Best-Laid Plans: Real World Implementation of Home Visiting Programs
Home visiting programs have rapidly expanded across the country as an evidence-based policy choice for supporting families with young children, but selecting an evidence-based model is not a guarantee of effectiveness. Implementation is a key determinant of whether or not children and families benefit from home visiting programs. Careful monitoring of whether the program implementation adheres to the program’s original design and purpose (i.e., model fidelity) is critical to ensuring that the program yields the range of outcomes observed in the randomized controlled trials, but to date, there is little research on how to achieve quality on-the-ground implementation.
Method
This paper presents analyses of both quantitative and qualitative data from the evaluation of the Texas Home Visiting Program (THV) to analyze how the characteristics of the families being served make implementation with fidelity difficult. THV, funded through the Maternal, Infant, and Early Childhood Home Visiting program (MIECHV), aims to ensure that Texas children ages zero to five in high-need communities are healthy and prepared for school. THV is currently implementing 24 home visiting programs in seven communities that serve more than 2,200 families.
Results
Analyses of demographic data show that THV is successfully targeting the high-risk Texan families that were required by MIECHV. The majority of families are low-income with a significant proportion living in poverty. Most are young, Hispanic females. The risk factors (e.g., poverty level, teen pregnancy, history of child abuse) that make families eligible for the home visiting programs are the same factors that make them incredibly difficult to recruit, serve, and retain. THV staff described their families’ many and often very basic needs (including food, housing, and heat) as the primary barrier to delivering their program with fidelity. These needs often have to be met before the actual program can be delivered. Home visitors try to slip the curriculum in while also assisting their families or they forego the curriculum all together and double-up at the next visit. The many needs of their families also make it challenging for home visitors to provide families with the required dosage of the program. Frequent and last-minute cancellations along with changing phone numbers make it difficult for home visitors to conduct visits with their clients.
Conclusions and Implications
Implementing home visiting programs with fidelity requires serving the intended population and doing so while adhering to the program’s original purpose and design. Evidence from the on-going evaluation of THV suggests that serving the high-risk families who are eligible for the program creates a significant implementation challenge because the risk factors that make families eligible for a program also make it difficult for home visitors to fully deliver the program. Additional research needs to be directed toward identifying the core components of home visiting programs so that home visitors can prioritize delivering the parts of the program that are critical for improving outcomes for families and children in the midst of their families’ needs.