The workshop was not intended to debate whether home visiting belongs in the toolbox of early intervention strategies, but rather to refine understanding of home visiting’s niche within the array of interventions designed to help families and promote child development. Similarly, the workshop did not attempt to reach a consensus about the effectiveness of home visitation, to recommend particular models of home visiting as more effective than others, or to compare the impacts of home visiting programs with other forms of intervention. Instead, experts presented analyses of a variety of home visiting programs and other forms of intervention, sharing information about how, when, and with whom their programs seemed to work best, the challenges they face, and ideas about directions for the next generation of programs. The workshop also did not attempt to address the topic of children with disabilities or special health care needs.
There currently is tremendous interest and enthusiasm, especially on the part of state and local policymakers, in expanding home visiting models. As Matthew Melmed, of ZERO TO THREE: National Center for Infants, Toddlers and Families, observed, a window of opportunity exists for interventions focused on helping young children and their families. Legislators understand that the early years are vitally important, and they are searching for ways to ensure that young children get off to a good start in life. For example, California recently approved Proposition 10, a law that allocates funds from taxes on tobacco products (which experts estimate could total as much as $690 million a year) to support early childhood development programs throughout the state (Lieberman, 1999). At the same time, findings from evaluations of a diverse range of home visiting programs have been less consistent and less positive than many had hoped they might be.
How does one reconcile enthusiastic and concerned policymakers on one hand, with mixed research results on the other? Meeting participants agreed that the answer to this question lies in examining the research to determine when, how, and for whom home visiting is most effective. Although there is concern that constructive critical analysis will be used by others to remove support for home visiting interventions, those involved in home visiting are poised and motivated to examine their goals and practices in light of new findings.
CHARACTERIZING HOME VISITING
The term “home visiting” has many meanings. Participants agreed that home visiting is neither a program nor an intervention. Home visiting is a strategy for delivering services, a type of program, and a location. It is the activities that occur within the context of home visiting that constitute the intervention -- although what actually transpires during a visit has seldom been documented.
Different programs that employ home visiting as a service delivery method have very different goals -- ranging from preventing child abuse to preparing children for school -- which in turn influence program design and implementation. For example, the Parents as Teachers
program aims to promote children’s development by: (1) empowering parents and increasing their feelings of competence and confidence, (2) giving children a solid foundation for school success, (3) preventing and reducing child abuse, and (4) developing home-school-community partnerships on behalf of children. In contrast, the Nurse Home Visitation Program’s goals are to: (1) improve pregnancy outcomes for first-time mothers, (2) improve child health and development, and (3) improve families’ economic self-sufficiency (see Gomby et al., 1999 for a fuller description of the six home visiting models mentioned earlier).
The diversity of goals, designs, and philosophies makes generalizations about home visiting difficult to draw. Anne Cohn Donnelly, of the Kellogg School of Management at Northwestern University, asked, “Should we be looking at home visiting, which is how the intervention is being delivered, or should we be looking at the [intended] outcomes, which is what the program is trying to accomplish?”
In part because home visiting strategies have been applied to so many different objectives, there is a growing tendency to think that a home visitor can address all the challenges a family faces. Heather Weiss, of the Harvard Family Research Project, has previously noted, “There is a long history of setting up home visiting as a silver bullet -- the panacea for poverty -- and of subsequent disappointment, reconsideration, and revamping of the role home visits can play in ameliorating the effects of poverty” (Weiss, 1993). Workshop participants cautioned that it is important to remember that, when broken down into its day-to-day working parts, home visiting is based on individuals (the home visitors) making connections with other individuals (families targeted for services) and effecting behavioral changes. Effecting behavioral change is a daunting challenge that requires the delivery of learning activities that are appropriate for both the caregiver and the child. Moreover, it is not uncommon for home visiting programs to target families who are otherwise unable or unmotivated to utilize services available in their communities. Lack of motivation to change is a major barrier to producing better outcomes.
Although this approach can potentially have an impact on individual families (those who are motivated to change), home visiting alone is an inadequate means of addressing a multiply determined societal problem such as poverty. As Melmed observed, “We should not expect to change lives dramatically, particularly by visiting people sometimes once or twice a month. But we should expect to make a dent, to make their lives and the lives of their children at least a little bit better, taking small steps towards change.”
Not only is there great diversity from one home visiting model to another, but there is also a tremendous amount of variability within a single program. This is due in part to the need to individualize services to meet each family’s needs. However, visitors’ different understandings of program goals and approaches also contribute to variable program delivery. Amy Baker, of the Children’s Village in Dobbs Ferry, New York, and evaluator of the Home Instruction Program for Preschool Youngsters, noted that, despite the fact that the Home Instruction Program for Preschool Youngsters is a structured program with a core curriculum, her research revealed that the staff held very different ideas about the program. Some staff viewed it as a school readiness program, so spent more time reviewing the program materials with the parent, while others saw its purpose as community outreach and spent more time linking the