This review focuses on the evidence supporting home visiting’s impact on parenting outcomes among families with children under age 3. The review does not focus on a particular program model, but rather examines the effectiveness of a variety of program models as demonstrated in rigorous meta-analyses. Program models in the studies reviewed include, but are not limited to, Early Head Start (EHS) Home Visiting, Healthy Families America (HFA), Healthy Start, Home Instruction for Parents of Preschool Youngsters (HIPPY), the Nurse-Family Partnership (NFP), Parents as Teachers (PAT), Play and Learning Strategies (PALS) Infant, and SafeCare. The effects of individual program models have been presented independently in other reviews.B,E
The research discussed here meets our standards of evidence for being methodologically strong and allowing for causal inference, unless otherwise noted. Each strong causal study reviewed has been assigned a letter, and a complete list of causal studies can be found at the end of this review, along with more details about our standards of evidence and review method. The findings from each strong causal study reviewed align with one of our eight policy goals from Table 1. The Evidence of Effectiveness table below displays the findings associated with evidence-based home visiting programs (beneficial, null,iii or detrimental) for each of the strong studies (A through E) in the causal studies reference list, as well as our conclusions about the overall impact on each studied policy goal. The assessment of the overall impact for each studied policy goal weighs the timing of publication and relative strength of each study, as well as the size and direction of all measured indicators.
Table 2: Evidence of Effectiveness for Evidence-Based Home Visiting Programs by Policy Goal
|Policy Goal||Indicator||Beneficial Impacts||Null Impacts||Detrimental Impacts||Overall Impact on Goal|
|Nurturing and Responsive Child-Parent Relationships||Parenting Knowledge and Attitudes||A||Mixed|
|Quality of Family Relationships and the Home Environment||E||A|
|Parenting Behaviors and Skills||C, D|
*The HomVEE study found positive impacts on parenting in most of the 21 home visiting models included, but because the study examined a very large set of outcomes, null effects outnumbered significant effects.
Nurturing and Responsive Child-Parent Relationships
Among parenting programs, home visiting programs are the most extensively studied, likely in part because of MIECHV and the emphasis on implementing evidence-based programs. Parenting has been conceptualized and measured in a variety of ways as an outcome across studies of home visiting, including: “positive parenting,”iv,A “parenting behavior and parenting attitudes,”17 “parenting skills,”v,E “positive parenting practices,”vi,B and “maternal parenting behavior.”vii,D Studies have consistently shown small but significant effects for improving parenting behaviors (overall effect sizes on parenting outcomes from meta-analyses range from 0.09 to 0.37),A,17,C,D,E but studies have failed to consistently demonstrate significant impacts for other outcomes (birth outcomes,A,19 child maltreatment,C,17 child health,A,C etc.). Importantly, across outcomes, including parenting, the significant effects that emerge do so within the context of many more null findings.B,E Further, studies have done little to clarify which components of home visiting are particularly effective for outcomes (e.g., targeted population, frequency of visits).
A 2010 meta-analysis of 29 RCT and QED studies of home visiting programs targeting families at risk found a weighted mean effect size for home visiting that was significant and positive for maternal behavior (0.37).D A 2013 meta-analysis of 51 studies (experimental and nonexperimental, but with comparison groups) of home visiting programs targeting pregnant women and families with young children (ages 0 to 3) found a significant average effect size of 0.23 on parent behaviors and skills.C A 2016 meta-analysis of 156 studies (experimental and nonexperimental, but with comparison groups) of nine evidence-based home visiting programs focusing on children under age 5 found larger effects for positive parenting (0.26) and parenting knowledge (0.21) compared to other outcomes, including birth outcomes (0.08), child health (0.03), and child behavior (0.05).A
The federally funded HomVEE review of home visiting programs reviewed over 400 RCT or QED studies of 50 home visiting programs and identified 21 home visiting models as “evidence-based,” and most have demonstrated favorable impacts on positive parenting practices.BHowever, the favorable impacts on positive parenting practices emerged in the context of many more null findings.B The authors of the federally funded RCT evaluation of MIECHV (the Mother and Infant Home Visiting Program Evaluation—MIHOPE) provided a summary of the evidence from past studies of the four program models in MIHOPE (HFA, EHS, NFP, and PAT) and noted that “the quality of the home environment during early childhood is one of the most examined outcomes in the home visiting literature, but most estimated effects from studies have not been statistically significant” (pp. 48–49).E The authors went on to quantify the number of significant impacts relative to null impacts across outcomes in past studies and concluded that only “125 of the 1,104 estimated effects – or 11 percent – are statistically significant and indicate improved outcomes for families” (p. 20).E In addition to the review of past studies, the MIHOPE report also presented a current analysis of findings from 88 home visiting programs in 12 states across the four key program models. The analysis found a significant effect (0.09 effect size) for improving the quality of the home environment, but no significant effect on parental supportiveness.E
Finally, a 2004 meta-analysis of research articles and reports (both experimental and nonexperimental, including pre-post designs) of 60 home visiting programs17 serving families prenatally through age 5 that were included in a larger 2001 meta-analysis of family support programs20 found small but significant effects on parenting behavior and parenting attitudes (weighted mean standardized effect sizes were 0.14 and 0.11, respectively). The 2004 study is not included in the evidence review (Table 2) because of the inclusion of pre-post analyses.17
Several of the meta-analyses conducted in the last decade have examined studies across home visiting program models to identify the specific characteristics or components of home visiting programs that are associated with positive impacts, but a consistent pattern has failed to emerge.C,17 Targeting programs to families with one or more risk factors produced larger effect sizes overall compared to universal programs in one meta-analysis (0.20 versus 0.18),A but not in the MIHOPE evaluation of four program models.E And, in another meta-analysis, targeting higher-risk families was associated with smaller effect sizes for some outcomes, including parenting behavior, compared to universal approaches.17 Dosage demonstrates a similarly inconsistent trend—one meta-analysisD found that programs with more frequent visits were more likely to demonstrate improvements in maternal behaviors, but in the MIHOPE study, estimated effects were not larger among families who received more visits compared to families who received fewer visits.E
- An impact is considered statistically significant if p<0.05.
- Positive parenting referred to positive observed parent-child interactions; positive self-reported quality of relationships (supportive, accepting); positive behaviors (nonviolent discipline, praise, provision of play materials, reading to child); and parent involvement.
- Parenting skills encompassed the quality of the home environment and parental supportiveness.
- Positive parenting practices included observational measures of parent-child interactions or of the home environment and parent self-reports of parenting attitudes and practices.
- Improvements in maternal behavior were measured using observational scales, including the Home Observation for Measurement of the Environment (HOME) Scale, the Nursing Child Assessment Satellite Training (NCAST) scale, the CARE-Index of adult-child interaction, and the Maternal Interactive Behavior Scale.