House Calls

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Home-visiting programs are run by a variety of human-services agencies and serve a variety of different goals.

The program began in 1977 with 400 women in Elmira, N.Y., and has since expanded to Memphis, Tenn., and Denver.

The most recent research on the program showed that, after being visited frequently by a nurse during their child's first two years of life, the mothers were less likely to abuse or neglect their children, have another child, and abuse drugs or alcohol than mothers who did not receive home visits. The program, tested with mostly white mothers in semirural Elmira and in Memphis with African-American mothers, also successfully reduced the length of time the mothers spent on welfare.

But it was also expensive. Mr. Olds estimates the costs at roughly $7,000 per family a year.

Even though his work is considered by many to be the best in the field, he and his team of researchers held off on disseminating the model until 1995, when the U.S. Department of Justice offered to develop the prenatal and infancy home-visitation program as a pilot in six communities.

Professionals or Not?

Colorado and a few other states have begun efforts to combine both state and federal money to establish versions of the program. But Mr. Olds still maintains that it cannot be duplicated on a large scale in a short time without being watered down. "If we are not careful, we will squander both money and hope on programs that don't work," he says.

He is also concerned that because of the growing popularity of home visiting, some organizations are using his research to promote other, less intensive visitation models.

Home-visiting programs are run by a variety of human-services agencies and serve a variety of different goals, from ensuring that children have proper nutrition to providing new mothers information on breast-feeding or preventing child abuse. One of the goals of future research will be to identify which programs best meet differing needs.

And experts point out that although some programs may not be designed specifically to bring about future school success, that doesn't mean educators should ignore them. Programs that focus more on moving families off welfare or improving a mother's parenting skills can have less obvious but still important benefits for schools.

A study under way in Hawaii is exploring that question by looking at the extent to which Hawaii Healthy Start, a home-visiting program designed to prevent child abuse, is helping children in other ways.

Researchers at Johns Hopkins University in Baltimore are following 684 families for three years to determine whether Hawaii's well-regarded program also enhances children's development and better prepares them for school.

The program's administrators "started to realize that they weren't just preventing child abuse and neglect, but improving parenting along the whole continuum," says Anne K. Duggan, an associate professor of pediatrics at Johns Hopkins who is the study's principal investigator.

The issue of exactly who should be making home visits is another priority for research. Several researchers are exploring whether nurses or nonprofessionals, for example, make the best home visitors.

Common sense may suggest that nurses or social workers are best equipped to respond to the complex and deep-seated problems of poor mothers.

But others argue that paraprofessionals--especially those who come from the same communities as the families they are serving--can relate more effectively because they might share the same values and, ideally, have overcome some of the same problems.

'Wonderful Mentoring'

HIPPY, for example, relies on paraprofessionals. "Our philosophy is that the families that we are dealing with have so many obstacles to overcome and have so many negative experiences with professionals," says Miriam Westheimer, the president of HIPPY USA.

The federal government recently declared that working as a home visitor for HIPPY fulfills the work requirements of the 1996 welfare-reform law.

Another advantage of paraprofessionals is that they cost less. But Ms. Westheimer and others strongly emphasize that when paraprofessionals are used, they must have extensive training not only in the program they are using, but also on how to avoid becoming so personally involved with families that they lose their ability to help.

"It's really tough for home visitors to draw those boundaries," says Rebecca Maynard, a professor of education and social policy at the University of Pennsylvania. Ms. Maynard is involved in an evaluation of the Home Visiting Services Demonstration, a program that uses paraprofessionals, many of whom are former welfare recipients.

There is a growing consensus in the field that both nurses and nonprofessionals are appropriate home visitors at different times in a child's life.

The program, a joint project of the Henry J. Kaiser Family Foundation and the federal government, serves about 2,400 families in Chicago; Dayton, Ohio; and Portland, Ore. Results of the study are expected this summer.

In Denver, Mr. Olds is also exploring whether, in his model, well-trained paraprofessionals can be as effective as nurses. The first results are due later this year.

While it's clear that further research is needed, there is a growing consensus in the field that both nurses and nonprofessionals are appropriate home visitors at different times in a child's life.

In programs that serve infants, researchers say, it's more desirable to have a nurse or other professional because the mother is more likely to have questions about her child's general health and development. But in programs that serve older children, many experts agree that paraprofessionals can be very effective at sharing lessons with parents that prepare children for school.

Link to Other Services

A program for 3-year-olds in the northern Kentucky city of Covington has found a way to use both teachers and noncertified assistants for every visit. For the assistants, who often come from the community they are visiting, it's a "wonderful mentoring experience," says Diane Roketenetz, the director of the James E. Biggs Early Childhood Education Center in the 4,950-student Covington district.

For families with more-critical needs, it is the length and frequency of the visits that matter--not whether the visitor has a college degree, says Ms. Winter of PAT.

The services home-visiting programs provide don't always occur just in the home. Several models also include regular group meetings for the parents and center-based activities for the children. And there is widespread agreement that home visitors must be knowledgeable about other services families might need, such as health care, job training, transportation, or Head Start.

Heather B. Weiss, the director of the Family Research Project at Harvard University, wrote in a 1993 article that home visiting by itself is not sufficient to meet the needs of families in poverty, but should be part of a comprehensive approach to family support.

Often, families are struggling to meet their most basic needs for food, clothing, shelter, or heat, and experts note that home visitors must be able to respond to a crisis before trying to proceed with that week's parenting lesson.

"We can't meet all the needs of the family because that's not our goal, but we can't ignore them either," Ms. Winter says.

Most home-visiting programs target poor or other at-risk families, but PAT is unique because it is a universal program, open to anyone who wants it. Because of that, some observers question the model's success.

A study being conducted by SRI International, a nonprofit research organization in Menlo Park, Calif., will investigate the effects of the program on low-income and minority families in four cities--Wichita, Kan.; Fort Worth, Texas; Newark, Del.; and Winston-Salem, N.C. The study is supported by the U.S. Department of Education's office of educational research and improvement.

"We have confidence that the program meets the needs of high-risk families, because we certainly have many of them in our state," Ms. Winter says.

When recruiting new families, PAT seeks out teenage mothers, single parents, and others who have a greater need. But Ms. Winter still believes the strength of the program is its take-all approach: "Every family is entitled to access this kind of support."

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