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7
Family Literacy and Home Visiting Programs
Deanna S. Gomby
Home visiting programs reach hundreds of thousands of families with young children annually
and have been endorsed by the American Academy of Pediatrics (2009), the United States Gen-
eral Accounting Offi ce (1990), and the National Academy of Sciences (Chalk & King, 1998). In
fi scal year 2009–10, 46 states and the District of Columbia had state-based home visiting systems,
with state funding totaling at least $1.36 billion (Pew Center on the States, n.d.). Investment in
home visiting is growing: the federal 2010 Patient Protection and Aff ordable Care Act autho-
rized $1.5 billion over 5 years for home visiting expansion and evaluation.
Home visiting is an attractive strategy because it can bring services to socially or geographi-
cally isolated families; services can be tailored to meet the needs of individual families; and, if
services positively infl uence parenting skills, the programs can benefi t siblings as well as target
children (Gomby, 2005). In addition, the act of a service provider visiting a client’s home can
signal respect that may increase family acceptance of services (Korfmacher, Green, Spellman, &
Thornburg, 2007).
Home visiting is pertinent to family literacy in at least two ways. First, many family literacy
programs employ home visiting as the means to deliver parenting education. Second, many
stand-alone home visiting programs aim to achieve goals relevant to family literacy, such as pro-
moting children’s early language and literacy skills, or helping parents improve their parenting
skills, advance their education, gain employment, and/or promote their health literacy (a special
type of literacy).
This chapter begins with descriptions of the typical home visiting program and specifi c
national models that have family literacy goals. Then, research fi ndings from these and other
home visiting programs are summarized. Factors associated with quality in home visiting pro-
grams are discussed, along with strategies national models are employing to improve quality.
The chapter concludes with a discussion of the new federal legislation and its implications for
home visiting services.
Home Visiting Programs and Strategies to Promote Family Literacy Goals
Although many types of home visiting programs exist, this chapter focuses on the subset of
primary prevention programs that visit families with pregnant women, newborns, or young
children under age 5 on an ongoing basis, and seek to improve the lives of the children by
encouraging change in the attitudes, knowledge, and/or behaviors of the parents.
Most home visiting programs aim to create change by providing parents with (a) social sup-
port, (b) practical assistance such as linking families with other community services, and (c)
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education about parenting or child development (Larner, Halpern, & Harkavy, 1992). Figure
7.1 illustrates the logic model for a typical home visiting program with the seven outcomes most
relevant to family literacy listed in bold.
Figure 7.1 shows that the social support and practical assistance provided by home visitors to
families help to engage families and to build a trusting relationship between home visitor and
parent, which is key to home visiting eff ectiveness (Korfmacher, Green, Spellman, & Thorn-
burg, 2007; Krysik, LeCroy, & Ashford, 2008). Then, home visiting programs address parents’
knowledge of child development, their attitudes toward parenting, and/or their view of them-
selves as parents, leading to the stronger parenting skills and warm, responsive, parent-child
relationship that foster children’s healthy development. Programs may give books, toys, and
educational materials to families to encourage language and literacy development.
Other programs also seek to help mothers improve their economic self-suffi ciency, employ-
ment, and education—other outcomes relevant to family literacy programs. They do so by teach-
ing necessary skills, linking to job training or educational services, and/or by helping families to
access economic supports such as Temporary Assistance for Needy Families (TANF), Food Stamps,
and Medicaid.
Many programs also seek to promote children’s health by helping parents gain skills to navi-
gate the health care system and understand the health care advice given them by doctors or home
visitors. These skills are a form of “health literacy.” If programs can improve parental health
literacy, they should also improve child health.
Most programs also provide referrals for parents and children, including referrals to thera-
peutic services for children identifi ed with developmental delays or hearing or vision problems.
National Home Visiting Programs Relevant to Family Literacy
Six national home visiting models—Home Instruction for Parents of Preschool Youngsters
(HIPPY), Parents as Teachers (PAT), the Parent-Child Home Program (PCHP), Nurse-Family
Partnership (NFP), Healthy Families America (HFA), and Early Head Start (EHS)—have gener-
ated benefi ts for children or parents related to family literacy in one or more studies. Described
below, most serve populations similar to those served by family literacy programs.
Home Instruction for Parents of Preschool Youngsters (HIPPY)
HIPPY aims to maximize children’s chances for successful early school experiences by empow-
ering parents as primary educators of their children and fostering parent involvement in school
and community life. HIPPY operates 132 sites in 22 states and the District of Columbia (www.
hippyusa.org).
HIPPY off ers either 2- or 3-year programs (i.e., for 3- to 5-year-olds or for 4- to 5-year-olds).
Available in English and Spanish, the curriculum provides books and materials for parents to
use with their children—all designed to promote children’s cognitive skills, including language,
problem solving, logical thinking, and perceptual skills. Targeted early literacy skills include
phonological and phonemic awareness, letter recognition, book knowledge, and early writing
experiences. HIPPY also fosters the development of social/emotional and fi ne and gross motor
skills.
At least 30 times per year, HIPPY’s paraprofessional home visitors role-play activities (e.g.,
reading, writing, drawing, listening, talking, singing, playing games, puppetry, cooking, sew-
ing, poetry, movement, and fi nger plays) with parents, usually in home visits, although in some
programs, parents and home visitors meet regularly to role-play in a group.
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Parents as Teachers (PAT)
The mission of PAT is “to provide the information, support and encouragement parents need
to help their children develop optimally during the crucial early years of life.” The program
encourages the voluntary participation of all families. In 2010, about 3,000 Parents as Teachers
(PAT) sites operated in all 50 states and the District of Columbia, serving children prenatally to
age 5 (www.patnc.org).
PAT programs include home visits by trained and credentialed parent educators, scheduled
weekly to monthly, depending upon family needs; parent group meetings; health and develop-
mental screenings; and referrals to link families to community services.
PAT programs are off ered by school districts, hospitals, churches, and social service agencies
as stand-alone programs or as part of more comprehensive service delivery systems, such as Early
Head Start, Head Start, or Even Start programs, family resources centers, or in partnership with
other home visiting programs such as Healthy Families America (Gomby, 2005).
The Parent-Child Home Program (PCHP)
PCHP focuses on increasing parent-child verbal interaction and enabling parents to prepare their
children to enter school ready to learn and to achieve long-term academic success. In 2010, 137
PCHP sites operated in 14 states (www.parent-child.org).
Families receive two home visits per week for a minimum of 23 weeks in each of 2 years.
Families with children as young as 16 months may enter the program, but participants are usually
families with 2- and 3-year-olds. Paid paraprofessionals from the community, many of whom are
former parent-participants in the program, visit families who face poverty, low levels of educa-
tion, language barriers, and other obstacles to educational success.
PCHP works with primary caregivers to strengthen their parenting skills and to develop their
children’s skills in the cognitive (sensory-motor, conceptual development, and language devel-
opment) and aff ective (social emotional competence) domains. Home visitors emphasize verbal
interaction and learning through play using books and toys. Families are given the books and
toys used in the home visits, so that, upon completion of the program, each family has a library
of children’s books and a collection of educational puzzles, blocks, and games.
Nurse-Family Partnership (NFP)
NFP employs nurses to visit fi rst-time, low-income mothers and their families to accomplish
three goals:
1. Improve pregnancy outcomes by helping women to alter their health-related behaviors,
including reducing the use of cigarettes, alcohol, and illegal drugs;
2. Improve child health and development by helping parents provide more responsible and
competent care for their children; and
3. Improve families’ economic self-suffi ciency by helping parents develop a vision for their
futures, plan future pregnancies, continue their education, and fi nd work.
The program has been tested in randomized trials in three communities (Elmira, New York;
Memphis, Tennessee; and Denver, Colorado). As of 2010, the program operated in 195 sites in
32 states (www.nursefamilypartnership.org).
Nurses, typically public health nurses with a minimum of a bachelor’s degree, visit families
from pregnancy (beginning before the end of the second trimester) through the child’s second
year of life. Visits are scheduled every one to two weeks early on, changing to monthly as the
child nears two years of age.
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Healthy Families America (HFA)
HFA’s mission is to “prevent the abuse and neglect of our nation’s children through intensive
home visiting.” Its program goals are “to systematically reach out to parents to off er resources
and support; to cultivate the growth of nurturing, responsive, parent-child relationships; to pro-
mote healthy childhood growth and development; and to build the foundations for strong family
functioning” (www.healthyfamiliesamerica.org). HFA programs reach families in 34 states and
the District of Columbia to provide services aimed at helping improve the lives of both parents
and children and to link children with a medical home and other community services.
HFA does not require program sites to use a particular curriculum. Instead, a credentialing
process documents that each HFA program adheres to 12 critical elements related to service ini-
tiation, service content, and staff characteristics.
Systematic assessment of all families in an intended population within a community is a dis-
tinguishing feature of HFA. Around the time of birth, either in the hospital or at home, a trained
person listens to the family’s interests and concerns, links the family with community resources,
and, if families are at greater risk of parenting diffi culties, encourages the family to participate in
home visiting, beginning with weekly visits. Visit frequency is reduced as families meet goals,
which they develop with their home visitors. Services begin at a child’s birth (or during preg-
nancy) and can continue until the child is 5 years of age.
Early Head Start (EHS)
EHS provides services to pregnant and parenting families. In FY 2009, the budget for EHS was
$709 million, which funded more than 650 programs serving more than 66,000 children under
age 3. An additional $1.1 billion was appropriated for EHS as part of the American Recovery and
Reinvestment (U.S. Department of Health and Human Services, 2010).
Early Head Start serves low-income pregnant women and families with infants and tod-
dlers. Families must have incomes at or below the federal poverty level or be eligible for public
assistance, although 10% of children may be from families that exceed these income eligibility
criteria. At least 10% of program spaces are for children with disabilities.
EHS seek to promote the development of children, families, staff , and communities. Services
include early education in and out of the home, parenting education, comprehensive health and
mental health services, nutrition education, and family support services. Programs may off er
these services through center-based, home-based, or mixed models (center- and home-based).
Performance standards must be met for each component (e.g., weekly home visits or biweekly
group socialization opportunities). This chapter focuses on the home-based model. (See Boller
et al., this volume, for additional information on EHS.)
Benefi ts of Home Visiting Programs for Parents and Children
Each of the program models described above has produced benefi ts on one or more family-
literacy-related outcomes in one or more studies. Across evaluations of these and many other
home visiting models, however, the results have diff ered across program models, sites, and fami-
lies within sites. Meta-analyses suggest eff ect sizes for most outcomes, including those related
to family literacy, that typically range from .1–.2 in magnitude (Layzer, Goodson, Bernstein, &
Price, 2001; Sweet & Appelbaum, 2004). The following summarizes the results related to fam-
ily literacy outcomes, drawn from meta-analyses and literature reviews of home visiting. These
include a federally funded assessment that identifi ed evidence-based home visiting programs (the
Home Visiting Evidence of Eff ectiveness [HomVEE study] http://homvee.acf.hhs.gov/docu-
ment.aspx?rid=5&sid=20&mid=1).
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Benefi ts for Parents
Many evaluations of home visiting programs assess changes in parent knowledge, attitudes, and
behavior. Some also assess eff ects on maternal education, employment, and income. An even
smaller set of studies have begun to examine changes in parents’ health literacy and parents’
involvement in their children’s education.
Parenting knowledge, attitudes, and behavior. Several home visiting programs have demonstrated improvements in parents’ knowledge about child development, changes in their
attitudes toward parenting or disciplinary practices, or changes in behavior. Improvements in
parental self-effi cacy have been found in studies of Hawaii Healthy Start (Duggan et al., 1999),
Healthy Families Alaska (Caldera et al., 2007), and, for a subgroup of Latina mothers, Parents
as Teachers (Wagner & Clayton, 1999). More positive and sensitive parenting interactions have
been demonstrated in studies of Healthy Families New York (Rodriguez, Dumont, Mitchell-
Herzfeld, Walden, & Greene, 2010) and Early Head Start (Love et al., 2002).
Children who participated in Healthy Families Alaska (Duggan et al., 2007) were more likely
to live in homes that promoted their development, as measured by the HOME. So too were
children who participated in NFP in Memphis (Kitzman et al., 1997), while at the Denver NFP
site, just children whose mothers had low psychological resources at enrollment showed benefi ts
on the HOME at an age 4 follow-up (Olds et al., 2004).
Children who participated in Early Head Start home visiting were more likely than coun-
terparts in a control group to show benefi ts at an age 5 follow-up on the HOME language and
literacy subscales, and they were more likely to be read to daily (Love et al., in press).
A meta-analysis of United States home visiting programs concluded that home visiting pro-
duces small benefi ts in parenting attitudes (.11 of a standard deviation) and parenting behavior
(.14 of a standard deviation) (Sweet & Appelbaum, 2004).
Maternal education and employment. NFP, HFA, and EHS seek to improve the lives of mothers outside their roles as parents, with a focus on maternal education and economic
self-suffi ciency.
For example, in the Elmira, New York, NFP site, over the course of 15 years after the birth
of their children, the poor, unmarried women in the sample who had been home-visited spent
fewer months on welfare (Olds et al.,1999). In the fi rst 15 months of the EHS program, parents
who received home visiting services were more likely than control group parents to take part
in high school and ESL classes and in vocational courses, although there were no diff erences in
achievement of educational degrees, credentials, or employment (Love et al., 2001).
Other studies have shown no diff erences in having a degree or being enrolled in school (Dug-
gan et al., 1999); or in graduation from high school, earning a GED, or employment (Olds et
al., 2004).
A meta-analysis of American programs concludes that home visiting services have a small
eff ect (.13 of a standard deviation) on educational outcomes but no eff ect on maternal economic
self-suffi ciency (Sweet & Appelbaum, 2004).
Health literacy. At least 25% of parents have limited health literacy skills (Yin et al., 2009). These parents know less about health outcomes, behaviors, and health services (DeWalt &
Hink, 2009), are less able to calculate dosages of medication for their children or to understand
powdered formula mixing instructions (Sanders, Federico, Klass, Abrams, & Dreyer, 2009), and
their homes have fewer children’s books (Sanders, Zacur, Haecker, & Klass, 2004).
To address the problem, the federal government issued the National Action Plan to Improve
Health Literacy, which recommended expansion of “local eff orts to provide adult education,
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English language instruction, and culturally and linguistically appropriate health information
services in the community,” including via family literacy programs (U.S. DHHS, 2010). Though
some researchers have suggested that home visiting programs might be a strategy to improve
health literacy (e.g., Sanders et al., 2009), only a few home visiting interventions have focused
on health literacy.
One exception is an intervention to help Head Start and Early Head Start parents learn to
manage their children’s health care needs (Herman & Mayer, 2004; Herman & Jackson, 2010).
In a 2-hour training session, parents learn to use a health guide that describes how to handle 50
common childhood medical problems. In one study, parents received monthly home visits for 3
months prior to and 6 months after the training. At 6 months, parents reported that they were
less likely to seek help fi rst by going to the doctor’s offi ce or an emergency room when their
children were ill. Two years later, a subset of parents reported fewer workdays missed and fewer
school days missed by their children. The authors estimate savings of $554 per family per year
(Herman & Jackson, 2010).
In another approach, attention to health literacy is incorporated into existing home visiting
programs. Using a measure called the Life Skills Progression (LSP) (Wollesen & Peifer, 2006),
researchers have found benefi ts in (a) parents’ use of information and health care services and
(b) self-management of personal and child health at home. For participants in six home visiting
programs (including Healthy Families America and Early Head Start sites), these improvements
in LSP scores were correlated with child health care use (e.g., up-to-date immunizations and
well-baby check-ups) (AHRQ Health Care Innovations Exchange, n.d.).
Parent involvement in their children’s education. Surveys of parents in PAT (Pfannenstiel, Lambson, & Yarnell, 1996) and HIPPY ( Jacobson & Ramisetty-Mikler, 2000) and reports by
kindergarten teachers about children who had participated in PAT (O’Brien, Garnett, & Proctor,
2002) suggest that these parents were likely to participate in their children’s later schooling (e.g.,
attending school events and parent-teacher conferences, PTA events, volunteering, and helping
with homework).
Benefi ts for Children
Several home visiting programs have demonstrated benefi ts in cognitive or language develop-
ment and school achievement for at least some participating children.
Children’s cognitive development, language development, and academic achieve- ment. Studies of Parents as Teachers (Coates, 1994, as cited in Winter, 1999), HIPPY (Bradley & Gilkey, 2002), and the Parent-Child Home Program (Levenstein, Levenstein, Shiminski, &
Stolzberg, 1998) have demonstrated that home-visited children out-perform other children in
the community through grades 4, 6, or 12, respectively, on measures such as school grades and
achievement test scores on reading and math, suspensions, or high school graduation rates.
In many studies, however, only some participants show gains. Diff erent results have been
obtained by cohort and program site (Baker, Piotrkowski, & Brooks-Gunn, 1999), for low-SES
participants only (Drotar, Robinson, Jeavons, & Kirchner, 2008), by ethnic/racial group (Wag-
ner & Clayton, 1999), and only for children whose mothers had low psychological resources at
enrollment (Kitzman et al., 2010; Olds et al., 2007).
Meta-analyses report eff ects of home visiting on cognitive child development of .09 (Layzer,
Goodson, Bernstein, & Price, 2001; Nelson, Westhues, & MacLeod, 2003) to .18 (Sweet &
Appelbaum, 2004).
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Delivering Home Visits in Combination with Center-Based Early Childhood Education
The previous sections describe results for programs in which home visiting was the primary
service strategy, but home visiting is sometimes combined with center-based early childhood
education services. The literature about such eff orts is highly relevant to family literacy programs
which often employ home visits as a strategy to deliver parent education or other services.
In model programs such as the High/Scope Perry Preschool Program (Schweinhart, 2004),
the Syracuse University Family Development Research Program (Lally, Mangione, & Honig,
1987), and the Houston Parent Child Development Center ( Johnson & Walker, 1987), home vis-
iting services were combined with center-based early education services for children. Children
demonstrated benefi ts in school academic achievement and were more productive adults (less
crime and delinquency, higher educational attainment and employment) (Yoshikawa, 1995).
More recently, children who participated in PAT and center-based early childhood education
services outscored their peers on school readiness scales when they entered kindergarten (Pfan-
nenstiel, Seitz, & Zigler, 2002) and on communication arts achievement at third grade (Zigler,
Pfannenstiel, & Seitz, 2008). In Early Head Start, the children in program sites that off ered both
home visits and center-based services demonstrated larger and broader cognitive and language
development benefi ts than children in center-based or home-visiting-only sites when children
were 3 years of age (Love et al., 2002). The pattern of outcomes is somewhat diff erent at age 5,
and the authors draw no conclusion regarding which approach is better at the later age (Love et
al., in press).
The National Academy of Sciences concluded, “Programs that combine child-focused edu-
cational activities with explicit attention to parent-child interaction patterns and relationship
building appear to have the greatest impacts” (National Research Council and Institute of Medi-
cine, 2000, p. 11). In other words, the combination of parent- and child-focused services present
in family literacy programs should yield the largest and broadest benefi ts for children.
The Importance of Quality Services
The diverse results of home visiting programs reported above may be due to variation in service
quality. The National Academy of Sciences concluded that the key to program eff ectiveness is
“likely to be found in the quality of program implementation” (National Research Council and
Institute of Medicine, 2000, p. 398). National home visiting program models have begun to
focus on key elements of program quality. Summarized below, these elements are likely to be of
equal importance to family literacy programs.
Family engagement. Family engagement involves the ability of the program to (a) enroll families, (b) deliver services at the intended level of intensity, (c) retain families in the program,
and (d) maintain family involvement during home visiting and in recommended activities
between visits (Gomby, 2005).
Home visiting programs often have diffi culty in achieving all four elements, with the result
being that families receive fewer services than intended (Gomby, 2005). Often, 20% to 50% or
more of enrolled families leave home visiting programs before services are scheduled to end
(Duggan et al., 2007; Hicks, Larson, Nelson, Olds, & Johnston, 2008; McGuigan & Pratt, 2001;
Wagner, Spiker, Hernandez, Song, & Gerlach-Downie, 2001). Families that remain in the pro-
gram usually receive fewer than the scheduled number of home visits (Duggan et al., 1999;
Kisker et al., 1999).
Generally, literature reviews and meta-analyses suggest that families that receive more visits
achieve better results than those that receive fewer visits (e.g., Early Head Start, 2006), with some
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Family Literacy and Home Visiting Programs
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researchers concluding that at least three or more visits per month are needed to produce benefi ts
(Kahn & Moore, 2010; Nievar, Von Egeren, & Pollard, 2010).
Multiple factors infl uence family engagement, including the quality of the parent-home visi-
tor relationship; demographic characteristics of parents, home visitors, and the match between
the two (Early Head Start Research & Evaluation Project, 2003); maternal history of attachment
disruptions and maternal emotional needs (Domian, Baggett, Carta, Mitchell, & Larson, 2010);
parental beliefs regarding the need for services, the likelihood of change, and characteristics of
the services (McCurdy et al., 2006); families’ progress in the program (Williams, Stern & Associ-
ates, 2005); and home visitor turnover (Hicks et al., 2008).
The skills and abilities of the home visitors. Hiring the right home visitor is critical for program success. Researchers have examined questions regarding staff training and background
(e.g., paraprofessional versus professional home visitors; nurse home visitors versus home visitors
with some other professional background) (Cowan, Powell, & Cowan, 1998; Olds et al., 2002;
Wasik, 1993), but no fi rm conclusions can be drawn yet. The HomVEE review identifi ed as
evidence-based program models that employ professionals, paraprofessionals, or both, as well as
home visitors from multiple backgrounds (U.S. DHHS HomVEE website: http://homvee.acf.
hhs.gov/).
Content and focus of visits. Benefi ts are most likely to occur in the program areas emphasized by home visitors (Caldera et al., 2007; Early Head Start Research and Evaluation Project, 2003).
In other words, if home visitors focus time and eff ort on child development, it is more likely that
benefi ts will be achieved in that area than in some other outcome area. However, home visitors
may focus more on parent than child needs when working with parents who are at greater risk
(Early Head Start Research and Evaluation Project, 2003), suggesting that (a) program content
and curriculum should clearly address program goals; and (b) center-based early education
services may be more important for children living in families with greater risk to help ensure
that children receive an intervention that focuses on them (Raikes et al., 2006).
Cultural consonance. Parents of diff erent cultures possess strongly held beliefs about the best approaches to handling sleeping, crying, breastfeeding, discipline, early literacy skills,
and obedience in children (Cowan, Powell, & Cowan, 1998; National Research Council and
Institute of Medicine, 2000; Vernon-Feagans, Hammer, Miccio, & Manlove, 2001). To ensure
that families accept home visitors’ advice, visitors must ensure that services are responsive to and
respectful of family culture and values (National Research Council and Institute of Medicine,
2000; Wagner, Spiker, Gerlach-Downie, & Hernandez, 2000).
Developing services appropriate for high-risk families. The new federal home visiting funding aims to serve families living in high-risk communities (see below). For most programs,
therefore, quality services require having curricula and staff in place to serve a high-risk
population.
Research suggests three risk factors can impede success of home visiting programs: (a) domestic
violence; (b) maternal mental health problems, especially depression; and (c) parental substance
abuse. Though these are among the hardest issues for home visitors to recognize, discuss openly,
or address eff ectively, they nevertheless absorb a great deal of home visitor time and infl uence
program outcomes (Duggan et al., 2009; Duggan, Fuddy, Burrell, et al., 2004; Eckenrode et al.,
2000; Family Violence Prevention Fund, 2010; Zeanah, Larrieu, Boris, & Nagle, 2006).
These family issues are very common and may co-occur. More than 80% of a sample of
home visitors from the Healthy Families Arizona program, for example, reported that they had
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Deanna S. Gomby
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confronted each of these issues in their caseloads in the past year (LeCroy & Whitaker, 2005). As
many as half of families may have symptoms of mental health problems (Duggan, Berlin, Cas-
sidy, Burrell, & Tandon, 2009; Windham et al., 1998). Fully 43% of families in a study of Hawaii
Healthy Start reported a history of partner violence (Duggan, McFarlane, Fuddy, et al., 2004),
and 16% of the families in an HFA program in Oregon experienced domestic violence within
the fi rst 6 months after enrollment (McGuigan & Pratt, 2001). In a study of Lousiana NFP, 26%
of study participants scored above the cutoff for depressive symptomatology, and 41% of women
reported experiencing violence (Boris et al., 2006).
Approaches to address these issues include adding a mental health consultant to nurse home
visitor teams (Boris et al., 2006) and, for women exposed to domestic violence, inviting the
women to choose among strategies to meet goals for themselves and their children (Family Vio-
lence Prevention Fund, 2010). Because many family literacy programs serve the same popula-
tions as do home visiting programs, they too may fi nd it necessary to develop approaches to deal
with these complex issues.
Responses of home visiting models to improve quality. Program quality can be monitored and improved, and many individual program sites and national models have undertaken quality
improvement eff orts (Weiss & Klein, 2006), including establishing quality standards and
performance benchmarks and/or requiring local programs to submit data to the national offi ce
for monitoring.
Such eff orts bear fruit. The Every Child Succeeds program, which manages HFA and NFP
home visiting services for fi rst-time mothers in Ohio and Kentucky, employs continuous qual-
ity improvement techniques to monitor and improve program implementation and outcomes.
A web-based management information system enables program managers to measure the per-
formance of each site against established benchmarks, performance of other sites in the net-
work, and the averages across the entire network. Underperformance is addressed through action
plans. The result has been decreased programmatic variation and improved quality across sites
(Ammerman et al., 2007).
When service quality improves, outcomes improve, too. Early Head Start sites that had early,
full implementation of performance standards produced larger benefi ts in children’s cognitive
and language development than did sites which had not yet met standards (Love et al., 2002).
In Hawaii’s Healthy Start program, sites that delivered services with the greatest fi delity to the
model had the greatest eff ect on mothers’ mental health (Windham et al., 1998).
The New Federal Legislation
The Maternal, Infant, and Early Childhood Home Visiting Program, authorized by the Aff ord-
able Care Act of 2010 (P.L. 111-148), will provide $1.5 billion over 5 years to states and tribes
for voluntary home visiting services for pregnant women and families with young children. The
new program is designed “to strengthen and improve home visiting programs, improve service
coordination for at risk communities, and identify and provide comprehensive evidence-based
home visiting services to families who reside in at risk communities” (Federal Register, July 23,
2010, 75(141), p. 42173).
The Maternal, Infant, and Early Childhood Home Visiting Program
Funding is to be prioritized for serving high-risk families, including (a) those in communities
at need as demonstrated by needs assessments; and families with (b) low income; (c) pregnant
women under 21 years of age; (d) a history of child abuse or neglect or involvement with the
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Family Literacy and Home Visiting Programs
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child welfare system; (e) a history of substance abuse or who need substance abuse treatment; (f )
tobacco users in the home; (g) children with low school achievement; (h) children with devel-
opmental delay or disabilities; and (i) family members who serve or have served in the Armed
Forces, including multiple deployments outside the United States (CLASP, n.d.).
States must report on progress for participating families in six benchmark areas: (a) improved
maternal and newborn health; (b) prevention of child injuries, child abuse, neglect, or maltreat-
ment, and reduction of emergency department visits; (c) improvement in school readiness and
achievement; (d) reduction in crime or domestic violence; (e) improvements in family eco-
nomic self-suffi ciency; and (f ) improvements in coordination and referrals for other community
resources and supports.
States must use at least 75% of funds for “evidence-based” home visiting models, while 25% of
funds can be used for “promising” or new models. The HomVEE review identifi ed seven home
visiting models as evidence-based.1 Funded programs must have the capacity for and exhibit a
commitment to quality by employing well-trained, competent, and well-supervised home visi-
tors, participating in ongoing training on the specifi c home visiting model being developed, and
monitoring fi delity of implementation.
Implications of the Legislation for Home Visiting and Family Literacy
States may be interested in using the new funding to support family literacy-home visiting pro-
grams, as at least two of the six benchmark areas (i.e., improvement in children’s school readiness,
improvements in family economic self-suffi ciency) are relevant to family literacy. These goals
provide an opportunity for family literacy programs to link more closely with other community
services. A few issues, however, may create challenges for some home visiting or family literacy
programs.
To be responsive to the federal legislation, it appears that states will have to report information
about participating clients (e.g., demographics, numbers), service delivery (e.g., fi delity to model,
performance levels, referrals to other services), as well as outcomes (e.g., changes in children and
families). Some home visiting programs may already have fairly sophisticated system data collec-
tion systems, but others may collect only some of the information likely to be requested, and it is
unlikely that any model already has in place systems to collect all the desired information in the
eventually recommended formats.
The legislation also designates particular populations that are high-priority, including chil-
dren with developmental delays or disabilities. The home visiting programs outlined in this
chapter all aim to identify children with delays or disabilities but most are not designed to pro-
vide the in-depth specialized services that those children need.
Similarly, the legislation specifi es that programs also focus on communities with histories of
child maltreatment, substance abuse, and domestic violence. However, as discussed above, these
conditions have stymied the eff ectiveness of home visiting programs. The typical home visiting
program model may therefore need to develop new content or methods to address these complex
family issues.
Conclusions
The research reviewed in this chapter indicates that home visiting services can produce the
results that prepare children for school and help parents achieve educational goals, but they
do not always do so. Variations across program models, sites, and participants are common
and benefi ts are often modest, but quality of services and implementation is key to achieving
benefi ts
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Deanna S. Gomby
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When delivered with quality, home visiting services can help prepare children for school and
can help parents become better parents and achieve their own educational and economic goals.
Especially when linked with services such as center-based early childhood education, home
visiting can produce meaningful benefi ts for children and families. For that reason, home visit-
ing services should be embedded in a system that employs multiple service strategies, focused
both on parents and children. In other words, home visiting services may best be delivered just
as they often are in family literacy programs: in combination with center-based early childhood
education services.
Note
1 Th e evidence-based models include Early Head Start, PAT, HIPPY, NFP, HFA, as well as two models not discussed in this chapter: Healthy Steps, which embeds in pediatric practices a child development specialist who delivers up to six home visits to families over 30 months; and Family Check Up, which delivers three home visits to families with children ages 2–17 years to address child behavior issues. PCHP was not identifi ed as evidence-based in the HomVEE review.
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