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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 2017.  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.
BENEFIT-COST
META-ANALYSIS
CITATIONS
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2016). 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 $2,408 Benefits minus costs ($211)
Participants $10,418 Benefit to cost ratio $0.98
Others $217 Chance the program will produce
Indirect ($4,796) benefits greater than the costs 49 %
Total benefits $8,247
Net program cost ($8,457)
Benefits minus cost ($211)
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
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Labor market earnings associated with employment $449 $988 $0 $0 $1,436
Public assistance ($676) $287 $0 ($338) ($726)
Food assistance ($656) $592 $0 ($327) ($390)
Subtotals ($883) $1,867 $0 ($665) $320
From secondary participant
Crime $311 $0 $579 $155 $1,044
Labor market earnings associated with test scores ($314) ($691) ($299) $0 ($1,303)
Child abuse and neglect $149 $1,675 $0 $74 $1,899
Out-of-home placement $34 $0 $0 $17 $51
K-12 grade repetition ($37) $0 $0 ($18) ($55)
K-12 special education ($244) $0 $0 ($122) ($366)
Property loss associated with alcohol abuse or dependence $0 $1 $1 $0 $2
Health care associated with major depression ($8) ($3) ($10) ($4) ($25)
Labor market earnings associated with child abuse & neglect $3,519 $7,749 $0 $42 $11,310
Costs of higher education ($120) ($181) ($54) ($60) ($416)
Subtotals $3,291 $8,550 $217 $84 $12,142
Adjustment for deadweight cost of program $0 $0 $0 ($4,214) ($4,214)
Totals $2,408 $10,418 $217 ($4,796) $8,247
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $5,293 2016 Present value of net program costs (in 2016 dollars) ($8,457)
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.
Estimated Cumulative Net Benefits Over Time (Non-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 non-discounted dollars to simplify the “break-even” point from a budgeting perspective. 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.

^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.

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
Cannabis use^ 22 Primary 1 211 -0.013 0.201 25 -0.013 0.201 25 -0.037 0.853
Employment 22 Primary 1 212 0.031 0.096 25 0.000 0.000 26 0.087 0.368
Food assistance 22 Primary 1 211 0.075 0.096 25 0.075 0.096 25 0.210 0.030
High school graduation^^ 22 Primary 1 211 0.072 0.139 23 0.072 0.139 23 0.199 0.167
Public assistance 22 Primary 1 212 0.047 0.096 25 0.047 0.096 25 0.131 0.173
Regular smoking^^ 22 Primary 1 156 -0.132 0.126 22 -0.132 0.126 22 -0.132 0.293
Attention-deficit/hyperactivity disorder symptoms 1 Secondary 1 187 -0.061 0.137 9 0.000 0.007 10 -0.169 0.216
Child abuse and neglect 1 Secondary 3 222 -0.392 0.233 2 -0.392 0.233 17 -0.392 0.093
Emergency department visits^^ 1 Secondary 2 339 0.112 0.084 1 0.000 0.000 2 0.112 0.184
Externalizing behavior symptoms 1 Secondary 1 187 0.048 0.137 9 0.023 0.071 12 0.134 0.326
Internalizing symptoms 1 Secondary 1 187 -0.006 0.137 9 -0.005 0.107 11 -0.017 0.899
K-12 grade repetition 1 Secondary 2 190 0.061 0.136 9 0.061 0.136 9 0.171 0.212
K-12 special education 1 Secondary 2 190 0.043 0.136 9 0.043 0.136 9 0.118 0.388
Out-of-home placement 1 Secondary 2 91 -0.075 0.161 2 -0.075 0.161 17 -0.075 0.640
Preschool test scores^ 1 Secondary 6 625 0.034 0.057 3 0.007 0.063 17 0.053 0.349
Test scores 1 Secondary 2 192 -0.016 0.102 9 -0.010 0.112 17 -0.031 0.828

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.