From RCTs to Community-Level Change: What to Expect from the Evidence Base
The 2010 Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) required states to spend at least three-quarters of the funding on home visiting models that met federal standards of evidence-based effectiveness. Selecting an evidence-based model may increase the probability of improved outcomes, but it does not guarantee them. Most of the evidence comes from small-scale, tightly controlled efficacy trials with limited external validity. Additionally, there is little evidence of effectiveness across populations or contexts and little empirical understanding of the core components of home visiting programs—the components that must be replicated in order for the program to be effective.
Currently, evidence-based home visiting programs in the U.S. are receiving unprecedented support at both the state and federal levels. The expectations for their success are high, but an extensive review of the prior research suggests that home visiting programs may make only modest improvements in either parents’ or children’s outcomes when taken to scale. Small or modest improvements will limit the extent to which any large differences will be evident at the community or state level.
Method
The primary aim of this paper is to review the effects of evidence-based home visiting models on multiple aspects of early parenting to guide expectations about the extent to which home visiting programs can demonstrate significant and meaningful change when implemented at the community level. This paper reviews the evidence-base for four of the evidence-based home visiting programs being implemented across the country with MIECHV funding to provide a realistic context for understanding how much improvement in early parenting outcomes can be expected from home visiting programs. The overarching goal of home visiting programs is to promote the health and development of at-risk children by positively influencing parenting. Thus the focus of this paper is the influence of home visiting programs on parenting outcomes.
Results
The findings of our review show that home visiting programs are associated with positive outcomes for children and families, but also suggest several reasons why it may be difficult for these improvements to be apparent at the community level. First, the average effect sizes for the associations between home visiting programs and both parent and child outcomes are small (typically ranging between 0.1 and 0.2 of a standard deviation). Second, the populations being served from MIECHV-funded programs differ from the populations in the RCTs. Finally, the MIECHV-funded home visiting programs are serving a small number of families in each community, which means that community-level change depends on a very small proportion of the population.
Conclusions and Implications
If MIECHV-funded home visiting programs demonstrate only small improvements in child and family wellbeing, researchers’ task moving forward will be to focus on how home visiting programs can do more good for more families. Strengthening the evidence base for home visiting programs and focusing on which components of home visiting programs are critical to success are discussed as next steps for researchers.