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Healthy Families America

Public Health & Prevention: Home- or Family-based
Benefit-cost methods last updated December 2019.  Literature review updated July 2017.
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Healthy Families America ( is a network of programs that grew out of the Hawaii Healthy Start program. Healthy Families America programs aim to reduce child maltreatment and promote positive parent-child relationships. At-risk families are identified and enrolled either during pregnancy or shortly after the birth of a child. The intervention involves home visits by trained paraprofessionals who provide information on parenting and child development, parenting classes, and case management. Participants typically receive weekly home visits in the first six months after a child’s birth and may continue to receive periodic home visits until the child is three years old. Among programs included in the meta-analysis, participants typically received 29–43 home visits over a period of about 16 months.
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2018). 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 $4,972 Benefits minus costs $2,415
Participants $3,323 Benefit to cost ratio $1.46
Others $81 Chance the program will produce
Indirect ($693) benefits greater than the costs 57 %
Total benefits $7,683
Net program cost ($5,268)
Benefits minus cost $2,415
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
Crime $0 $0 $17 $0 $17
Labor market earnings $999 $2,348 $0 $0 $3,347
Health care associated with major depression $91 $26 $94 $45 $255
Public assistance ($82) $30 $0 ($41) ($93)
Property loss associated with problem alcohol use $0 $9 $16 $0 $24
Health care associated with emergency department visits ($3) ($1) ($4) ($1) ($9)
Food assistance ($159) $140 $0 ($79) ($98)
Mortality associated with problem alcohol $2 $5 $0 $86 $94
Subtotals $849 $2,556 $122 $10 $3,538
From secondary participant
Crime $31 $0 $61 $15 $107
Child abuse and neglect $13 $143 $0 $6 $162
Out-of-home placement ($104) $0 $0 ($52) ($155)
K-12 grade repetition $15 $0 $0 $7 $22
K-12 special education $3,926 $0 $0 $1,963 $5,890
Property loss associated with alcohol abuse or dependence $0 $0 $0 $0 $0
Health care associated with externalizing behavior symptoms $143 $40 $147 $71 $402
Health care associated with emergency department visits ($169) ($46) ($249) ($85) ($548)
Labor market earnings associated with child abuse & neglect $268 $629 $0 $0 $897
Mortality associated with child abuse and neglect $0 $0 $0 $4 $4
Subtotals $4,123 $766 ($41) $1,931 $6,780
Adjustment for deadweight cost of program $0 $0 $0 ($2,634) ($2,634)
Totals $4,972 $3,323 $81 ($693) $7,683
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $5,071 2016 Present value of net program costs (in 2018 dollars) ($5,268)
Comparison costs $0 2016 Cost range (+ or -) 10 %
Treatment cost estimates for this program reflect costs beyond treatment as usual. The per-participant cost is based on an average annual cost per family and the weighted average length of time in the program for included studies, which was 16.4 months. The average annual cost per family was $3,718 (provided by Kathryn Harding at Prevent Child Abuse America, August 2017).
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.

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
Emergency department visits 22 Primary 1 263 0.006 0.146 25 0.000 0.000 26 0.006 0.967
Employment 22 Primary 2 462 0.077 0.091 25 0.000 0.000 26 0.077 0.397
Food assistance 22 Primary 3 2226 0.033 0.031 25 0.033 0.031 25 0.033 0.286
Major depressive disorder 22 Primary 4 1080 -0.057 0.051 25 -0.029 0.063 27 -0.057 0.269
Problem alcohol use 22 Primary 1 373 -0.166 0.172 25 -0.166 0.172 35 -0.166 0.335
Public assistance 22 Primary 3 2226 0.006 0.031 25 0.006 0.031 25 0.006 0.838
Repeat birth^ 22 Primary 1 263 0.041 0.187 21 n/a n/a n/a 0.041 0.827
Substance use^ 22 Primary 1 373 0.021 0.163 25 n/a n/a n/a 0.021 0.895
Child abuse and neglect 1 Secondary 9 5003 -0.026 0.060 3 -0.026 0.060 17 -0.026 0.663
Emergency department visits 1 Secondary 1 263 0.190 0.099 7 0.000 0.000 8 0.190 0.055
Externalizing behavior symptoms 1 Secondary 2 578 -0.081 0.115 6 -0.044 0.072 9 -0.081 0.482
Internalizing symptoms 1 Secondary 2 720 -0.151 0.161 6 -0.151 0.161 8 -0.151 0.348
K-12 grade repetition 1 Secondary 1 452 -0.012 0.122 8 -0.012 0.122 8 -0.012 0.920
K-12 special education 1 Secondary 1 452 -0.216 0.116 8 -0.216 0.116 8 -0.216 0.062
Out-of-home placement 1 Secondary 2 2006 0.180 0.164 6 0.180 0.164 6 0.180 0.274
Preschool test scores^ 1 Secondary 2 321 0.145 0.085 3 n/a n/a n/a 0.145 0.089

Citations Used in the Meta-Analysis

Anisfeld, E., Sandy, J. (with Guterman, N. B., & Rauh, V.). (2004). Best Beginnings: A randomized controlled trial of a paraprofessional home visiting program (Technical Report). Email from E. Anisfeld on February 2, 2011.

Caldera, D., Burrell, L., Rodriguez, K., Crowne, S. S., Rohde, C., & Duggan, A. (2007). Impact of a statewide home visiting program on parenting and on child health and development. Child Abuse & Neglect, 31(8), 829-852.

Center on Child Abuse Prevention Research. (1996). Intensive home visitation: A randomized trial, follow-up and risk assessment study of Hawaii's Healthy Start program (Final Report). Chicago: Prevent Child Abuse America.

Chambliss, J. W., & Emshoff, J. G. (1999). The evaluation of Georgia's Healthy Families Program: Results of phase 1 and 2. Atlanta, GA: EMSTAR Research. Unpublished manuscript.

Duggan, A., McFarlane, E., Fuddy, L., Burrell, L., Higman, S. M., Windham, A., & Sia, C. (2004). Randomized trial of a statewide home visiting program: Impact in preventing child abuse and neglect. Child Abuse & Neglect, 28(6), 597-622.

Duggan, A., Fuddy, L., Burrell, L., Higman, S. M., McFarlane, E., Windham, A., & Sia, C. (2004). Randomized trial of a statewide home visiting program to prevent child abuse: Impact in reducing parental risk factors. Child Abuse and Neglect, 28(6), 625-645.

Duggan, A., Caldera, D., Rodriguez, K., Burrell, L., Rohde, C., & Crowne, S. S. (2007). Impact of a statewide home visiting program to prevent child abuse. Child Abuse & Neglect, 31(8), 801-827.

DuMont, K., Kirkland, K., Mitchell-Herzfeld, S., Ehrhard-Dietzel, S., Rodriguez, M. L., Lee, E., . . . Greene, R. (2010). Final report: A randomized trial of Healthy Families New York (HFNY): Does home visiting prevent child maltreatment? Renssalaer, NY: New York State Office of Children and Family Services.

Earle, R.B. (1995). Helping to prevent child abuse and future criminal consequences: Hawai'i Healthy Start. Washington, DC: National Institute of Justice. (ERIC Document Reproduction Service No. ED 394651).

Easterbrooks, A., Chaudhuri, J., & Fauth, R. (2017). The Massachusetts Healthy Families Evaluation phase 2: Early childhood (MHFE-2EC): Final report to Massachusetts Department of Public Health, Children's Trust of Massachusetts. Medford, MA: Tufts Interdisciplinary Evaluation Research (TIER), Eliot-Pearson Department of Child Study and Human Development, Department of Urban and Environmental Planning, Tufts University.

Galano, J., & Huntington, L. (1999). Year VI evaluation of the Hampton, Virginia Healthy Families Partnership: 1992-1998. Hampton, VA: Virginia Healthy Families Partnership.

Green, B.L., Sanders, M.B., & Tarte, J. (2017). Using administrative data to evaluate the effectiveness of the Healthy Families Oregon home visiting program: 2-year impacts on child maltreatment & service utilization. Children and Youth Services Review, 75, 77-86.

Landsverk, J., Carrilio, T., Connelly, C.D., Ganger, W.C., Slymen, D.J., Newton, R.R., . . . Jones, C. (2002). Healthy Families San Diego clinical trial: Technical report. San Diego, CA: The Stuart Foundation.