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Implementing Early Head Start-Home Visiting (EHS-HV)

Meets DHHS criteria for an evidenced based model

Implementation Experiences

Last Updated

August 2016

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Summary of Sources

Information in this section is based on studies included in the HomVEE review. For EHS-HV, we reviewed 28 studies, including 7 randomized controlled trials or quasi-experimental designs and 21 standalone implementation studies. (Please see the study database for a list of the studies.)

In the sections below, we consider all pieces of research about a particular sample to be a single study. For example, six studies described the characteristics of the same group of participants at the time they enrolled into a national cross-site evaluation. These six publications are cited as one study. There are 17 distinct samples across the 28 publications.

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Characteristics of Program Model Participants

Caregivers in EHS-HV studies were primarily mothers (87 to 100 percent) (11 studies). In studies of populations that involved fathers, 1 to 13 percent of caregivers were fathers (six studies).

The average caregiver age ranged from 17 to 27 (six studies), and approximately 22 to 39 percent of parents were younger than 20 (three studies). Twelve to 39 percent of mothers were pregnant at the time of enrollment (five studies). The average age of children involved varied. In two studies, about 40 percent of children were four months old or younger. In one additional study, the average child’s age at enrollment was 14 months.

Programs served racially and ethnically diverse families (14 studies). Nine to 100 percent of program participants were white (seven studies); the percentage who were African American ranged from 3 to 100 percent (13 studies); and the percentage of participants who were Hispanic ranged from 7 to 62 percent (12 studies). Two to 11 percent of program participants identified as another race or multiple races (eight studies).

Twenty-one to 43 percent of caregivers were unemployed (four studies); families had low incomes (five studies); and 21 to 77 percent of caregivers received public assistance (six studies). About one-third to three-quarters of caregivers did not have their high school diploma or a high school equivalency degree (eight studies).

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Location and Setting

Programs were located in 18 states (10 studies). Studies occurred in all but one Census region of the United States, including:

  • Midwest (six studies)
  • Northeast (five studies)
  • South (one study)
  • West (five studies)

Programs sites included urban (eight studies), rural (six studies), and suburban (two studies) settings.

A variety of agencies implemented EHS-HV, including:

  • Head Start or EHS agencies (five studies)
  • Community-based/nonprofit organizations (five studies)
  • Health clinics (three studies)
  • Government human service departments (three studies)
  • Universities (two studies)
  • School districts (two studies)
  • Foundations (one study)
  • Child care agencies (one study)

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Staffing and Supervision

EHS-HV staff included home visitors who worked with families in their homes (17 studies), supervisors (nine studies), and program managers or directors (three studies).

Additional staff supported EHS-HV programs, including nurses or health care specialists (four studies); family support specialists or advocates (four studies); psychologists or other mental health professionals (three studies); male involvement specialists (three studies); child development specialists (two studies); and speech and language specialists (two studies). A national survey of EHS-HV reported that some programs also included disability, literacy, and nutrition specialists (one study).

Most programs required that staff had at least an associate’s degree, and some programs preferred a bachelor’s degree or higher (nine studies). Other programs only required a high school diploma (two studies). Home visitors had educational backgrounds in human services fields including child development, nursing, counseling, and other disciplines (seven studies). Some programs required that home visitors had experience conducting home visits with infants and toddlers or with low-income populations (five studies); others required a child development associate credential (two studies).

Four studies described pre-service training that included (1) general pre-service orientation (two studies), (2) a one-week training for key program staff, and/or (3) a two-week intensive training for staff (three studies). Pre-service training often consisted of two or more of these training types for any given program.

Seven studies described in-service training, which consisted of (1) ongoing trainings on EHS-relevant topics such as child development and nutrition (five studies), (2) individual observation and feedback (two studies), and/or (3) annual trainings at training institutes (two studies). In-service training often consisted of two or more of these training types for any given program.

Supervision activities included (1) individual meetings with supervisors (two studies), (2) staff meetings or group sessions (two studies), (3) in-field observations of home visits (one study), (4) case reviews (two studies), (5) reflective supervision sessions (four studies), and/or (6) performance reviews (two studies). The ratio of home visitors to supervisors ranged from four to seven home visitors for every supervisor (three studies).

Home visiting staff’s caseloads ranged from 6 to 24 families (six studies).

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Program Model Components

Participants received home visiting plus center-based group socializations (15 studies). The home visits covered:

  • Child development (10 studies)
  • Health services, including medical, dental, mental health, or vision screenings and referrals (nine studies)
  • Community resources (five studies)
  • Parent-child interactions (five studies)
  • Family goals around employment, adult education, housing, and family relationships (three studies)
  • Nutrition (two studies)
  • Family well-being (one study)

Most programs followed federal EHS guidelines, which recommend weekly visits (14 studies) for 90 minutes (nine studies). EHS guidelines also recommended families participate from the birth of the child to age 3 (11 studies).

Programs used the following assessments (seven studies):

  • Denver Developmental Screening Test II (two studies)
  • Hawaii Early Learning Profile® (one study)
  • Ages and Stages Questionnaires® (one study)
  • Early Learning Accomplishment Profile (one study)
  • The Infant Toddler Development Assessment (one study)
  • Behavioral, Emotional, Social Screening Checklist (one study)
  • Infant/Toddler Home Inventory (one study)
  • Family Assessment Tool (one study)

Programs used the following curricula (five studies):

  • Parents as Teachers® (two studies)
  • Hawaii Early Learning Profile® curriculum materials (two studies)
  • WestEd’s Program for Infant/Toddler Caregivers (one study)
  • Partners in Parenting® (one study)
  • Teaching Strategies GOLD® (one study)
  • Partners for a Healthy Baby® (one study)
  • Games to Play with Babies (one study)
  • Games to Play with Toddlers (one study)

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Program Model Adaptations or Enhancements

Five studies described adaptations or enhancements to the core EHS-HV model.

Infant mental health consultation. An infant mental health consultant provided intensive training for home visitors on infant mental health (two studies). In one study, the program managers and direct-service staff participated in a 12-week seminar; the other study included 36 hours of training over six weeks focused on home visiting, early relationships, and development. Home visitors participated in infant mental health case conferences and received reflective supervision (both studies). Home visitors had master’s degrees (one study).

Professional home visitors. Both professionals and paraprofessionals served as home visitors (one study).

Parental employment training. Parents were offered training to become child care providers (one study).

Parent-child communication protocols. Parent-child communication protocols were used to enhance the development of secure attachment between the child and parent (one study).

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Dosage

Families received an average of three to four visits per month (five studies). Visits were shorter than the recommended 90 minutes, lasting 60 to 70 minutes (two studies).

Half to two-thirds of families participated for about two years of the three-year intervention (two studies). Families participated an average of 21 to 22 months (two studies).

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Lessons Learned

Studies discussed lessons learned about implementation, including lessons about staffing, intensity and content of services, and engagement with families:

Staffing. Several lessons related to staffing considerations.

  • Finding a diverse, yet qualified staff was difficult (four studies).
  • Turnover among home visitors and supervisors led to low staff morale and disruption of services for families (four studies). In one study, staff reported dissatisfaction with low wages, which contributed to turnover.
  • Studies noted the importance of reflective supervision and monitoring home visitor caseload (five studies).
  • Studies noted the importance of initial training, ongoing training to respond to children’s cognitive and developmental needs, on-the-job training, and frequent one-on-one supervision (seven studies).

Intensity and content of services. Lessons related to the services families received included:

  • Studies noted the need for greater intensity of services, including increasing the frequency of home visits and group socializations, and better addressing the child’s cognitive and developmental needs (two studies).
  • Community partnerships and access to community resources are important to address health issues, identify disabilities, and connect families with needed services (two studies).
  • Programs may need to focus more on adult mental health issues for families to participate and engage in activities (six studies).
  • Although studies indicated that many of the programs met EHS performance standards, there was considerable variation in how the model was implemented (one study).
  • Programs should offer services to involve fathers (three studies).
  • The prevalence of disabilities among young children in poverty suggests that programs would benefit from additional help in connecting children with disability support (two studies).

Engagement with families. Lessons related to participant retention included:

  • One study noted the difficulty in reaching full enrollment due to families’ lack of understanding of the required commitment, moving out of the area, and other obligations that interfered with families’ ability to participate fully.
  • Programs should engage families in an ongoing manner to prevent attrition (three studies).
  • Barriers to engagement included staff turnover, difficulties in scheduling visits, and families’ personal challenges (four studies).
  • To achieve family goals, home visitors need to build strong working relationships with families that are trusting, sensitive, and secure (four studies).
  • Programs need to develop new strategies to prevent families with many demographic risk factors from dropping out (two studies).

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