Typical Results by Goal Area (cont.) • Children • Promotion of child health • Nutrition/breastfeeding • Immunizations, well-baby check-ups • Birth outcomes: preterm birth, low birth weight • Child health status and physical growth • Health and safety • Home safety hazards • Unintentional injuries • Prevention of child abuse and neglect(rates;proxy measures) • Children’s cognitive development • Language development • Academic achievement • Social and emotional development

  11. Home Visiting Services: Typical Results by Goal Area (cont.) • Other outcomes (proposed or anecdotal) • Parent involvement in school activities • Parent support for schools (voting) • Likelihood to enroll in center-based early childhood programs • Home visitors’ life-course/professional development

  12. Explaining the Results • Working through parents or directly with children • Mediated versus direct • Intensity • Content matters • Addressing underlying risk factors (substance abuse, mental illness, domestic violence, cigarette smoking…) • Delivering content as intended • Time spent on parent versus child needs • Quality matters

  13. Home Visiting Plus Other Services • Home visiting plus center-based child-focused early childhood education • High/Scope Perry Preschool and others • IHDP (different population); 18-year-old results forthcoming • Early Head Start • Project CARE • Counter-examples: Even Start, CCDP…

  14. Long-Term Outcomes • Very few studies assess children beyond age 6 (Appendix C) • Most assess school achievement outcomes • Quasi-experimental studies: benefits through 6th grade and maybe high school, but scarcer with randomized trials • Best longitudinal study: NFP in Elmira, NY, but: • Focus on outcomes other than school achievement • Some mixed results across outcomes • Unclear if same magnitude of results will be achieved at other sites

  15. Long-Term Outcomes (cont.) • Rarely assessed but possible: • Effects on siblings • Effects on grandchildren • Fade-out and sleeper effects • Fade-out for IQ • Sleeper effects: Child abuse and neglect rates (NFP, Elmira)

  16. Cost-Benefit Analyses • Best analysis of an individual program: NFP • Best reviews: RAND (forthcoming) and Aos et al (2004) • Results: • From $0-$5.70 in benefits per dollar of cost, depending on program and families served, with NFP best. • Costs and benefits may not be estimated accurately • Site-to-site differences are likely because of differences in implementation and quality

  17. Quality Matters • Engagement of families: • 35-50% attrition within 1 year; as much as 80% attrition in 3 years • about 50% of scheduled visits actually delivered; as little as 6-8 hours of contact per year • Staffing • Limited training or supervision • Turnover: 50% over a few years • Content (focused and with fidelity): mixed • Cultural consonance: mixed • Services appropriate to high-need families: mixed

  18. Which Families Benefit Most? • Highest need – if matched with the right program • Families that are motivated to change

  19. Lessons • Home visiting produces benefits for parents and children, but typically, these benefits are modest in size • Quality matters • Home visiting plus center-based early childhood education – for longest lasting outcomes, and largest cognitive/school achievement outcomes

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