The Assignment (2 page paper APA Style format): Title ” Role of Change Theory in Social Change. Briefly describe the issues you anticipate encountering in your strategic plan for the United Nations Environmental Protection . Explain the change you thin

An understanding of change theory is critical to the success of human and social services professionals. A classic model of change theory consists of three phases: (a) unfreezing, (b) movement, and (c) refreezing (Lewin, 1951). Another model describes the differences between first- and second-order change and how first-order change may continue to perpetuate the very problems human services professionals seek to remedy (Watzlawick, Weakland, & Fisch, 1974). Developmental theory and systems theory may also be relevant to implementing change in human and social services related agencies and organizations.

As you develop your Capstone Project strategic plan, think about the element of change and how change might affect the change processes that will be associated with the agency, organization, or community for your strategic plan. Think of principles from relevant change theories and how you can implement those procedures to manage the individual and organizational change that may come about as a result of the strategic plan. Along with change theory and processes, you also should consider codes of ethics to guide you in addressing these issues.

References:
Lewin, K. (1951). Field theory in social science. New York, NY: Harper.
Watzlawick, P., Weakland, J. H., & Fisch, R. (1974). Change: Principles of problem formation and problem resolution. Oxford, England: W.W. Norton.

To prepare:

Select a change theory and the related change processes (e.g., force-field analysis, developmental theory, systems theory) that you might apply to address the issues related to the strategic plan for the agency, organization, or community you selected in Week 1 Discussion 2(The United Nations Environmental Protection)

In addition, consider the ethical challenges that you might encounter and codes of ethics you might apply to address these challenges.

The Assignment (2 page paper APA Style format): Title ” Role of Change Theory in Social Change.

Briefly describe the issues you anticipate encountering in your strategic plan for the United Nations Environmental Protection .

Explain the change you think is needed to address these issues and factors that might influence that change.

Describe a change theory and related change processes that may be applied to the issues related to your strategic plan.

Explain how you might apply the theory and processes.

Briefly explain two ethical principles, issues, or challenges that might arise in your efforts to apply these changes.

Explain how a professional code of ethics might advise in each case. Be specific, citing elements from an applicable code of ethics.

Explain the opportunities and challenges that you might encounter in fostering and implementing the change.

Required Readings

Homan, M. S. (2016). Promoting community change: Making it happen in the real world (6th ed.). Boston, MA: Cengage.
Chapter 8, “Powerful Planning” (pp. 206–231)
https://ereader.chegg.com/books/9781305445673/pageid/257 (will give you access to the book when assignment is accepted)
Mayne, J. J. (2015). Useful theory of change models. The Canadian Journal of Program Evaluation, 30(2), 119–142. Retrieved from the Walden Library databases.

National Organization for Human Services. (n.d.). Ethical standards for human service professionals. Retrieved from http://www.nationalhumanservices.org/ethical-standards-for-hs-professionals

Segal, L., Sara Opie, R., &namp; Dalziel, K. (2012). Theory! The missing link in understanding the performance of neonate/infant home-visiting programs to prevent child maltreatment: A systematic review. Milbank Quarterly, 90(1), 47–106. doi:10.1111/j.1468-0009.2011.00655.x. Retrieved from the Walden Library databases.

Wasserman, D. L. (2010). Using a systems orientation and foundational theory to enhance theory-driven human service program evaluations. Evaluation and Program Planning, 33(2), 67–80. Retrieved from the Walden Library databases.

These codes of ethics may be used as resources to support this week’s Discussion:

Academy of Criminal Justice Sciences. (2000). Code of ethics. Retrieved from http://www.acjs.org/page/Code_Of_Ethics

American Counseling Association. (2014). ACA code of ethics. Retrieved from https://www.counseling.org/resources/aca-code-of-ethics

The Counselors for Social Justice (CSJ) Code of Ethics. (2011). Journal for Social Action in Counseling and Psychology, 3(2), 1–21. Retrieved from the Walden Library databases.

National Association of Social Workers. (2008). Code of ethics of the National Association of Social Workers. Retrieved from http://www.naswdc.org/pubs/code/code.asp

National Organization for Human Services. (n.d.). Ethical standards for human service professionals. Retrieved from http://www.nationalhumanservices.org/ethical-standards-for-hs-professional

Social Change, Leadership, and Advocacy

Social Change, Leadership, and Advocacy
Program Transcript

NARRATOR: Change is a process that involves leadership and collaboration.
Listen as Dr. Judy Lewis explains the change process, some of the barriers to
effective change, and the ethical considerations counselors must keep in mind
when pursuing change.

JUDY LEWIS: Change is around us all the time. The leaves change in the fall.
The weather changes with the seasons. Change is so much a part of life that
sometimes it seems as though the difficult part is being able to respond and react
and adjust to it.

But what we’re really talking about here is purposeful change. A person, or
people, decide that there is a gap between what is and what should be. There’s a
gap between the real and the ideal. What they want to do, then, is to find a way
to bridge that gap. To find a way to make change so that the real and the ideal
come closer together.

Now, once you try to do that, that’s the farthest thing from easy. It’s always very
difficult to bring about change.

First you have to look at how you can prove that the need for change is there.
You have to have a needs assessment. Why do we have to have this change?
You have to come up with data that indicate that the change is necessary and
possible.

But then, even though you may have the most logical story in the world, you still
come up against barriers. There will be people who are uncomfortable with the
change. The system fights back against it.

What you’ll need to do is find ways around those barriers, especially by having
allies who agree with you. Who, maybe for a different reason, are also in favor of
this kind of change.

Then, working together, you need to come up with a plan for implementation.
How can you make that change happen?

It’s difficult. It doesn’t always work. But when it works, it’s really worth it. It’s really
worth that effort, because you’ve done something important.

Helping professionals bring a special flavor to the process of change. First of all,
we’re accustomed to change. That’s what our business is. When we’re working
with individual clients, what are we trying to do but help them bridge a gap
between a problem that they’ve seen in their own lives and a solution?

Social Change, Leadership, and Advocacy

Sometimes though, we realize that the solution isn’t necessarily just in the hands
of the client. Sometimes, we realize that there are barriers that are preventing the
client from achieving his or her goals. That’s when we get into social change. And
we have, I think, a particular talent for that, once we get comfortable with it.

Another thing that I think is important about counselors, in particular, and social
change, is that, once we have that needs assessment, we do have the skill that it
takes to bring about change. We’re used to having the kinds of interpersonal
connections and communication styles that really are at the heart of effective
change.

So we have a reason to be involved in change, and we have some skills that help
us to do a good job when it comes to change.

I think of so many examples of when counselors, for instance, have been
involved in social change projects that have been effective. There’s one example
in particular that I’ve always found interesting. And that is, a group of mental
health counselors in a town in the Southwest. They were working with families of
young people who were involved in the juvenile justice system.

What they had been told was that the problem was that these families didn’t
seem to be motivated, that they didn’t show up with their appointments when they
were supposed to see their probation agents. That they didn’t follow through
when they were supposed to go to various offices to take care of advocacy for
their kids.

Now, what happened was that the counselors kept seeing this again and again
with so many families. And they kept being told, oh, these families just aren’t
motivated. But they realized that there were other things that were getting in the
way.

One thing was that a lot of the offices were only open during the day when the
parents had to work.

Another thing was that sometimes there were long distances that they had to go
and they couldn’t afford it. They didn’t have cars or they couldn’t afford the gas.
Sometimes it just was too difficult for them to do what they wanted to do to help
their kids.

What the counselors did was to connect up with some community groups who
had also been working on similar issues. And what they found was that they were
able to bring about change by setting up offices in churches and schools that
were more convenient for kids and their parents to get to.

They even got involved with changing the bus route so it was easier for the
families to get to the appointments that they needed.

Social Change, Leadership, and Advocacy

This was really an amazing example that points up some real issues. One is that,
you can’t always know in advance what kind of change is needed. That idea
about your clients being the needs assessment, that really came into play there.

Who would’ve guessed, if counselors started thinking about what’s needed in this
community, that what was needed was a change in the bus routes? But it was.
And because they were listening to their clients, listening to the families that they
were working with, they were able to get involved in making a difference.

There’s another point, I think, that’s important here with this example, too. And
that is that, when you look for the source of the problem, there’s a lot of pressure
to look at the source of the problem within the client or within the family.

But if you open your mind as a helping professional, and look beyond the
individual and beyond that family, you can see that sometimes the source of the
problem is in the community. And then you can have a positive impact on a lot of
clients by making a change with other community members.

A professional code of ethics has some clout in the profession. What that means
is that there is a strong expectation, a requirement, that people who belong to a
particular profession do their work in a way that adheres to the code of ethics.

So, if an ethical code of a profession says, for instance, that counselors must be
aware of the importance of multi-culturalism and diversity in working with their
clients; if the ethical code says that counselors must be able to use advocacy as
needed on behalf of their clients; if the ethical code says that clients need to be
seen, not as totally the source of the problem, but maybe as victims of a problem
in the community; if the ethical code says that that’s an expectation for what
counselors should be able to do, then I think it happens.

Traditionally, the codes of ethics across most of the helping professions have
dealt with, say, multi-culturalism and diversity, not from an action orientation, but
from a negative. In the sense that most of the codes of ethics would say, a
counselor will not discriminate against the client based on race or gender, say. It
wouldn’t say, the counselor must stick up for the client when the client is
discriminated against by someone else.

So the focus, traditionally, has not been on change. The focus has been on
avoiding hurt. I think it will be interesting to see, over the future, what happens
with the codes of ethics. Because I believe that the codes of ethics should
become stronger. I think they’re moving in that direction. But I think they should
be stronger, to indicate that a counselor must not only avoid discrimination, but
must actively recognize discrimination when it’s happening to client and try to do
something about it.

Social Change, Leadership, and Advocacy

That reflects a change. And it’s an orientation of codes of ethics toward change.
And when that happens, then I think that professions will move in that direction.
Because it’s through the code of ethics that counselors and other professionals
know what it is they have to do in order to be meeting their professional
standards.

Social Change, Leadership, and Advocacy
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Using a systems orientation and foundational theory to enhance theory-driven
human service program evaluations

Deborah L. Wasserman *

The Ohio State University Center for Family Research, COSI 333 West Broad Street, Columbus, OH 43209, USA

Evaluation and Program Planning 33 (2010) 67–80

A R T I C L E I N F O

Article history:

Received 26 September 2008

Received in revised form 2 June 2009

Accepted 8 June 2009

Keywords:

Program evaluation

Logic models

Self-Determination Theory

Evaluation anxiety

Human service programs

Cultural responsiveness

Foundational

theory

Systems thinking

A B S T R A C T

This paper offers a framework for using a systems orientation and ‘‘foundational theory’’ to enhance

theory-driven evaluations and logic models. The framework guides the process of identifying and

explaining operative relationships and perspectives within human service program systems. Self-

Determination Theory exemplifies how a foundational theory can be used to support the framework in a

wide range of

program evaluations.

Two examples illustrate how applications of the framework have

improved the evaluators’ abilities to observe and explain program effect. In both exemplars

improvements involved addressing and organizing into a single logic model heretofore seemingly

disparate evaluation issues regarding valuing (by whose values); the role of organizational and program

context; and evaluation anxiety and utilization.

Contents lists available at ScienceDirect

Evaluation and Program Planning

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / e v a l p r o g p l a n

1. Introduction

Human service program outcomes depend on the relationships
within and between systems that surround two groups of people—
program providers and the individuals they target. Therefore
evaluation of these programs involves either measuring or
controlling for the functionality of these relationships or making
assumptions about them. These assumptions might include, for
instance, that program administrators support the successful
functioning of program providers; that program providers have
interest in providing program services; that individual partici-
pants’ family and community systems interact with the program to
support the intended outcomes; that there is a positive relation-
ship between program providers’ targeted outcomes and indivi-
dual participants’ more generalized well-being; and that the
evaluation process has a ‘‘do no harm’’ relationship to achieving
program outcomes. The evaluation literature has provided little
guidance for systematically measuring or controlling for the effects
of these relationships. This paper addresses that gap by introdu-
cing a framework that helps evaluators organize, define, measure,
and integrate these otherwise assumed effects into a typical
outcomes-based evaluation design.

* Tel.: +1 614 570 6711.

E-mail address: wasserman.12@osu.edu.

0149-7189/$ – see front matter � 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.evalprogplan.2009.06.005

A feature that distinguishes evaluation researchers (i.e.,
researchers specifically trained in the evaluation discipline) from
researchers trained in other disciplines who conduct program
evaluations is that evaluation researchers have been highly
concerned with identifying these influential, and too often ignored,
contextual relationships. They have sought to account for them in
ways that will enhance evaluation validity and utility. For instance,
issues such as valuing (by who’s values); the role of organizational
and program context in the achievement of desired outcomes; and
evaluation anxiety and utilization have been central to dialog
within the American Evaluation Association (Chen, 2004; Donald-
son, Gooler, & Scriven, 2002; Mark & Henry, 2004; Scriven, 1999;
Wandersman, Imm, Chinman, & Kaftarian, 2000). Despite the
acknowledgement of the importance of these issues, in all too
many program evaluations, the underlying assumptions – each
related to at least one of these important evaluation issues –
remain undefined and unmeasured. But, as evaluation researchers
are aware, accepting these assumptions as true and constant can
severely compromise the meaning, utility, and consequences of

evaluation results.

One means for addressing these assumptions and related issues
has been to introduce systems thinking to program evaluation
(Cabrera, Colosi, & Lobdell, 2008; Williams & Imam, 2007). These
systems-thinking approaches can be infused into any discipline
(e.g., engineering, philosopy, social science, economics, etc.) or
type of evaluation. As Cabrera and colleagues explain, systems
thinking is ‘‘based on contextual patterns of organization rather

mailto:wasserman.12@osu.edu

http://www.sciencedirect.com/science/journal/01497189

http://dx.doi.org/10.1016/j.evalprogplan.2009.06.005

D.L. Wasserman / Evaluation and Program Planning 33 (2010) 67–8068

than specific content. For example, systems thinking balances the
focus between the whole and its parts, and takes multiple
perspectives into account. . . [It is thinking that] transgresses parts
and wholes, takes new perspectives, forms new relationships, and
makes new distinctions (p. 301).

Cabrera and colleagues have synthesized the many methodo-
logical systems approaches (e.g., soft systems, critical systems,
complex adaptive systems, etc., many of which have been
described in Williams & Imam, 2007) into four simple systems-
thinking rules involving Distinctions, Systems, Relationships and
Perspectives (D–S–R–P). They have shown how these rules, used
for defining and understanding systemic patterns, are important to
evaluation research. Within that effort, Wasserman (2008) has
provided a guide for applying these D–S–R–P rules to human
service program evaluation (Table 1). This paper furthers that
guide.

This paper’s first section demonstrates how building a program
model with a systems orientation invites a more general use of
social science theory than has been described to date in the theory-
driven evaluation literature. The term foundational theory will be
used to reference this broader use of social science theory. The
paper’s second section delineates the operative distinctions,
systems, relationships and perspectives of human service pro-
grams. The third section introduces Self-Determination Theory
(SDT, Ryan & Deci, 2000b) as an example of how a foundational
theory guides the selection, measurement, and analysis of the
operative relationships and perspectives. Finally, two exemplar
evaluations designed and implemented by The Ohio State
University Center for Family Research illustrate how use of this
foundational theory-based framework has enhanced the evalua-
tors’ ability to observe and explain program effect while being

Table 1
Operative distinctions, relationships, and perspectives of human service programming

Provider system Target sy

Distinctions

between

nested parts (from least

to most encompassing)

Program goals and objectives; program

activities; program providers;

administrators; funders; community

stakeholders; macroenvironment and

relationships between

them.

Personal

condition

family, fr

macroenv

between

Operative relationships Funders to administration;

administration

to providers; provider, administrator,

and funders to program objectives;

program objectives and resources to

program activitiesa; providers to

program activity; funder, and administration

effect on program activity; program

activity effect on funder, administration

and providers.

Targeted

condition
condition

Target en

condition

on target

Perspectives View of the various relationships to

program activities and program objectives

View of t

existing c

Program providers Targeted

and comm

makers a

Administrators

Funders

Macrosystem stakeholders

Related Evaluation Research Organizational assessment; performance

assessment and evaluation; organizational

development studies; program monitoring.

Needs ass

assessme

epidemio
a Relationship explained by causative theory.

more responsive to the needs, influences, and values of the
program stakeholders, i.e., the individuals who comprised each
program’s provider–recipient systems.

2. The Need For A Systems Orientation And
Foundational Theory

Program evaluators have come to understand the value of
explicating relationships between program resources, activities,
and effects. To this end, program logic models have been adopted
widely (Hatry, Van Houten, Plantz, & Greenway, 1996; Knowlton &
Phillip, 2009; W K Kellogg Foundation, 2004) as the tool for
articulating those relationships. By revealing processes within the
black box between program activities and outcomes, logic models
provide an important tool for program evaluation and quality
improvement (Kaplan & Garrett, 2005; McLaughlin & Jordan, 1999;
Rogers, 2000; Savaya & Waysman, 2005).

In the language of theory-driven evaluation (Chen, 2004), these
components and processes constitute a program’s change model.
When based on an underlying formal or informal causative theory
that establishes how the posited relationships lead to intended
outcomes, these models can become more valid, informative, and
useful (Chen, 1990, 2004; Stame, 2004). However, even theory-
driven change models have been criticized for their limited ability
to explain complex, sometimes contradictory, program results and
the influences that produce them (Davies, 2004; Gasper, 2000;
Rogers, 2000).

Recognizing the limitations, evaluation theorists have long
acknowledged the need to augment change models with the
additional context and feedback variables of what Chen (1990)
labeled the ‘‘action model.’’ (Altschuld & Kumar, 1995; Cronbach,

systems with related areas of evaluation research.

stem(s) Human service program system

goals and objectives; existing

s; targeted individual(s);

iends, and community;

ironment; and relationships

them.

Program outcomes; program participation;

and all nested parts and relationships of

the provider and target systems that

affect and experience effect of the

program service.

individual’s effect on existing

s and effect of existing

s on targeted individual.

vironment affect on existing

s; effect of existing c

onditions

environment.

All operative relationships listed in provider

and target systems. In addition: participant

to program provider; participant to program

activities; participant’s environment to

program activities; program activities to

program outputs and outcomesa; provider

environment (funders, administration,

other stakeholders) to program evaluation

results; participant environment

(family, friends, community) to program

evaluation results.

he relationships to targeted

onditions

All operative perspectives listed in provider

and target systems.

In addition:

individuals; family, friends,

unity; macrosystem policy

nd resource providers.

View of the value of

program activities

View of the value of expected and

unexpected outcomes

Response to evaluation

feedback

Program participants

Influential members among program

participants, family, friends, or community.

Program providers, administrators, funders, etc.

essments; risk and asset

nts; behavioral research;

logical studies.

Formative and summative human service

program evaluations.

D.L. Wasserman / Evaluation and Program Planning 33 (2010) 67–80 69

1982; Davies, 2004; Rogers, 2000; Schalock & Bonham, 2003).
However, these authors have provided limited direction for doing
so. Often, guides for evaluators have lumped contextual factors
together under generic terms such as ‘‘influential factors’’ (W K
Kellogg Foundation, 2004) or ‘‘ecological context’’ (Chen, 2004).
One handbook for creating logic models goes a bit further, dividing
‘‘external factors’’ into political environment, economic situation,
social/cultural context and geographic and other constraints
(Innovation Network and Inc., 2009). If any of these potential
modifiers lie outside the explicit causative theory of why and how
activities produce outcomes, there is no systematic way of
identifying them other than informally answering fairly arbitrary
questions like those that explain the categories in the handbook,
e.g., ‘‘Is bad weather likely to interfere with service delivery?’’ Or,
‘‘Are you working in a community that welcomes your program?’’
(p. 20).

Along with contextual factors, unexpected outcomes also occur
outside of the change model. Recognizing the importance of
tracking these unexpected outcomes, proponents of goal-free
evaluation approaches urge the avoidance of logic models
completely (Scriven, 1991). In other words, an evaluation based
on a delineated system excludes results occurring outside the
system. A challenge therefore is to find a way to systematically
identify indicators that expand the evaluation beyond the change
model’s boundaries and identify theory that explains them.

Literature on theory-based evaluation provides some guidance
to this expansion. Donaldson (2007) demonstrates how contextual
variables can be statistically modeled as moderators (i.e. con-
textual influences) of either the mediator-outcome relationship or
the program-mediator relationship. In both cases, the mediator is
defined as program outputs or shorter-term outcomes. Chen’s
(2004) change-model/action-model conceptual framework defines
the change model as consisting of intervention, intermediating
‘‘determinants,’’ and outcomes. In turn, the action model consists
of contextual system parts with logical links from ‘‘implementing
organizations and implementers’’, through ‘‘associated organiza-
tions’’ and ‘‘ecological context,’’ to the ‘‘intervention and service
delivery protocols’’ and the ‘‘target population’’ (p. 29). In this
framework, ‘‘causative’’ theory explains the change model (i.e.,
how certain conditions generate or influence targeted effects) and
‘‘normative’’ theory explains the action model (how various
components work together to support the change model).
Additionally, Chen’s framework includes feedback loops both
within and between the change

and action models.

Using established social science theory, where it exists, has
been a useful and often preferred approach to explaining the
change model (Chen, 2004). At times–as is the case with multi-
systemic therapy (Henggeler, 1999), for instance–the social
science theory underlying the change model involves an array
of factors often included in the action model (e.g., family and
community involvement). However, even in these cases, also
operative is an additional array of action-model assumptions not
included in the change model (e.g., those related to fidelity). From
Chen’s perspective at the time of writing, he noted that although he
would welcome social science theory to explain action models,
social science theory appeared to be limited only to explaining
change models. He wrote:

The action model deals with nuts and bolts issues, which are not
a major topic in most modern social science theory, perhaps due to
the social sciences’ emphasis on developing generalizable proposi-
tions, statements, and laws. ‘‘How to’’ program issues tend to be
trivialized by contemporary social science theory. Plus, the action
model has no proposition-like format resembling that defined by
and familiar to modern social scientists (Chen, 2004, p. 18).

Without a systems orientation and the consequent systematic
way of detailing operative relationships and perspectives, proposi-

tion-like formats are indeed difficult to formulate from the action
model. But when contextual factors are understood with a systems
orientation and with Cabrera et al.’s (2008) four D-S-R-P rules
(referenced above), propositions emerge and social science theory
that explains them can be selected and applied. The selected social
science theory to explain an action model and its relationship to
the change model is necessarily different than the social science
theory used as causative theory to explain the change model itself.
The systems-defined propositions of a change model call for a
foundational theory that more generally explains the ‘‘how-to’’
relationships between distinct parts and operative perspectives of
any human system, and how these perspectives and relationships
function to affect the interaction between systems. Foundational
theory is far less specific than what Chen (2004) describes as the
normative theory that explains the action model. Normative
theory defines and describes specific components or ‘‘nuts and
bolts’’ that support and contribute to the change model. Founda-
tional theory explains why and under what conditions those
components function and how their quality can be evaluated.

Foundational theory also enhances causative theory. Whereas
causative theory explains why and how program activities will
lead to intended outcomes, foundational theory explains why and
under what conditions the causative theory will be valid. For
instance, a causative theory may explain how a given curriculum
produces learning or how a treatment regimen inhibits a disease:
those are the mechanisms by which specific programs function.
Foundational theory, which generally explains how human
systems function and interact, explains the assumptions that
make causative theories valid: e.g., when a student will pay
attention to a curriculum or how to know when inhibiting a disease
is in line with the intentions of the patient.

Supported by measurements made possible through founda-
tional theory, relationships found within and between the change
and action models become more informative to the evaluation. In
addition, a systems orientation enhances both the change and
action models with the concept of perspective. Explanation of
program system relationships based on causative and normative
theory alone involves only a singular perspective, one agreed to by
whatever combination of stakeholders have contributed to the
evaluation design, however wide and diverse that group might be.
A systems orientation reminds the evaluator to consider that,
within that singular perspective, a full range of perspectives
operate. A systems orientation suggests that the quality of system
relationships not only varies, but varies across perspectives and
that the variance within each perspective may differently affect
outcomes. Foundational theory explains how and why, the
perceptions, definition, and value of these relationships vary
within and

between perspectives.

Selection and application of foundational theory, however, is
dependent on being able to develop specific propositions that the
theory explains. The next subject to be addressed, therefore, is the
systematic delineation of the components of a human service
program system that require those propositions: the distinctions,
relationships and perspectives.

3. A systems orientation: defining human service program
system distinctions, relationships, and perspectives

For the purpose of describing human service program systems,
a human service program will be defined here as any situation
wherein one human system intentionally attempts to affect at least
one human being nested within an otherwise virtually indepen-
dent ‘‘target’’ system (Wasserman, 2008). What makes this
situation a program is the distinction between the provider system
and at least one target system and the intentional nature of the
relationship between them. From a systems-thinking perspective,

D.L. Wasserman / Evaluation and Program Planning 33 (2010) 67–8070

evaluating the functionality of a human service program therefore
involves possible analysis of patterns that emerge from distinc-
tions, relationships and perspectives (Cabrera et al., 2008) formed
from or functioning in relation to the interaction between the
provider and target systems. The components of each of these
systems along with the new components defined by the
interaction between them are listed in Table 1 (first introduced
in Author, 2008).

The provider’s system constitutes one set of relationships
(Table 1, column 2) included in a human service program system.
In its simplest form, this set of nested relationships houses the
program activities—produced by a program provider within a
program within an organization within a larger environment of
practices, programs, policies, resources and norms (the program’s
macroenvironment). The target system comprises a second set of
relationships (Table 1, column 3) included in the program system.
Certain conditions exist within or around any of the program’s
targeted individuals. Each is nested within a family or community,
and within other programs (social, medical, bio-behavioral,
educational, etc.), all of which are also situated in a macroenvir-
onment of practices, policies, resources and norms, some over-
lapping but often independent of those affecting the provider
system.

Analysis of either a provider or target system alone is
insufficient for a human service program evaluation which
depends on analysis of both systems along with additional analysis
of relationships formed as a result of one system’s intention to
affect the other (Table 1, column 4). Studies involving only the
provider system (i.e., where there is no independence between
provider and target systems) can be considered organizational
assessments or organizational development evaluations; those
involving only the target system might be considered needs
assessment, risk or asset assessment, assessment of the person-in-
environment fit, or perhaps even a form of interactional behavioral
research. Studies involving the target system’s unrequited inten-
tional relationship with the provider system might also be
considered needs assessment. As conceptualized here, a focus
on interactions within and between both provider and target
systems and independence between those systems is necessary for
the research to be considered program evaluation.

Defining and viewing a human service program as simulta-
neously existing within the two nested provider and target

Fig. 1. A generic program model with eight pulse points

systems creates a way for an evaluator to systematically scan a full
range of relationships available for measurement, and then to
identify, select, and focus on those relationships important to
answering evaluation questions of interest. In this conceptualiza-
tion of program systems, outcomes exist in the context of program
participation. Both participation and outcomes are nested within
the relationship between a program’s activities and a participant’s
existing conditions, each of which are nested in their own
respective systems. Moreover, the program system includes formal
and informal program evaluation feedback. For providers this
feedback arrives both directly and indirectly through adminis-
trators and other stakeholders. For participants, feedback about
program success arrives usually indirectly through program
providers, family, friends, and community.

A generic model of these relationships is presented in Fig. 1. In
addition to the relationships explained by change models
(comprised of inputs, activities, outputs and outcomes; shown
shaded in Fig. 1), this systems-based model includes the action
model in the form of operative system distinctions (shown in white
boxes in Fig. 1 and summarized in Table 1, column four),
relationships between them (black arrows) and evaluation feed-
back relationships (gray arrows). This generic model postulates
that outcomes are mediated by outputs which are in turn mediated
by participants who are influenced not only by program activities,
but also by both program climate and family/community climates.
Moreover, in addition to being the result of program resources,
program activities are mediated by providers who are influenced
by the nature of their environments and how they are affected by
program objectives, resources, etc. In addition to producing
program activities, program providers affect (along with the
organizational climate) program climate which in turn influences
participants’ receptivity to program activities. Finally, the model’s
design emerges from the acknowledgement that acknowledges
that outcomes vary in their value to participants (shown in the
model as ‘‘outcome effect’’) and therefore also vary in their longer
term impacts.

Each of these relationships will be explained in more detail
below. However, given that they exist, and given theory that
explains how they contribute to the functionality of the systems
with which they are involved, it is possible to map eight potential
measurements (numbered in Fig. 1) or what will be called ‘‘pulse
points,’’ because they indicate a human service program system’s

for measuring inter and intra-system functioning.

Table 2
How causative, normative, and foundational theories contribute to the explanation of program system relationships (as organized by pulse points).

Causative theory explains: Normative theory explains: Foundational theory explains

Overall purpose How participants’ interaction with

program activities is expected to

produce targeted

outcomes.

How context and feedback variables are

expected to influence the program

and outcomes.

How (and why) the perception,

definition, and value of the

relationships vary within and

between perspectives.

Program model Change model. Action model. How various perspectives affect

and respond to the effectiveness

of the distinctions and

relationships in both change

and action models.

Pulse point relationship

#1 Participant to outcome Intended intermediate and longer-term

outcomes and how they can be measured.

(Assumes the targeted outcome is

functional)

How human beings value changes

in attitudes, skills, behaviors, etc.

#2 Participant to program activities The amount and nature of interaction

with activities necessary to produce

outcomes.

Contextual influences expected to affect

the quality of the

activities.

How human perception/experience

of an activity affects the outcomes

the activity produces.

#3 Participant to provider Expected quality of the

provider–participant relationship.

Contextual influences expected to affect

the quality of the provider–participant

relationships.

How human perceptions of

relationships affect the

relationship and its outcomes.

#4 Family, community, and

other programs on the

participant’s program outcomes

(Assumes relationship is functional) Expected family, community and other

program influence on program activities,

program participation, or outcome

sustainability.

Quality of influence of support

networks.

#5 Family, community, and other

programs’ functionality as buffers

of formal and informal

evaluation results

(Assumes relationship is functional) Expected social network participants’

response to evaluation results and how

those responses affect the production

of targeted outcomes.

Human response to performance

indicators and its affect on

motivation, productivity, etc.

#6 Providers to their outputs

(program activities)

(Assumes relationship is functional) Expected contextual influences on

providers’ abilities to produce program

activities.
How human perception/experience
of an activity affects the outcomes
the activity produces.

#7 Providers to sponsoring

organization

(Assumes relationship is functional) Expected organizational supports for

providers’ ability to produce program

activities.
How human perception/experience

of the workplace affects motivation,

productivity, creativity,

adaptability, etc.

#8 Provide’rs functionality as

a buffer of evaluation results

(Assumes relationship is functional) Expected provider response to evaluation

results and how those responses will

affect the production of outcomes.

Human response to performance
indicators and its affect on
motivation, productivity, etc.

D.L. Wasserman / Evaluation and Program Planning 33 (2010) 67–80 71

overall ‘‘health.’’ While it is probable that additional pulse points
exist in any given program to be evaluated, these eight provide a
schema for initial planning.

Table 2 lists the contribution of causative, normative and
foundational theories to understanding each relationship. As such,
it provides the reader with an understanding of the unique role of
each type of theory. Listed below are brief descriptions of the
relationships along with a synopsis of what their foundational
theory analysis can contribute to an evaluation.

Pulse point #1, assessing the relationship of the participant to the
outcome, generates information about the value of the outcome to
the participant (for example, how a stressed, anorexic adolescent
student experiences achieving a 4.0 average). This measure
modifies negative effects of evaluations that reward the achieve-
ment of narrowly focused outcomes while disregarding broader,
potentially negative unintended and unmeasured consequences of
achieving those outcomes. For instance, some evaluators and
evaluands might consider high stakes testing in schools to be an
example of accountability measurement that could benefit from
being further qualified by the value of the results to the program
participant, to the provider, or the target systems in general.

Pulse point #2, the relationship of the participant to program
activities, leads evaluators to question the validity of attributing to
the program, outcomes achieved in the absence of cooperative and
productive relationships between the participant and program
activities. For example, in the case of a high achieving student
bored or angered by the activities, the evaluator would be hard
pressed to claim that these activities led to durable, positive
outcomes. More likely, the ‘‘successful’’ student achieved the
outcomes despite, rather than because of, the activities.

Pulse point #3, assessment of the relationship between the
participant and the provider is an additional source of variance.
Consider, for instance, the effect of the physician–patient relation-
ship on health or of the teacher–child relationship on school
achievement. Explanations for what makes these relationships
successful as perceived from varying perspectives inform both
their measurement and strategies to improve program results.

Each of these three pulse points describes system distinctions
and relationships found in the change model. Five more pulse
points address relationships more typically found amid the context
and feedback variables of action models:

Pulse point #4, describes the influence of family, community, and
other programs on the participant’s program outcomes. Generally
addressed in evaluation literature as program context, these
relationships usually involve practical aspects of programming and
family resources such as transportation, network support, medical
and educational services, and other financial resources. However,
program context can also include less tangible influences such as
family and community values in relation to program values or even
overall emotional support from family and community members
or from outside service providers (e.g., school teachers, medical
providers, or counselors). The perspectives involved in a systems
orientation acknowledge that the quality of these family and
community support relationships not only affects outcomes but in
turn is affected by them.

A range of how both formal and informal evaluation results
(pulse point #5) are received by the families, communities, and
other service providers often determines program effectiveness.
Consider, for instance, how parent response to student report cards
can affect both the students and the school system.

D.L. Wasserman / Evaluation and Program Planning 33 (2010) 67–8072

Other types of contextual relationships involve organizational
context and more specifically, the productivity of the program
providers. Pulse point #6 describes the relationships of the providers
to their outputs (which are the program activities of the change
model). Although variance in program activities can be minimized
with standards, guidelines and even regulations, the quality of
program activities and their ability to produce outcomes still
depends on the relationship of the human being producing the
activities to the conditions of producing them. How a provider
experiences her or his work may affect outcomes as much as the
protocol for the work itself.

Similarly, a provider’s performance is influenced by the support
received from the organization that administrates the program.
Pulse point #7, the quality of support from an organization to a
provider, defines that relationship. But like the relationship
between a family support system and a program participant, the
quality of support from an organization to a provider also can be
influenced by evaluation feedback. Pulse point #8 measures the
effect of evaluation results on the providers’ production of outcomes.

Measuring any one of the pulse points will provide an indicator
for how well that relationship is supporting the overall function-
ality of a given provider–recipient system, i.e., its ability to produce
outcomes that further the functionality of its sub-systems. For each
pulse point, a broad range of questions might be asked. For
instance, with pulse point #8, the effect of evaluation results on the
providers’ production of outcomes, stakeholders might be
concerned with how evaluation feedback changes the nature of
the outcomes, how it changes the physical resources available to
program providers, or even how it affects the pressures and stress
placed on providers. Only a rare – and well funded – human service
program evaluation would address all eight pulse points. Instead,
this framework of systems-oriented considerations provides a
systematic way for evaluators, as they design program evaluations,
to consider a fuller scope of key evaluation concerns.

As shown, a wide range of propositions can be formulated for
each of these pulse points. Foundational theory will guide the
process. One example of a foundational theory is Self-Determina-
tion Theory, an organismic systems-based motivational theory
(Ryan, 1995; Ryan, Kuhl, & Deci, 1997) that explains productivity
and achievement within and between human systems. The
remainder of this paper will use Self-Determination Theory to
illustrate how a foundational theory and a systems orientation can
be used to formulate testable propositions and thereby organize
and enhance human service program evaluations. A description of
the theory will be followed by how it is being used to support
change and action models in two diverse evaluation projects.

4. Self-Determination Theory: an example of
a foundational theory

Based on thirty years of human motivation research, Self-
Determination Theory explains human productivity, motivation,
and well-being from an organismic systems perspective (Ryan,
1995; Ryan et al., 1997). As such, it directly applies to human
service programs that target productivity and well-being out-
comes. According to the theory, human systems function optimally
– mentally, physically, and socially – when two conditions exist:
first, each system part experiences itself as uniquely contributing
to the survival of the system that nurtures it, and second, the
system part is able to regulate its contribution in relation to its own
needs. This second condition, more concretely stated, requires that
a person contributing to a greater system has the autonomy to
choose to discontinue his/her contribution in order to eat, rest,
regenerate, and otherwise protect her/his own survival.

As sub-systems of nurturing super-systems, human beings have
intrinsic motivation to receive nurture from the larger system, to

contribute to the survival of that system (which in turn contributes
to their own survival), to reassure themselves by acknowledging
their own unique contributions to that survival, and to protect
themselves from being subsumed by the system. Each of these
intrinsic motivations is translated into three basic psychological
needs: for relatedness (receiving and giving nurture); competence
(contribution to system survival); and autonomy (regulation of the
contribution) (Ryan & Deci, 2000a).

SDT defines five types of motivation, each gauged by the degree
to which behavior is related to satisfying these basic psychological
needs (Deci & Ryan, 2000). The term, intrinsic motivation, refers to
the stimulus that causes actions that directly satisfy these needs.
The remaining four (integrated, identified, introjected and
extrinsic) motivations, all of which begin externally, divide into
two types, internalized and external, distinguished by their affect
on Basic Psychological Need Satisfaction. Internalized motivations
satisfy basic psychological needs; external motivations oppose
them. Finally SDT uses the term amotivation to describe lack of
motivation altogether.

Using SDT as a foundational theory to explain program models
from a systems orientation is based on the well supported SDT
hypothesis (Deci & Ryan, 2002) that outcomes associated with
internalized motivations are more predictive of longer term well-
being than outcomes associated with external motivations and
threatened need satisfaction. Internalized motivations are accom-
panied by Basic Psychological Need Satisfaction, measured as need
satisfaction in relation to authority (Koestner & Losier, 1996).
Therefore, Basic Psychological Need Satisfaction is the measurable
construct by which program evaluators can apply SDT to
measuring program outcomes, their value, and how they are
affected by context and feedback. Each subdomain of Basic
Psychological Need Satisfaction is defined with examples in
Table 3.

Evidence supporting the hypothesis that predicts longer term
well-being results from outcomes associated with Basic Psycho-
logical Need Satisfaction has been demonstrated in SDT research.
Specifically, researchers have established at least association and,
in some instances, a causal relationship between Basic Psycholo-
gical Need Satisfaction and health care compliance, mental health,
academic success, goal achievement, and pro-social activity (Deci
& Ryan, 2000; Deci et al., 2001a; Deci & Vansteenkiste, 2004;
Grolnick & Slowiaczek, 1994; Reis, Sheldon, Gable, Roscoe, & Ryan,
2000; Ryan & Deci, 2000a; Sheldon & Houser-Marko, 2001; Wiest,
Wong, Cervantes, Craik, & Kreil, 2001; Williams, McGregor,
Zeldman, Freedman, & Deci, 2004). These associations have been
demonstrated across child, adolescent, college student, workplace,
and elderly populations (Baard, Deci, & Ryan, 2004; Deci, Ryan, &
Koestner, 2001b; Grolnick & Slowiaczek, 1994; Kasser & Ryan,
1999; Reis et al., 2000; Veronneau, Koestner, & Abela, 2005; Wiest
et al., 2001). Although the actions, behaviors, or processes by which
need satisfaction occurs changes across cultures, developmental
age, and even individuals, throughout these groups, need
satisfaction itself has been found to be consistently measurable
and relevant to longer term well-being. (Deci et al., 2001a; Ryan
et al., 1999; Ryan, La Guardia, Solky-Butzel, Chirkov, & Kim, 2005;
Schmuck, Kasser, & Ryan, 2000; Vansteenkiste, Zhou, Lens, &
Soenens, 2005). SDT researchers have also found that, in contrast to
internalized motivators, reward and punishment (both being
external motivators associated with lower Basic Psychological
Need Satisfaction) have been shown to diminish performance
(Baker, 2004; Deci, Connell, & Ryan, 1989; Deci, Koestner, & Ryan,
1999; Edward et al., 2002; Ryan et al., 1995; Sheldon, Ryan, Deci, &
Kasser, 2004; Vansteenkiste, Simons, Lens, Sheldon, & Deci, 2004).

The three psychological needs are considered ‘‘basic’’ because
they emanate from the very survival of an organismic sub-system
within its super-system. This ‘‘basic’’ nature of Basic Psychological

Table 3
Basic Psychological Need Satisfaction (BPNS) definitions and examples.

Basic Psychological Need Satisfaction Definitions (Deci & Ryan, 2000) Examples of questionnaire items

Sense of competence: the self-perception of being engaged in optimal challenges and experiencing the

ability to effectively affect both physical and social worlds

I feel very capable and effective.

I seldom feel inadequate or incompetent.

Sense of relatedness: the perception that one is both loving and caring for I feel loved and cared about.

others while being loved by and cared for by others in a social system. I seldom feel a lot of distance in my relationships.

Sense of autonomy: the perception of having organized one’s own experience and behavior, and this

self-organized activity maintains an integrated sense of self while serving to enhance the

satisfaction of the other two needs.*

I feel free to be who I am. I seldom feel controlled

and pressured to be certain ways.

*This second facet of the definition distinguishes sense of autonomy from independence, individualism,

detachment, selfishness, or internal locus of control. Sense of autonomy involves internal regulatory

schemas consistent with a sense of an integrated, joyful self rather than extrinsic regulatory schemas

associated with experience of tension, and ambivalence due to extrinsic pressures

(Ryan and Deci, 2000a). SDT researchers have distinguished integrated from non-integrated

choice making by the terms reflective autonomy for the former and reactive autonomy for the latter

(Koestner and Losier, 1996)

People experiencing sense of reflective (versus reactive)

autonomy will experience these feelings even in the

presence of authority figures such as teachers, parents,

popular peers, employers, police and corrections

officers, etc. (Koestner & Losier, 1996)

D.L. Wasserman / Evaluation and Program Planning 33 (2010) 67–80 73

Need Satisfaction makes the Basic Psychological Need Satisfaction
construct a powerful tool for evaluating human service programs
that seek to enhance the functioning and well-being of human
systems. Measuring outcomes without considering their effect on
Basic Psychological Need Satisfaction contains the risk of counting
as ‘‘successful’’ outcomes that may be either short lived, or in the
long-term, detrimental to the program participant’s capacity for
productively contributing to the system generating the outcomes.
Basic Psychological Need Satisfaction – the combined sense of
competence, relatedness, and autonomy – measured in relation to
a given outcome indicates the degree to which the outcome
benefits the individual producing it. Thus Basic Psychological Need
Satisfaction can be used to assess the ‘‘value’’ of an outcome while
simultaneously respecting the very unique value systems of
individual program participants.

Basic Psychological Need Satisfaction is also highly sensitive to
the conditions of a given moment (Ryan, 1995). For example, an
individual’s experience of need satisfaction may be high in the
presence of one parent and low with another—or high in relation to
participating in a program and low at home. Thus, measuring need
satisfaction can reveal differing effects of given environments on
unique individuals. Because it is so sensitive to varying conditions
and perspectives, the Basic Psychological Need Satisfaction
construct can be used to measure some of the relationships in a
foundational theory-based program model. For instance, consider-
ing pulse point #1, an outcome that enhances the well-being of a
participant should improve participants’ overall Basic Psycholo-
gical Need Satisfaction, or at least not diminish it. Likewise,
programming that diminishes Basic Psychological Need Satisfac-
tion will, according to Self-Determination theory (Edward et al.,
2002), be less productive than programming that enhances it
(pulse point #2). Similarly, a provider’s activities accompanied by
low Basic Psychological Need Satisfaction will be less effective than
activities provided with enhanced need satisfaction (pulse point
#6).

Another important SDT construct for evaluating programs from
a whole-system perspective is that of Support for Autonomy. SDT
research has established across age groups and cultures, the
relationship of autonomy support to Basic Psychological Need
Satisfaction (Gagne, 2003; Gagne, Ryan, & Bargmann, 2003;
Grolnick & Ryan, 1989; Grolnick, Ryan, & Deci, 1991; Wiest,
Wong, & Kreil, 1998; Williams & Deci, 1996; Williams, Rodin, Ryan,
Grolnick, & Deci, 1998; Wong, Wiest, & Cusick, 2002). Thus
evidence of Support for Autonomy throughout the system—from
provider and families to the participant (pulse points #3 and #4)
and from program administration to provider (pulse point #7)

provides important contextual information, particularly useful for
quality improvement. Program outcomes and participant well-
being will be enhanced as participants experience autonomy
support. Support for Autonomy is measured with a six-item
climate questionnaire (Deci & Ryan, 2008). Items can be tailored to
any supporting environment and involve Likert scale response to
statements such as ‘‘my counselor encourages my questions,’’ ‘‘my
counselor conveys confidence in my ability to succeed,’’ and ‘‘my
counselor asks how I see things before suggesting new ways to do
things.’’ Measuring Support for Autonomy reveals information
about how well providers are influencing the reflective autonomy
and consequent internalized motivation of the people they serve,
or for instance, how families communicate to the participant their
response to program results.

To date, Self-Determination Theory research has provided no
specific tool for measuring the motivational

effect of evaluation

feedback (pulse points #5 and #8). However, it may be that either
or both need satisfaction measures and/or autonomy support
measures may be adaptable for validly and reliably measuring the
effect. For example, to measure feedback effect, need satisfaction
items could be phrased, ‘‘When I receive my performance review. I
feel admired and cared about. I feel capable and effective. I
(seldom) feel controlled and pressured to be certain ways, etc.’’
Likewise, the autonomy support measure could be modified to
read, ‘‘The evaluation process encourages me to ask questions’’
shows that the evaluators understand me and what I want to
accomplish, acknowledges how I see things before suggesting new
ways of doing them, etc. In this way, an SDT-based logic model
builds into a program evaluation, the long-standing concern of
evaluators for evaluation anxiety (Donaldson et al., 2002) and a
way to measure its presence and effect.

5. Using Self-Determination Theory as a foundational theory
for evaluation design

As discussed above and shown in Fig. 1, a foundational theory-
based human service program evaluation includes – in addition to
the input, activity, output, and outcome elements found in the
change model and the ‘‘nuts and bolts’’ of the action model (Chen,
2004) – measurement of any of the eight pulse points that help
describe varying perspectives of interactions between the provider
and target systems. As a foundational theory, Self-Determination
Theory will prescribe how to measure these pulse points. In order
to determine the productivity of the provider–target program
system as it is affected by its surrounding systems, an SDT-based
logic model utilizes the SDT-based constructs of Basic Psycholo-

D.L. Wasserman / Evaluation and Program Planning 33 (2010) 67–8074

gical Need Satisfaction and Support for Autonomy (Program,
Organization, and Family/Community Climate) to operationalize
the eight inter- and intra-system relationships.

Similarly, an evaluator might utilize other systems approaches
to analyze these relationships. It is possible that a different
foundational theory may even reveal additional or different pulse
points. Although exploring those other theories is beyond the
scope of this paper, essential to the thesis of this paper is that
whatever foundational theory or systems approach is used, it must
both explain and provide a way to measure the functionality of the
relationships that affect the productivity of the human service
program. It must also explain and make measurable how varied
understanding of these relationships as seen from varied
perspectives affects system productivity.

The following examples from two diverse SDT-based program
evaluations conducted by The Ohio State University Center for
Family Research illustrate how evaluators can utilize a single
foundational theory to produce widely varying evaluation designs.
Each example is accompanied by a graphic model that illustrates
its change model (shaded boxes), action model (white boxes), and
the pulse point relationships that define the models (small
squares). Each example is also explained with a table that
delineates the program’s underlying theories and the program
model’s pulse points. Each pulse point is further described with a
description of the specific evaluation question(s) it addresses, the
relationship and operative perspectives involved, the measurable
indicators of those perspectives and relationships, and its related
area of evaluation inquiry.

5.1. Example #1: longitudinal evaluation of a comprehensive

out-of-school program

The broadest use of an SDT-based logic model to date has been
for a longitudinal evaluation of the Scotts Miracle-Gro Cap Scholars
out-of-school program. The evaluation addressed questions
related to six of the eight pulse points, all but the two concerning
evaluation feedback. The program’s causative theory and change
model (shown in the shaded boxes in Fig. 2), was that ongoing
comprehensive academic and social support from the staff, and
incentive from the funder in the form of a paid college education
would lead to academic success and career readiness. The
evaluation therefore addressed outcomes related to four specific

Fig. 2. SDT-based program model with six pulse points fo

objectives (academic achievement, career focus, self-efficacy,
social responsibility). The action model (shown with white boxes
and arrows), is described below with the use of the six pulse point
relationships that comprise it (Table 4).

In this SDT-based model, pulse point #1, the relationship of the
participant to the outcomes, addressed the question, did the four
outcomes contribute to the students’ overall well-being? The
answer was operationalized by nesting program outcomes within
students’ overall Basic Psychological Need Satisfaction. In so doing,
for each measured outcome (academic achievement, self-efficacy,
etc.), the data could be organized into a four-square pattern of
outcome results (Table 5): on the y axis is the expected outcome
achieved or not achieved and on the x axis, positive or negative
effect on overall Basic Psychological Need Satisfaction (as
measured in relation to authority).

Following SDT, outcomes achieved with maintained or
improved need satisfaction were considered to be true successes;
cases of lack of outcome with diminished Basic Psychological Need
Satisfaction were true failures. The opposite diagonal of the four-
square yielded deeper insight than afforded by more traditional
evaluations. Outcomes achieved with diminished Basic Psycholo-
gical Need Satisfaction were considered to be either short lived or
predictive of additional unintended and probably negative
consequences. Improved Basic Psychological Need Satisfaction in
the presence of outcomes not achieved indicated that measured
outcomes were failing to capture the full range of benefits achieved
by the program, especially if

need satisfaction in relation to the

program was also high. Within this category of results might
perhaps be the student with whom program staff had been
working to establish enough academic footing, confidence, and
interest to engage academically the following year. To label this
student a failure because of low GPA or homework motivation after
the first year would have robbed both the student of necessary
preparation time and the teacher of being able to individually
address student needs. On the other hand, improved overall need
satisfaction would reflect both concurrent positive behaviors in a
realm outside of school and predict future positive behaviors in
school.

The second pulse point, the relationship of the participant to
program activities, was operationalized with the shortest term
outcomes of the change (activities to outcomes) model. For this
evaluation, the program outputs and short term outcomes

r evaluating a comprehensive after-school program.

Table 4
Out-of-school program evaluation: questions addressed by causative theory, normative theory and foundational theory.

Theoretical support Pulse pointa Evaluation question addressed Perspective Measurement Findings enhanced

by foundational

theory

Causative theory (e.g., ongoing

comprehensive academic and social

support for students and families

will lead to program engagement

that will result in academic success.)

#2 Participant

to program activities

Did the program resources and activities

demonstrate fidelity to the action and

change models?

Funder-approved-activities and outcomes

(often agreed developed by and jointly

agreed to by other stakeholders)

(Outputs) Number and type of

activities; attendance; levels

of engagement.

#2 Participant to

program activities
Did the program resources and activities

contribute to academic success?

Outcome achievement

(GPA, homework motivation,

critical thinking, career decision

making, social responsibility).

Normative Theory includes innovative

programming from staff and mentors,

a supportive administrative environment,

supportive program environment, parent

commitment, regular attendance, a

counselor on staff who works with both

parents and teachers; use of a

discovery-based science museum as a

supportive and inspirational program

home; etc.

#1 Participant

to Outcomes

Did program resources and activities

lead to outcomes that enhanced

participant well-being? (pulse point #1)

Participant Outcomes in relation to overall

need satisfaction.

#2 Participant to
program activities
Did program resources and activities

lead to participants’ internalized

motivation to achieve program

outcomes?

Participant Higher score on BPNS in Relation

to Program Scale (BPNS-Program)

than concurrent Overall BPNS.

#3 Participant

to Provider

Foundational Theory Self-Determination

Theory: Internalized motivation throughout

the programming system leads to

successful production of outcomes that

beneficial to the students’ overall well-being

as measured by their Basic Psychological

Need Satisfaction in relation to authority

#4 Participant

to Family or

Community

To what degree did the participants’

family/community environment further

or hamper program efforts?

Participant BPNS in relation to family; BPNS

in relation to community; Family

Support for Autonomy.

#6 Provider

to activities

and outputs

Did program staff support participants’

internalized motivation to achieve

outcomes?

Participant Provider Participant perception of staff

Support for Autonomy; participant

BPNS in relation to program;

provider BPNS in relation

to program.

#7 Provider

to administration

How well did the administration support

staff’s optimal

performance?

Provider Staff perception of autonomy

support.
a Note that these pulse points are used in addition to more typically monitored process and outcome measures.

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Table 5
Four outcome groups.

Overall Basic Psychological Need Satisfaction

High or improved Low or diminished

Outcome achievement

Achievement Success Questionable success

No achievement Possible success No success

D.L. Wasserman / Evaluation and Program Planning 33 (2010) 67–8076

included attendance and engagement. But in addition, those short
term outcomes were augmented with the understanding that the
Basic Psychological Need Satisfaction of a participant in relation to
the program reflected how much the program could be contribut-
ing to that person’s overall well-being. Consider for instance, a
highly successful, high need satisfaction performer in the out-of-
school program who reported low sense of relatedness, compe-
tence, and autonomy in relation to the program. Based on SDT and
the research supporting it, the chance that the program had
contributed to this student’s success was very low.

Both of these first two pulse points tempered outcome
information with additional information about the quality of the
outcome and its association with the program. In this way,
outcomes irrelevant to the well-being of program participants
were documented, and outcomes occurring outside of the
program’s influence could be explored.

The third pulse point, assessment of the relationship between the
participant and the provider was operationalized as the participants’
perceptions of program support for their autonomy. Adminis-
trators recognized that students experiencing less autonomy
support from staff would, in the long run, receive less long-term
benefit from the program. Also, students came to recognize that
their responses to the SDT-based questionnaires gave them an
important voice, letting staff know how they were feeling about
program participation.

In addition to recognizing program Support for Autonomy as an
important element, SDT guided the evaluator to consider family
and community climate when assessing the program’s effect on
the family and community conditions (pulse point #4) that would
reinforce the academic outcomes the program was working to
create. Based on information that revealed students’ perception

Fig. 3. SDT-based program model with four pulse points for evaluating a data collectio

that parental support for their autonomy was weak, program
providers added family strengthening programming with the
intention of bolstering overall Basic Psychological Need Satisfac-
tion. Thus, measuring student’s perspective on family climate
helped determine how well families were supporting the aims of
the program.

Provider context (pulse point #7) was operationalized as the
program staff’s perception of management’s support for their
autonomy. This measurement was based on the SDT premise that
staff who felt supported in their work environment would in turn
experience improved Basic Psychological Need Satisfaction in their
work (measured with pulse point #6) and in turn would create
higher quality opportunities for program participants both within
and outside of the prescribed program activities.

5.2. Example #2: a statewide effort to utilize data to enhance child

mental health service coordination

The second exemplar involves a formative evaluation project
designed to help county-level service coordination agencies build
capacity for collecting and using evaluation data to enhance
outcomes for families of children with mental health needs. Having
been based on a child outcomes-based program theory, the service
coordination effort had yet to realize its focus on families. Part of
the intention of this project was to enhance child outcomes
through inclusion of family outcomes and greater family engage-
ment. As with the previous exemplar, the change model is
represented in the shaded boxes of the program’s SDT-based
program model (Fig. 3) and the action model in the white boxes,
defined by the pulse points explained below.

Whereas the first exemplar illustrated use of foundational
theory to explain system effects primarily on participant out-
comes, this second exemplar demonstrates the use of foundational
theory to explain and monitor the effects of the evaluation itself. As
illustrated in Fig. 3, for this evaluation pulse points, #5 and #8—the
relationships of provider and participant to evaluation feedback—
were of paramount importance (Table 6).

For both families and providers, how providers and evaluators
managed evaluation anxiety would directly impact the success of
the program. While use of data to make service coordination
decisions was the program objective, using that data with the end

n and utilization program to enhance service coordination for youth and families.

Table 6
Service coordination data collection and utilization: evaluation questions addressed by causative theory, normative theory, and foundational theory.

Theoretical support Pulse point relationship Evaluation question addressed Perspective Indicators (quality of relationships between

distinct system parts)

Area of evaluation inquiry

Change Theory: Use of data to track

family needs, characteristics, services

provided, changes in needs and

goals attained will lead to effective

service coordination and improved

child outcomes.

#2 Participant to
program activities

Did the county coordinators input data and utilize

the data reporting system in a way that was

consistent with generating accurate information?

Funder and evaluator (Outputs) Number of cases entered consistent

with other county records. Number of

Completed planning and data reports.

Formative evaluation;

quality improvement

#2 Participant to
program activities

Did the data collection and reporting system

contribute to improved outcomes?

County Service

coordinators

Outcome achievement: number of completed

referrals for positive screens

Accountability

Normative Theory: Evaluators will supply

program data to program administrators

in a way that enhances providers’

interest in adopting the innovation.

In turn they supply services to families

in ways that enhance families’ sense

need satisfaction in relation to the

services they receive.

#5 Provider system

to outcome evaluation

feedback

How well equipped were family caregivers to

respond to outcome feedback with appropriate

access to services?

Family caregivers Improved satisfaction of family caregiver

wants and needs.

Quality Improvement

Valuing (by whose

values?)

#6 Provider to activities

and outputs

Did county service coordinators and other

personnel involved with data entry experience

the data entry system as enhancing their ability

to do their work?

County Service

coordinators and

data entry personnel

Perception of innovation adoption

(observability, complexity, compatibility)

in relation to the data entry system

Quality improvement

Do county service coordinators and other

county-level stakeholders experience the

data feedback system as enhancing their

ability to do their work?

County Service
coordinators and

other county-level

stakeholders.

Perception of innovation adoption
(observability, complexity, compatibility)

in relation to data collection and report

planning and feedback process.

Effect of program context

Foundational Theory: Self-Determination

Theory: internalized motivation

throughout the programming system

leads to successful production of

outcomes that are valuable throughout

both target and provider sub-systems.

#7 Provider to

administration

How well did the data planning and reporting

process support program staff’s optimal

performance?

County service

Coordinators

Perception of autonomy support from

data and planning process.

Effect of organizational

context and quality

improvement.

#8 Administration to

evaluation feedback

Do county service coordinators and other

providers experience the relationship with

the evaluator as enhancing their ability

to do their work?
County Service

coordinators.

Perception of autonomy support from

the evaluator.

Evaluation anxiety:

effect of evaluation

feedback.

Do county service coordinators utilize the

data in a way that enhances family and

child outcomes?

Evaluator Qualitative analysis of county Continuous

Quality Improvement planning reports in

relation to data reports.

D
.L
.
W
a
sse
rm
a
n
/
E
v
a
lu
a
tio
n
a
n
d
P
ro
g
ra
m
P
la
n
n
in
g
3
3
(2
0
1
0
)
6
7
–
8
0

7
7

D.L. Wasserman / Evaluation and Program Planning 33 (2010) 67–8078

result of dampening family involvement would be counter-
productive to engaging them. To monitor family response to both
formal and informal evaluation of their child’s progress and
behavior (pulse point #5), families completed the Family Caregiver
Wants and Needs Scale (Gavazzi et al., 2008) a measure of family
caregivers’ perceptions of how well their needs were being heard
and met by both formal and informal service resources.

Even more important to this data-enhanced service coordination
project was monitoring provider response to the evaluation reports
and limiting the anxiety the reports produced (pulse point #6).
According to SDT, internalized motivation to utilize the evaluation
data would be indirectly related to the anxiety generated by that
data. Thus, with an eye toward ‘‘teaching to the test’’ the evaluation
involved providers (county service coordinators) in the semi-annual
process of completing continuous quality improvement ‘‘Do-Study-
Reflect-Plan’’ reports (Langley, Nolan, Norman, Provost, & Nolan,
1996). These reports, constructed initially in one-on-one conversa-
tions with the evaluator, involved four steps: (1) reviewing the most
recent data report and/or identifying evaluation questions and their
purpose (2) selecting instruments available in the on-line system to
collect information to answer those questions; (3) identifying new
operating, reporting, or data-use strategies to be implemented; and
(4) expected results in the next report along with what they will do
about them. The resulting data report would be as simple or
complicated as they needed/wanted and would reflect data gathered
with only the instruments they chose.

To evaluate the relationship of provider to data collection
activities and outputs (pulse point #6), County Service Coordina-
tors and other data entry personnel completed two versions of the
Perception of Innovation Adoption Questionnaire (Pankratz,
Hallfors, & Cho, 2002). This survey assesses perception of an
innovation’s observable benefit, complexity, and adaptability.
Selection of the questionnaire was based on the assumption that
internalized motivation would be highest if the program was easily
adaptable, had observable benefit and minimal complexity. The
first version related to the on-line data entry system using, for
instance, the wording, ‘‘The online data collection system fits well
with the way I work’’; the second version asked about the data
planning, reporting, and support system, worded, ‘‘Using the Do-
Study-Reflect-Plan process will increase the quality of how we
serve children and families in our county.’’

After each reporting cycle, to gauge how well the system was
supporting provider autonomy (i.e., the relationship of the
provider to the program administration; pulse point #7), County
coordinators completed autonomy support questionnaires related
to the Do-Study-Reflect-Plan process (e.g., ‘‘The Do-Study-Reflect-
Plan process encourages me to ask questions that will help to
enhance service coordination in my county.’’). In addition, the
evaluator conducted qualitative analysis of the planning reports as
related to the data reports and feedback (pulse point #8) to
determine system alterations that would further county use of the
system and ultimately family engagement.

In this exemplar, use of a Foundational Theory coordinated into
a single model the multi-layered units of analysis: service
coordinators, families, and children. Whereas the causative model
that had focused resources on child outcomes only had discour-
aged meaningful data collection and use, the systems orientation
and foundational theory-based model (in this case, SDT) encour-
aged data collection while reengaging service coordinators’ focus
on families in addition to improving child outcomes.

6. Lessons learned: contributions of foundational
theory-based models

This paper has introduced the notion that by adopting a systems
orientation and foundational theory, evaluators can (1) system-

atically define eight operative ‘‘pulse points’’ of a program’s action
and change models using relationships and perspectives within
and between provider and target systems; (2) identify social
science theory as a foundational theory that explains how to
determine the ‘‘health’’ of these pulse points relative to how they
contribute to the change model and the outcomes; and with both
systems thinking and foundational theory to support it,(3)
significantly enhance the design and conclusions of their human
service program evaluations. The paper has also introduced Self-
Determination Theory as an example of a useful and informative
foundational theory.

Two exemplars have shown that depending on the topic of
inquiry and the related questions, each evaluation design will
involve different combinations of pulse points. Few evaluation
designs will incorporate all eight. To use the framework, evaluators
will first identify the relevant provider and target system
distinctions, and then the operative relationships and perspectives
within and between them. Next they use the pulse points to decide
which evaluation questions they want to answer, and then
construct the evaluation logic accordingly.

None of the questions related to the system pulse points in any
of these examples are new to evaluation practice. Evaluators have
long been concerned with the evaluation issues of valuing by
whose values, evaluation anxiety, and the effect of context on both
providers and participants. However in practice they have
primarily designed causative theory-based program models with
no formal theory to explain or systematic way to define the action
model and its effect on the change model. Thus attention to these
contextual and feedback issues often have been considered
incidental to determining if human service programs achieved
their projected outcomes. Yet both program providers and
evaluators have known that these additional ‘‘peripheral’’ context
and feedback issues have profound impact on the quality of not
only the programming, but the outcomes as well. A systems-
oriented program model with foundational theory to support it
moves these heretofore sidelined areas of investigation into a more
central and purposeful focus.

Although the two examples of program evaluations designed
using this framework have shown the breadth and flexibility of a
single foundational theory, there is much work to be done to
explore uses of a foundational theory across the vast array of
human service programs, each with unique designs, stakeholder
concerns, and evaluation questions to be addressed.

As for the use of Self-Determination Theory as a foundational
theory, although it is based on empirical findings from across
multiple disciplines, the SDT-based evaluation framework
remains theoretical until it is empirically tested in the context
of evaluation practice. That process will be multi-faceted and
include many steps that test both instruments and methodology.
Although most of the measurement instruments have been tested
for reliability and validity in the context of SDT research (which is
continually expanding in the literature by researchers world-
wide), their utility for program evaluation per se has not been
confirmed. The use of the BPNS-authority scale needs to be
validated as an overall BPNS measure and one that, in a program
evaluation setting, discriminates between reflective and reactive
autonomy. Also, as noted in section III, no instrument has been
designed yet to measure the effect of evaluation feedback on Basic
Psychological Need Satisfaction. In addition to the instruments,
the relationships between participant and provider Basic Psy-
chological Need Satisfaction and program outcomes needs to be
confirmed in the context of a full range of program evaluations.
Testing also needs to confirm that the theoretical assumptions
contained within the framework transfer to the wide range of
human service programs by and for a wide range of cultures.
Despite these potential limitations, evaluators can utilize the

D.L. Wasserman / Evaluation and Program Planning 33 (2010) 67–80 79

concepts and measurement tools to answer important evaluation
questions.

The advantage of Self-Determination Theory as a foundational
theory is that it provides a way to interpret disparate behaviors,
attitudes and contextual supports in a way that can be
standardized to individual human well-being. Other foundational
theories will no doubt be found to have equally useful and possibly
different advantages. Future theorists and practitioners may be
able to explore other broad-based motivational or productivity
theories such as exchange theory, structural functionalism, net-
work theory, ecological theory or any of the many systems theories
as equally as useful foundational theories.

Whatever theory is used to support it, this systems-oriented
approach to designing human service program evaluations, is
offered as one more tool for stimulating continual dialogue around
difficult evaluation questions: how do evaluators systematically
account for the contextual factors that affect how a human service
program’s merit, value or worth is assessed? In what ways can
evaluators discourage negative impacts of the evaluation process—
on either program providers or participants? What strategies exist
for maximizing the program-improvement benefits of outcome
evaluation? By understanding human service program outcomes
as resulting from various relationships within and between
systems, evaluators have the opportunity to shed new light on
age-old questions.

Acknowledgements

Earlier versions of this paper were presented at the joint
Canadian Evaluation Society/American Evaluation Association
conference in Toronto, Ontario October, 2005 and at the American
Evaluation Association conference in Portland, Oregon, November,
2006.

The author first acknowledges the Ohio State University Center
for Family Research which has adopted Foundational Theory-
Driven Evaluations as the basis for its evaluative work and has
provided each of the exemplars used in this paper. Acknowl-
edgements also go to the Nationwide Children’s Research Institute
Center for Innovation in Pediatric Practice. Also to Kathi Pajer and
the Nationwide Children’s Research Institute writer’s group, and
Stephen M. Gavazzi, William Meezan, Robin Miller, Jonny Morell,
Marilyn McKinley, Amy Hoch, and David Yorka for valuable
editorial feedback.

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Deborah Wasserman is the evaluation and research specialist at the Center for Family
Research at The Ohio State University and the President of PERSolutions: Program
Evaluation and Research Solutions. Her evaluation research centers on exploring the
feasibility and utility of using Self-Determination Theory-based logic models for
explaining the multi-systemic relationships necessary for understanding and measur-
ing program success.

http://www.wkkf.org/Pubs/Tools/Evaluation/Pub3669

Using a systems orientation and foundational theory to enhance theory-driven human service program evaluations

Introduction
The Need For A Systems Orientation And Foundational Theory
A systems orientation: defining human service program system distinctions, relationships, and perspectives
Self-Determination Theory: an example of a foundational theory
Using Self-Determination Theory as a foundational theory for evaluation design
Example #1: longitudinal evaluation of a comprehensive out-of-school program
Example #2: a statewide effort to utilize data to enhance child mental health service coordination
Lessons learned: contributions of foundational theory-based models
Acknowledgements
References

Theory! The Missing Link in Understandin

the Performance of Neonate/Infan

Home-Visiting Programs to Prevent Child
Maltreatment: A Systematic Review

L E O N I E S E G A L ,

R A C H E L L E S A R A O P I E , 1,

and K I M D A L Z I E L

1University of South Australia; 2Alfr

Hospital; 3Caulfield Hospital

Context: Home-visiting programs have been offered for more than sixty year

to at-risk families of newborns and infants. But despite decades of experienc

with program delivery, more than sixty published controlled trials, and mo

than thirty published literature reviews, there is still uncertainty surrounding
the performance of these programs. Our particular interest was the performan

of home visiting in reducing child maltreatment

Methods: We developed a program logic framework to assist in understanding
the neonate/infant home-visiting literature, identified through a systematic
literature review. We tested whether success could be explained by the logic
model using descriptive synthesis and statistical analysi

Findings: Having a stated objective of reducing child maltreatment—a theo

or mechanism of change underpinning the home-visiting program consistent
with the target population and their needs and program components that ca

deliver against the nominated theory of change—considerably increased the
chance of success. We found that only seven of fifty-three programs demon-
strated such consistency, all of which had a statistically significant positive
outcome, whereas of the fifteen that had no match, none was successful. Pro-
grams with a partial match had an intermediate success rat

The relation-
ship between program success and full, partial or no match was statistically
significant.

Conclusions: Employing a theory-driven approach provides a new way of
understanding the disparate performance of neonate/infant home-visiting

Address correspondence to: Leonie Segal, Health Economics & Social Policy Group,
Division of Health Sciences, University of South Australia, Box 2471 Adelaide,
South Australia, Australia 5

01 (email: leonie.segal@unisa.edu.au

The Milbank Quarterly, Vol. 90, No. 1, 2012 (pp. 47–106

)

THE

MILBANK QUARTERLY
A MULTIDISCIPLINARY JOURNAL OF POPULATION HEALTH AND HEALTH POLICY

48 L. Segal, R.S. Opie, and K. Dalziel

programs. Employing a similar theory-driven approach could also prove useful
in the review of other programs that embody a diverse set of characteristics
and may apply to diverse populations and settings. A program logic frame-
work provides a rigorous approach to deriving policy-relevant meaning from
effectiveness evidence of complex programs. For neonate/infant home-visiting
programs, it means that in developing these programs, attention to consistency
of objectives, theory of change, target population, and program components is
critical.

Keywords: Policy-relevant evidence synthesis, complex interventions, infant
home visiting.

Background

H
ome-visiting programs have been offered for more
than sixty years, with the aim of creating a safe and nurturing
environment for newborns and infants and preventing child

abuse and neglect. Home-visiting programs involve the use of a pro-
fessional (such as a nurse or social worker) or a trained paraprofessional
or layperson to make regular visits in the home of a mother (or family)
commencing prenatally or soon after the birth of a baby. Home visi

are provided for anything from a few months to two or more years, wi

more visits (e.g., weekly) closer to the birth and fewer (e.g., monthly)
as the child grows. The general aim is to improve outcomes for mothe

and babies.

The Nurse Family Partnership (NFP) developed by Olds (Olds
et al. 1986, 1997) is perhaps the best-known home-visiting program.
Home-visiting programs are now implemented widely, covering many
thousands of families across the United States (Barth 1991; Bugental
and Schwartz 2009; Duggan et al. 2004; Gessner 2008; Hardy and
Streett 1989; Lutzker and Rice 1984; Schuler et al. 2000), the Unit

Kingdom (Barlow et al. 2007; Wiggins et al. 2005), Canada (Infante-
Rivard et al. 1989; Larson 1980; Steel O’Connor et al. 2003), Austral

(Armstrong et al. 1999; Kemp et al. 2008), and elsewhere, includ-
ing Syria (Bashour et al. 2008), New Zealand (Fergusson et al. 2005),
Norway (Kaaresen et al. 2006) and Japan (Cheng et al. 2007

Home-visiting programs have a number of possible objectives, includ-
ing the health of the baby (e.g., immunization, breast-feeding), safety

Home-Visiting Programs to Prevent Child Maltreatment 49

(e.g. general risks, maltreatment), school readiness, and positive parent-
ing (e.g. infant mother bonding and responding to cues). The focus of
this article is home visiting for the prevention of child maltreatment.
Child maltreatment—defined as any act of commission or omission by
a parent or caregiver that results in harm, or the threat of harm, to a
child—is widespread and of global concern (WHO 2006). As reported
by Gilbert and colleagues (Gilbert et al. 2009a, 2009b), population
surveys in countries in the Organization for Economic Cooperation and
Development put rates of child physical abuse at 4 to 16 percent and
neglect at 1.4 to 15.4 percent.

In Australia, rates of child physical and/or sexual abuse are estimated
at 15.5 percent, based on the national mental health and well-being
survey (ABS 2008; Reeve and van Gool 2010). Furthermore, rates of
child maltreatment notifications in Australia nearly trebled between
2000/2001 and 2008/2009, from 115,471 to 339,454 (Productivity
Commission 2011), placing considerable pressure on child protection
services and calls for investment in preventive services.

Child maltreatment has well-documented adverse outcomes across
many domains, contemporaneous with the abuse and extending many
years into the future. It is associated with poor mental and physical
health, high rates of suicide, poor physical health, low educational out-
comes, high involvement in crime, incarceration, substance abuse, be-
havioral problems, homelessness, welfare dependency, and unemploy-
ment (Dube et al. 2003; Eckersley 1988; Evans, Hawton, and Rodham
2005; Gilbert et al. 2009b; Peden et al. 2008; Pinheiro 2006; Reeve
and van Gool 2010; Thornberry et al. 2010; WHO 2010).

Home visiting in the prenatal and early childhood period is an iden-
tified strategy for reducing child abuse and neglect. But despite decad

of experience with the delivery of home-visiting programs and more
than sixty published controlled trials and numerous literature reviews,
the performance of home visiting is still reported as equivocal. In this
article, we review the literature using a theory-driven framework in an
attempt to bring greater clarity to understanding the disparate evidence
base.

Existing Evidence Ba

Using a standard search strategy (described later), we identified fifteen
systematic literature reviews (including two meta-analyses) with a focus

50 L. Segal, R.S. Opie, and K. Dalziel

on home visiting as an intervention to prevent child maltreatment or ris

factors for maltreatment. The number of programs covered in the reviews
varied from two to sixty, reflecting distinct inclusion and exclusion
criteria (see table 1).

Most of the reviews reported on many outcomes. These might include
one or more direct child maltreatment measures (child abuse reports or
substantiations, out-of-home placement) plus predictors of child mal-
treatment (such as parenting knowledge, attitudes, or behaviors) or in-
direct evidence of maltreatment (such as injury hospitalizations or child
health development).

All the reviews sought to assess the overall performance of home vis-
iting, for programs “within scope,” with some also seeking to describe
the characteristics predictive of success (Drummond, Weir, and Kysela
2002; Kearney, York, and Deatrick 2000; Sweet and Appelbaum 2004).
The reviews generally reported mixed results across outcome measures
and struggled to generate meaning from the mixed findings. As re-
ported in table 1, the conclusion of most of the reviews, including the
high quality comprehensive review by Sweet and Appelbaum (2004),
was that the evidence of success was equivocal. Only the review by
Kendrick and colleagues (Kendrick et al. 2000) concluded that home
visiting was successful, although their review was restricted to studies
reporting HOME scores (a multicomponent questionnaire measuring
the nurturing potential of the home/parenting environment).

A range of reasons were offered to explain why the performance of
home-visiting programs might appear inconclusive. These included pos-
sible error that was caused by the poor reliability and validity of measures
(McNaughton 2004), the possibility that “certain outcome data are se-
lectively omitted from published reports because the results fail to reach
significance” (Roberts, Kramer, and Suissa 1996, 31), a follow-up period
that was too short (McNaughton 2004), and possible “surveillance bias”
(a higher rate of abuse notification related to contact with the home
visitor). More commonly, the reviewers postulated that the considerable
diversity in home-visiting programs was largely responsible for the con-
fusion. The programs varied with respect to models of service delivery
(when commenced and at what age concluded, number and length of
home visits), target population (risk profile, cultural group), home visi-
tor (qualifications, training, supervision), and program components (use
of multidisciplinary team, access to specialist services such as counseling,
drug and alcohol services, job placement, child care).

Home-Visiting Programs to Prevent Child Maltreatment 51

T
A

L
E

1
K

ey
C

n
cl

u
si

n
s

of
F

if
te

n
R

ev
ie

w
s

of
N

at
e/

n
fa

n
t

H
om

e-
V

is
it

n
g

St
u

d
ie

R
ev

ie
w

n
d

N
u

m
b

P
ri

m
ar

y
St

u
d

F
oc

u
s

f
R

ev
ie

w
C

on
cl
u
si

on
s

B
il

u
k

h
a

et
al

5
;

2
5

st
u

d
ie

s
T

o
as

se
ss

h
e

ef
fe

ct
iv

n
es

s
of

h
om

e-
vi

si
ta

ti
on

p
ro

g
ra

m
s

in
p

re
ve

n
ti

n
g

vi
ol

n
ce

“S
tu

d
y

fi
n

d
in

g
s

ar
e

in
co

n
si

st
en

t.
”.

.
.“

T
h

e
ev

d
en

e
is

n
su

ff
ic

e
n

t
to

d
et

er
m

n
e

th
e

ef
fe
ct
iv
en
es
s
of

ea
rl

y
h

m
e

n
te

rv
en

ti
on

s
in

p
re

ve
n

ti
n

g
vi

ol
en

ce
b

y
vi

si
te

d
ch

l
d

re
n

or
vi

si
te

d
p

ar
en

s
or

in
p
re
ve
n
ti
n
g

in
ti

m
at

e
p

ar
tn

er
vi

ol
en

ce
”

(p
.

1
7

g
g

et
t,

B
u

r
et

,
an

d
O

b
or

n
2

0
0

5
;

6
st

u
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ie

s
E

ff
ec

t
of

p
re

–
an

d
/o

r
p

os
tn

at
al

h
om

e
vi

si
ts

fo
r

w
om

en
w

it
h

d
ru

g
or

al
co

h
ol

p
ro

b
le

m
.

“T
h

s
re

vi
ew

fa
il

d
to

fi
n

d
ev

id
en

e
th

at
h

om
e

vi
si

ts
re

u
ce

d
th

e
ri

k
of

co
n

n
u

g
d

g
or
al
co
h
ol

u
se

”
(p

.
1

8
).

D
ru

m
m

d
,

W
ei

r,
an

d
K

ys
el

2
0

0
2
;

1
4

ar
ti

cl
es

n
9

p
ro
g
ra

m
s.

F
oc
u
se

s
on

p
ro
g
ra

m
co

m
p

on
en

ts
,

p
ra

ct
ic

es
,

tc
om

s
an

d
q

u
al

it
y

to
u

n
d

er
st

an
d

co
n

si
d

er
ab

le
va

ri
at

io
n

ac
ro

ss
st

u
d

ie
s.

“

P
ro

g
re

ss
in

ev
al

u
at

io
n

of
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om
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si

ta
ti

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as

b
ee

n
m

d
e,

b
u

t
m

u
ch

e
m

ai
n

s
to

b
e

cl
ar

if
ie

d
”

(p
.

1
5

7
).

G
on

za
le

z
an

d
M

ac
M

il
la

n
2
0
0

8
;

3
h

om
e
vi
si
ti
n

g
st

u
d

ie
s

R
es

tr
ic

e
d

o
co

n
tr

ol
le

d
tr

ia
ls

of
ve

ry
st

ri
n

g
en

t
m

et
h

d
ol

og
ic

al
cr

it
er

ia
.

“T
h
e
d

ev
el

op
m

en
t

of
fu

u
re

p
ro
g
ra
m
s

n
ee

d
s

to
b

h
eo

re
ti

ca
ll

y
d

ri
ve

n
”

(p
.

2
8

4
).

G
u

te
rm

an
1

9
9

9
;

1
9

st
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s
E

a
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in
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tc

m
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li
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k
ed

w
it

h
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if
fe

ri
n

g
sc

e
en

in
g

an
d

en
ro

m
en

t
st

ra
te

g
ie

“

P
op

u
la

ti
on

–

b
as

ed
en

ro
lm

en
t

t
ra

te
g

ie
s

p
p

ea
r

fa
vo

u
ra

b
le

to
sc

re
en

in
g
-b
as

d
on

es
in

ea
rl
y
h
om
e
vi
si
ta
ti

on
p

ro
g

ra
m

s
se

k
in

g
to

p
re
ve
n

t
p

h
ys

ic
al

h
il

d
ab

u
se
an
d

n
eg

le
ct

”
(p

.
8

6
3

C
on

ti
nu

52 L. Segal, R.S. Opie, and K. Dalziel

T
A

B
L
E

1
—

C
on
ti
nu
ed
R
ev
ie
w
an
d
N
u
m
b

er
of

P
ri
m
ar
y
St
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s
F
oc

u
s
of
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w
C
on
cl
u
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s

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ah

n
et

al
.

0
0

;
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1
st

u
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ie
s
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d

2
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in
te

rv
en
ti
on

ar
m

s
E
ff
ec

ti
ve

n
es
s
of
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rl

y
ch

il
d

h
oo

d
h

om
e
vi
si
ti
n

g
in

p
re
ve
n
ti
n
g
vi
ol
en

ce
.

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h

e
T

as
k

F
or

e
fo

u
n

d
in

su
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ie

n
t

ev
id

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ce

o
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er

m
in

e
th

e
ef

fe
ct

iv
en

es
s

of
ea

rl
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ch
il

d
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oo
d

h
om
e
vi
si
ta
ti
on
in
p
re
ve
n
ti
n
g
vi
ol
en
ce

b
y

vi
si

te
d

ch
il

d
re

n
an

d
b

w
ee

n
ad

u
lt

s”
(p

.
7
).

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ow

ar
d

an
d

B
ro

ok
s-

G
u

n
n

2
0
0
9
;

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s
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ar
ly

in
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en
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on

–
fa

m
il

ie
s

re
cr

u
it

ed
p

re
n
at
al

ly
or

ar
ou

n
d

b
ir

h
,

at
ed

ai
m

to
im

p
ro

ve
p

ar
en
ti
n

g
an

d
p
re
ve
n
t
ch
il
d
ab
u
se
an
d
n
eg
le
ct
.

“A
re

vi
ew

of
th

e
li

te
ra

tu
re

re
ve

al
s

a
m

ix
ed

p
ic

tu
re

re
g

ar
d
in
g
th
e

ef
fi

ca
cy

of
h

om
e-

vi
si
ti
n

g
p

ro
g
ra
m
s”
(p
.
1
7
).

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ea

rn
ey

,
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or
k

,
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k

2
0
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;

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0

ra
n

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om

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s
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th

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.S
.

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th
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lt

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-c
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il
d
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t,
an

d
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f
w

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l

ch
il
d
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ea
lt

h
ca

re
.

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n

n
u
rs
e-
d
el
iv
er
ed
h
om
e
vi
si
ti
n
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in

te
rv

en
ti
on
s

to
yo

u
n

g
fa

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il
ie
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te
rm
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ll

-t
er

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in

fa
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ts
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al

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l-
b

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an

d
li

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co

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rs

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d
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el
op
m

n
t,

m
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n

al
-i

n
fa
n
t
in
te
ra
ct
io
n
,
an
d
p
ar
en
ti
n

g
of

te
n

im
p
ro
ve
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,
b
u

t
ch

il
d
d
ev
el
op
m
en

t
g
ai

n
s

m
ai

n
ly

w
er

e
li

m
it

ed
to
p
re
te
rm

in
fa

n
ts

”
(p

.
3

7
5

)

.
K

en
d

ck
et

.
2

0
0
0
;

1
7

st
u
d
ie

s
re

p
or

ti
n

g
H

O
M

E
sc

or
es

.
R

es
tr

ic
te

d
to
st
u
d
ie
s
re
p
or
ti
n
g
H
O
M
E
sc

or
e

(t
h

at
m

ea
su

re
s

p
ar
en
ti
n
g
q
u

al
it

y
an

d
sa

fe
ty

of
h
om

e
en

vi
ro

n
m
en
t
fo
r

ra
is

in
g
ch
il
d
re

n
).

“

O
u

r
re

vi
ew
of
th
e
ef
fe
ct
iv
en
es
s
of
h
om
e
vi
si
ti
n
g
p
ro
g
ra
m
m
es

u
g

g
es

ts
th

ey
ar

e
ef
fe
ct

iv
e

n
in

cr
ea

si
n

g
th

e
q

u
al
it
y
of
th

e
h

om
e

n
vi

ro
n

m
en

t
as

m
ea

su
re

d
b

y
H

O
M
E
sc
or
es
”
(p

.
4

4
7

Home-Visiting Programs to Prevent Child Maltreatment 53

M
ac

M
il

la
n

et
al

.
2
0
0
9
;

2
h
om

e
vi
si
ti
n
g

m
od

el
s

(N
F

&
E

ar
ly

St
ar

E
ff

ec
t

on
th

e
fi

ve
m

aj
or

u
b

y
p

es
of

ch
il

d
m

al
tr

ea
tm

en
t

of
tw

o
h

ig
h

-p
ro

fi
le

n
u
rs
e-
vi
si
ti
n

g
p
ro

g
ra

m
s;

N
u

rs
e

F
am

il
y

P
ar

n
er

sh
ip

an
d

E
ar

ly
St

ar
t

(

F
er

g
u

ss
on

et
al
.
2
0
0

5
).

“D
es

p
it

e
th

e
p
ro

m
ot

io
n

of
a

b
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54 L. Segal, R.S. Opie, and K. Dalziel

T
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).

Home-Visiting Programs to Prevent Child Maltreatment 55

Several reviewers reported specific program features predictive of suc-
cess, such as targeting of low-income, first time adolescent mothers
(Howard and Brooks-Gunn 2009) or those “at elevated risk of maltreat-
ment” (Bilukha et al. 2005, 22); or when the program was delivered by
professional visitors (Bilukha et al. 2005; Hahn et al. 2003) or when
families received a longer and/or more intensive program (Bilukha et al.
2005; Howard and Brooks-Gunn 2009). Kearney and colleagues con-
clude that “effective nurse home visiting included nurses with advanced
education, frequent visits over a long period of time, and were focused
less on building parent resources, as in the social ecology model, and
more on building a relationship with the mother and providing her
with coaching in maternal-infant interaction and cognitive develop-
ment” (Kearney, York, and Deatrick 2000, 375). But they also report
uncertainty in the determinants of success. Sweet and Appelbaum, who
reviewed sixty controlled trials, conclude that “what exactly makes a
home visiting program successful is unclear at this time” (Sweet and
Appelbaum 2004, 1448). Yet none of the reviews consider this issue in
a rigorous way.

In short, despite the expectation that the attributes of home-visiting
programs will affect performance, the reviews published to date have
not established the determinants of success nor have they considered
this question in a rigorous way. So despite dozens of random controlled
trials (RCTs) and nearly as many reviews of home-visiting programs for
neonates and infants, the current state of knowledge leaves policymakers
without clear evidence-based advice.

Aim of Study

The aim of our study was to gain a new understanding of the home-
visiting literature for the prevention of child maltreatment by taking a
program logic approach that incorporated a theory of change.

We hypothesized that the success of home-visiting programs would
reflect the consistency between (1) the stated or implied theory (mech-
anism) of change underpinning the program, (2) the target population
and their specific needs, (3) the program components/activities, and
(4) the program objectives. Figure 1 depicts the overall program logic
incorporating these four levels. We sought to test this proposition by an-
alyzing all the published control studies of infant/neonate home-visiting

56 L. Segal, R.S. Opie, and K. Dalziel

figure 1. Program Logic Model for Reviewing Complex Interventions

interventions to prevent child maltreatment or known risk factors that
met our inclusion criteria.

The approach is complementary to theory-driven evaluation, in which
the underlying theory and fidelity of implementation are central to ex-
planations of program performance (Coryn et al. 2011). An overarching

Home-Visiting Programs to Prevent Child Maltreatment 57

aim of our article is to encourage the use of program logic in the sys-
tematic review of complex interventions and to demonstrate how this
may be achieved. Adopting a theory-driven approach to understanding
the complex home-visiting literature has a powerful internal logic. It
is also supported by evidence that behavior change programs developed
according to a defined theory are more likely to be successful than those
not so developed (Noar and Zimmerman 2005). Painter and colleagues
(2008) estimated that only one-third of health-related behavior change
studies explicitly identify an underlying theory, and that such identifi-
cation affects success. In relation to infant home visiting, we postulate
that greater attention to the underlying theory and the integrity of
the theory with program components, target population, and objectives
will provide a more coherent explanation of the observed results. For
example, Gardner and colleagues used a theory-driven approach to ev-
idence synthesis to review audit and feedback mechanisms in chronic
disease management (Gardner et al. 2003) and it was found to assist in
understanding program performance.

We are not aware that a program logic approach incorporating a theory
of change has been applied previously to a review of the home-visiting
literature in neonates and infants. Even though some of the reviews
identify whether individual programs specify and use a theory (of change)
in program development and implementation (McNaughton 2004) and
others specify objectives for each program that may imply a theory
of change (Drummond, Weir, and Kysela 2002; Howard and Brooks-
Gunn 2009; Sweet and Appelbaum 2004), none formally connects these
observations to the programs’ success.

In the evaluation of individual programs, it is not uncommon for a
theory of change to be considered in assessing performance (e.g., Barnard
et al. 1988), or for a theory-driven (program logic) approach to be
adopted (Rogers et al. 2000). However, it is the use of a program logic
framework for a systematic review, the approach taken here, that is
unique.

Our program logic–based review, though consistent with the growing
realist synthesis literature in arguing for a theory-driven approach to the
review of complex interventions (Pawson et al. 2005), has some impor-
tant differences. The realist synthesis approach proposes that context is
paramount, such that universal conclusions are unlikely to be possible.
Instead, our expectation is that by using a theory-driven approach, the
importance of context—albeit central—will not preclude overarching

58 L. Segal, R.S. Opie, and K. Dalziel

conclusions being drawn, but that this is unlikely to be a set of uni-
versally effective program elements. That is, by using a theory-driven
approach, what currently seems confusing in understanding predictors
of success will become clear.

Methods

Our research had four phases:

1. Developing the criteria for the literature review, data extraction,
and analysis for a systematic review of home visiting based on the
program logic approach shown in figure 1.

2. Conducting a comprehensive literature search to identify all
home-visiting programs meeting our inclusion criteria.

3. Extracting data using the established criteria including data on
the programs’ performance.

4. Testing whether a match of the program theory, the program
components, the target population, and the child maltreatment
objective predicts success.

Criteria for Analyzing Home-Visiting
Programs Using a Theory-Driven Approach

We developed a classification system to describe (1) the underlying the-
ory or mechanism of change, (2) the target population, (3) the program
components, (4) the program objective, (5) the definition of a program’s
success, and (6) the basis for classifying a match.

Theory Underpinning Home-Visiting Programs. The underlying theo-
ries of home-visiting programs to prevent child maltreatment draw on
various literatures, including child development, attachment, health
promotion, mental health, neuroscience, education and learning, and
evolutionary biology. The discussion in this article represents a start
on this complex area. It concentrates on the theories described in the
child protection literature, for example drawing on the psychodynamic,
sociological, social-psychological, and ecological theories (Sidebotham
2001).

We found that six reasonably distinct theoretical mechanisms (and
associated theories of change) are commonly used to explain poor par-
enting and poor child outcomes. These were based on (modified and

Home-Visiting Programs to Prevent Child Maltreatment 59

further developed) the state of Georgia’s Child Abuse Prevention The-
ory of Change and Logic Model Early Childhood comprehensive systems
implementation project, supported by the World Health Organization
(WHO) (WHO 2011).

1. Lack of knowledge and skills regarding important topics like normal
child development or how to look after or relate to a young infant
by some mothers (and fathers) that undermines the quality of their
parenting. For example, some of the early infant home-visiting
programs reflect a knowledge and skills deficit model, such as
the Parents as Teachers program developed in 1981 (Wagner and
Clayton 1999).

2. Limited access to health care due to financial, cultural, logistical
barriers, and/or competing priorities or chaotic life circumstances
that compromises the physical health of the mother and baby
(as might be seen in failure to thrive, failure to achieve baby
milestones). Home visiting seeks to address this by providing
direct access to the health and welfare system in the family’s home
(through the visitor/team) and through facilitating referral/access
to other health and welfare services.

3. Social isolation of mothers as a predictor of child maltreatment
(Runyan et al. 2002), reflecting the importance of good emotional
and social support for new mothers when they are particularly
vulnerable and at high risk of postpartum depression.

4. Disruptions to the mother-infant interaction and bonding and low
maternal sensitivity affecting the ability to be a good parent, de-
scribed in the attachment theory literature (Bowlby 1969/1982;
Lyons-Ruth 2008). The crucial importance of early infancy (in-
cluding in utero) and the mother-child relationship is emerging
also from the neuroscience literature (Schore 2005).

5. A poor or compromised psychological state that undermines a
mother’s capacity to parent and poses a direct threat to the
mother-infant attachment and meeting of the infant’s basic physi-
cal and emotional needs. This risk can be exacerbated by drug and
alcohol misuse and mental illness, especially when the mother was
abused or neglected as a child (Amos, Furber, and Segal 2011).
This would suggest a home-visiting program with a strong men-
tal health capability.

60 L. Segal, R.S. Opie, and K. Dalziel

6. Some home-visiting programs refer to an “ecological model,”
which places the mother and child within the family, commu-
nity, and societal context. The premise is that there are factors
beyond the individual mother or child that limit the mother’s ca-
pacity to parent. These factors could include a lack of employment
opportunities, poor access to affordable housing, or inadequate
social welfare support (Sidebotham 2001). Home-visiting pro-
grams that take an “ecological approach” may provide initiatives
to support the wider economic and social context, for instance,
supporting education or access to employment for the mother.

Target Population. Target populations were classified according to
characteristics correlated to risk of abuse or threats to a safe and nurturing
environment for the child (Runyan et al. 2002) in a way that would
establish a hierarchical schema. We sought to balance complexity in the
classification system with relative homogeneity within each population
subgroup, resulting in five population subgroups, ranging from (1) low-
risk / general population to (5) active abuse / domestic violence, with
three intermediate risk levels. The specific characteristics of the five
population risk levels are listed in the notes to table 2.

Program Components. Programs have been described in terms of their
constituent components using a classification system designed to capture
program diversity but limited to ten broad components (see table 3).

Program Objective. We wanted to establish whether the reduction of
child abuse and/or neglect was an explicit program objective, which was
not a criterion for inclusion in our review, although reporting at least
one direct or indirect child abuse outcome was.

Program Performance. We created a protocol to classify programs as
“successful or not” that was designed to weigh up all the relevant out-
comes that were measured, rather than to selectively report only those
that were statistically significant, without reference to those that were
not. Our aim was to assess whether, on balance, there was likely to be
a positive and important impact for the client population. Surprisingly
little attention has been paid to this task. Instead, most reviewers as-
sess performance one outcome measure at a time, collating the evidence
across all programs reporting that outcome. The general absence of
prespecified protocols for defining program success leaves considerable
opportunity for selective outcome reporting and interpretation. In their
2010 review of sixty-six home-visiting programs for infants, children,

Home-Visiting Programs to Prevent Child Maltreatment 61

TABLE 2
Match between Target Population and Program Theory

Population Target Matching Theorya

1. Low risk 1. Mothers lack parenting knowledge and skills.
2. Some elevated risk 2. Access to health care for health/developmental

milestones.
3. Mothers lack emotional/social support.

3. High risk 2. Access to health care for health/developmental
milestones.

3. Mothers lack emotional/social support.
4. Mother-infant interaction/attachment.

4. Very high risk 5. Poor mental health/therapeutic/psychological
model.

5. Current abuse 6. Ecological model.

Notes: aA match requires one of the theories in the matching theory column to be applied, although
a higher level theory also is acceptable. More complete descriptors of theory categories are provided
in the text and table 3.
Low risk: General population of families with neonates.
Some elevated risk: One of the following: mothers < 19 years old, racial minority group, low income, low socioeconomic status, unemployed, limited education, lack of social support / social isolation, single parent, unmarried, financial stress, underuse of needed community services, low self-esteem. High risk: Mental illness, unstable housing, chaotic lifestyle, low intelligence / low IQ, difficult child, ambivalence to pregnancy (sought termination / no antenatal care), ≥ two of “some elevated risk.” Very high risk: Criminal record, in-utero drug exposure, prenatal drug use, drug abuse, parent history of childhood abuse, suspicion of previous abuse by parent, or 3 or more combinations of level 3. Current abuse: At least one previous incident of child abuse or neglect and/or evidence of domestic violence.

and adolescents, Kahn and Moore (2010) defined the program’s suc-
cess by the report of at least one positive outcome (intervention group
statistically significantly better than control), regardless of the num-
ber of reported outcomes or the existence of negative results. This
might be considered a minimum hurdle for potential classification as
successful.

We adopted an approach to defining success that was based on the
primacy of outcome and the number and proportion of statistically
significant (p < 0.05) positive (or negative) outcomes, relative to all outcomes reported. The precise protocol adopted is described in the section “Approach to Data Extraction.”

62 L. Segal, R.S. Opie, and K. Dalziel

TABLE 3
Match between Program Theory and Program Components

Program Theorya Program Components

1. Mothers lack parenting knowledge and 1. Education, training, information∗

skills.

6. Problem solving/goal settingb

2. Limited access to health services pose a
threat to health of mother and baby.

5. Referral and linking to health
services/advocacy∗

6. Problem solving/goal settingb

9. Clinical services responsive to
mother/child family circumstance∗

3. Social isolation: mothers lack social 2. Emotional support∗

and emotional resources. 5. Referral and linking to health
services/advocacyb

6. Problem solving/goal settingb

4. Disruption to the mother-infant 3. Modeling/mentoring∗

interaction and bonding or of maternal
sensitivity.

4. Counseling/therapy by mental health
worker∗

6. Problem solving/goal settingb

5. A compromised psychological
state/poor mental health undermine
the capacity to parent.

4. Counseling (including drug and
alcohol)/therapeutic support by a
mental health worker (psychiatrist,
psychologist, mental health nurse)∗

8. Case management involving mental
health worker∗

6. Ecological modelc: ecological factors 5. Referral/link to services/advocacy∗

(social, community, and family level)
have a core influence on capacity of
mothers to parent.

7. Provision of goods and services (food,
contraception, transport, access to
education, training, job placement)

9. Clinical services responsive to
mother/child circumstanceb

10. Child careb

Notes: Match: At least one core component (identified with an asterisk, ∗) must be present for a
match.
aWhen more than one program theory is identified, a match requires a core (identified with an
asterisk, ∗) program component to be present for each theory.
bUseful but not sufficient.
cFor the ecological model, the core component plus ≥ 1b must be present for a match.

Home-Visiting Programs to Prevent Child Maltreatment 63

Definition of a “Match” between Program Theory, Components, and Popu-
lation. For each of these six theories, we selected those program com-
ponents that were consistent with the theory, based on the postulated
mechanisms of action. A match between program theory and program
components was tied to the mechanism inherent in the theory. At least
one “critical program component” needed to be present to yield a match
with the program theory. A match between the target population and
the theory was defined according to a hierarchy, starting with the sim-
ple knowledge deficit model matched with low-risk populations and
advancing to a therapeutic or ecological model matched with higher-
risk populations. For this purpose, the target populations were collapsed
from five to three. How we defined a match between population and
program theory is described in table 2 and that between theory and
components in table 3.

Literature Search

We conducted a literature search to identify all published controlled
studies of home visiting for neonates/infants at risk of child maltreat-
ment, searching electronic databases using key terms for “home visiting”
and “child.” Owing to the large number of published systematic reviews
of home-visiting programs, we used a three-step process:

Step 1: Search for systematic reviews using search filters and
pertinent databases—Cochrane, Medline, Embase, Meditext, and
Social Sciences Citation Index—locating all individual home-
visiting trials included in these reviews fitting our inclusion
criteria.
Step 2: Search for RCTs using search filters for 2000 onward
from Cochrane, Medline, Embase, PsychInfo, Meditext, and So-
cial Sciences Index (assuming earlier studies would have been
included in at least one of the several published reviews).
Step 3: Search of bibliographies, key authors, key journals (Child
Abuse & Neglect, Child Maltreatment) and the gray literature via
the National Child Protection Clearinghouse of Australia. The
full details of our search strategy and search filters are available
from the authors.

64 L. Segal, R.S. Opie, and K. Dalziel

Eligibility Criteria. One of us (Opie) excluded those articles that were
obviously irrelevant, based on an inspection of the abstract and title. We
then obtained the full articles that appeared to meet our broad selection
criteria or whose relevance could not be assessed from the abstract and
title. Opie and Dalziel assessed them separately for inclusion, reading a
total of 143 full text studies. Initial agreement was obtained on all but
five studies, which were discussed with Segal and agreement reached on
all studies.

Our inclusion criteria were the following:

• A randomized controlled trial or quasi-experimental design with
a control or comparison group.

• Home visiting (defined as at least two home visits by someone
other than a relative).

• Visits commencing during pregnancy or within six months of
birth for the purpose of reducing the risk of child maltreatment
or related outcome.

• At least one quantifiable outcome related to maltreatment or the
risk of maltreatment, primarily the notification or substantiation
of child abuse or neglect, out-of-home placement, cases of in-
tentional injury, hospitalization, ED visits, Child Abuse Potential
Inventory (CAPI), Conflict Tactics Scale (CTS), Home Observation
for Measurement of the Environment (HOME) inventory, Family
Stress Checklist (FSC), Parenting Stress Index, rapid repeat births,
substance misuse, Parent-Infant Relationship Global Assessment
Scale (PIRGAS), and Mother Infant Interaction Scale.

• Published in the English language.

Quality Assessment

Table 1 summarizes the study design and rating of each program’s
potential for bias. Dalziel formally assessed each included study for bias,
using criteria developed from the Cochrane Handbook (Higgins and Green
2009), the Centre for Reviews and Dissemination’s guidelines (2009),
and Edgeworth and Carr’s criteria specific to child abuse research (2000).
Each study was classified as of “good quality” (zero or one potential for
bias), “adequate quality” (two potentials for bias), or “poor quality”
(three or more potentials for bias). Potentials for bias were restricted
to quality items most likely to compromise study results: specifically

Home-Visiting Programs to Prevent Child Maltreatment 65

unadjusted group differences at baseline, failure to conduct intention to
treat analysis, outcome assessors not blinded to group status, provision
of intervention and control services by the same nurses, and nonrandom
allocation to groups. The quality of the studies were considered good for
fourteen (27%) programs, adequate for twenty-five (48%), and poor for
thirteen (25%).

Approach to Data Extraction

We created several tables to classify the programs by the underlying the-
ory (six options), program components (ten options), population target
(1 to 5), and objective (child abuse yes or no) according to the preceding
definitions. Dalziel and Opie independently double-extracted the data
for program theory, program components, and child abuse objectives.
When they differed, Segal helped them agree on an allocation. In every
case, the data were extracted based on what actually occurred (notably
the population who participated in the program and the program com-
ponents as delivered).

Underpinning Program Theory. The underpinning program theory was
directly obtained from the stated theory when it was described, or it was
drawn from the reported program goals or intention. In other words,
in the absence of an explicitly stated theory, a theory was inferred from
other related information. In most cases, one of the six theories was
identified as predominant and allocated to the program, but we allowed
up to three to be identified.

Population Target. The population target(s) for each program were se-
lected from the five options described in table 2, based on the character-
istics of the enrolled population. For example, a program that recruited
pregnant teenagers in Baltimore might be allocated to risk level 2, but
if the enrolled population included 75 percent with a drug addiction,
the program would be allocated to risk level 4. The allocation was made
independently by Rachelle Sara Opie and Kim Dalziel, with any differ-
ences resolved through discussion with Leonie Segal. Classification to
more than one population target was allowed.

Program Components. The program components were determined
based on the description of the service delivery components/activities
described for the intervention arm and allocated to one or more of the
ten categories listed in table 3. The components as delivered, even if
they differed from what was intended, were used.

66 L. Segal, R.S. Opie, and K. Dalziel

Objective of Child Maltreatment Prevention. A program was classified
as “yes” if any program reports stated that an objective was to prevent
child maltreatment or “no” if they did not.

Overall Success of the Program/Intervention Arm. We analyzed the pro-
gram results in two steps: first outcomes were classified as either (1) a
direct measure of child abuse, defined to include child protection ser-
vice reports, reports or substantiated cases of abuse or neglect (including
domestic violence), out-of-home placement, nonaccidental injury (cap-
tured in hospital admissions or hospital emergency department visit

or Child Abuse Potential Inventory (CAPI) score; or (2) indicator or risk
for child maltreatment, primarily the HOME score, rapid repeat births,
substance abuse, parent-child conflict tactics scales, mother-infant inter-
action rating scale, family stress checklist, and/or parenting stress index
(PSI).

The second task was to look for consistency in the direction of out-
come (positive or negative). Subgroup analyses were not considered,
only main program effects. For a program to be classified as having
an overall “positive outcome” and thus designated as a “success,” the
following protocol was adopted: If only one variable was reported, it
had to be statistically significantly positive. If two or more variables
were reported, at least one needed to be statistically significantly pos-
itive if all other variables showed, at worst, no difference. In all cases,
success required the absence of any reported statistically significant neg-
ative outcomes. Indicators of or risks for child maltreatment (considered
proxy outcomes) were considered only if no direct child maltreatment
variables were reported. Success was then defined using the same proto-
col described above. This approach to defining success was designed to
ensure that studies that collected many outcomes were not more likely
to be identified as successful simply because of the greater likelihood of a
chance positive finding. The approach also placed the greatest weight on
more direct child maltreatment outcomes as the best indicator of child
abuse or neglect. Although these might be considered low-risk events,
in the typically higher-risk populations that receive home visiting, they
are not uncommon.

Defining a Match. Once each program was allocated to a program
theory (1 to 6), a set of program components (1 to 10) and population
(1 to 5), as well as a child abuse objective (yes or no), the existence
of a match was assigned according to the protocols defined in tables 2
and 3. The programs were then classified as one of three categories: (1) a

Home-Visiting Programs to Prevent Child Maltreatment 67

“full match” across program theory, components, population, and yes for
stated child abuse objective; (2) a “partial match,” involving a match of
theory, components, and population but without a child abuse objective
or a match of theory, components, and child abuse objective but only
for part of the population; or (3) “no match,” a residual category. If a
program offered additional components beyond those deemed a necessary
minimum for the target population, this was recorded as a full match.
This may affect cost-effectiveness but seemed unlikely to undermine a
positive outcome.

Relationship between Match and Program Success. We hypothesized
that if the program components, population, and child abuse objec-
tive matched the underlying theory, the program was more likely to be
successful. If there was no match across these variables, we hypothesized
that the program was less likely to be successful. We then observed
whether there was a difference in rates of program success across the
“three defined match categories.” We also formally tested the relation-
ship by modeling program success against the match results.

Data Analysis

We used standard tests of statistical significance (Pearson’s chi-square
and Fisher’s exact) to test the relationship between program classification
as successful; and having a full, partial, or no match between theory and
program components and population.

Results

Study Selection

Our literature search yielded 2,243 articles, of which we examined
143 papers in full text (see appendix A), and identified fifty-two “dis-
tinct” home-visiting programs meeting the inclusion criteria (associ-
ated with forty-five models). Programs implemented in a unique set-
ting and/or with different populations were treated as distinct, even if
based on the one overarching model (e.g., three programs applied the
Olds’s Nurse Family Partnership model but in different settings and
for distinct populations). References to included programs are listed in
appendix B.

68 L. Segal, R.S. Opie, and K. Dalziel

Program Characteristics

Study Design. Of the fifty-two included programs, fourteen were
nonrandomized controlled studies; two were cohort studies; and the
remaining thirty-six were randomized controlled trials. Thirty-seven
programs were delivered in the United States, three in Australia, six in
Canada, two in the United Kingdom, and one each in New Zealand,
Syria, Japan, and Norway. The studies were published between 1969
and 2009.

Type of Home Visitor. Many programs used nurses for home visiting
(n = 19), but the use of other professionals (e.g., social workers n = 15),
“paraprofessionals” (n = 9) or laypersons (n = 6) for visiting was also
common. A formal multidisciplinary team was used for three programs.
Twenty programs used more than one discipline group on their team for
the home visit or for training and/or support.

Program Intensity. There was considerable diversity in program in-
tensity. Twenty-five home-visiting programs commenced during preg-
nancy, and the others began after birth. The child’s age at exit from the
program varied from one month up to five years. The mean number of
visits ranged from two to forty-one, and the length of visit varied from
twenty minutes to four hours, resulting in considerable variation in the
potential (as well as actual) hours of home visiting for the family.

Population Characteristics. Seven programs exclusively targeted
teenage/adolescent parents; four programs targeted high-risk families
defined by the Kempe Family Stress checklist; and four programs re-
cruited parents using illicit drugs. Many programs drew their popula-
tions from two or three risk categories. Most programs targeted persons
at considerably elevated risk, including current abuse, current drug or
alcohol problems, or existence of several risk characteristics (n = 23).
Often, the enrolled populations exhibited higher-risk attributes than
suggested by the enrollment criteria. Only two programs included the
entire range of population categories (see ).

Program Theoretical Underpinning. The predominant theory (or the-
ories) assigned to each program is reported in table 4. The four most
commonly defined theories, covering 80 percent of the programs, were
“mothers lack knowledge/skills,” “limited access to health care under-
mining the physical health of the mother and baby,” “mothers are isolated
and lack social/emotional resources,” and “disruption to mother-infant
interaction and bonding.” Only 10 percent drew on a theory related to
“compromised mental health” (n = 5).

Home-Visiting Programs to Prevent Child Maltreatment 69

Program Components/Activities. The program components identified
in the home-visiting programs were, in order of frequency: educa-
tion/training/information (n = 46), emotional support (n = 43), re-
ferral and linking to services/advocacy (n = 38), modeling/role model
(n = 19), problem solving (n = 16), counseling/therapy (n = 16), case
management (n = 5), provision of goods and services (n = 5), responsive
clinical services (n = 2), and provision of child care (n = 2) (see table 4).

Objective of Child Maltreatment Prevention. Twenty-five out of the fifty-
two programs had a stated objective of preventing child maltreatment,
and all of these reported direct child abuse outcomes. Of those that did
not identify a child abuse and neglect objective, 42 percent still reported
a “direct” child abuse outcome.

Program Success. A total of twenty-five (48%) of programs were de-
fined as successful and twenty-seven (52%) as not successful, using the
criteria described earlier. Outcomes were more likely to be indirect where
reducing child abuse and neglect was not a stated aim.

Match between Theory, Population, and Program Components. Only seven
of the fifty-two programs (13.5%) were described as having a complete
match for theory, population and program components, and a stated aim
to reduce child abuse and neglect. Thirty programs (58%) were classified
as a partial match, and fifteen programs (29%) as a clear mismatch.

Likelihood of Program Success and Observed
Match between Theory, Population, Program
Components, and Child Abuse Prevention
Objective

For the seven programs for which a complete match was observed,
all—that is, 100 percent—were defined as successful. For the fifteen
programs for which a clear mismatch was observed, none was defined
as successful; that is, the home-visiting group did no better than the
control in any of these programs. Those that had a complete match for
part of the target population or a match of the theory, target population,
and components but not an objective of reducing child abuse or neglect
had an intermediate success rate of 60 percent. For the programs that
did not have a child abuse objective, success was typically based on
intermediate outcomes, which have a less certain relationship with child
maltreatment (see table 5).

70 L. Segal, R.S. Opie, and K. Dalziel

T
A
B
L
E

4
K

ey
D

at
a

E
xt

ra
ct
io
n

:
P

re
d

om
in

an
t

T
h

eo
ry

,
P

op
u
la
ti

on
,

St
at

d
C

h
il
d
A
b
u

e
O

b
je

ct
iv

e,
P

ro
g
ra
m

C
om

p
on

en
ts

,
M

at
ch

,
O

u
tc

om
es

,
an
d
Su
cc
es

s
A

m
:

M
at

ch
f

R
ed

u
ce

C
h

d
T

h
eo

ry
T

h
eo

F
u

/
P

ot
en

ti
al

P
ro
g
ra

m
,

oc
at

io
n

T
ar

g
et

C
or

e
A

b
u

se
P

ro
g
ra
m
an
d
an
d
P
ar
ti
al
/
P

ri
m

ar
y

O
th

er
Su

cc
es

s
fo

r
(k

ey
re

e
re

n
ce

)

a
P

op
u
la

ti
on

b
T

h
eo

ry
c

(y
es

/n
o)

d
C

om
p

on
en

ts
e

C
om
p
on
en
ts
P
op
u
la
ti
on

N
o

M
at

h
O

u
tc

om
eg

O
u
tc
om

es
h

(y
es
/n
o)

i
B

V
er

y
H
ig
h

R
is

k
(e

.g
.,

il
li

ci
t

d
ru

g
u
se

)/
C

u
rr

en
t

A
b

u
se

P
op
u
la
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on

1
.

Sp
ec

ia
l

F
am
il
ie

s
C

ar
e
P
ro

je
ct

,
M

N
(C

h
ri

st
en

se
n

,
Sc

h
om

m
er

,
an

d
V

el
as

u
ez

1
9

8
4

)

5
5

Y
es

1
,

2
,

4
,

5
,

6
Y

es
Y

es
F
u
ll

∗ A

b
u
se

∗

N
eg

le
ct

∗ O
u

t-
of

-h
om

e
p

la
ce

m
en

t
/

fo
st

er
ca

re
Y
es
1

2
.

P
ro
je
ct
1
2

-W
ay

s,
IL

(

L
u

k
er

an
d

R
ic

e
1

9
8

4
)

5
6

Y
es
1
,
2
,
4
,
5
,

7
Y

es
Y
es
F
u
ll
∗ A
b
u
se

or
n

le
ct

in
ci

d
en

ts
∗ S

u
b

st
an

ti
at

ed
in

st
an
ce
of

ab
u
se

or
n
eg

le
ct
Y
es
2

4
.

H
om
e
vi
si
ti

n
g
,

P
er

,
A

u
st

a
li

a
(B

ar
tu

et
al

2
0
0
6
)

4
(i

ll
ic

t
d

g
u
se

)
2

N
o
1
,

,
5

Y
es
N
o
N
o

N
A

†D
ru

g
u

se
in

cr
ea

se
d

N
o
1

5
.

H
om
e
vi
si
ti
n
g
,

B
al

ti
m
or
e

(

N
ai

r
et
al
.

2
0

0
3

;

Sc
h

u
le

r
et
al
.

2
0

0
0
)

4
(d

ru
g

u
se

)
4

N
o
1
,

2
,
5

6
N

o
N

o
N
o
N

A
†N

ar
co

ti
c,

al
co
h
ol
,
or
m
ar

ij
u

an
a

u
se

†M
at

er
n

l
re

sp
on

si
ve

–
n
es

s
or
in
fa
n
t

w
ar

m
th

N
o
0

Home-Visiting Programs to Prevent Child Maltreatment 71

6
.

H
ea

h
y

F
am
il
ie
s
A
m
er

ic
a

(

H
FA

)

,
H

ea
lt
h
y
F
am
il
ie
s
N

ew
Y

or
k

(

D
u

on
t

et
al

2
0

0
8

)

3
–
5

4
,
5

6
Y

es
1

2
,

3
,

5
N

o
Y

es
N

o
Y
ea
r

2
:

†C
om

p
os

it
e

sc
or

e
se

ri
ou

s
ab

u
se
or
n

g
le

ct
,

p
re

va
le

n
ce
,
or

fr
eq

u
en

cy
†F

q
u
en

cy
of

su
b

st
an
ti
at

ed
C

P
S

re
p

or
ts

N
o
0

3
1

N
u
rs

e
V

is
it

in
g
,

B
al
ti
m
or
e

(

B
la

ck
et

al
.
1
9

9
4

)

4
,
5

(p
re

n
at

al
il

li
ci

t
d
ru
g
u

se
)

6
Y

es
1
,

2
,
3
,

4
,
5
,

6
Y
es
Y
es
F
u
ll

∗

C
A

P
I

∗ D
ru

g
fr

ee
∗ O

ve
ra

ll
h
om

e
sc

or
e

†

P
SI

Y
es
0

H
ig

h
to

ve
ry

h
ig

h
ri

sk
ta

rg
et

p
op

u
la
ti
on

3
.

H
om
e
vi
si
ti
n
g
,

D
en

ve
r

(

G
ra

y
et

al
.

1
9

7
7

)

3
–
5

4
Y

es
1
,
2
,
3
,

5
,
9

Y
es
P
ar

t
P

ar
ti

al
∗ H

s
p

it
al

at
te

n
d

an
ce

fo
r

in
ju

ri
es

d
u
e

to
ab

n
or

m
al

p
ar
en
ti
n
g
p
ra
ct
ic
es
Y
es
2

7
.

H
om
e
vi
si
ti
n
g
,

Q
u
ee

n
sl

an
d
,

A
u

st
ra

li
a

(

A
rm

st
ro

n
g
et
al

1
9
9
9
)

3
–
5
4
Y
es
1
,
2
,
3
,
4
,
5
Y
es
P
ar
t
P
ar
ti

al
∗ C

A
P

I
(b

as
el

in
e

to
7

m
on

th
s)

∗ S
el

f-
re

p
or
te
d

fe
w

r
in

u
ri

es
an

d
b
ru

is
es

†U
se

of
h
ea

lt
h

se
rv

ic
es

∗ I
m

p
ro
ve
m
en
t

in
ov

er
al

l
P

D
sc

or
e

(P
SI

)
∗ H

O
M

E
(a

ll
su

b
sc

al
es

an
d

to
ta

l
H

O
M
E
sc

or
e)

Y
es
0
C
on
ti
nu
ed

72 L. Segal, R.S. Opie, and K. Dalziel

T
A
B
L
E

4
—

C
on
ti
nu
ed

A
im

:
M

at
ch
f
R

ed
u
ce

C
h
il

d
T
h
eo
ry
T
h
eo
ry
F
u
ll
/
P
ot
en
ti
al
P
ro
g
ra
m

,
L

oc
at
io
n
T
ar
g
et
C
or
e
A
b
u
se
P
ro
g
ra
m
an
d
an
d
P
ar
ti
al
/
P
ri
m
ar
y
O
th
er
Su
cc
es
s
fo
r
(k
ey
re

fe
re

n
ce
)a
P
op
u
la
ti
on
b
T
h
eo
ry
c
(y
es
/n
o)
d
C

m
p
on

en
ts

e
C

om
p
on
en

s
P

op
u
la
ti

on
N

o
M

at
ch
O
u
tc
om

eg
O

u
tc
om
es

h
(y

es
/n

o)
i

B
ia

8
.

C
h
il

d
P

ar
en

t
E

n
ri

ch
m

en
t
P
ro
je
ct

,
C

on
tr

a
C

os
ta

C
ou

n
ty

,
C

A
(B

ar
th

1
9
9
1
)

3
–
5

(m
os

t
ve

ry
h
ig

h
ri

sk
)

6
Y
es
1
,
2
,
3
,
5
N
o
Y
es
N

o
†U

n
su

b
st

an
ti
at
ed
re
p
or
ts

†C
A

P
I

†Il
ln

es
s/

E
D

vi
si
ts
N
o
1

9
.

C
om

m
u

n
it

y
In

fa
n
t
P

ro
je

ct
,

B
ou

d
er

,
C

O
(H

u
xl

ey
an

d
W

ar
n

1
9

9
3

)

3
–
5

3
Y

es
1
,
2
,
4
,

5
,
8

Y
es
P
ar
t
P
ar
ti

al
∗ E

m
er
g
en

cy
ro

om
u
se

∗ C
on

fi
rm

ed
ch

il
d
ab
u
se

ep
is

od
e

†C
h

d
ab
u
se
or
n

eg
le

ct
re

p
or
t

∗

H
O

M
E

:
to

ta
l
H
O
M
E
sc
or

e,
+

so
m

e
su

b
sc
or
es

†H
O

M
E

ot
h

su
b

sc
al

es
Y
es
2

0
.

E
ar

ly
In

te
rv
en
ti

n
P

ro
g
ra
m

,
Sa

n
B

n
ar

d
in

o,
C

A
(K

n
ia

k
-G

ri
ff

in
et

al
.
2
0
0
2
)

3
–
5
3
Y
es
1
,
2
,
4
,

,
6

8
Y

es
P

ar
t
P
ar
ti
al

∗

T
ot

al
d
ay

h
os

p
it

al
iz

at
io

n
∗ N

u
m

b
er

of
ep

is
od

es
of
h
os
p
it
al
iz
at
io

n
†T

ot
al

n
u
m
b
er
of
E
D
vi
si

ts
∗ N

ev
er

u
se

d
E

∗ N
ex

t
co

n
ce

p
ti

on
†T

im
e

to
re

p
ea

t
p
re

g
n
an

cy
∗ M

ar
ij

u
an

a
u
se

†A
lc

oh
ol

an
d
to
b

ac
co

†H
O
M
E
sc
or
es
Y
es
1

1
1
.

H
aw

ai
i

H
ea

lt
h
y

St
ar
t
P
ro
g
ra
m
,
H

I
(D

u
g
g
an

et
al
.
1
9
9
9
)
3
–
5
1
,
3
,
4
Y
es
1
,
2
,
3
,

5
,
6

Y
es
P
ar
t
P
ar
ti

al
†F

re
q
u
en
t
an
d
se

ve
re

se
lf

-r
ep

or
te

d
ab
u
se

b
eh

av
io

rs
†M

at
er
n
al
n
eg
le
ct

†S
u

b
st
an
ti
at
ed

C
P

S
re

p
or
t
ra

te
s

†

H
os

p
it
al
iz
at
io
n
s

†

M
ot

h
er

re
li

n
q
u
is

h
p

ri
m
ar
y

ca
re

g
iv

er
†H
O
M
E

:
ac

ce
p

ta
n
ce
of
ch
il

d
†P

C
-C

T
S

†

R
R

B
N
o
1

Home-Visiting Programs to Prevent Child Maltreatment 73

1
2
.

H
ea
lt
h
y
F
am
il
ie
s
A
m
er
ic
a
(H
FA

),
H

ea
lt
h
y
F
am
il
ie
s
A

la
sk

a
(G

es
sn

er
2
0
0
8
)k

3
–
4

3
,

5
Y

es
1
,

,
3

5
,
6
N
o
Y
es
N

o
H

FA
ve

rs
u
s

h
ig
h
ri

sk
m

at
ch

d
co

n
tr

ol
†C

P
S

re
fe

rr
al

†S
u
b
st
an
ti
at
ed
n
eg
le
ct
an
d
ab
u
se
N
o
2

3
2

(H
FA
),
H
ea
lt
h
y
F
am
il
ie
s
A
la
sk

a
(D

u
g
g
an
et
al

.
2
0

0
7

)

R
C

T
k

3
–
4
3
,
5
Y
es
1
,

2
,
3

5
,
6
N
o
Y
es
N

o
†C

P
S

R
ep

or
ts
an
d
N
eg
le
ct
†H
os
p
it
al
iz
at
io
n
an
d
E

D
vi

si
ts

†

B
ir

th
m

ot
h

er
re

li
n
q
u
is

h
ed

h
er

ro
le

∗ F
ew

er
ex

tr
em

el
y

p
oo

r
to

ta
l
H
O
M
E
sc
or

es
†G

ro
u
p

sc
or

es
fo

r
H

O
M

E
su

b
sc

al
e

†S
u
b
st

an
ce
ab
u
se

†T
ot

al
P

SI
sc

or
es
N
o
0

1
3
.

H
om
e
vi
si
ti
n
g
,

W
es

te
rn

A
u
st
ra
li
a

u
in

li
va

n
,

B
ox

,
an
d
E

va
n

2
0
0
3
)

3
–
5
1
,
2
,
3
Y
es
1
,
2
,
3
,
5
Y
es
P
ar
t
P
ar
ti
al

∗ N
eo

n
at

al
ad

ve
rs

e
ou

tc
om

e
(d

ea
th

s,
in

ju
ry

n
on

-v
ol

n
ta

ry
fo

st
er

ca
re

p
la

ce
m

en
t)

Y
es
0
C
on
ti
nu
ed

74 L. Segal, R.S. Opie, and K. Dalziel

T
A
B
L
E
4
—
C
on
ti
nu
ed
A
im
:
M
at
ch
f
R
ed
u
ce
C
h
il
d
T
h
eo
ry
T
h
eo
ry
F
u
ll
/
P
ot
en
ti
al
P
ro
g
ra
m
,
L
oc
at
io
n
T
ar
g
et
C
or
e
A
b
u
se
P
ro
g
ra
m
an
d
an
d
P
ar
ti
al
/
P
ri
m
ar
y
O
th
er
Su
cc
es
s
fo
r
(k
ey
re
fe
re
n
ce
)a
P
op
u
la
ti
on
b
T
h
eo
ry
c
(y
es
/n
o)
d
C
om
p
on
en
ts
e
C
om
p
on
en
ts
P
op
u
la
ti
on
N
o
M
at
ch
O
u
tc
om
eg
O
u
tc
om
es
h
(y
es
/n
o)
i
B
ia
sj
1
4

.
E

ar
ly
St
ar

,
N

ew
Z

ea
la

n
d
(F
er

g
u
ss

on
et

al
.
2
0

0
5

)

3
–
5
1
,
3
Y
es
1
,
2
,
3
,
6
Y
es
P
ar
t
P
ar
ti
al

∗ S
ev

er
e

p
h
ys
ic

al
as

sa
u

lt
†R

at
es

of
ag

n
cy

co
n
ta

t
fo

r
ch

il
d
ab
u
se
an
d
n
eg
le
ct
∗ F
ew

er
h
os

p
it

al
at

te
n

d
an

ce
s

fo
r
in
ju
ry

∗ N
on

u
n
it

iv
e
p
ar
en
ti
n
g

†N
ex

t
p
re
g
n
an

cy
†A

lc
oh

ol
/

su
b
st
an

ce
u
se

†L
if

e
st

re
ss

es
,
fa
m
il
y

fu
n

io
n
in

g
Y
es
1

1
5
.

F
am
il
y
P
ar

tn
er

sh
ip

M
od

el
,

w
o

co
u

n
ti

es
in
th
e

U
K

(

B
ar

lo
w

et
al
.
2
0
0
7
)
3
–
5

(6
5
%

m
en
ta
l
h
ea

lt
h
,

3
4

D
V

)
3
Y
es
1
N
o
P
ar

t
N

o
†H

os
p
it
al

iz
at

io
n

at
6

m
on

th
s

†C
h
il

d
p
ro

te
ct

io
n
re
g

is
te

r
or

ca
re
p
ro

ce
ed

in
g
s

†C
h
il
d
re
n
re
m

ov
ed

fr
om
h
om
e
†H
O
M
E

∗ (
M

C
I–

C
A

R
E

d
ex

)
se

n
si
ti
ve

to
b
ab

ie
s,

w
h
o

w
er
e
m
or
e

co
op

er
at

iv
e
N
o
0

1
6

N
u
rs

e
F
am

il
y
P
ar
tn
er
sh
ip
(N
F

P
)

N
u
rs
e
h
om
e-
vi
si
ti
n
g
,
D
en
ve
r

(

O
ld

s
2
0
0
2
)

2
–

(l
ow

in
co
m
e

+/
−

D
V

)
1

,
2

,
4

N
o
1
,
2
,
5
Y
es
Y
es
P
ar
ti
al

∗

A
n

y
d
om

es
ti

c
vi

ol
en
ce

∗ T
im

in
g

n
ex

t
b
ir

th
s

†

M
ar

ij
u
an

a
†A

lc
oh

ol
u
se

†H
O
M
E
sc
or
e
Y
es
1

Home-Visiting Programs to Prevent Child Maltreatment 75

1
6

b
.

(N
F
P

)
P

ar
ap

ro
fe

ss
io

n
al
h
om
e
vi
si
ti
n
g
,
D
en
ve
r
(O
ld
s
2
0
0
2
)
2
–
5
1
,
2
,

4
N

o
1

2
,
5
Y
es
Y
es
P
ar
ti

al
†A

n
y

d
om
es
ti
c
vi
ol
en

ce
†S

b
se

q
u
en
t
p
re
g
n
an

ci
es

an
d
b
ir
th
s
†M
ar
ij
u
an

a/
al

co
h
ol

u
se
†H
O
M
E
sc
or

e
∗ M

or
e
se
n
si
ti

e
an

d
re
sp
on
si
ve
in
te
ra
ct
io
n
N
o
1

1
7
.

P
ar
en
ti
n
g

n
E

g
e,

G
A

(

M
u

ow
an

d
M
u
rr

ay
1
9
9
6
)

3
–
4
6
Y
es
1
,

2
N

o
Y
es
N

o
†In

ci
d
en

ce
of
ab
u
se
or
n
eg
le
ct
re
p
or
ts

†N
re

p
or

ts
p

er
m
ot
h
er
N
o
2

1
8

L
in

k
ag

es
fo

r
P

re
ve
n
ti

on
P

ro
je
ct
,

u
rh

am
,

N
C

(M
ar

g
ol

s
et

al
.

2
0
0
1
)

3
–
4
6
N

o
1
,

2
,
5
N
o
Y
es
N

o
†S

u
b
st
an
ti
at

d
n
eg

le
ct
†S
u
b
st
an
ti
at
ed

ca
se

s
of
ab
u

se
†E

D
or

h
os
p
it
al
iz
ed
†D
ru
g
or
al
co
h
ol
u
se

∗ 3
/5

sa
fe

ty
m

ea
su
re
s
ch
il
d
h
om
e
en
vi

ro
n
m

en
t

∗ H
O

M
E
sc
al
e
N
o
2

3
3

A
d
d
it

io
n

of
in

te
n
si

ve
h
om

e
vi
si
ti
n
g

to
(C

A
M

P
),

D
en
ve
r

(S
te

ve
n
s-

Si
m

on
,

N
el

li
g

,
an
d
K

el
ly

2
0
0
1
)
4
,
5
4
Y
es
1
,
2
,
3
,
4
,
5
Y
es
P
ar
t
P
ar
ti
al

†A
ll

m
al

tr
ea

tm
en

t,
(p

h
ys
ic
al
ab
u
se

,
n
eg

le
ct

,
ab

an
d
on

m
en
t)

†R
ep

ea
t

p
re
g
n
an

cy
ra

e
N

o
1
C
on
ti
nu
ed

76 L. Segal, R.S. Opie, and K. Dalziel

3
4
.

H
om
e
vi
si
ti
n
g
,

P
h
il

ad
el

p
h
ia

,
(M

ar
ce

n
k

an
d

p
en

ce
1
9
9
4
)

3
–
5

(h
ig

h
-r

is
k

fo
r

p
sy

ch
os

oc
ia

l
re

as
on

s)
3
Y
es
1
,
2
,
3
,
4
,
5
,
6
Y
es
P
ar
t
P
ar
ti

al
†P

la
ce
d
in

ou
t-

of
-h

om
e
ca
re

†H
om

e
In

ve
n

to
ry

N
o
1
M
od
er
at

e-
ri

sk
ta
rg
et
p
op
u
la
ti
on

1
9
.

C
h
il
d
an

d
Y

u
th

P
ro
g
ra

m
M

od
u

le
,

B
al
ti
m
or
e

(

H
ar

d
y
an
d

St
re

et
t

1
9
8
9
)

2
,
3
1
Y
es
1
,
2
,
5
Y
es
P
ar
t
P
ar
ti
al
∗ C
h
il
d
ab
u
se
an
d
n
eg
le
ct

∗ I
n

p
at

ie
n

t
ca

re
∗ C

n
ic

r
E

D
vi

si
t

fo
r

fa
ll

or
h
ea

d
in
ju
ry
Y
es
1

2
0
.

(N
F
P

),
O

ld
s

N
u
rs
e
F
am
il
y
p
ar
tn
er
sh
ip
,
M

em
p
h
is

(

K
it

m
an

et
al

1
9

9
7

)

3
6

N
o
1
,
5
,
6

,
7

Y
es
Y
es
P
ar
ti
al

F
ir

st
2

ye
ar

s:
∗ I

n
ju
ri
es
an
d

in
g
es

ti
on

s
†E

D
vi
si
ts
†H
os
p
it
al
iz
at
io
n
s

∗

L
es

s
h
os
p
it
al
iz
at
io
n
fo
r
in
ju
ry
an
d
in
g
es
ti
on
B
ir

th
to

g
e

9
:

∗ D
ea

th
F
ir
st
2
ye
ar

s:
∗ S

ec
on

d
p
re

g
n
an

cy
an

d
su

b
se
q
u
en

t
li

ve
b
ir

th
s
∗ H
O
M
E
sc
or

es
B

ir
th

to
ag

e
9
:

∗ S
u

b
se

q
u
en
t
b
ir
th
s
∗ S
u
b
st
an
ce
u
se
Y
es
1

6
a.

(N
F
P
),
O
ld
s
N
u
rs
e
F
am
il
y
P
ar
tn
er
sh
ip

,
p

–
an

d
p
os

tn
at

al
,

E
lm

ir
a,

N
Y

(O
ld
s
et
al
.
1
9
9
7
)

2
–
3

1
,
2
,
3
Y
es
1
,
2
,
5
Y
es
Y
es
Y
es
2
5

5
0

m
on

th
s:

†

N
ew

ca
se

s
ch

il
d
ab
u
se
an
d
n
eg
le
ct

∗ I
n
ju

ri
es
an
d
in
g
es
ti
on

s
∗ E

D
vi
si
ts
†H
os
p
it
al
iz
at
io
n
s
1
5
ye
ar

s:
∗ C

h
il
d
ab
u
se
an
d
n
eg
le
ct
su
b
st
an
ti
at
io
n
s
2
5
to
5
0
m
on
th
s:
†H
O
M
E
to
ta

l
sc

or
e
1
5
ye
ar

s:
†N

ex
t

p
re
g
n
an
cy
an

d
b
ir

th
†S

u
b
st
an
ce
u
se
Y
es
0

Home-Visiting Programs to Prevent Child Maltreatment 77

6
b

(N
F
P

)
O

ld
s
N
u
rs
e
F
am
il
y
P
ar
tn
er
sh
ip
,
p
re
n
at
al

,
E

lm
ir

a,
N

Y
(O

ld
s
et
al

.
1
9
9
7
)

2
–
3
1
,
2
,
3
Y

1
,
2

5
Y
es
Y
es
Y

es
2

to
5
0
m
on
th
s:
†N
ew
ch
il
d
ab
u
se
an
d
n
eg
le
ct
ca
se

s
∗ I

n
ju
ri
es
an
d
in
g
es
ti
on
s
∗ E
D
vi
si
ts
†H
os
p
it
al
iz
at
io
n
s
1
5
ye
ar
s:
∗ C
h
il
d
ab
u
se
an
d
n
eg
le
ct
su
b
st
an
ti
at
io
n
s
2
5
to
5
0
m
on
th
s:
†H
O
M
E
to
ta
l
sc
or
e
1
5
ye
ar
s:
†N
ex
t
p
re
g
n
an
cy
an
d
b
ir
th
s
†S
u
b
st
an
ce
u
se
Y
es
0

2
1
.

T
h
re

e
G

en
er

at
io

n
St

u
d

,
B

al
ti

m
or

e
(B

la
ck

et
al

.2
0

0
6
)

3
3
N
o
1
,
2
,
3
,
6
,
7
Y
es
Y
es
P
ar
ti
al
N
A

∗ E
xt

en
d
ti
m

e
to

se
co

n
d
b
ir

th
Y

es
0

2
2
.

P
ar
en
t

T
ra

in
in

g
b

C
E

T
A

ai
d
e,

M
ia

m
i

(

F
ie

ld
et

al
.
1
9

8
2

)

3
4
N
o

1
,
3

Y
es
Y
es
P
ar
ti
al
N
A

∗ R
ep

ea
t
p
re
g
n

an
cy

Y
es
1

2
3
.

C
om
p
re

h
en

si
ve
C
h
il
d
D
ev
el
op
m
en
t
P
ro
g
ra

m
,
U

SA
(S

.
P

ie
rr

e
an

d
L

ze
r

1
9
9
9
)
2
–
3
6
N
o
1
,
2
,
4
,
5
,

6
,

7
,

8
Y
es
Y
es
P
ar
ti

al
N

A
†H

O
M
E
sc
or
e

†P
C

I
N

o
2

C
on
ti
nu
ed

78 L. Segal, R.S. Opie, and K. Dalziel

2
4

H
om
e
vi
si
ti
n
g
,

C
O

(

D
aw

so
n

va
n

D
oo

rn
in

ck
,

an
d
R
ob

n
so

n
1
9
8
9
)

2
–
3

3
N

o
1
,
2
,
5
,
7
Y
es
Y
es
P
ar
ti

al
†C

h
il
d
ab
u
se
an
d
n
eg
le
ct
re
p
or
ts

†A
cc

id
en

ts
or

h
os
p
it
al
iz
at
io
n

†S
u
b
se

q
u
en
t
ch

il
d

b
ea

ri
n
g

N
o
2
2
5

a.
P

ar
en

ts
as

T
ea

ch
er

s
(P

A
T

)
P
ro
g
ra
m

—
T

ee
n
s
C

b
in

ed
=

b
as

ic
+

ca
se
m
an

ag
em

en
t,
C
A

(

W
ag

n
er
an
d

C
la

t
on

1
9
9
9
)
2
–
3
1
,
6
Y

1
,
2
,

3
,
5
,

7
,
8

Y
es
Y
es
Y
es

∗ O
p

en
ed

ca
se
s
of
ch
il
d
ab
u
se
or
n
eg
le
ct
†C
h
il
d
ab
u
se
†C
h
il
d
tr
ea
te
d
fo
r
in
ju
ry
†T
ot

al
H

O
M
E
sc
or
e
Y
es
1

2
5
b
.

P
ar
en
ts

as
T

ea
ch

er
s

(

P
A

T
)

P
ro
g
ra

m
–

b
as

ic
p

ro
g
ra
m
,
C

A
(W

ag
n
er

an
d
C
la

yt
on

1
9
9
9
)
2
–
3

1
N

o
1
,
2
,
3
,
5
Y
es
Y
es
P
ar
ti

al
†T

re
at

ed
fo

r
in
ju
ry

†E
D

vi
si

ts
†T

ot
al
H
O
M
E
sc
or
e
N
o
1
2
5

c.
P

ar
en
ts
as
T
ea
ch
er
s
(P
A
T
)
P
ro
g
ra
m

,
T

ee
n
P
A

T
(b

as
ic

te
en

ag
e
p
ro
g
ra

m
),

C
A
(W
ag
n
er
an
d
C
la
yt
on
1
9
9
9
)
2
–
3

(t
ee

n
ag

e
p
ar
en

ts
)

1
N
o
1
,
2
,
3
,
5
Y
es
Y
es
P
ar
ti

al
†O

p
en

ed
ca

se
s

of
ch
il
d
ab
u
se
or
n
eg
le
ct
†C
h
il
d
ab
u
se
†C
h
il
d
tr
ea
te
d
fo
r
in
ju
ry
†T
ot
al
H
O
M
E
sc
or
e
N
o
1

Home-Visiting Programs to Prevent Child Maltreatment 79

2
7

So
ci

al
Su

p
p
or
t
an

d
F
am

il
y
H
ea
lt
h
St
u

d
y,

L
on

d
on

(

W
ig

g
in
s
et

al
.
2
0
0
4
)

2
–
3
3
N
o
1
,

2
Y

es
Y
es
P
ar
ti

al
†in

ju
ri

es
re

q
u
ir

in
g

m
ed

ic
al
at
te
n
ti

on
†m

at
er
n
al

sm
ok

in
g
N
o
1

2
8
.

H
om
e
vi
si
ti
n
g
,

u
eb

ec
,

C
an
ad
a

(I
n

fa
n

te
-R

iv
ar

d
et

al
.
1
9
8
9
)

2
–
3
1
N
o
1
,
4
Y
es
P
ar
t
N
o
†H
os
p
it
al
iz
at
io
n
†T
ot
al
H
O
M
E
sc
or

e
‡a

n
d
∗ H
O
M
E
sc
or
e
co
m
p
on
en
ts
N
o
1

2
9

a.
P
os
tn
at
al
h
om
e
vi
si
ti
n
g
,

M
on

tr
ea

l
(L

ar
so

n
1
9

8
0

)

2
,
3
4
N
o
1
,
2
,
4
Y
es
Y
es
P
ar
ti

al
∗ A

cc
id

en
t
ra
te

@
1
2

m
on
th
s
†A
cc
id
en
t
ra

e
@

6
an

d
1

m
on
th
s

†R
at

e
of
E
D
vi
si

ts
ov

er
1
8

m
on
th
s
†H
O
M
E
N
o
2

2
9
b
.

P
re

an
d
p
os
tn
at

al
vi

si
ti
n
g
,
M
on
tr
ea
l
(L
ar
so
n
1
9
8
0
)
2
,
3
4
N
o
1
,
2
,
4
Y
es
Y
es
P
ar
ti
al
∗ A
cc
id
en
t
ra
te

@
6

m
on
th
s

∗ A
cc

id
en
t
ra
te
@

2
m

on
th

s
†A

cc
id
en
t
ra
te

@
1
8
m

on
th

s
†R

at
e

of
E

D
vi
si
ts

ov
er

1
8
m
on
th
s
∗ H
O
M
E
sc
or

e
Y

es
2
C
on
ti
nu
ed

80 L. Segal, R.S. Opie, and K. Dalziel

T
A
B
L
E
4
—
C
on
ti
nu

ed
A

im
:
M
at
ch
f
R
ed
u
ce
C
h
il
d
T
h
eo
ry
T
h
eo
ry
F
u
ll
/
P
ot
en
ti
al
P
ro
g
ra
m
,
L
oc
at
io
n
T
ar
g
et
C
or
e
A
b
u
se
P
ro
g
ra
m
an
d
an
d
P
ar
ti
al
/
P
ri
m
ar
y
O
th
er
Su
cc
es
s
fo
r
(k
ey
re
fe
re
n
ce
)a
P
op
u
la
ti
on
b
T
h
eo
ry
c
(y
es
/n
o)
d
C
om
p
on
en
ts
e
C
om
p
on
en
ts
P
op
u
la
ti
on
N
o
M
at
ch
O
u
tc
om
eg
O
u
tc
om
es
h
(y
es
/n
o)
i
B
ia
sj

3
5

.
R

E
A

C
H

-F
u

tu
re
s
p
ro
g
ra
m
,
C
h
ic

ag
o

(

N
or

r
et

.
2
0
0
3
)

3
2
,

6
N
o
1
N
o
Y
es
N
o

†H
ea

lt
h
p
ro
b
le

m
va

ri
ab

le
s

†F
or

m
al

or
in

fo
rm

al
fo

st
er
ca
re
†R
ep
ea
t
p
re
g
n
an

cy
†H

O
M

E
:

p
ar

en
ti
n
g

at
ti

tu
d

es
∗ H

O
M
E
:

ap
p

p
ri

at
e
p
la
y
m
at
er
ia
ls

†O
th

er
H

O
M
E
su
b
sc
al
es
N
o
1

3
6
.

N
ew

M
ex

ic
o

an
d

A
ri

zo
n
a

H
FA
(B
ar
lo
w
et
al
.
2
0
0
6
)
2
–
3

(

A
m

er
ic

an
In

d
ia

n
ad

ol
es

ce
n

ts
)
2
N
o
1
N
o
Y
es
N
o
N
A

†

L
ow

er
d
ru

g
u
se

b
u
t

n
o

d
if

fe
re
n
ce
N
o
1

3
7

a.
E

ar
ly
H
ea

d
St

ar
t,

h
om

e-
b

ed
on

ly
,

1
7
si
te

s
ac

ro
ss

U
SA

(L
ov

e
et

al
.
2
0
0
5
)
2
–
3
1
,
2
N
o
1
,
2
,
5
,

,
1

Y
es
Y
es
P
ar
ti
al
N
A
∗ H
O
M
E
sc
or

e
∗ P

C
I

Y
es
0
3
7
b
.
E
ar

ly
H

ea
d

St
ar

t,
m

ix
ed

(h
om

e-
+

ce
n

te
r-

b
as

ed
),

1
7
si
te
s
ac
ro
ss
U
SA
(L
ov
e
et
al
.
2
0
0
5
)
2
–
3
1
,
2
N
o
1
,
2
,
5
,

8
,

1
0

Y
es
Y
es
P
ar
ti
al
N
A
∗ H
O
M
E
sc
or

e
†P

C
I
Y
es
0

G
en

er
al
p
op
u
la
ti
on

+
lo

w
to

m
ed

iu
m

ri
sk

3
0

H
om
e
vi
si
ti
n
g
,

G
re

en
sb

or
o,

N
C

(S
ie

g
el

et
al

.
1
9
8
0
)

1
–
3

4
Y

es
1
,
2
,

5
,

9
N

o
P

ar
ti
al
N

o
†R

ep
or

ts
of

ab
u

se
an

d
n
eg
le
ct
†H
os
p
it
al
iz
at
io
n
an
d
E
D
vi
si
ts

†M
II

:
th

re
e

at
ta

ch
m
en
t
m
ea
su
re
s
N
o
2

Home-Visiting Programs to Prevent Child Maltreatment 81

3
8
.

H
ea
lt
h
y

St
ep

s
fo

r
Y

ou
n
g

C
h
il
d
re
n
P
ro
g
ra
m

(H
S)

P
ac

if
ic

N
or

h
w

es
t

(U
SA

an
d
C
an

ad
a)

(J
oh

n
st

on
et
al
.
2
0
0
6
)
1
5
N
o
1
,
2
N
o
N
o
N
o

†

E
xp

os
u

re
to

g
n
if

ic
an

t
p
h
ys
ic
al
d
om
es
ti
c
vi
ol
en
ce
†U
se

of
il

li
ci
t
d
ru
g
s

†S
m

ok
in

g
∗ I

n
ju

ry
co

n
tr

ol
b
eh

av
io
rs
N
o
2

3
9
.

H
om
e
vi
si
ti
n
g
,

D
am

as
cu

s,
Sy

ri
a

(

B
as

h
ou

r
et
al
.
2
0
0
8
)
1
2
N
o
1
,
2
,
5
,
6
Y
es
Y
es
P
ar
ti
al

†S
ee

k
in
g
m

ed
ic

al
tr
ea
tm
en
t
N
o
0

4
0

C
og

n
it
iv
e
ex
te
n
si
on
of
th
e
H
ea
lt
h
y
St
ar
t
P
ro
g
ra

m
,
Sa

n
ta
B
ar

b
ar

a,
C

A
(B

u
g
en

ta
l
an
d

Sc
h
w

ar
tz

2
0
0
9
)

1
,

2 (c
h
il

d
re

n
b

n
at
m
ed
ic
al
ri
sk
)
4
Y
es
1
,
4
,
5
,
6
Y
es
P
ar
t
P
ar
ti

al
∗ I

n
ju

ry
†P

h
ys
ic
al
ab
u
se

∗ C
T

S
P

C
:

rp
or

al
p
u
n
is

h
m
en
t

∗ H
om

e
sa

fe
ty
Y
es
1

4
1

.
H

om
e
vi
si

t-
in

g
,Y

am
an

as
h

Ja
p

(C
h
en

g
et

al
.
2
0
0
7
)

1
4
N
o
1
,
2
,
3
,
4
,
6
Y
es
N
o
N
o
N
A

P
IR

G
A

S
∗ R

el
at

n
sh

ip
g
ro

u
p

†a
d

ap
te

d
re
la
ti

on
sh

ip
g
ro
u
p
N
o
1
C
on
ti
nu
ed

82 L. Segal, R.S. Opie, and K. Dalziel

4
2
.

M
od
if
ie
d
M

ot
h
er

-I
n

n
t
T
ra

n
sa

ct
io

n
P
ro
g
ra
m

(M
IT

P
),
N
or

w
ay

(

K
aa

re
se

n
et
al
.
2
0
0
6
)
2
,

3 (b
ir

th
w

ei
g

h
t

b
el

ow
2
0
0
0
g
)

4
N
o
1
,
2
,
3
Y
es
Y
es
P
ar
ti
al
N
A
P
SI

:
∗ T

ot
al

st
re

ss
6

,
1
2
m
on
th

s,
m

ot
h

er
;

1
2
m
on

th
s,

fa
th

er
∗ C

h
il

d
d
om

ai
n
,

6
m

on
th
s,
m
ot
h
er
;
1
2
m
on
th
s,
fa
th

er
∗ P

ar
en

t
d
om

ai
n
,
6
m
on
th
s,
m
ot
h
er
;
1
2
m
on
th
s
fa
th
er
Y
es
0

4
3
.

R
E

T
,

SA
(K

ee
fe

et
al
.2
0
0
6
)
1
,

2 (i
n
fa

n
ts
w
it

h
.

ir
ri

ta
b

it
y

or
co

li
c)

3
,
2
N
o
1
,
2
,
3
,
4
,
5
Y
es
Y
es
P
ar
ti
al
N

A
∗ P

SI
to

ta
l
sc
or
e
@

8
w

ee
k
s

∗ P
-C

D
I

su
b
sc
al

e
†O

th
er

tw
o
su
b
sc
al

es
:

p
ar

en
ta

l
d

is
tr

es
s
an
d
d
if

fi
cu

lt
ch

il
d
Y
es
1

4
4
.

H
om
e
vi
si
ti
n
g
,

O
n

ri
o,

C
an
ad
a
(S
te

l
O

’C
on

n
or
et
al
.
2
0
0
3
)
1
2
N
o
2
,
5
Y
es
Y
es
P
ar
ti

al
†H

ea
lt
h
p

ro
b

le
m

s
†N

u
m
b
er
of
E
D
vi
si
ts

†N
u

m
b
er
of
h
os
p
it
al
ad

m
is

si
on

s
N
o
2

Home-Visiting Programs to Prevent Child Maltreatment 83

N
ot

es
:

a D
ef

in
ed
in
te

xt
.

b
T

ar
g

t
p
op

u
la
ti
on

d
ef

in
ed

in
ta

b
le
2
.

c C
or

e
th
eo
ry
d
ef
in
ed
in
ta
b
le
3
.
d
A

im
as

st
at

ed
in
th
e

or
ig

in
al

m
an

u
sc

ri
p
ts

re
p
or

ti
n
g

on
ea

ch
p
ro

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∗ :
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In

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e.

84 L. Segal, R.S. Opie, and K. Dalziel

T
A
B
L
E

5
“M

at
ch

”
an

d
Su
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s
of
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-T

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o

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u

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la
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m

b
er

(%
)

P
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s
N
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(%
)
P
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(%
)
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7
(1

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1
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2
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2
6
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(0

)
7

(1
3
.5

)
P
ar
ti
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at

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:

1
8

(6
0
)

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(4
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)

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(5
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.7

)
th

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ry
,
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,
p
lu

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se
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je
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e
3
,
7
,

9
,

1
0
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1
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,

1
4
,

1
6
a,

1
9
,

4
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1
,

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6
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,

3
3
,

3
4

th
eo

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,

co
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,
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je

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e

2
0
,

2
1
,

2
2
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2
9
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3
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7
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,

4
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,

4
5
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2
3
,

2
4
,

2
5
b
,

2
5
c,

2
7
,

2
9
a,

3
9
,

4
4
N
o
m
at

ch
:
n

ot
a

fu
ll

or
p
ar

ti
al
m
at

ch
0

(0
)

1
5

(1
0
0
)

4
,
5
,
6
,
8
,

1
2
,

1
5
,

1
7
,

1
8
,

2
8
,

3
0
,

3
2
,

3
5
,

3
6
,

3
8
,
4
1
1
5

(2
8
.8

)
T
ot
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s
2
5

(4
8
)

2
7

(

5
2

)

5
2
(1
0
0
)
N
ot
es
:

D
er

iv
ed

fr
om

ta
b
le

4
.

a S
ee

d
ef

in
it

io
n
in
te
xt
.

Home-Visiting Programs to Prevent Child Maltreatment 85

TABLE 6
Relationship between Program Success and Full, Partial, or No Match for

Theory, Components, Population, and Child Abuse Objective

Successful Not Successful Fisher’s Exact p
(n = 25) (n = 27) Value (two sided)

Full match (n = 7)
Yes 7 0
No 18 27 0.004a

Partial match (n = 30)
Yes 18 12
No 7 15 0.055

No match (n = 15)
Yes 0 15
No 25 12 <0.0001a

Note: aStatistically significant (p < 0.05).

Statistical Analysis

We used Fisher’s exact test, owing to our small sample size and the small
number of observations (<5) occurring in some cells. The data analysis was consistent with the preceding descriptive analysis, with statistically significant (at p < 0.05) associations found between program success and full, partial, and no match (see table 6).

Discussion

Key Findings

We found that a match between the underpinning theory and program
components together with a match between the theory and target pop-
ulation did predict program success. This result is consistent with our
hypothesis, that the combination of program theory, program compo-
nents, and target population is critical. In line with other reviewers, we
failed to find any single program component, such as type of profes-
sional, timing of intervention, or target population that predicted the
success of home visiting (see table 4).

Limitations

Our model did not capture all aspects of program delivery that may
be important to program success, such as fidelity in program delivery,

86 L. Segal, R.S. Opie, and K. Dalziel

program intensity and resourcing, quality of management and staff
training, and staff values and approach to their work. However, finding
a clear relationship between theory, program components, population,
and objective despite this gap might be seen as enhancing the strength
of this finding.

Our classification of programs according to a defined theory and,
to some extent, program components, lacks precision because of un-
clear reporting. But two reviewers independently assessed all programs
in this regard, with a third reviewer brought in when differences
emerged. Defining the target populations tends to be a simpler task,
although we often found a difference between the initial description of
the target population and the characteristics of persons enrolled in the
program.

A dichotomous classification of the performance of individual pro-
grams into success or failure necessarily represents a simplification of
something that is quite complex. However, we suggest that it is de-
sirable to report on whether or not an individual program worked—or
at least to make clear if this cannot be established with certainty. This
classification is not a simple matter of looking at statistical signifi-
cance but of balancing often divergent results across possibly dozens of
outcomes, measured at different time points in various subpopulations.
Greater attention to this issue in original study reports and by reviewers
is warranted.

There is also debate about the outcome measures themselves. For
instance, it is argued that home visiting may increase child abuse re-
ports, owing to surveillance bias, whereas self-report also suffers from
incompleteness and possible bias. The definition and reporting of child
maltreatment are also known to differ across jurisdictions and across
countries.

Further exploration of the value of the proposed hierarchy in outcome
measures would be useful, to explore more fully how to give the greatest
weight to the more robust, objective, and meaningful measures, such
as childhood injury or failure to thrive resulting in a hospital visit
or admission. We have made a start by describing a clear process for
classifying programs as successful, which uses a two-step hierarchy that
incorporates in a stepwise fashion both direct and indirect child abuse
and neglect outcomes.

As we noted, our measure of success says nothing about value
for money, which we have explored elsewhere through a comparative

Home-Visiting Programs to Prevent Child Maltreatment 87

cost-effectiveness analysis in those programs reporting a direct child
abuse outcome (Dalziel and Segal forthcoming).

Policy Implications for Home Visiting

This review has a number of key messages for policymakers seeking
to implement programs to reduce rates of child maltreatment in vul-
nerable families. Because it is known that neonate/infant home-visiting
programs are not always successful, care must be taken in their design
and implementation. Our study suggests that a way to maximize success
is through fidelity to a program logic model. Specifically, in designing
a home-visiting program, it is important to be clear about the objective
(in our review, to reduce child maltreatment) to ensure a sound under-
standing of the client population and its needs and strengths (the nature
of the threats to a safe and nurturing environment), the associated theory
or mechanism of change, and the program components that can deliver
the change mechanism. Adequate resources and an appropriately skilled
team with access to requisite training and quality assurance processes
are also crucial. We note that if there is little understanding about how
to work with a particular population to achieve a safe and nurturing en-
vironment, then it is unlikely that a successful home-visiting program
can be developed and delivered.

Even though manualized programs can support fidelity in program
delivery, adopting “off-the-shelf program models” is no guarantee of
success, particularly if they are not designed for the target population
and their specific circumstances.

Conclusion

Our research supports the value of a program logic approach, incor-
porating a theory (or mechanism) of action, for the review of complex
human services interventions to yield new insights. We postulate that
the approach will have wide applicability to a range of contexts, partic-
ularly for assessing the performance of multifaceted interventions that
can target different populations.

A program logic–based systematic review can enhance policy rel-
evance and will be most valuable to policymakers seeking to design
and implement effective and efficient programs for improving societal

88 L. Segal, R.S. Opie, and K. Dalziel

well-being, to ensure that scarce resources are not wasted, and to offer
the best prospect of improving outcomes for vulnerable families.

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Acknowledgments: This study was funded by the Australian Research Council
(ARC) as a linkage grant, ID LP0883743, from 2008 to 2012. The funding
source played no role in the study’s design, conduct, interpretation, writing, or
the decision to submit it for publication. The authors declare that they have no
conflicts of interest.

We would also like to acknowledge the very generous and detailed comments
from Karen Monsen and two anonymous reviewers that have contributed to the
clarity of our argument.

Home-Visiting Programs to Prevent Child Maltreatment 97

APPENDIX A

Search Results and Inclusion/Exclusion

Titles & Abstracts identified + screened:
• Databases (RCTs & Reviews) 1557 hits
• Key Journals 625 hits
• Key Author 61 hits (Medline Only)
• Bibliographies

Full text retrieved and assessed:
• Systematic reviews 40
• RCTs and Controlled Trials 143

Included:
RCTs and controlled studies 67 papers
covering 52 distinct programs

Excluded:
• not controlled study (n = 25)
• not home visiting (n = 17)
• not mother/child at risk of abuse or

neglect (n = 4)
• (n 8

Excluded:
• not systematic review, meta-analysis, or

controlled trial
• not home visiting
• not child at risk of abuse or neglect
• duplicates

wron outcomes = 1 )g

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ss
,
C
h
il
d
A
b
u
se
P
ot
en
ti
al
an
d
C
h
il
d

D
ev

el
op
m
en

t.
C

hi
ld
A
bu
se
&
N
eg
le
ct
2
7

(9
):

9
9
7
–
1
0
1
7
.

Home-Visiting Programs to Prevent Child Maltreatment 99

6
.
H
om
e
vi
si
ti
n
g

,
D

en
ve

r
G

ra
y,

J.
D

.,
C

A
.

C
u

tl
er

,
J.

G
.

ea
n

,
an
d
C
.
H

en
ry

K
em

p
e.

1
9
7
7
.
P
re
d

ic
ti

on
an
d
P
re
ve
n
ti
on
of
C
h
il
d
A
b
u
se
an
d
N
eg
le
ct
.
C
hi
ld
A
bu
se
&
N
eg
le
ct

1
(1

):
4
5
–
5
8
.

7
.
H
om
e
vi
si
ti
n
g
,
Q
u
ee
n
sl
an
d
,
A
u
st
ra
li
a
A
rm
st
ro
n
g
,
K
.L
.,

J.
A

F
ra

se
r,

M
.R

.
D

ad
d

s,
an

d
J.

M
or

ri
s.

1
9
9
9
.
A
R
an
d
om

iz
ed

,
C
on
tr
ol
le
d
T
ri
al
of
N
u
rs

e
H

om
e
V
is
it
in
g
to

V
u

ln
er

ab
le

F
am
il
ie
s
w
it
h
N
ew
b
or
n
s.
Jo
ur
na
l

of
P

ae
di

at
ri

s
&

C
hi

d
H

ea
lt

h
3
5

(3
):

2
3
7
–
4
4
.

A
rm
st
ro
n
g
,
K
.L
.,
J.
A

.
F

ra
se
r,
M
.R
.
D
ad
d
s,
an
d
J.
M
or
ri
s.
2
0
0
0
.
P

ro
m

ot
in

g
Se

cu
re

A
tt

ac
h
m
en

t,
M

at
er
n
al

M
oo

d
an
d
C
h
il
d
H
ea
lt

h
in

a
V

u
ln

er
ab

le
P

op
u
la
ti

on
:

A
R

an
d
om
iz
ed
C
on
tr
ol
le
d
T
ri
al
.
Jo
ur
na
l
of

P
ae

di
at

ri
cs

an
d
C
hi

ld
H

ea
lt

h
3
6

(6
):

5
5
5
–
6
2
.

F
ra
se
r,
J.
A

.,
K

.L
.

A
rm
st
ro
n
g
,
J.

P.
M

or
ri

s,
an
d
M

R
.

ad
d

s.
2

0
0
0
.
H
om
e
V
is
it
in
g
In
te
rv
en
ti
on
fo
r

V
u
ln

er
ab

le
F

am
il

ie
s
w
it

h
N

ew
b

or
n

s:
F

ol
lo

w
-U

p
R

es
u

lt
s

of
a
R
an
d
om
iz
ed
C
on
tr
ol
le
d
T
ri

al
.
C

hi
ld
A
bu
se
&
N
eg
le
ct
2
4

(1
1
):

1
3
9
9
–
1
4
2
9
.

8
.
C
h
il
d
P
ar
en
t
E
n
ri
ch
m
en
t
P
ro
je
ct
,
C
on
tr
a
C
os
ta
C
ou
n
ty
,
C

al
if

or
n
ia
B
ar

th
,
R

.P
.

1
9
9
1
.

A
n
E
xp

er
im

en
ta

l
E

va
lu

at
io
n
of
In
-H
om
e
C
h
il
d
A
b
u
se
P
re

ve
n
ti

on
Se

rv
ic

es
.
C

hi
ld
A
bu
se
&
N
eg
le
ct
1
5

(4
):

3
6
3
–
7
5
.

9
.
C
om

m
u
n
it

y
In
fa
n
t
P
ro
je
ct
,
B

ou
ld

er
,

C
ol

or
ad

o
H
u
xl

ey
,

P.
,

an
d
R
.

W
ar

n
er
.
1
9
9
3
.
P
ri
m
ar

y
P

re
ve
n
ti
on
of
P
ar
en
ti
n
g

D
ys

fu
n
ct
io
n
in
H
ig

h
-R

is
k

C
as

es
.
A

m
er
ic
an
Jo
ur
na
l
of
O

rt
ho

ps
yc

hi
at

ry
6
3

(4
):

5
8
2
–
8
8
.

1
0
.
E
ar
ly
In
te
rv
en
ti
on
P
ro
g
ra
m
,

Sa
n

B
er

n
ar
d
in
o,
C
al
if
or
n

ia
K

on
ia
k
-G
ri
ff

in
,
D

,
I.

.
V

er
ze

m
n

ie
k

s,
N

.L
.R

.
A
n
d

er
so

n
,
M

.
B

re
ch

t,
J.

L
es
se
r,

S.
K

im
,

an
d

C
.

u
rn

er
-P

lu
ta

.
2
0
0
3
.
N
u
rs
e
V
is

it
at

io
n
fo
r
A
d
ol
es
ce
n

t
M

ot
h

er
s—

T
w

o-
Y

ea
r

In
fa

n
t
H
ea
lt
h
an
d
M
at
er
n

al
O

u
tc
om
es
.
N
ur
si

ng
R

es
ea

rc
h

5
2
(2
):

1
2
7
–
3
6
.

K
on

ia
k

-G
ri

ff
in

,
D

.,
N

.L
.R
.
A
n
d
er
so
n
,

M
.L

.
B
re
ch

t,
I.

V
er

ze
m

n
ie

k
s,

J.
L

es
se

r,
an

d
S.

K
im

.
2
0
0
2
.

P
u

b
li

c
H

ea
lt
h
N
u
rs
in
g

C
ar

e
fo

r
A

d
ol

es
ce

n
t
M
ot
h
er

:
Im

p
ac

t
on
In
fa
n
t
H
ea
lt
h
an
d

Se
le

ct
ed

M
at
er
n
al
O
u
tc
om
es

at
1

Y
ea

r
P

os
tb

ir
th
.
Jo
ur
na
l
of

A
do

le
sc

en
t
H
ea
lt
h
3
0

(1
):

4
4
–
5
4
.

C
on
ti
nu
ed

100 L. Segal, R.S. Opie, and K. Dalzie

l
A

P
P

E
N

D
IX

B
—

C
on
ti
nu
ed
P
ro
g
ra
m
N
u
m
b
er

,N
am

e,
an

d
L
oc
at
io
n
R
ef
er
en
ce
1
1
.
H

aw
ai

i
H

ea
lt
h
y
St
ar
t
P
ro
g
ra
m
,
H
aw
ai

i
D

u
g
g
an
,
A

.,
E

.
M

cF
ar

n
e,

L
.

F
u
d
d
y,

L
.

B
u
rr

el
l,

S.
M

.
H

ig
m

an
,

A
.

W
in

h
am

,
an
d
C

.
Si

a.
2

0
0
4
.
R
an
d
om
iz
ed
T
ri

al
of

a
St

at
ew

id
e

H
om
e
V
is
it
in
g
P
ro
g
ra
m
:

Im
p

ac
t

in
P

re
ve
n
ti
n
g
C
h
il
d
A
b
u
se
an
d
N
eg
le
ct
.
C
hi
ld
A
bu
se
&
N
eg
le
ct
2
8
(6
):

5
9
7
–
6
2
2
.

D
u
g
g
an

,
A

.K
.,

E
.C

.
M
cF
ar
la
n
e,

A
.M

.
W

in
d
h
am

,
C

.A
.

oh
d
e,

D
.S

.
Sa

lk
ev

er
,

L
.
F
u
d
d
y,

L
.A

.
R

os
en

b
er
g
,

S.
B

.
B
u
ch
b
in
d
er
,
an
d
C

.C
.

Si
a.

1
9
9
9
.

E
va

lu
at

io
n
of
H
aw
ai

i’

s
H

ea
lt
h
y
St
ar
t
P
ro
g
ra
m
.
F

ut
ur

e
of
C
hi

ld
re

n
9
(1
):

6
6
–
9
0
,

d
is

cu
ss

io
n

1
7
7
–

7
8

E
l-

K
am

ar
y,

S.
S.

,
S.
M
.
H
ig
m
an
,
L
.
F
u
d
d
y,
E
.

M
cF

ar
la

n
e,
C
.

Si
a,

an
d

A
.K

.
D
u
g
g
an
.
2
0
0
4
.
H
aw

ai
i’s

H
ea
lt
h
y
St
ar
t
H
om
e
V
is
it
in
g
P
ro
g
ra
m
:

D
et

er
m

in
an

ts
an

d
Im

p
ac
t
of

R
ap

d
R

ep
ea

t
B

ir
th
.
P

ed
ia

tr
ic

s
1
1
4

(3
):

e3
1
7
–
2
6
.

1
2
.
H
ea
lt
h
y
F
am
il
ie
s
A
la
sk

a
G

es
sn

er
,
B

D
.

0
0
8
.
T
h
e
E
ff
ec
t
of

A
la

sk
a’

s
H
om
e
V
is
it
at
io
n
P
ro
g
ra

m
fo

r
H
ig
h

-R
is

k
F

am
il
ie
s

on
T

re
n
d
s

in
A

b
u
se
an
d
N
eg
le
ct
.
C
hi
ld
A
bu
se
&
N
eg
le
ct
3
2
(3
):

3
1
7
–

3
3
.

1
3
.
H
om
e
vi
si
ti
n

g
,
W

es
te
rn
A
u
st
ra
li

a
Q

u
in
li
va
n
,
J.
A

.,
H

.
B

ox
,

an
d

S.
F.

E
va
n
s.
2
0
0
3
.
P
os
tn
at
al
H
om
e
V
is
it
s
in

T
ee

n
ag

e
M

ot
h

er
s:

A
R
an
d

om
is

ed
C
on
tr
ol
le
d
T
ri
al

.
T

he
L

an
ce

t
3
6
1

(9
3
6
1
):

8
9
3
–
9
0
0
.

1
4
.
E
ar
ly
St
ar

t,
N

ew
Z
ea
la
n
d
F
er
g
u
ss
on
,
D

.M
.,

H
.

G
ra
n
t,

L
.J

.
H

or
w

oo
d
,
an
d
E
.M
.

R
id

d
er
.
2
0
0
5
.
R
an
d
om
iz
ed
T
ri
al
of
th
e
E
ar
ly
St
ar
t
P
ro
g
ra

m
of

H
om
e
V
is
it
at
io

n
.

P
ed

ia
tr

ic
s

1
1
6

(6
):

e8
0
3
–
9
.

1
5
.
F
am
il
y
P
ar
tn

er
sh

ip
M

od
el

,
tw

o
co

u
n
ti

es
in
th
e
U
K
B
ar
lo
w

,J
.,

H
.D

av
is

,E
.M

cI
n

to
sh

,P
.J

ar
re

tt
,C

.M
oc

k
fo

rd
,a

n
d

.
St

ew
ar

t-
B

ro
w

n
.2

0
0
7
.

R
ol

e
of
H
om
e
V
is
it
in
g

in
Im

p
ro

vi
n

g
P
ar
en
ti
n
g
an
d
H
ea
lt
h
in
F
am
il
ie

s
at

R
is
k
of
A
b
u
se
an
d
N
eg
le
ct
:
R
es
u
lt
s
of
a
M
u

lt
ic

en
tr

e
R

an
d
om
is
ed
C
on
tr
ol
le
d
T
ri
al
an
d

E
co

n
om

ic
E

va
lu
at
io
n
.

A
rc

hi
ve

s
of

D
is

ea
se

n
C

hi
ld

ho
od

9
2

(3
):

2
2
9
–
3
3
.

1
6

a.
N

u
rs

e
fa

m
il
y
p
ar
tn
er
sh

ip
h

om
e
vi
si
ti
n

g
,
D

en
ve

r
O

ld
s,

D
.L

.,
J.

R
ob
in
so
n
,
L
.

P
et

ti
tt

,
D

W
.

u
ck

ey
,

J.
H

ol
m

b
er
g
,

R
.K

.
N
g
,

K
.

ac
k

s,
K

.
Sh

ef
f,

an
d

C
.R

.
H
en
d
er
so

n
Jr

.
2
0
0
4
.
E
ff
ec
ts
of
H
om
e
V
is

it
s

b
y
P
ar

ap
ro

fe
ss

io
n
al
s
an
d
b
y
N
u

rs
es

:
A
g
e

4
F

ol
lo
w
-U
p
R
es
u
lt
s
of
a
R
an
d
om
iz
ed
T
ri

al
.
P

ed
ia
tr
ic
s
1
1
4
(6
):

1
5
6
0
–
6
8
.

1
6
b
.
P
ar
ap
ro
fe
ss
io
n
al
h
om
e
vi
si
ti
n
g
,
D
en
ve
r
O
ld

s,
D

.L
.,
J.
R

ob
in

so
n
,
R
.
O

’B
ri

en
,
D

.W
.

L
u

ck
ey

,
L

.M
.
P

et
ti

tt
,
C

.R
.

H
en

d
er
so
n

Jr
.,

R
.K
.
N

g
,
K

.L
.
Sh

ef
f,

J.
K

or
fm

ac
h

er
,
S.

H
ia

tt
,a

n
d

A
.
T

al
m

i.
2

0
0

2
.
H

om
e
V
is
it
in
g
b
y
P
ar
ap
ro
fe
ss
io
n
al
s
an

d
b
y

N
u
rs
es
:
A
R
an
d
om
iz
ed
,
C
on
tr
ol
le
d
T
ri
al
.
P
ed
ia
tr
ic

s
1
1
0

(3
):

4
8
6
–
9
6
.

Home-Visiting Programs to Prevent Child Maltreatment 101

1
7
.
P
ar
en
ti
n
g
on

E
d

g
e,

G
eo

rg
ia

M
u

ls
ow

,
M

.H
.,

an
d

V
.M

.
M
u
rr

ay
.

1
9
9
6
.
P
ar
en
ti
n
g
on
E
d

g
e:

E
co
n
om
ic
al
ly
St
re
ss

ed
,

Si
n

g
le
,
A

fr
ic

an
A

m
er
ic
an
A
d
ol
es
ce
n
t
M
ot
h

er
s.

Jo
ur
na
l
of
F
am
il

y
Is

su
es
1
7
(5
):

7
0
4
–
2
1
.

1
8
.

L
in
k
ag
es
fo
r
P
re
ve
n
ti
on
P
ro
je

ct
,
D

u
rh
am
,
N
or

h
C

ar
ol

in
a

M
ar
g
ol

is
,
P.

A
.,

R
.

St
ev

en
s,

W
.C

.
B

or
d

le
y,

J.
St

u
ar

t,
C

.
H
ar
la

n
,
L
.

K
ey

es
-E

ls
te

in
,
an

d
S.

W
is

se
h
.
2
0
0
1
.

F
ro

m
C

on
ce

p
t

o
A

p
p
li

ca
ti

on
:
T
h
e

Im
p
ac

t
of
a
C
om
m
u
n
it

y-
W

id
e
In
te
rv
en
ti
on

to
Im

p
ro

ve
th

e
D

el
iv

er
y

of
P
re
ve
n
ti

e
Se

rv
ic

es
to

C
h
il
d
re
n
.
P
ed
ia
tr
ic

s
1
0

(3
):

e4
2
.

1
9
.
C
h
il
d
an
d
Y
ou
th
P
ro
g
ra
m
M
od
u
le
,
B
al
ti
m
or
e
H
ar
d
y,

J.
B

.,
an
d
R
.
St

re
et

1
9
8
9
.

F
am
il
y

Su
p

p
or

t
an
d
P
ar
en
ti
n
g

E
d
u
ca

ti
on
in
th
e
H

om
e:

A
n
E
ff
ec
ti

ve
E

xt
en

si
on
of
C
li
n

ic
-B

as
ed

P
re
ve
n
ti
ve
H
ea
lt
h
C
ar
e
Se
rv
ic
es
fo
r
P

oo
r

C
h
il
d
re
n
.
Jo
ur
na
l
of
P
ed
ia
tr
ic

s
1
1
5

(6
):

9
2
7
–
3
1
.

2
0
.
H
om
e
vi
si
ti
n
g
,

M
em

p
h

is
K

it
zm

an
,
H

.,
D

.L
.
O
ld

s,
C

.R
.
H
en
d
er
so
n
Jr
.,
C
.

H
an

k
s,

R
.
C

ol
e,

R
.

T
at

el
b

au
m

,
K
.M
.

M
cC

on
n

oc
h

ie
,

K
.
Si

d
or

a,
D

.W
.
L
u
ck
ey
,
D
.
Sh

av
er

,
K
.
E
n
g

el
h

ar
d

t,
D

.
Ja

m
es
,
an
d
K
.
B
ar
n
ar
d
.
1
9
9
7
.
E
ff
ec
t
of
P
re
n
at
al
an
d
In
fa
n
cy
H
om
e
V
is
it
at
io
n
b

y
N

u
rs

es
on

P
re
g
n
an
cy
O
u
tc
om

es
,
C

h
il
d
h
oo
d

In
ju

ri
es
,
an
d
R
ep
ea
te
d
C
h
il
d
b
ea
ri
n
g
.
A
R
an
d
om
iz
ed
C
on
tr
ol
le
d
T
ri
al

.
JA

M
A

2
7
8

(8
):

6
4
4
–
5
2
.

K
it

zm
an

,
H
.,
D
.L
.
O
ld
s,
K
.
Si
d
or
a,
C
.R
.
H
en
d
er
so
n
Jr
.,

C
.
H

an
k

s,
R

.
C
ol
e,

D
.W

.
L
u
ck
ey
,
J.
B

on
d

y,
K

.
C
ol
e,
an
d

J.
G

la
zn

er
.
2
0
0
0
.
E
n
d
u
ri
n

g
E

ff
ec
ts
of
N
u
rs
e
H
om
e
V
is
it
at
io
n
on
M
at
er
n

al
L

if
e

C
ou

rs
e—

A
3
-Y

ea
r

F
ol

lo
w

-U
p

of
a
R
an
d
om
iz
ed
T
ri
al
.

JA
M

A
2

8
3

(1
5
):

1
9
8
3
–
8
9
.

O
ld
s,
D
.L
.,
H
.
K
it
zm
an
,
R
.
C
ol
e,
J.
R
ob
in

so
n
,

K
.

Si
d
or

a,
D
.W
.

L
u
ck

ey
,
C
.R
.
H

en
d
er

so
n
Jr
.,
C
.
H
an
k
s,
J.
B

on
d
y,

an
d
J.
H
ol
m
b
er
g
.

2
0
0
4
.

E
ff
ec
ts
of
N
u
rs
e
H
om
e-
V
is
it
in
g
on
M
at
er
n

l
L
if

e
C

ou
rs

e
an
d
C
h
il
d
D
ev
el
op
m

en
t:

A
g

e
6

F
ol
lo
w
-U
p
R
es
u
lt
s
of

a
R

an
d
om
iz
ed
T
ri
al
.
P
ed
ia
tr
ic
s
1
1
4
(6
):

1
5
5
0
–
5
9
.

O
ld
s,
D
.L
.,
H
.
K
it
zm
an
,
C
.
H

an
k
s,

R
.
C
ol
e,
E
.
A
n
so
n
,
K
.
Si
d
or

a-
A

rc
ol

eo
,
D

.W
.
L
u
ck
ey
,
C
.R
.
H
en
d
er
so
n
Jr
.,
J.
H
ol
m
b
er
g
,

R
.A

.
T

u
tt

,
A

.J
.
St

ev
en

so
n
,
an
d
J.

B
on

d
y.

2
0
0
7
.
E
ff
ec
ts
of
N
u
rs
e
H
om
e
V
is
it
in
g

on
M

at
er
n
al
an
d
C
h
il
d
F
u

n
ct

io
n
in
g
:
A

g
e-

9
F

ol
lo
w
-U

p
of

a
R
an
d
om
iz
ed
T
ri
al
.
P
ed
ia
tr
ic

s
1
2
0

(4
):

e8
3
2
–
4
5
.

C
on
ti
nu
ed

102 L. Segal, R.S. Opie, and K. Dalziel
A

P
P
E
N
D
IX
B
—
C
on
ti
nu
ed
P
ro
g
ra
m
N
u
m
b
er
,N
am
e,
an
d
L
oc
at
io
n
R
ef
er
en
ce
2
1
.
T
h
re
e
G
en
er
at
io
n
St

u
d
y,

B
al
ti
m
or
e
B
la

ck
,
M

.M
.,
M
.E
.
B

en
tl

ey
,

M
.A

.
P

ap
as

,
S.

O
b

er
la

n
d

er
,
L

O
.

T
et

i,
S.

M
cN
ar
y,
K
.

L
e,

an
d
M
.

O
’C

on
n
el

l.
2
0
0
6
.

D
el

ay
in

g
Se

co
n
d

B
ir
th
s

am
on

g
A

d
ol
es
ce
n
t
M
ot
h
er

s:
A

R
an
d
om
iz
ed
,
C
on
tr
ol
le
d
T
ri
al
of
a
H
om

e-
B

as
ed

M
en

to
ri

n
g
P
ro
g
ra
m
.
P
ed
ia
tr
ic
s

1
1
8

(4
):

e1
0
8
7
–
9
9
.

2
2
.
P
ar
en
t
T
ra
in
in

g
b
y

C
E
T
A
ai
d
e,
M
ia
m
i
F
ie

ld
,

T
.,

S.
W

id
m

ay
er

,
R
.
G
re
en
b
er

g
,
an

d
S.

St
ol

le
r.

1
9
8
2
.
E
ff
ec
ts
of
P
ar
en
t
T
ra
in
in
g
on
T
ee
n
ag
e
M
ot
h
er
s
an
d
T
h

ei
r

In
fa
n
ts
.
P
ed
ia
tr
ic

s
6
9

(6
):

7
0
3
–
7
.

2
3
.
C
om
p
re
h
en
si
ve
C
h
il
d
D
ev
el
op
m
en
t
P
ro
g
ra
m
,
U
SA

St
.

P
ie

rr
e,

R
.G

.,
an
d
J.

I.
L

ay
ze

r.
1

9
9
9
.
U
si
n
g
H
om
e
V
is
it
s
fo

r
M

u
lt

ip
le

P
u

rp
os

:
T

h
e
C
om
p
re
h
en
si
ve
C
h
il
d
D
ev
el
op
m
en
t
P
ro
g
ra
m
.
F
ut
ur
e
of
C
hi
ld
re
n
9
(1
):

1
3
4
–
5
1
.

2
4
.
H
om
e
vi
si
ti

n
g
,
C

ol
or

ad
o

D
aw
so
n
,
P.
,

W
.J

.
va

n
D

oo
rn

in
ck

,
an
d
J.

L
.
R

ob
in

so
n
.

1
9
8
9
.
E
ff
ec
ts
of
H
om
e-
B
as
ed
,

n
fo

rm
al

So
ci
al
Su
p
p

or
t

on
C

h
il
d
H
ea
lt

h
.
Jo

ur
na
l
of
D
ev
el
op
m
en
ta
l

&
B

eh
av

io
ra

l
P
ed
ia
tr
ic
s
1
0
(2
):

6
3
–
6
7
.

2
5

a.
T

h
e
P
ar
en
ts
as
T
ea
ch
er
s

(P
A

T
)

(a
)

T
ee
n
s
C
om
b
in

ed
(i

n
cl
u
d
in
g
ca
se
m
an
ag
em
en
t)

,
So

u
th
er
n

C
al

if
or

n
ia
W
ag
n
er

M
.M

.,
an
d
S.
C
la
yt
on

,L
.1

9
9

9
.T

h
e
P
ar
en
ts
as
T
ea
ch
er
s
P
ro
g
ra

m
:R

es
u
lt
s
fr
om
T
w

o
D

em
on

st
ra
ti
on

s.
F

ut
ur
e
of
C
hi
ld
re
n
9
(1
):

9
1
–
1
1
5
.

2
5
b
.

(b
)

B
as
ic
p
ro
g
ra
m
,
Sa
li
n

as
V

al
le

y,
N

or
th
er
n
C
al
if
or
n
ia
2
5

c.
(c

)
T

ee
n
P
A
T
,

So
u

th
er
n
C
al
if
or
n

ia
2

6
a.
(a
)
N
u
rs
e
F
am
il
y
P
ar
tn
er
sh
ip
,
p

re
–

an
d
p
os
tn
at

al
,
E

lm
ir
a,
N
ew
Y
or
k

E
ck

en
ro
d
e,

J.
,
B

.
G

an
ze

l,
C

.R
.
H
en
d
er
so
n
Jr
.,
E
.

Sm
it

h
,
D
.L
.
O
ld
s,

J.
P

ow
er

s,
R
.
C
ol
e,
H
.
K
it
zm
an
,
an
d
K
.
Si
d
or
a.
2
0
0
0
.
P
re
ve
n
ti
n

g
C

h
il
d
A
b
u
se
an
d
N
eg
le

ct
w

it
h
a
P
ro
g
ra
m
of
N
u
rs
e
H
om
e
V
is
it
at
io
n
:
T
h
e

L
im

it
in
g
E
ff
ec
ts
of
D
om
es
ti
c
V
io
le
n
ce
.
JA
M
A

2
8
4

(1
1
):

1
3
8
5
–
9
1
.

Home-Visiting Programs to Prevent Child Maltreatment 103

2
6
b
.
N
u
rs
e
F
am
il
y
P
ar
tn
er
sh
ip

,
(b

)
p
re

n
at

al
on

ly
,
E
lm
ir
a,
N
ew

Y
or

k
E
ck
en
ro
d
e,

J.
,
D

.
Z

ie
li

n
sk

i,
E

.
Sm

it
h
,
L
.A
.
M
ar

cy
n

ys
zy

n
,
C
.R
.
H
en
d
er
so
n
Jr
.,
H
.
K
it
zm

an
,
R

.
C
ol
e,
J.
P
ow
er
s,
an
d
D
.L
.
O
ld
s.
2
0
0
1
.
C
h
il
d

M
al

tr
ea
tm
en
t
an
d
th
e
E
ar
ly
O
n

se
t

of
P
ro
b
le
m

B
eh

av
io

rs
:
C

an
a
P
ro
g
ra
m
of
N
u
rs
e
H
om
e
V
is
it
at
io
n
B

re
ak

th
e
L
in

k
?

D
ev
el
op
m
en

t
&

P
sy

ch
op

at
ho

lo
gy

1
3
(4
):

8
7
3
–
9
0
.

Iz
zo

,
C

.V
.,

J.
J.

E
ck
en
ro
d
e,

E
.G

.
Sm
it
h
,
C
.R
.
H
en
d
er
so
n
Jr
.,
R
.
C
ol

e,
H

.
K
it
zm

an
,
an

d
D
.L
.
O
ld

.
2
0
0
5
.

R
ed
u
ci
n
g
th
e
Im
p
ac
t
of

U
n
co

n
tr

ol
la

b
le
St
re

ss
fu

l
L
if
e
E

ve
n
ts

th
ro

u
g
h
a
P
ro
g
ra
m
of
N
u
rs
e
H
om
e
V
is
it
at
io
n
fo

r
N

ew
P

ar
en

ts
.

P
re

ve
nt

io
n

Sc
ie

nc
e

6
(4

):
2
6
9
–
7
4
.

O
ld
s,
D
.L
.,
C
.R
.
H
en
d
er
so
n
Jr
.,
R
.
T
at

el
b
au

m
,
an

d
R
.
C
h
am
b
er

li
n
.
1
9
8
6
.

Im
p
ro

vi
n
g

th
e
D
el
iv
er
y
of
P
re
n
at

al
C

ar
e
an
d
O
u
tc
om
es
of
P
re
g
n
an
cy
:
A
R
an
d
om
iz
ed
T
ri
al
of
N
u
rs
e
H
om
e
V
is
it
at
io

n
.
[e

rr
at

u
m
ap
p

ea
rs

in
P
ed
ia
tr
ic

s,
Ju

ly
1
9
8
6
,

7
8
(1
):

1
3
8
].

P
ed
ia
tr
ic
s
7
7
(1
):

1
6
–
2
8
.

O
ld
s,
D
.,
C
.R
.
H
en
d
er
so
n
Jr
.,
H
.
K
it
zm
an
,
an
d
R
.
C

ol
e.

1
9
9
5
.
E
ff
ec
ts
of
P
re
n
at

al
an

d
In
fa
n

cy
N

u
rs
e
H
om
e
V
is
it
at
io
n

on
Su

rv
ei

ll
an

ce
of
C
h
il
d
M
al
tr
ea
tm
en

t.
P

ed
ia
tr
ic

s
9
5

(3
):

3
6
5
–
7
2
.

O
ld
s,
D
.L
.,

J.
E

ck
en

ro
d

e,
C

.R
.
H
en
d
er
so
n
Jr
.,

H
.
K

it
zm

an
,
J.

P
ow

er
s,

R
.
C
ol

e,
K

.
Si
d
or

a,
P.

M
or

ri
s,

L
.M

.
P
et
ti

tt
,
an

d
D
.
L
u
ck

ey
.

1
9
9
7
.
L
on
g

-T
er

m
E

ff
ec
ts
of
H
om
e
V
is
it
at
io
n
on
M
at
er
n
al
L
if
e
C
ou
rs
e
an
d
C
h
il
d
A
b
u
se
an
d
N
eg
le
ct

.
F
if

te
en

-Y
ea

r
F

ol
lo
w
-U
p
of
a
R
an
d
om
iz
ed
T
ri
al
.
JA
M
A
2
7
8
(8
):

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–
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.

O
ld
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.,
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en
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.
1

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9
4
.

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om
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av
e

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d
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ri
n
g
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ff
ec
ts
on
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al
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ie
s
of
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ar
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C
ar

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iv

in
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e?

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tr
ic
s
9
3
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):

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n
er

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it

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re
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ur
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om
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it

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ea
lt

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9

(4
):

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8
8
–
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5
.

C
on
ti
nu
ed

104 L. Segal, R.S. Opie, and K. Dalziel

A
P
P
E
N
D
IX
B

—
C

on
ti

nu
ed

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ro
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ra
m
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m
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am
e,
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L
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ig
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M
.,
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om

is
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er

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it

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sm
en

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8

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2
):

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0
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8
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om
e
vi
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In
fa
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te

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C

.,
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au

m
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te

n
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8
9
.
A
P

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b
li

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H
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H

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F
am

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ld

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H
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lt
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ar
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):

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0
2
–
7
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9
a.
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os
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ic

ac
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of
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om
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V
is
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D
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en
t.
P
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ic

s
6
6

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):

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9
1
–
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7
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9
b
.
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re
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H
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ti

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tr
ic
s
6
6
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):

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8
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–
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0
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M
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4
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om
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s
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4

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):

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):

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–
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p
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om
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se
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N
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le
ct
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1
(8
):

8
2
9
–
5
2
.

Home-Visiting Programs to Prevent Child Maltreatment 105

3
3
.
A
d
d
it
io
n
of
in
te
n
si
ve
h
om
e
vi
si
ta
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co
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(C
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M
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),
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s-

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.,

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1
.
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is
k
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M
is
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T
h
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ar

t
II

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li
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ic

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as

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ve
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ti
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ra
m
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ld
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bu
se
&
N
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le
ct
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(6
):

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5
3
–
6
9
.

3
4
.
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om
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g
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M

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k

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.,

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d
M
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9
9
4
.
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om
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t-

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en
:
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R
an
d
om
iz
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T
ri

al
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m
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an
Jo
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of
O
rt
ho
ps
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at

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):

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6
8
–
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8
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3
5
.

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E

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.,
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en
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ng

2
0
(3
):

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9
0
–
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0
3
.

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6
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ar
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A
.,
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V

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om
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V
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R
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iz
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of
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1
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1
–
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ar
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M

.,
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):

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8
5
–
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0
1
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8
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st
em

—
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h
il
d
an
d
P
ar
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O
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tc
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at
3
0

M
on
th
s.
A
rc
hi
ve
s
of
P
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ia
tr
ic
s

&
A

do
le

sc
en

t
M
ed
ic
in
e
1
6
0
(8
):

7
9
3
–
8
0
0
.

C
on
ti
nu
ed

106 L. Segal, R.S. Opie, and K. Dalziel
A

P
P
E
N
D
IX
B
—
C
on
ti
nu
ed
P
ro
g
ra
m
N
u
m
b
er
,N
am
e,
an
d
L
oc
at
io
n
R
ef
er
en
ce
3
9
.
H
om
e
vi
si
ti

n
g
,
D

am
as

cu
s,

Sy
ri

a
B
as
h

ou
r,

H
.N

.,
M

.H
.
K

h
ar

ou
f,

A
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.
A

b
d

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ls

al
am

,
K
.
E
l
A

sm
ar

,
M

.A
.
T

ab
b

aa
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d

S.
A

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h

ei
k

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2
0
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ff

ec
t
of
P
os
tn
at
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om
e
V
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b
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(c
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s
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a,
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c;

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;
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9
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;
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d
4

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sh

ar
e
th
e

sa
m

e
re
fe
re
n
ce

(s
).

emailed to multiple sites or posted to a listserv without the copyright holder’s express written permission.

However, users may print, download, or email articles for individual use.

Process Development Template

Use this Process Development Template as an iterative and cumulative worksheet for keeping notes and ideas about the different elements that will be addressed in your grant proposal. While this document will not be submitted for grading, it will inform assignments that are submitted. You are encouraged to use this template as both an organizer for and record of the work you are doing.

Project Summary

The Project Summary is the last piece you pull together for a grant proposal. This piece of the proposal summarizes key information designed to convince a funder that the project is a viable candidate for their funding. The Project Summary should briefly address:

· The Problem

· The Solution

· Funding Requirements

· The Organization and Its Expertise

Project Narrative

Background information about the applying organization

What need or problem will this project address?

What is the overall goal of this project?

What objectives will need to be met in order to meet the goal?

What activities will be carried out during the project period so the objectives are met?

What is the timeline for project activities?

Who will be taking part in the project? Who is the project director?

What is the plan to evaluate the success of meeting the objectives?

Other Narrative notes

Funders

Names and URLs of potential funders

Search results

Key takeaways

Other Funder notes

Budget

What are costs associated with carrying out the project activities?

· Personnel (salary and benefits)

· Equipment

· Supplies

· Travel

· Consultants/Contractual

Will the project continue after the grant period ends? If so, how will it be sustained?

Other Budget notes

Project Summary

What is the problem?

What is the solution?

What are the funding requirements?

What is the organization and explain its expertise?

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The Assignment (2 page paper APA Style format): Title ” Role of Change Theory in Social Change. Briefly describe the issues you anticipate encountering in your strategic plan for the United Nations Environmental Protection . Explain the change you thin

Required Readings

Process Development Template

Project Summary

Project Narrative

Funders

Budget

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