The Welcome Baby Program: An Implementation and Outcomes Evaluation.

In 2015, First 5 LA contracted with the RAND Corporation to perform an implementation and outcomes evaluation of its Welcome Baby universal home visitation program. RAND designed and executed a mixed-methods implementation and outcomes evaluation program that examined program fidelity across 12 sites in Los Angeles County, each site's community referral and resource process, staff and participant experiences with the program, factors that may influence program attrition, short-term outcomes, and the relationship between program fidelity and outcomes. Data from multiple sources were used, including interviews with staff and focus groups with participants, quantitative data from staff and participant surveys, data collected by staff and entered into an administrative database, and document review. There was significant variation across the sites in meeting fidelity thresholds. Staff qualifications and training, reflective supervision, enrolling clients in the maternity ward, and service dosage elements were most challenging. Sites performed well in participant perceptions of their home visitor, supervisory requirements, and home visit content. Considerable variation in sites' community referral and resource process was also found. Welcome Baby participants achieved better outcomes compared to local and national benchmarks in more than half of the areas measured, including more positive parenting practices, higher levels of any breastfeeding, and safer sleep environments. Few clear patterns were evident in terms of relationships between meeting fidelity thresholds and outcomes. It is important to note challenges in evaluation, such as the lack of data to assess some of the fidelity and outcome domains.

Investing Early: Taking Stock of Outcomes and Economic Returns from Early Childhood Programs.

The past two decades have been characterized by a growing body of research from diverse disciplines-child development, psychology, neuroscience, and economics, among others-demonstrating the importance of establishing a strong foundation in the early years of life. The research evidence has served to document the range of early childhood services that can successfully put children and families on the path toward lifelong health and well-being, especially those at greatest risk of poor outcomes. As early childhood interventions have proliferated, researchers have evaluated whether the programs improve children's outcomes and, when they do, whether the improved outcomes generate benefits that can outweigh the program costs. This study examines a set of evaluations that meet criteria for scientific rigor and synthesizes their results to better understand the outcomes, costs, and benefits of early childhood programs. The authors focus on evaluations of 115 early childhood programs serving children or parents of children from the prenatal period to age 5. Although preschool is perhaps the best-known early childhood intervention, the study also reviewed such programs as home visiting, parent education, government transfers providing cash and in-kind benefits, and those that use a combination of approaches. The findings demonstrate that most of the reviewed programs have favorable effects on at least one child outcome and those with an economic evaluation tend to show positive economic returns. With this expanded evidence base, policymakers can be highly confident that well-designed and -implemented early childhood programs can improve the lives of children and their families.

METHODOLOGICAL CONSIDERATIONS FOR HOME-VISITING RESEARCH IN TRIBAL COMMUNITIES.

Drawing on previous studies and the collective experience of conducting rigorous evaluations as part of the Tribal Maternal, Infant, and Early Childhood Home Visiting grants, we outline methodological considerations that will inform future research in tribal communities, particularly in the area of home visiting. The methodological issues we discuss are study design choices, measurement and data collection, and including community members in all aspects of the research.

Home Visiting and Use of Infant Health Care: A Randomized Clinical Trial.

BACKGROUND AND OBJECTIVES: Evaluations of home visiting models have shown that they can reduce children's health care use in the first year of life. Models that exclusively use nurses as home visitors may cost more and be infeasible given nursing shortages in some locations. The goal of this study was to test whether a universal home visiting model employing a nurse-parent educator team as home visitors reduces health care use in the first year of life. METHODS: This study was a randomized controlled clinical trial of an intensive home visiting program delivered in homes of primary caregivers and their first-born children in Santa Fe, New Mexico. Intention-to-treat and contamination-adjusted intention-to-treat models were estimated, and 244 primary caregivers participated in the survey. RESULTS: In their first year of life, treatment group children were one-third less likely to visit the emergency department (control group mean, MC = 0.42, treatment group mean, MT = 0.28, P = .02) and were also 41% less likely to have visited a primary care provider ≥9 times (MC = 0.49, MT = 0.29, P < .001). We found no differences between the treatment and control groups for hospitalizations or injuries requiring medical attention. The universal program reduced infant health care use for high-risk and lower-risk families. CONCLUSIONS: Children in families randomly assigned to the program had less health care use in their first year, demonstrating that a universal prevention home visiting model delivered by a nurse-parent educator team can reduce infant health care use.

Home Visiting Start-Up: Lessons Learned From Program Replication in New Mexico.

Growth in federal, state, and private funding is fueling the initiation of home visiting programs around the country. As communities expand home visiting programs, they need information to help them successfully start up new sites. This paper documents lessons learned about home visiting installation and initial implementation from the replication of the First Born(®) Program in six counties in New Mexico. Specifically, we examine how well sites met staffing, family referral and enrollment, program model fidelity, and financing goals in the first year of providing services. Data come from semi-structured interviews with program staff and document review. The findings are likely to be valuable to a wide spectrum of communities starting or expanding home visiting services, as well as to public and private funders of programs.

Process Evaluation of the New Mexico Maternal, Infant, and Early Childhood Home Visiting Competitive Development Grant.

This article describes the evaluation of the New Mexico Home Visiting Competitive Development Grant, which sought to pilot test the use of implementation supports to improve the development and implementation of home visiting programs. Each community was to use Getting To Outcomes® (GTO) and ECHO® (Extension for Community Healthcare Outcomes) to support their work. The GTO framework promotes capacity for high-quality programming by specifying ten steps that practitioners should take and by providing support to complete those steps. ECHO involves specialists providing training and technical assistance via distance technology to community practitioners in rural areas to improve the quality of services. The grant was delayed, and the project's scope shifted significantly from the original plan. The evaluation documents significant challenges in meeting grant goals. A local team hired to facilitate GTO did not use it as designed, and no communities were trained in GTO. The coalitions that were developed operated with few resources or accountability, and made little progress on plans to enhance services. Only two of the four communities started home visiting after nearly a year and a half. ECHO was used with fidelity with those two programs. There was no change in the continuum of services to support children and families. Due to delays and lack of implementation of the proposed intervention, the evaluation was not able to assess the project's impact on child or family outcomes, nor did the project serve as a robust pilot test of the use of GTO and ECHO to improve home visiting implementation.

Priorities for Investments in Children and Families in Caddo and Bossier Parishes: Application of a Unique Framework for Identifying Priorities.

In Louisiana, the Community Foundation of Shreveport-Bossier pools funds from sources in Caddo and Bossier Parishes, manages the funds, and allocates the funding within the two-parish region. (The City of Shreveport is in Caddo Parish; the city of Bossier City is in Bossier Parish.) In 2008, the foundation selected education, health, and poverty as priority areas for its investments in children and families, and it asked the RAND Corporation to assist the community in identifying priority strategies within these three focus areas. RAND researchers developed a unique framework based on the intersection of needs, assets, and best practices. Applying this framework to the Shreveport-Bossier community, they identified health care providers, public school teachers, and Barksdale Air Force Base as strong assets that can help the community address three high-need areas: infant health, child maltreatment, and educational attainment. The "Needs-Assets-Best Practices" framework developed to assist the Shreveport-Bossier community can be applied in many other settings; this article can be viewed as a case study of the application of the framework.

Endowments and parental investments in infancy and early childhood.

This article tests whether parents reinforce or compensate for child endowments. We estimate how the difference in birth weight across siblings impacts specific parental investments: breast-feeding, well-baby visits, immunizations, and preschool attendance. Our results indicate that normal-birthweight children are 5%-11% more likely to receive early childhood parental investments than their low-birth-weight siblings. Moreover, the presence of additional low-birth-weight siblings in the household increases the likelihood of investments such as well-baby visits and immunizations for normal-birth-weight children. These results suggest that parental investments in early childhood tend to reinforce endowment differences.