Hebbeler Gerlach2002

Early Childhood Research Quarterly 17 (2002) 28–51
Inside the black box of home visiting: a qualitative

analysis of why intended outcomes were not achieved
Kathleen M. Hebbeler∗ , Suzanne G. Gerlach-Downie
SRI International, 600 Mockingbird Place, Davis, CA 95616, USA
Accepted 10 January 2002
Abstract
A longitudinal qualitative investigation of a home visiting program was conducted to explore why
the program was not more effective. The sample included 21 case study families and 9 home visitors,
plus 60 other mothers who participated in focus groups. Data from interviews with parents and home
visitors, videotapes of home visits, and children’s assessments were used to construct and examine
a theory of change for the program. The study found that home visits had a consistent structure and
that the home visitors emphasized their social support role and placed little emphasis on changing
parenting behavior. The discussion suggests that the program’s flawed theory of change that minimally
acknowledged parent–child interaction limited the program’s effectiveness. The findings underscore the
need to critically examine the theories that underlie home visiting programs and guide the day-to-day
interactions of home visitors. © 2002 Published by Elsevier Science Inc.
Keywords: Home visiting; Parent–child interaction; PAT; Intervention
1. Introduction
Home visiting has become increasingly popular with policy-makers and program planners
as a strategy for delivering services to families (Gomby, Culross, & Behrman, 1999; Powers
& Fenichel, 1999). Although home visiting is currently riding a wave of popularity, it actually
has a long history as an approach in family programs (Wasik, Bryant, & Lyons, 1990; Weiss,
1999). The body of research on home visiting is growing but can be challenging to synthesize
and apply because of the diversity of home visiting programs. As has been often noted, home
∗
Corresponding author. Tel.: +1-530-758-7483; fax: +1-530-753-0832.
E-mail address: kathleen.hebbeler@sri.com (K.M. Hebbeler).
0885-2006/02/$ – see front matter © 2002 Published by Elsevier Science Inc.

PII: S 0 8 8 5 - 2 0 0 6 ( 0 2 ) 0 0 1 2 8 - X
K.M. Hebbeler, S.G. Gerlach-Downie / Early Childhood Research Quarterly 17 (2002) 28–51 29
visiting is not a single service but rather a strategy for delivering a service (Powell, 1993;
Powers & Fenichel, 1999). Co-existing under the rather large umbrella called home visiting
are programs that seek to improve pregnancy outcomes, programs that are trying to prevent child
abuse and neglect, and programs designed to improve school achievement to name but a few
of the many goals espoused by home visiting programs. Programs have different philosophical
orientations with some emphasizing parent education and others emphasizing family support
(Halpern, 1993). Programs also differ with regard to when services begin (before birth, at birth,
later), how much service is provided (e.g., once a week, once a month for 1 year, 3 years),
the focus of the service (e.g., to deliver a curriculum, to link the family with other services
in the community), the recipient of the service (parent, child, the parent–child relationship)
and the qualifications of who provides the service (e.g., nurse, child development specialist,
paraprofessional) (Berlin, 1998; Gomby et al., 1999; Powell, 1993).
Both the popularity and the diversity of home visiting programs underscore the need to
examine the effectiveness of this strategy. The research on home visiting presents a mixed
picture. A recent journal issue reported findings from rigorous studies of six different and well
known home visiting programs. In summarizing the results, Gomby et al. (1999) noted that
“no home visiting model produces impressive or consistent benefits in child development or
child health” (p. 24). Consistent with previous research (Larner, 1992; Olds & Kitzman, 1993;
Pfannenstiel, Lambson, & Yarnell, 1995; Pfannenstiel & Seltzer, 1989), the newer studies show
some models of home visiting are effective for some families for some outcomes but that we are
far from being able to specify which families and outcomes are best suited for which program
models. The general conclusion was that a more modest view of the potential impact of home
visiting programs should be taken and that the home visiting field should focus on improving
the quality and implementation of existing services (Gomby et al., 1999).
One critical aspect of advancing the research on home visiting and ultimately improving the
services provided is understanding more about the nature of what is supposed to happen and
what does actually happen over the course of a home visiting program. Research has examined
multiple measures of multiple outcomes and has included measures of the amount of service
received but there remains a need to elucidate the “black box” of home visiting programs
(Berlin, 1998; Gomby, Larson, Lewit, & Behrman, 1993; Larner, Nagy, & Halpern, 1987).
Understanding the inner workings and critical characteristics of home visiting programs may
help explain why such an appealing strategy as home visiting has yet to live up to its promise
and what has to happen for it to do so.
The study reported here examined home visiting through a longitudinal investigation of a
program that provided monthly home visits to mothers over the first 3 years of the child’s life.
The study used qualitative methods to provide an in depth look at the content of the home visits
and the nature of the interaction between the home visitor and the mother in order to understand
precisely how the program improved developmental outcomes for children or, alternatively, to
explain why it did not. It was designed as a companion study to an experimental study that was
examining the effectiveness of the same program (Wagner, 1995; Wagner & Clayton, 1999).
Both studies began at approximately the same time.
The experimental study used a randomized design with 500 families assigned to the home
visiting treatment or control group. The study found small and inconsistent effects of par-
ticipation in the home visiting program on parent knowledge, attitude and behavior but no
30 K.M. Hebbeler, S.G. Gerlach-Downie / Early Childhood Research Quarterly 17 (2002) 28–51
overall gains in child development or health. Sub-group analyses indicated that children in
non-English-speaking Latino families benefited more than children in non-Latino or English-
speaking families. Additional information about the study can be found in Wagner and Clayton
(1999).
Because the qualitative data were collected and analyzed concurrently with the quantitative
data, much of the early focus in the qualitative analysis was on identifying how the program
might or might not be achieving its outcomes. After the quantitative data were analyzed, it
was clear the qualitative analyses needed to elucidate why the program had not been more
successful.
To understand how this home visiting program worked, we sought to describe the precise
nature of the intervention and also the assumptions that were held about how the intervention
would bring about change. Researchers within and outside of the field of home visiting have
observed that programs are based on theories of how a given intervention is expected to bring
about the desired outcome (Gomby et al., 1999; Lipsey, 1993; Powell, 1993). The concept of
a “theory of change” has been used to describe the goals, methods, and assumptions on which
social programs are based (Weiss, 1995). As Green and McAllister (1998) note, theory in this
usage does not refer to a grand theory such as attachment theory but rather to a model of how
the program is supposed to work. A theory of change may be implicit or explicit but either
way it shapes the program at multiple levels from the theoretical program design level to the
operational level of service delivery up to and including the interaction between a home visitor
and a parent.
In this study, we developed a theory of change to describe from the home visitors’ perspective
how the interactions between the home visitor and the parent were related to the intended out-
comes of the program. For example, a possible theory of change to describe how a home visiting
program could improve developmental outcomes is illustrated in Fig. 1. This is a simplified ex-
ample of how a theory of change provides testable propositions about what should be occurring
during a home visit and what should result from home visiting, given the particular theory.
We used the qualitative data to compile a working theory of change for the program and then
scrutinized that theory for consistency and reasonableness in light of current developmental
Fig. 1. Example of a theory of change for a home visiting program.

knowledge. As part of examining the validity of the theory, we also looked at what the parents
who participated thought the program was trying to do and their general impressions of the
program. We conclude that shortcomings in the program’s theory of change, including some
faulty assumptions, kept the program from achieving the parent and child outcomes that were
intended.
2. Method
The program studied used the Parents as Teachers (PAT) model of home visiting (Powers
& Fenichel, 1999; Winter, 1999). The study was conducted in an agricultural community in
northern California. The PAT program as implemented in this community consisted primarily
of monthly home visits which began either before the child was born or shortly thereafter and
continued until the child’s third birthday. The average home visit ranged from 26 to 50 minutes
across home visitors. PAT program participants received an average of 20 visits over the 3
years of the program. More information about the program is contained in Wagner and Clayton
(1999).
The data for the study included focus groups with participating parents, focus groups with
home visitors, and interviews with parents and home visitors and videotapes of home visits
collected as part of 3-year longitudinal case studies of participants.
2.1. Study participants
The sample included 21 case study families and another 60 mothers in the home visiting
program who participated in focus groups. The sample also included the nine home visitors
who delivered the program.
2.1.1. Case study families

Characteristics of the mothers in the 21 case study families are shown in Table 1. Two
families dropped out of the program and the study when the target children were about 1 year
old and 20 months old, respectively. They were not replaced. All children in the case study
families were under 3 months of age when the study started and 36 months old when it ended.
2.1.2. Home visitors

Each family was assigned one home visitor. At the start of the study, the 21 case study
families were served by a total of six home visitors. Over the course of the study, some home
visitors left and were replaced. By the time the children were 36 months old, nine home visitors
had worked with the case study families. Table 2 summarizes descriptive information about
the case study home visitors.
2.1.3. Focus group participants

A total of 60 program mothers participated in 10 focus group sessions. Individual groups
ranged in size from 2 to 10. Approximately 60% of the mothers in the focus groups were
Table 1
Characteristics of case study mothers at enrolment (n = 21)
Latina/othera (n = 14) White (n = 7)
Age at enrolment
Less than 20 6 2
20 or older 8 5
Number of siblings for target child at enrolment
None 7 3
At least one 7 4
Education at time of child’s birth
Less than high school 9 0
High school graduate or GED 3 2
Some college 2 5
a
One mother was Asian.
Latina, half of whom were primarily English-speaking. Approximately half of the mothers in
the focus groups were first-time parents, and approximately half were less than 20 years old.
2.2. Procedures
Case study families were followed for 3 years corresponding to their 3 years of program
participation. Data collection for the case study families included interviews with the case study
participants, individual interviews with the home visitors, videotapes of home visits with case
study families, and the children’s developmental assessment data. In addition, the analysis also
drew on focus group interviews with other parents, focus group interviews with home visitors,
and the transcript of one staff meeting of the home visitors.
Table 2
Descriptive characteristics of home visitors (n = 9)
Age
Average 32
Range 25–43
Ethnicity
White 2
Latina 5
African American 2
Female 9
Bilingual 5
Never married 3
Parent of a child 4
Education level
Some college, AA 3
BA 6
Former early childhood teacher 6
2.2.1. In home parent interviews

Semi-structured interviews lasting up to an hour were conducted in English or Spanish with
the case study parent(s). With a few exceptions, each family was interviewed six times between
the child’s birth and when s/he turned 3 years old. The timing of the interview was tied to the
child’s age. Interviews were conducted in the month the child turned 3, 4, 11, 18, 25 and
32 months of age or as soon thereafter as possible. Families were reimbursed $25 for each
interview. All interviews were confidential; information learned in family interviews was not
shared with home visitors. (Similarly, information learned in the home visitor interviews was
not shared with the families.)
Interviews focused on home visiting experiences and relationships with the home visitor.
Multiple family members were included in the interviews if the family chose, although most
interviews were conducted with the mother. Interviews were audiotaped with the permission
of the family and later entered into a text database for analysis.
2.2.2. Home visitor interviews

The home visitor serving each case study family was interviewed four times over the course
of the family’s participation in the program. The timing of the interview was also tied to
the child’s age (5, 17, 25, and 35 months). When a case study family experienced a change
in home visitor, the new home visitor was interviewed. The interviews focused on the home
visitor’s perception of the developing relationship with the family, the life circumstances of the
family, the home visitor’s approach to serving the family, and some background information
on the home visitor herself. The home visitor also was asked to comment about her role
as home visitor in general, as well as with regard to any specific case study family. These
interviews were audiotaped, with the permission of the home visitor, and later entered into a
text database.
2.2.3. Videotaping of home visits

Four home visits were videotaped for most case study families over the course of a family’s
3 years in the program. The timing of the videotaping was tied to child’s age and interspersed
between the parent interviews (6, 15, 20, 29 months). A total of 75 home visits were videotaped.
Written consent was obtained from families before sessions were taped.
2.2.4. Assessment data

As part of the simultaneously occurring experimental study, the case study children were
assessed with several different instruments. The children were assessed at 12, 24, and 36 months
on the Bayley Scales of Infant Development (Bayley, 1993), although not all were assessed
at all time points. The Bayley assessment was conducted by two fully trained administrators,
following the standard procedures. One who was bicultural and bilingual in Spanish and English
conducted the assessments for children for whom Spanish was the first language.
The Developmental Profile II (DPII) (Alpern, Boll, & Shearer, 1984) was administered in
the home at 12, 24, and 36 months by a trained data collector not associated with the case study
research. The DPII measures multiple aspects of a child’s development (physical, self-help,
social, academic/cognitive, and communication), as reported by his/her parent and observed
by the data collector.
The Peabody Picture Vocabulary Test (PPVT) (Dunn & Dunn, 1981) was administered at
36 months by a trained data collector. The PPVT was administered in English or Spanish,
depending on which language the mother identified as being the child’s primary language.
Parents were asked to bring their child to a centralized location for the administration of the
Bayley and the PPVT and thus not all children were assessed on these instruments.
Parents received a written (in Spanish, when necessary) description of their child’s perfor-
mance on the DPII and PPVT and a verbal summary and written description of their child’s
performance on the Bayley. If a child scored low on any of these assessments, the parents were
encouraged to take the child to a professional for further assessment.
2.2.5. Parent focus groups

Focus groups were conducted independently of the case study data collection. None of the
case study families participated in the focus groups. During the focus groups, the mothers were
asked to talk about their experiences with the program. As part of the focus group, mothers
were asked to describe the program, explain the logistics of the home visits, talk about their
relationship with their home visitor, list what they had learned from the program, assess whether
and how the program had an effect on their lives and the lives of their family members, describe
the types of mothers to whom they would recommend the program, and provide suggestions on
ways to improve the program. Four focus groups took place during the first year that families
received home visits, four focus groups took place during the second year, and two focus
groups took place during the third year the families received home visits. The focus groups
were audiotaped and transcribed for later analysis.
2.2.6. Home visitor focus groups

Two focus groups were conducted with the home visitors, with the second occurring 2 years
after the first. Six home visitors participated in each focus group. Most of these home visitors
were working with one or more case study families. These same home visitors worked with
the families who participated in the focus groups.
During the focus group sessions, the home visitors were asked to talk about their experiences
with the program. They were asked to describe their role, list the qualities and characteristics of
a good home visitor, describe how to develop a good relationship with parents, describe a home
visit, analyze differences across different types of parents, and describe how they dealt with con-
flict situations with parents. During the second focus group, they were also asked to talk about
their view of the PAT program, their job, and the effect of the home visits on the families over
3 years of participation. The focus groups were audiotaped and transcribed for later analysis.
2.2.7. Audiotape of home visitor staff meeting

The transcript of an audiotape of a staff meeting in which six home visitors discussed their
home visitor role and the program’s goals was also analyzed.
2.3. Data analysis
The data were analyzed in a variety of ways. Two members of the research team, the authors,
participated in all phases of the analysis. They were assisted at various points by two other
team members who collected the interview, videotape and focus group data. Because the
data collection for the case studies extended over 3 years and many of the issues of interest
to the study, especially the questions about why the program did or did not promote good
developmental outcomes, required the entire 3 years to unfold, the actual case studies were not
developed or analyzed as such until all the data were collected. Prior to the completion of data
collection, however, data from each of the data sources were analyzed and results compared
and contrasted across the data sources.
The interviews with case study parents and home visitors were analyzed across cases as
each set of interviews was completed. This was easy to do because the interviews were
semi-structured and the responses were entered into a text database by each question asked.
Thus, we began the analysis by looking at commonalities and variations in answers to the same
questions when the children were 3-, 4-month-old and so forth.
Similarly, the first set of videotapes were viewed repeatedly by members of the research
team to identify and describe the key features of what was observed. Most of the videotapes in
a set (e.g., the videotape at 6 months) captured the same lesson in the curriculum being given
so lesson variation was somewhat controlled for. Some of the videotapes were in Spanish and
these were transcribed completely so the sequence of events could be understood by the entire
research team. Critical segments of the English videotapes were transcribed as needed. Notes
describing what happened on the tapes were made and compared across different parents and
home visitors to identify commonalities and differences. The length of each home visit was
also recorded.
The focus groups were also held over 3 years. As each was completed, it was transcribed.
Transcripts were read repeatedly and codes developed and applied to the dialogue. The focus
groups were organized around a set of questions posed to the group so preliminary analyses
focused on summarizing the responses to these questions. The focus groups were also conducted
over the course of the study which meant the children of the participants’ in any given group
were approximately the same age and the participants had been participating in the home
visiting program for approximately the same amount of time. The data from the focus groups
were analyzed as they were completed. Thus, the analysis for the focus group for parents of
infants was completed before the focus group for parents with toddlers was conducted.
Throughout the waves of interview, videotape and focus groups analyses, memoing was used
extensively to capture observations about the data that were outside the scope of the questions
and responses, to note possible emerging patterns, to suggest synthesizing themes, and to raise
questions that should be addressed in subsequent data collections (Huberman & Miles, 1994).
When all of the data collection for the case study families was complete (i.e., at the end of 3
years), all data related to a case study family were integrated and summarized in an extensive
case study report on each family. Each case study report addressed core categories, including
but not limited to: a description of the mother’s and the father’s background, the parents’
descriptions of the content of home visits, the home visitor’s descriptions of the family’s home
visits, a description of the parents’ evaluation of the home visiting program, a description of
the home visitor’s view of the value of the home visiting program for the family in question,
a summary of the content of the videotaped home visits, and the assessment data available
on the child. After the case reports were developed, a cross-case analysis was completed.
Using a matrix format, summary information for each category for each case was presented
and reviewed by the research team (Yin, 1994). This process was iterative beginning with the
categories used to organize the reports and adding categories related to the theory of change
conceptualization. The review sought to identify patterns across cases as well as exceptions
with an emphasis on how the program would, could, or did work to improve developmental
outcomes.
Three years of qualitative data produced a wealth of information about both the similarities
and differences among home visitors and participating families and their children. In this
paper, we have chosen to focus for the most part on the similarities across home visitors
and families. We believe these similarities to be significant precisely because they cut across
the differences observed such as differences in the style and personality of the home visitor,
the level of engagement of the mother, or the magnitude of the personal challenges faced
by the family. The minimal attention given to these differences in this paper should not be
taken to mean that differences did not exist.
The findings as presented also represent a synthesis across the data sources. With regard to
the theory of change, the findings from the case studies were consistent with the findings from
the focus groups so both sources have been combined.
3. Results
The various data sources were used to assemble a detailed specification of a working theory
of change for this program including the program’s intended outcomes, how the program was
to produce these outcomes and any associated assumptions. A description of the PAT program,
including its goals, assumptions, and strategies, is presented first, followed by a description of
what occurred during the home visits. This information is supplemented by a description of what
the home visitors saw themselves as doing and their views on how program participation would
improve outcomes for parents and children. Since this represents the program as implemented,
this is considered the program’s theory of change. The working of theory of change is then
compared to how the parents saw the program. Finally, we summarize the outcomes experienced
by the children.
3.1. What the PAT program is trying to do
The PAT program as implemented at the time of the study had 10 goals related to children and
parents: (1) empower parents to give their children the best start in life; (2) increase parents’
feelings of competence and confidence; (3) increase parents’ knowledge of child develop-
ment and appropriate ways to stimulate their child’s language, social and motor development;
(4) improve parent–child interactions and strengthen family relationships; (5) give children
solid foundations for school success; (6) help children reach their full potential; (7) develop
true partnerships between parents and schools; (8) turn everyday settings into learning oppor-
tunities; (9) help create a greater sense of family success; and (10) reduce child abuse (Missouri
Department of Elementary and Secondary Education, 1989).
The PAT program materials identified several interim processes that should ultimately lead to
children being successful in school. By fostering optimal development from birth, identifying
delays and disabilities as early as possible, and involving parents in their children’s education
from the beginning, PAT saw itself as putting parents and children on the right track. The
program made several assumptions: children are born learners; parents are experts on their
own children; parents and professional educators have much to learn from and teach each
other (PAT National Center Inc. & HIPPY USA Inc., 1995).
In the program studied, these goals were to be achieved through monthly home visits in
which the PAT curriculum was presented and through periodic drop-in and play and parent
group meetings.1 The curriculum for the home visits included demonstrations by the home
visitor of developmentally appropriate activities. The curriculum also included handouts list-
ing the typical developmental characteristics of the target child’s age in the physical, social,
cognitive, and emotional domains. Ideas about alternatives to physical punishment, ways to
make the home safer for children, ways to promote healthy children, alternative toilet training
practices, and information about community social service agencies are also included in the
PAT curriculum. According to the PAT National Center, the curriculum was designed to en-
able professionally trained parent educators to provide timely child development knowledge
to parents and to help parents relate this knowledge to their own observations and interactions
with their child (PAT National Center Inc. & HIPPY USA Inc., 1995).
The PAT materials provide a very global theory of how the program is expected to improve
outcomes for children. This is consistent with previous research on home visiting in that the
“black box” of precisely how a program is to work tends not to be well articulated by the
program developers. The program implemented in the study site, as seen in the home visits
and the home visitors’ descriptions of what they were trying to do, revealed a far richer and
more detailed theory.
3.2. The home visit
The content of the home visits was similar across home visitors and across families. A typical
home visit began with general conversation while the home visitor set up toys or the day’s
activity. The home visitor often commented on changes in the home, the parent’s appearance,
or the child’s appearance or skills. The home visitor talked to all present, which for some
families was only the mother or the mother and child and for others was the mother, the father,
the child, and several older siblings. In some families, aunts or grandmothers also participated.
Latino families tended to have more people present.2
After general conversation, the home visitor asked about new things the child had been
doing since the last visit. Parents were encouraged to provide information on the child’s devel-
opmental milestones, skills, abilities, and home experiences. If the parent answered that she
had little to report, the home visitor asked questions about the child’s behavior. For example, a
home visitor might ask a parent of a 9-month-old, “Is he pulling himself up on the coffee table?
Is he trying to take a few steps? Does he walk if you only hold one hand? Is he saying ‘Mama’
or ‘Papa’?” The home visitor also provided interpretation of the child’s behavior for the parent.
For example, one home visitor observed the target child and then said to the parent, “Look how
she [the child] is squatting. She has complete control of her muscles now.” In another example,
the home visitor was reading a book to the target child and said to the parent, “Look, he seems
very interested in the book. His arms are flailing. He is getting very excited about it.”
The brief discussion of the child’s newest accomplishments was followed by the presen-
tation of the topic or lesson for the home visit. The home visitors followed the curriculum
closely. At most home visits, the parent received a handout with a list of developmental mile-
stones or other types of information. Almost all the handouts were available in Spanish; if not,
the bilingual home visitor discussed their content with Spanish-speaking families. Also, the
home visitor typically presented some type of activity involving toys or materials. For example,
one activity involved a plastic farm set with a barn and animals. The home visitor encouraged
the child to play with animals and talk about the sounds the animals make and to use dif-
ferent prepositions to describe the placement of the figures. The home visitor explained or
commented on the child’s behavior for the parent. The home visitor also usually invited the
parent to play with the child and the materials. Some accepted this invitation, and others did
not. Home visitors sometimes read to children as part of the home visit. Annually, the home
visitor completed the Denver Developmental Screening Test (Frankenburg, 1973) as part of
the home visit program.
Discussion between the home visitor and the parent occurred throughout the home visits.
The focus of the talk generally was on the child—for instance, what the child had done recently,
how the child reacted to the materials, or the value of the activity for the child. Home visitors
encouraged parents to ask questions about the child and to voice any concerns about parenting.
Throughout the visit, the home visitor provided numerous positive comments. Upon seeing a
child perform or hearing about a new skill, the home visitor would exclaim “that’s great” or
“I’m impressed.” There was also much praise directed toward the parent. Examples of home
visitors’ comments included “Everything seems to be going very well here. You are doing a
great job.” “Give yourself some credit. You have help, but you are doing a great job.” “Well,
for you to observe it [the child’s behavior] and then mention it, that’s great. . . You are an
observant mother.”
The home visitors occasionally engaged in conversation that was adult focused, but they
reported being uncomfortable spending too much time on issues not related to the child. The
home visitors reported that their teen mothers in particular talked more about their friends,
relationships, and social lives than did other parents. Mothers with more than one child also
talked and asked questions about their other children. Single mothers were more likely to
talk about their relationships with the child’s father and other men. Home visitors encouraged
mothers to take time for themselves (e.g., go to an exercise class) and to do things for themselves
(for example, get a driver’s license). Overwhelmingly, however, across the home visits the
primary focus of the conversation was the target child.
The end of the home visit involved a review of what had been discussed, a request for
questions from the mother, announcements of upcoming events that might be of interest to the
family, and the scheduling of the next home visit.
3.3. How the home visitors saw their work
The home visitors were similar in how they saw the functions of various components of the
home visits and the role they played vis-à-vis the parent and child development. They shared
a number of assumptions about the parents and the intended outcomes of the home visiting
program.
Asking for observations of the child was recognized as an important part of the home
visit. The home visitors interpreted the parents’ ability to respond with information about what
the child had been doing recently as one indicator that the parents were fulfilling their role in
the home visit. An increase in the ability to share observations was also seen as evidence of
the benefit of the home visiting program in that it was increasing the parent’s attention to the
child. As one home visitor explained, “To me it tells me that you [the parent] spend time with
your child. . . You spend time with them [the children], you are watching them, you have the
interest in what they are doing and how they are doing it.”
The extensive praising of the parents, the child, the siblings, and any other persons who
cared for the child was purposeful. The home visitors reported that praise served to validate
the particular behavior and the parenting in general. The home visitors talked about wanting
parents to feel “empowered.” The teaching style encouraged discussion and was not didactic.
The home visitors reported that when they interacted with the child, they were modeling for
the parent. The home visitors said they provided alternative perspectives and information but
did not tell the parents what to do. One home visitor described her role in these terms:
We are not out there doing it to say, “I’m the teacher and you have to listen to me.” That’s
not our focus. Our focus is to empower them [the parents]. Because they [the parents] have a
lot of knowledge inside. It [the teaching style] is asking questions, open-ended questions. The
parents come to the “aha” stage. [They say] “Oh, yeah, now I know what you mean.” That’s
what our focus is. And in that way, whatever the parents have learned, it comes from them in
a sense and stays there. And it validates them.
The home visitors generally did not discuss parenting behaviors that seemed to need im-
provement with parents, with a few notable exceptions. An example of an exception was the
home visitor who continually reminded a mother about the importance of getting her twins
immunized when, month after month the children remained behind on their immunizations.
Similarly, the home visitors rarely asked parents whether they had carried out any of the ac-
tivities they had been shown on previous home visits. The home visitors reported that when
the curriculum required them to return to an issue that was sensitive for parents or provided
advice the parents seem to resist, they felt embarrassed and put the onus of responsibility for
repeating a lesson on the curriculum.
The home visitors emphasized that it was counter to the program’s goal of empowerment to
push for change in behavior. Home visitors acknowledged that they did not often ask parents
to list or describe the parent–child activities in which they engaged during the previous month
for fear of making parents feel pressure to engage in the suggested activities. Similarly, home
visitors said they hesitated to evaluate the parent–child interaction during the home visits, citing
concerns of being unfair or too critical. The home visitors reported that they wanted to provide
an atmosphere in which the parents felt they had the freedom to choose parenting ideas.
The home visitors also were ambivalent about their level of parenting expertise as compared
with the parents’. They often talked about their expertise as something that was useful primarily
as a way to validate the parents’ opinions or behavior. These beliefs were expressed well by
the home visitors during a focus group. For example:
Home visitor 1: “So you have to be patient, and you encourage, and you repeat, and you leave
it alone. And you model, and you encourage, and you give more information.”
Home visitor 2: “I am a person who supposedly knows [about parenting and child development].
So if she [the mother] knows what I know, then it [the visit] reaffirms that ‘Yes, I do know.’ I
am a confirmation to her feelings of what she already knows. I think that parents need support.
We are not in the home to fix anything. That is another thing about our program. We are not
trying to fix anything.”
Home visitor 3: “. . . not coming in their house, bombarding them. Like you’re the professional,
you have this degree, and you know all this information. It’s just, you let them take the lead
and let them know that ‘This is your house, you’re the number one person. I’m just here to give
you a little information. And I can learn from you.”’
Home visitor 4: “I don’t want them to think that I am pushing and pressuring and criticizing
that ‘naughty, naughty.’ It [the knowledge] will come . . . I continue to step, but I step lightly,
with respect. But I don’t drop the issue because they don’t want to hear it. Because it is my
responsibility to share this information, and it is their choice to take it or not.”
The home visitors believed that the children would be affected by the program primarily
through the parents. They often expressed the belief that “if the mother feels good, the child
will feel good.” The home visitors also believed that the child would benefit when the parents
implemented the knowledge they received through the home visits.
The home visitors identified a number of benefits for parents from program participation.
They reported that parents were validated through praise and when they were assured the child
was developing well. Home visitors believed that parents learned new information about child
development through the home visits. They said that parents learned how to create a safe,
stimulating environment for their child through the information in the handouts, through the
discussion at the home visits, from observing their child, and from observing the home visitor
model appropriate interactions. They also stated that parents benefited because the program
provided alternatives to physical punishment. According to the home visitors, the home visits
were an opportunity for the parents to talk about their child with an objective person trained
in child development, think through their concerns, and engage in problem-solving. Other
benefits to the parents listed by the home visitors included the opportunity to talk to another
adult during the day. The home visit provided a break for some mothers from having sole
responsibility for child care. Home visitors also emphasized the importance of mothers’ taking
care of their own needs. Home visitors gauged the program as successful when mothers took
actions that demonstrated increasing independence, such as going to the gym or taking classes.
Key elements of the theory of change based on the home visits and the home visitors
descriptions of assumptions, interventions, and intended outcomes are shown in Fig. 2. Central
to the theory were the beliefs that all parents want to be good parents; that if the mother feels
good, the child feels good; and that parents have the knowledge within themselves to be good
parents. The concept of “good parenting” or a “good parent” was not specified in much detail.
As presented earlier, the PAT program has a number of intended child outcomes including
giving children a solid foundation for school, helping children reach their full potential, and
reducing child abuse. The first and second of these are general child outcomes that are assumed
to incorporate more specific outcomes such as communication skills, motor skills, and self-help
skills. The strategies for achieving the parent outcomes included asking questions about the
child, providing information, modeling interactions, and providing praise and support for the
parent.
Fig. 2. The home visitors’ theory of change for the home visiting intervention.
Certain reasonable assumptions and strategies were missing from this theory and were
notable in their absence. Other parts of the theory were somewhat contradictory. The home
visitors verbalized little interest in changing or bringing about particular parent behaviors. They
rarely provided feedback to parents on any observations of parent–child interaction other than
to tell the parents what a good job they were doing. Although they emphasized the importance
of activities such as talking, singing, and reading to the child, the home visitors put almost
no pressure on parents to do these things. Despite the fact that the home visitors spent much
time during the home visit talking about what the target child was doing and would be doing
shortly and what parents could do with their child, the home visitors seemed to believe that the
transmission of knowledge was a relatively minor part of their role. We saw a contradiction
between their role as information provider and the assumption that parents had the expertise
to parent well, although the home visitors never acknowledged any such contradiction. In the
theory of change as implemented in this program, the primary goal of the intervention was for
parents to feel good about themselves as people and as parents. When this happened, the home
visitors believed that good developmental outcomes would result.
3.4. How the parents saw the program
Program participation was voluntary and open to all families, regardless of income level.
Families signed up to participate in the program because they wanted to be better parents.
They believed that they had something to learn and that the program had something to teach
them. For example, one parent said:
I was real concerned about doing things, I don’t know, that would help his mind develop and
make sure I was giving him the right amount of whatever kind of emotional things that he
needed—and I wasn’t sure I was going to be able to do that, since I was a first-time mom. I
didn’t know what to look for, and it [the program’s promotional materials] said it [the program]
would give you that kind of information.
Another parent said:
Because there was a lot to learn, I thought, you know, they could help me out with what the
baby was doing, or whatever. They could help me learn more stuff I could do, if I had problems
or didn’t know who to talk to, or whatever. That’s how come I wanted to [join the program]. I
thought they could give me a lot of advice.
Throughout their 3 years in the home visiting program, parents were overwhelmingly pos-
itive about their participation. Parents spoke very highly of their relationship with their home
visitor, often describing her as being “like a friend.” Parents said that even if they had others
to support their parenting, they liked having the home visitor to talk to about their child. They
liked the child development information provided by the home visitors, especially the handouts
on developmental milestones. They saw the home visit as creating a special time for their child
in their busy day. They liked having a regular opportunity to talk about their child and their
parenting. To a lesser extent, parents reported that they enjoyed having someone they could
talk to about things not closely related to the child or parenting.
Although the home visitors preferred not to see themselves as experts, the parents clearly did
and valued their expertise. Parents viewed the home visitors as people with knowledge in child
development, access to helpful information because of their professional status, and experience
with children that allowed them to be more objective than parents and other family members in
their assessment of a child’s development. While explaining the essential characteristics of a
good home visitor, one parent said, “If somebody came without having any information, they’d
be worthless. So they [home visitors] have to have the book knowledge . . . ” Another parent
said she liked “having somebody else from a different point of view” observe and comment
on her child’s development. It was a commonly expressed opinion among parents that the
home visitors’ ability to evaluate their child’s progress was superior to their own or that of
other family members and friends, and thus was especially valued. Parents were comforted by
knowing that someone trained to detect delays was observing their child’s development.
The parents and home visitors identified many of the same benefits of program participation
for parents. Parents indicated that home visits made them feel good about their parenting. As
one mother expressed it:
It does make me feel like I’m a good mom. It does make me feel good. It’s changed my view
because she told me I know how to take care of kids good. She made me happy because no one
had ever told me that before.
Almost all the case study parents reported that the program made them more aware and
observant of their children. The comments from two mothers were typical. One said, “It [the
home visits] has made me more aware of things to look for. I probably wouldn’t be as aware.
Not that I am always doing something about it constantly.” Another said, “I’m more aware of
what she [the child] is doing and where she is at. Each home visit, she’s improved and doing
more of this, and I’m noticing more.” Parents reported that they learned new information
from the program. When asked about the most useful advice they received from the program,
parents typically referred to specific advice they had received in the first year of the program.
After the first year, the parents talked more about the home visits in terms of the activities
and toys that the child enjoyed rather than advice they received. Some parents said that the
program had encouraged them to interact more with their child and to provide more stimulating
environments. Some parents suggested that the program had increased their patience with their
child and had perhaps decreased their use of physical punishment.
Unlike the home visitors, all the parents to varying extents saw the home visit itself as a
specific form of intervention with the child. For parents, this one-on-one time with an expert
was like a high-dosage vitamin that the child received monthly. One mother explained that
because of the home visits, “They [her children] have probably learned more. Because of all
of the things [activities and toys] that she [the home visitor] brings them.” Another echoed the
same sentiment, “Oh yes, he’s [the child] different. Because she [the home visitor] shows him
a lot of things and she plays with him. He is learning a lot.”
Although parents were very positive about the program and identified many benefits that
they had received, they did not believe that program participation had affected their parenting
to any great extent. When asked whether being in the program had changed her, one mother
responded, “Not different but more like she [the home visitor] helps me understand things.
She gives me advice. I don’t feel different. I just feel like I have somebody to talk to besides
the people that live here . . . ” Another mother, in response to the same question, answered,
“Well, no, but I think it’s a good program, and it shows you a lot. It teaches you what you don’t
know . . . I think I am the same. I just have more information based on the program.” Parents
reported that they incorporated some concepts from the program and ignored the rest, and they
sometimes did not incorporate what they had learned into their parenting, even though they
wanted to. For example, many parents said that although they would rather not use physical
punishment and that the program had suggested a lot of alternatives, they still found they
spanked their child.
The parents’ view of the program and how it worked shared many similarities with the home
visitors’, but it also differed in some ways. The two groups were similar with regard to the
assumption that parents wanted to be good parents and the outcomes identified for parents.
They also were similar in not seeing a focus on the development of specific parent behaviors.
The home visitors did not focus on particular parenting behaviors, and the parents reported
that, by and large, they were not that different as parents as a result of the home visits.
The parents and the home visitors differed with regard to expertise of the home visitor and
the intent of the activities demonstrated with the child. Whereas the home visitors talked about
the parents as the real experts, the parents saw the home visitors as experts. Parents expected the
home visitor to have knowledge that they as parents did not have, saw sharing information as
the home visitor’s role, and were comfortable with the home visitor as a teacher. The parents
saw the time the home visitor spent interacting with the child as a direct intervention that
would enhance the child’s development, whereas the home visitor saw the same interaction as
modeling for the parent.
3.5. Outcomes for children
One test of a theory of change is whether the hypothesized outcomes were obtained. Both
the companion experimental study and the qualitative study provide a perspective on how the
children were doing after 3 years of home visits. As noted above, the experimental study
found no overall gains in child development or health. Sub-group analyses showed chil-
dren in non-English-speaking Latino families benefited more than children in non-Latino or
English-speaking families (Wagner & Clayton, 1999).
The data on child outcomes for the case study families can be interpreted from a more clinical
perspective combining data across the multiple measures from multiple time points available
on a given child. Two issues emerged in the outcome data for the case study children: how
people perceived the children to be developing and the scores obtained on the developmental
measures.
The home visitors were asked periodically about the development of each of the case study
children. In general, the home visitors reported that the children were doing well throughout
the study and at the end of the 3 years. Home visitors expressed concerns about two children’s
development, but even in these cases, the home visitor felt that each child would probably catch
up once enrolled in preschool.
The home visitors’ assessments were based primarily on their own observations of each child,
reports from the family, and the developmental screenings of the child that they performed.
In a few cases, a home visitor mentioned the child’s performance on assessments that were
conducted by others. As part of the experimental study, the home visitors’ supervisor received
notification of each child who received a low score on the DPII, the PPVT, or the BMDI. We
do not know how much of this information was communicated to the home visitors. Parents
sometimes reported to their home visitor about their child’s performance on the assessments,
but not systematically. Parents seemed to report high scores to the home visitor more often
than low scores.
Parents were not asked directly how they thought their child was developing. As noted earlier,
many parents expressed a general level of concern about whether their child was developing
normally. A few parents indicated to their home visitor that they had specific concerns about
their child. For example, one family expressed concern during one home visit about their son’s
language development. The home visitor reassured the mother that he was slower because
he heard both Spanish and English and that this would not be a problem once the child had
opportunities to interact with more English-speaking children his own age.
The assessment data available for the children does not corroborate the home visitors’
conclusion that all the children were doing well. On the basis of all available information, three
children from case study families were doing very well. These children scored above-average
on the BMDI, the DPII, or the PPVT, or on all three. When observed by the researchers,
these children were found to be very verbal, curious, and responsive. Another small group of
children appeared to be developing normally, on the basis of their scores and observations of
the researchers.
Considerable evidence exists to suggest that about half of children in the case studies were
developing less than optimally.3 Six of the 11 case study children to whom the Bayley was
administered scored 75 or lower on the BMDI at 36 months. Likewise, many of the children
scored below their age in one or more areas of the DPII. Children in the case study sample
who were seen as developing well scored 4 or more months ahead on the DPII at 36 months.
On the PPVT, 5 of the 18 children who were tested scored 5 or more months below their age;
4 of the 5 scored 9 months below their age. The assessment data showed a mixed picture for
some of these children, with very low scores on one assessment and average scores on another.
In general, the findings from the assessment data were confirmed by the informal observations
of the researchers, who did not examine any of the assessment data until the contact with the
families was completed but who had seen the children during the videotaping of the home
visits. Despite the home visitors’ pronouncements that all the children were doing well, other
evidence indicated that some were showing early signs of possible developmental problems.
4. Discussion
We set out to understand how a home visiting program worked and, more specifically, why
it would or would not be successful in achieving the intended developmental outcomes for
children. As the data from the experimental study and the case study were analyzed, it was
clear the question to be addressed was why the home visits were not more effective in achieving
their outcomes.
We learned that the home visits had a consistent structure across visits and home visitors. We
also learned that home visitors had a strong sense of what they were trying to do. They shared
beliefs about how good developmental outcomes would be brought about and acted on their
assumptions. We compiled the various assumptions and implied hypotheses guiding the work
of the home visitors into the theory of change to illustrate how they thought the program would
operate to improve development for children. Although the PAT program itself provided some
of the general elements in the theory of change, the local program staff added considerable
detail to the overall program philosophy and goals.
When the home visitors’ assumptions were compared to how the parents saw the program,
similarities as well as differences were identified in what the two groups saw as key program
components and how they thought these components would promote the children’s develop-
ment. The evidence supported that the parents wanted to be good parents, and that praising
parents helped them to feel confident in their parenting. Both the home visitors and the parents
believed that having a strong relationship with a home visitor was important and beneficial
to the parents. They differed on how they viewed the expertise of the home visitor and the
intended purpose of the home visitor showing the child a new activity.
To address the question why the program was not more effective we begin with the home
visitors’ theory of change. Were their assumptions justified? Were the hypothesized relation-
ships reasonable? Were key elements missing? An examination of the home visitors’ theory
of change suggests several reasons why the program was not more effective. First, the home
visitors saw the provision of social support as their primary responsibility. Critical to the home
visitors’ belief system was the off-repeated theme that “if the mother feels good, the child will
feel good.” Interestingly, the PAT program would be considered a program focused on parent
education but the home visitors saw their role of providing family support as more impor-
tant than their information sharing role. Consistent with the emphasis on helping mothers feel
good about themselves was the de-emphasis on any expected or desired goals for parent–child
interaction.
A second possible reason the program was not more effective was that even though the
home visitors provided the parents with much information, the behavioral implications or
expectations associated with that information were minimized if they were articulated at all.
Research suggests that interventions intended to promote child development by working with
parents need to affect the nature of the interaction between the adult and the child (Barnard,
1998; Barnard, Morisset, & Spieker, 1993; Mahoney, Boyse, Fewell, Spiker, & Wheeden,
1998). The home visitors recognized the importance of promoting parent–child interaction but
de-emphasized it to such an extent that it was nearly non-existent as a mediating factor to
promote good development.
The home visitors talked a lot about what the children were doing but not much about what
the parents should be doing. Both the home visitors and the parents indicated that repeatedly
asking parents about new things their child was doing led parents to pay more attention to their
child’s changing behaviors and become better reporters. Neither group seemed to understand
how increasing the parent’s observation skills was supposed to enhance the child’s develop-
ment. The home visitors did not communicate to the parents what they were expected to do
with what they were noticing. Similarly, although the parents enjoyed learning at which age
various developmental milestones occur, much of this information did not translate easily to a
behavior on the parent’s part. (There was some evidence, however, that repeated presentation
of alternatives to physical punishment and much discussion about how the toddler years can
be particularly challenging helped parents to be more accepting of and react more calmly to
their child’s difficult behaviors.)
Even the modeling of the adult-child interaction that the home visitors thought they were
providing as they demonstrated an activity was not recognized as modeling by parents and had
little influence on them. Some of the parents thought the intent of the activity was for the home
visitor to teach the child something. Many parents did not see the importance of duplicating
the types of home visitor-child interactions and activities they observed.
The findings further suggest that the home visitors had recurring opportunities to help parents
improve their parenting but that they did not take advantage of them. The home visitors were
uncomfortable being cast as experts, even though the parents saw them as experts and wanted to
learn how to be better parents. It is conceivable that, had the home visitors been more directive
or more actively encouraged parents to engage in the behaviors being promoted, the parents
would not have been so positive about the program or would not have developed as warm a
relationship with the home visitors. On the other hand, the strong relationships that were built
between the home visitor and the parent did not always help the children. Mahoney et al. (1998)
note that many professionals have avoided encouraging parents to modify their interactions
with their children for fear that these patterns conflict with the family’s cultural, religious, and
individual values and beliefs about parenting and child rearing. The parents in our study wanted
to learn how to be good parents. Our findings suggest that intervention programs that focus on
parenting need to accept and support parents while actively helping them to adopt behaviors
that have been demonstrated to promote healthy development and that the parents themselves
want to learn. We should note that we have no data available on the actual nature or quality of
the parent–child interaction of the parents in the study. It is reasonable to conjecture, however,
that this outcome was not strongly affected by program participation. Consistent with their
theory of change, the home visitors placed minimal emphasis on helping parents interact with
their babies. The home visitors focused on helping the parents feel good about themselves as
parents. The lack of goals for parent behavior, the lack of follow-up, and the lack of feedback
on their parenting (as opposed to blanket praising regardless of the behavior) appeared to lessen
the potential effectiveness of the home visit for the parent and ultimately for the child.
The poor outcomes experienced by some case study children also raise questions about the
ability of the home visitors to detect possible developmental problems, one of the expressed
goals of the program. One possible explanation is that the home visitors were not sufficiently
trained to recognize potential delays. Another hypothesis is that the home visitors’ strong bond
with the mothers and their belief in the mothers themselves, core elements of the theory of
change, blinded the home visitors to the children’s problems. The home visitors appeared to
believe so strongly in the intentions and capability of the parents to be good parents that they
could not conceive that the children would not develop well. In several cases, the children
displayed behaviors that signaled potential problems and that were readily noticed by the
researchers, who had only minimal interaction with the children. And yet, the home visitors
communicated with conviction to the parent that the child was doing well or would be fine. The
parents were reassured, unfortunately, that they did need not be concerned about the child’s
development.
An inadequate theory of change is a fundamentally different explanation from those typically
put forward in the literature when a home visiting program does not achieve its intended results.
Typical explanations include that the program was not fully implemented, the program was
not intensive enough, or the program was not comprehensive enough. The qualitative data also
provide insight into why these explanations are not the most reasonable explanation for the
findings presented here.
Was the program implemented? The videotapes and interviews substantiate that the PAT
curriculum was implemented. The implementation was not perfect, and there were variations
in emphasis and style across home visitors, but the program was presented with considerable
fidelity (allowing for the typical real world deviations caused by ill staff or parent, re-scheduled
or forgotten appointments, or personal crises that necessitated a different focus for some home
visits). The home visitors were trained, and they were well supervised. They were also provided
with regular feedback on their performance. They carried out their responsibilities as they had
been instructed to do, and they did it relatively consistently across families and across time.
Furthermore, the program as implemented was entirely consistent with the PAT program’s
theory of change. The home visitors’ theory of change was considerably more detailed than
the program’s theory, but the critical elements of parent support combined with the provision
of parenting information leading to improved outcomes for children were found in both.
Another common explanation offered when home visiting programs do not achieve their
intended result is that the program was not intense enough (Burchinal, Campbell, Bryant,
Wasik, & Ramey, 1997). At one visit per month, the intensity of the program we studied
was far less than those of some other home visiting program models and is subject to that
criticism. Also, some families received far fewer than the full contingent of visits, as often
occurs in home visiting programs (see, e.g., Infant Health and Development Program, 1990).
However, if one accepts that the theory underlying the intervention was inadequate, then it is
unlikely that increasing the number of home visits would have produced better outcomes for
children.
Would the program have been more effective if it had addressed more of the families’
needs? As Halpern (1993) noted, some families need a more comprehensive approach than a
home visiting program focused on the child can deliver. The case study families were dealing
with many other issues besides parenting. Over the course of the 3 years, they experienced
separation and divorce, troubled relationships, drug addiction, domestic violence, a drive-by
shooting that left a house riddled with bullets, incarceration, and attempted suicide. Many of
the case study families were very poor and living in inadequate housing. Some were minimally
engaged in the home visits and did not keep appointments. These families could well require
a more complex theory of change and a more comprehensive intervention because of the
other multiple issues affecting their parenting. This pattern did not apply to all the families
we followed, however. Some of the poorest families were extremely engaged in the home
visits and were very interested in what home visiting had to offer, and yet their children had
poor outcomes. Of critical importance for policy and program design is that poverty and other
major challenges are barriers for some, but not all, families who want to improve their parenting.
Stand-alone home visiting programs might not be as helpful as more comprehensive programs,
but our data suggest that they have the potential to be helpful to some families if they are based
on solid theory.
The study’s findings do not imply that home visiting programs do not or cannot work.
As has been often pointed out, interventions are complex undertakings, and the question to be
asked is not “does it work?” but “what works for whom under what circumstances?” (Guralnick,
1993). Home visiting is a mechanism for delivering many different kinds of interventions using
different types of home visitors and focusing on different goals for families. We studied one
particular model, and our findings might not even apply to all the variations in implementation
of this model. The insights produced by describing and examining the theory of change attest
to the value in this approach. Regardless of the intervention, the type of intervenor, or the
intended outcome, a program can be strengthened by articulating and testing the hypothesized
program model or theory of change.
4.1. Implications for practice
The study findings suggest several important components for effective home visiting pro-
grams. To improve developmental outcomes for children, home visiting programs must be
well conceptualized at both the macro and micro levels, and this conceptualization must be
well-grounded in knowledge of child development. Program designers and implementers need
to articulate and explicitly address both short- and long-term goals for parents. These goals
can be developed with families through a process that is culturally respectful and supportive
yet helps parents understand that all parenting behaviors are not equally beneficial to children.
The goals need to be sufficiently precise (e.g., parents will read to their children several times
a week) so home visitors and parents can actually reflect on whether they are being achieved.
The findings from the study underscore the necessity of building a strong relationship between
the parent and the home visitor. The emotional support provided by the home visitors was a
significant contributor to the strength of this relationship. Effective home visiting programs
need to address both the parents’ need for support as well as their desire to improve their par-
enting skills. Unlike the home visitors in this study, the parents did not see supporting parents
as conflicting with seeking to change parenting behaviors. The implication for home visiting
programs is that they can and should address both.
Programs would also be well-served to articulate the intervening processes that are as-
sumed to connect the intervention provided with the intended goals for parents. If a program is
providing basic information about child development, is the hypothesis that increasing parent
knowledge will lead to new parenting behavior? How is this expected to happen? For goals that
address parenting behaviors, the program needs to reflect on whether the intervention offered is
sufficient to bring about the intended outcome. The PAT curriculum provided parents a wealth
of information about development. Identifying the assumptions linking the intervention to the
intended outcome strongly suggested the program needed to more directly address what it was
trying to do. Using home visitors to model parent–child interactions was too subtle and many
developmental milestones have no obvious behavioral response. Even teaching the parents to
be good observers did not translate into new parenting behaviors. The curriculum could be
modified to address all of these shortcomings.
The findings from this study also emphasize how important it is that home visiting staff be
adequately trained to recognize indicators of atypical development. Unusual affect or delayed
language development in young child easily can go undetected. Well-trained home visitors
should be a valuable asset for getting children with special needs and their families connected
to the resources they need. Those lacking such skills can do harm to children by providing false
assurances to parents. In sum, home visiting programs needs to be solidly grounded in good
theory and practitioners need to understand the theory at a relatively detailed level. It is not
enough that staff know how to implement a program; they need to understand how the program
is supposed to work. If each home visitor were equipped with a thorough understanding of the
overall goals of the program, the specific goals for parents, and the nature of the intervention
and how it is expected to work, he or she would have the capacity to monitor effectiveness for
each parent and child individually and for the program overall.
Home visiting programs also need theories that incorporate the reality that some parents
cannot or will not follow through on what the home visit provides and that additional strategies
will be required to ensure that children’s development is not compromised. Programs might
need a more flexible structure to accommodate those who can take advantage of what a home
visit has to offer and to provide the additional assistance to those who need more.
Both home visiting programs and research on these programs could benefit from an in depth
look at the theory underlying how programs are expected to produce their intended outcomes
and what they actually do. Intervention research has moved beyond pre- and post-measures
to recognize the importance of examining program variables but the nature and measurement
of such variables is still challenging. Describing the nature of the program is more than the
philosophy of the curriculum or the number of visits in a time period. This study used qualitative
methods to show the importance of understanding the belief systems of the people involved
and the nature of their interactions. The home visitors in this study were dedicated practitioners
who acted on a theory of change that was faulty in some of its key assumptions and hypotheses.
Additional research is needed to develop and implement theories of change for home visiting
that will result in positive outcomes for both parents and children in a variety of circumstances.
Using sound theory to illuminate the black box will allow the scarce resources available for
home visiting to be expended in ways that maximize their effect for the greatest number of
families and children.
Notes
1. The drop-in and play and parent group components were a relatively minor part of the
research because few of the case study mothers participated.
2. For convenience, we will use the term parent to describe the participant in the home visit.
3. The mean BMDI score was 90.8 (SD = 13.28, N = 131), the mean PPVT months
differential was .3 (SD = 8.91, N = 188), and the mean DPII cognitive development
scale months differential was −.5 months (SD = 6.09, N = 210) for the entire participant
sample in the experimental study at 36 months. Scores were lower for children of Latina
mothers (mean BMDI score = 88.9, mean PPVT months differential = .3, mean DPII
cognitive development scale months differential = −1.7 months), who were the majority
of participants.
Acknowledgments
This study was supported by a grant from the Ford Foundation. We would like to ac-
knowledge the important contribution of the home visiting staff and the parents who gave so
generously their time to the 3 years of this study.
References
Alpern, G. D., Boll, T. J., & Shearer, M. S. (1984). Developmental Profile II. Los Angeles, CA: Western Psychological
Services.
Barnard, K. E. (1998). Developing, implementing, and documenting interventions with parents and young children.
Zero to Three, 18(4), 23–29.
Barnard, K. E., Morisset, C. E., & Spieker, S. (1993). Preventive interventions: Enhancing parent–infant relation-
ships. In C. H. Zeanah (Ed.), Handbook of infant mental health (pp. 386–401). New York: Guilford Press.
Bayley, N. (1993). Bayley Scales of Infant Development. New York: Psychological Corp.
Berlin, L. J. (1998). Opening the black box. Zero to Three, 18(4), 1–3.
Burchinal, M. R., Campbell, F. A., Bryant, D. M., Wasik, B. H., & Ramey, C. T. (1997). Early intervention and
mediating processes in cognitive performance of children of low-income African–American families. Child
Development, 68, 935–954.
Dunn, L. M., & Dunn, L. M. (1981). Peabody Picture Vocabulary Test revised. Circle Pines, MN: American Guidance
Service.
Frankenburg, W. K. (1973). Denver Developmental Screening Test: Manual/workbook for nursing and paramedical
personnel. Boulder: University of Colorado Medical Center.
Gomby, D. S., Larson, C. S., Lewit, E. M., & Behrman, R. E. (1993). Home visiting: Analysis and recommendations.
The Future of Children: Home Visiting, 3(3), 6–22.
Gomby, D. S., Culross, P. L., & Behrman, R. E. (1999). Home visiting: Recent program evaluations—analysis and
recommendations. The Future of Children: Home Visiting: Recent Program Evaluations, 9(1), 4–26.
Green, B. L., & McAllister, C. (1998). Theory-based participatory evaluation: A powerful tool for evaluating family
support. Zero to Three, 18(4), 30–36.
Guralnick, M. (1993). Second generation research on the effectiveness of early intervention. Early Education and
Development, 4, 366–378.
Halpern, R. (1993). The societal context of home visiting and related services for families in poverty. The Future
of Children: Home Visiting, 3(3), 158–171.
Huberman, A. M., & Miles, M. B. (1994). Data management and analysis methods. In N. O. Denzin & Y. S. Lincoln
(Eds.), Handbook of qualitative research (pp. 428–444). Thousand Oaks, CA: Sage.
Infant Health and Development Program (1990). Enhancing outcomes of low-birth weight pre-term infants. JAMA,
263, 3035–3042.
Larner, M. (1992). Realistic expectations: Review of evaluation findings. In M. Larner, R. Halpern, & O. Harkavy
(Eds.), Fair start for children: Lessons learned from seven demonstration projects. New Haven, CT: Yale Uni-
versity Press.
Larner, M., Nagy, C., & Halpern, R. (1987). Inside the black box: Understanding home visiting programs. Pre-
sented at the annual meeting of the American Public Health Association, New Orleans, LA. ERIC Document
Reproduction Service No. ED 328336.
Lipsey, M. W. (1993). Theory as method: Small theories of treatment. New Directions for Program Evaluation, 57,
5–38.
Mahoney, G., Boyce, G., Fewell, R. R., Spiker, D., & Wheeden, C. A. (1998). The relationship of parent–child
interaction to the effectiveness of early intervention services for at-risk children and children with disabilities.
Topics in Early Childhood Special Education, 18, 5–17.
Missouri Department of Elementary and Secondary Education (1989). Parents as Teachers program planning and
implementation guide. St. Louis, MO: Author.
Olds, D. L., & Kitzman, H. K. (1993). Review of research on home visiting for pregnant women and parents of
young children. The Future of Children: Home Visiting, 3(3), 53–92.
The Parents as Teachers National Center Inc. & Home Instruction Program for Preschool Youngsters USA Inc.
(1995). PAT and HIPPY: Exploring the potential for collaboration. New York: Author.
Pfannenstiel, J. C., & Seltzer, D. A. (1989). New Parents as Teachers: Evaluation of an early parent education
program. Early Childhood Research Quarterly, 4, 1–18.
Pfannenstiel, J. C., Lambson, T., & Yarnell, V. (1995). The Parents as Teachers program: Longitudinal follow-up
to the second wave study. Overland Park, KS: Research and Training Associates. Prepared for the Missouri
Department of Elementary and Secondary Education.
Powell, D. R. (1993). Inside home visiting programs. The Future of Children: Home Visiting, 3(3), 23–38.
Powers, S., & Fenichel, E. (1999). Home visiting: Reaching babies and families where they live. Washington, DC:
Zero to Three.
Wagner, M. (1995). The Salinas Valley Parents as Teachers demonstration: First year evaluation findings. Menlo
Park, CA: SRI International.
Wagner, M. M., & Clayton, S. L. (1999). The Parents as Teachers Program: Results from two demonstrations. The
Future of Children: Home Visiting: Recent Program Evaluations, 9(1), 91–115.
Wasik, B. H., Bryant, D., & Lyons, C. (1990). Home visiting: Procedures for helping families. Newbury Park, CA:
Sage.
Weiss, C. H. (1995). Nothing as practical as good theory: Exploring theory-based evaluation for comprehensive
community initiatives for children and families. In J. P. Conell, A. C. Kubisch, L. B. Schorr, & C. H. Weiss (Eds.),
New approaches to evaluating community initiatives: Concept, methods, and contexts (pp. 65–92). Washington,
DC: The Aspen Institute.
Weiss, H. B. (1999). Home visits: Necessary but not sufficient. The Future of Children: Home Visiting, 3(3),
113–128.
Winter, M. M. (1999). Parents as Teachers. The Future of Children: Home Visiting: Recent Evaluations, 3(3),
179–181.
Yin, R. K. (1994). Case study research: Design and methods. Thousand Oaks, CA: Sage.

Hebbeler Gerlach2002

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Hebbeler Gerlach2002

Uploaded by

Copyright:

Available Formats

Early Childhood Research Quarterly 17 (2002) 28–51

Inside the black box of home visiting: a qualitative

Keywords: Home visiting; Parent–child interaction; PAT; Intervention

0885-2006/02/$ – see front matter © 2002 Published by Elsevier Science Inc.

Fig. 1. Example of a theory of change for a home visiting program.

2.1. Study participants

2.1.1. Case study families

2.1.2. Home visitors

2.1.3. Focus group participants

2.2.1. In home parent interviews

2.2.2. Home visitor interviews

2.2.3. Videotaping of home visits

2.2.4. Assessment data

2.2.5. Parent focus groups

2.2.6. Home visitor focus groups

2.2.7. Audiotape of home visitor staff meeting

2.3. Data analysis

3.1. What the PAT program is trying to do

3.2. The home visit

3.3. How the home visitors saw their work

3.4. How the parents saw the program

3.5. Outcomes for children

4.1. Implications for practice

You might also like