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Other home visiting programs for at-risk families

Public Health & Prevention: Home- or Family-based
Benefit-cost methods last updated December 2023.  Literature review updated April 2018.
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This broad topic includes home visiting programs for families considered to be at risk for parenting problems based on factors such as maternal age, education, low household income, or in some programs, mothers testing positive for drugs at the child’s birth. Depending on the program, the content of the home visits may include parenting instruction, referrals for service, education on child health and development, or social and emotional support. Home visitors are typically paraprofessionals, with varied levels of training. Families in the included studies received home visiting services for 12 to 27 months, with an average of 25 total hours of home visiting over the course of the intervention.

This topic does not include home visiting programs for pregnant or parenting adolescents.
 
ALL
BENEFIT-COST
META-ANALYSIS
CITATIONS
For an overview of WSIPP's Benefit-Cost Model, please see this guide. The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2022). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $3,307 Benefits minus costs $1,805
Participants $13,127 Benefit to cost ratio $1.18
Others $627 Chance the program will produce
Indirect ($5,252) benefits greater than the costs 51%
Total benefits $11,808
Net program cost ($10,003)
Benefits minus cost $1,805

^WSIPP’s benefit-cost model does not monetize this outcome.

^^WSIPP does not include this outcome when conducting benefit-cost analysis for this program.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases. See Estimating Program Effects Using Effect Sizes for additional information.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Treatment age Primary or secondary participant No. of effect sizes Treatment N Adjusted effect sizes(ES) and standard errors(SE) used in the benefit - cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Regular smoking
Smoking tobacco on a regular basis.
 22 Primary 1 156 -0.132 0.126 22 -0.132 0.126 22 -0.132 0.293
Employment
Any employment, including part-time work.
22 Primary 1 212 0.031 0.096 25 0.000 0.000 26 0.087 0.368
Public assistance
Any form of welfare assistance, such as Temporary Assistance for Needy Families (TANF) or Assistance for Families with Dependent Children (AFDC).
22 Primary 1 212 0.047 0.096 25 0.047 0.096 25 0.131 0.173
Food assistance
Receipt of food assistance, such as from the Supplemental Nutrition Assistance Program (SNAP).
 22 Primary 1 211 0.075 0.096 25 0.075 0.096 25 0.210 0.030
High school graduation^^
On-time completion of high school with a diploma (excluding GED attainment).
 22 Primary 1 211 0.072 0.139 23 n/a n/a n/a 0.199 0.167
Cannabis use^
Adult use of cannabis that does not rise to the level of “disordered.”
22 Primary 1 211 -0.013 0.201 25 n/a n/a n/a -0.037 0.853
K-12 grade repetition
Repeating a grade. This is sometimes called "grade retention."
 1 Secondary 2 190 0.061 0.136 9 0.061 0.136 9 0.171 0.212
K-12 special education
Placement into special education services.
1 Secondary 2 190 0.043 0.136 9 0.043 0.136 9 0.118 0.388
Test scores
Standardized, validated tests of academic achievement.
1 Secondary 2 192 -0.016 0.102 9 -0.010 0.112 17 -0.031 0.828
Emergency department visits
Whether someone visited the emergency department, or the number of times they visited the emergency department.
1 Secondary 2 339 0.112 0.084 1 0.000 0.000 2 0.112 0.184
Attention-deficit/hyperactivity disorder symptoms
Clinical diagnosis of attention-deficit/hyperactivity disorder (ADHD) or symptoms measured on a validated scale.
1 Secondary 1 187 -0.061 0.137 9 0.000 0.141 10 -0.169 0.216
Externalizing behavior symptoms
Symptoms of externalizing behavior (e.g., aggressive, hostile, or disruptive behavior) measured on a validated scale.
 1 Secondary 1 187 0.048 0.137 9 0.027 0.083 12 0.134 0.326
Internalizing symptoms
Symptoms of internalizing behavior (e.g., sadness, anxiety, or withdrawal) measured on a validated scale.
 1 Secondary 1 187 -0.006 0.137 9 -0.006 0.137 11 -0.017 0.899
Child abuse and neglect
Substantiated or founded reports to child protective services.
 1 Secondary 3 222 -0.392 0.233 2 -0.392 0.233 17 -0.392 0.093
Out-of-home placement
The removal of a child from parental care, most often to foster care.
 1 Secondary 2 91 -0.075 0.161 2 -0.075 0.161 17 -0.075 0.640
Preschool test scores^
Measures of cognition in young children on standardized scales.
 1 Secondary 6 625 0.034 0.057 3 n/a n/a n/a 0.053 0.349
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1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Affected outcome: Resulting benefits:1 Benefits accrue to:
Taxpayers Participants Others2 Indirect3 Total
Regular smoking Health care associated with smoking $551 $156 $568 $275 $1,550
Mortality associated with smoking $2 $4 $0 $257 $263
Public assistance Public assistance ($691) $252 $0 ($345) ($784)
Employment Labor market earnings $394 $928 $0 $0 $1,323
Food assistance Food assistance ($410) $363 $0 ($205) ($252)
Subtotals ($154) $1,703 $568 ($18) $2,099
From secondary participant
Test scores Labor market earnings associated with test scores ($399) ($940) ($495) $0 ($1,834)
Child abuse and neglect Child abuse and neglect $178 $1,971 $0 $89 $2,238
Property loss associated with alcohol abuse or dependence $0 $0 $1 $0 $1
Labor market earnings associated with child abuse & neglect $4,420 $10,413 $0 $0 $14,834
Mortality associated with child abuse and neglect $3 $6 $0 $49 $57
K-12 grade repetition K-12 grade repetition ($87) $0 $0 ($43) ($130)
K-12 special education K-12 special education ($990) $0 $0 ($495) ($1,486)
Out-of-home placement Out-of-home placement $82 $0 $0 $41 $123
Externalizing behavior symptoms Criminal justice system ($12) $0 ($24) ($6) ($43)
Health care associated with externalizing behavior symptoms ($101) ($28) ($104) ($50) ($283)
Internalizing symptoms Health care associated with internalizing symptoms $3 $1 $4 $2 $10
Subtotals $3,097 $11,424 ($619) ($415) $13,487
Program cost Adjustment for deadweight cost of program $0 $0 $0 ($4,820) ($3,778)
Totals $3,307 $13,127 $627 ($5,252) $11,808
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Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $5,293 2016 Present value of net program costs (in 2022 dollars) ($10,003)
Comparison costs $0 2016 Cost range (+ or -) 70%
The per-participant cost estimate is based on a weighted average of the costs of each study and includes the cost of provider time, training, travel, materials, and administrative costs. We used the costs reported in the studies when possible (Olds et al. 2002 and Black et al. 1994). For studies that did not provide cost estimates, we estimated an average cost per hour of home visiting, using program costs and number of home visiting hours as reported in other studies (Olds et al. 2004 and Black et al. 1994). We then applied this average cost per hour to the number of home visiting hours reported in each study.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Benefits Minus Costs
Benefits by Perspective
Taxpayer Benefits by Source of Value
Benefits Minus Costs Over Time (Cumulative Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in discounted dollars. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

Citations Used in the Meta-Analysis

Barlow, J., Davis, H., McIntosh, E., Jarrett, P., Mockford, C., & Stewart-Brown, S. (2007). Role of home visiting in improving parenting and health in families at risk of abuse and neglect: Results of a multicentre randomised controlled trial and economic evaluation. Archives of Disease in Childhood, 92(3), 229-233.

Black, M.M., Nair, P., Kight, C., Wachtel, R., Roby, P., & Schuler, M. (1994). Parenting and early development among children of drug-abusing women: Effects of home intervention. Pediatrics, 94(4), 440-448.

Culp, A.M.D., Culp, R.E., Anderson, J.W., & Carter, S. (2007). Health and safety intervention with first-time mothers. Health Education Research, 22(2), 285-294.

Doyle, O., Harmon, C., Heckman, J.J., Logue, C., & Moon, S.H. (2017). Early skill formation and the efficiency of parental investment: A randomized controlled trial of home visiting. Labour Economics, 45, 40-58.

Hardy, J.B., & Streett, R. (1989). Family support and parenting education in the home: An effective extension of clinic-based preventive health care services for poor children. The Journal of Pediatrics, 115(6), 927-931.

Howell, E., Lawton, E., Dubay, L., Hill, I., Gadsden, S., Wilkinson, M., . . . Ho, J. (2017). Effects of Welcome Baby Home Visiting on Maternal and Child Medi-Cal enrollment and utilization. Los Angeles, CA: Urban Institute, University of California at Los Angeles.

Lyons-Ruth, K., Connell, D.B., Grunebaum, H.U., & Botein, S. (1990). Infants at social risk: Maternal depression and family support services as mediators of infant development and security of attachment. Child Development, 61(1), 85-98.

Olds, D.L., Holmberg, J.R., Donelan-McCall, N., Luckey, D.W., Knudtson, M.D., & Robinson, J. (2014). Effects of home visits by paraprofessionals and by nurses on children: follow-up of a randomized trial at ages 6 and 9 years. JAMA Pediatrics, 168(2), 114-21.

Olds, D.L., Robinson, J., O'Brien, R., Luckey, D.W., Pettitt, L.M., Henderson, C.R., Jr., . . . Talmi, A. (2002). Home visiting by paraprofessionals and by nurses: A randomized, controlled trial. Pediatrics, 110(3), 486-496.

Olds, D.L., Robinson, J., Pettitt, L., Luckey, D.W., Holmberg, J., Ng, R.K., . . . Henderson, C.R. (2004). Effects of home visits by paraprofessionals and by nurses: Age 4 follow-up results of a randomized trial. Pediatrics, 114(6), 1560-1568.

Velasquez, J., Christensen, L., & Schommer, B.L. (1984). Part II: Intensive services help prevent child abuse. American Journal of Maternity and Child Nursing, 9(2), 113-117.