A realist model for home visitation program evaluation

Increased attention on home visitation as a strategy to reduce child maltreatment and increased funding to support home visitation programs has led to their rapid and widespread adoption in the United States and internationally. The rapid adoption of home visitation programs has occurred without an adequate understanding of the underlying mechanisms of influence on child maltreatment. Consequently, there is a lack of consistency in structures and processes across programs. The variability in structures and processes within and across programs has contributed to the inconsistent findings related to the effectiveness of home visitation as a strategy to constrain child maltreatment. Identifying the underlying mechanisms that are facilitating or constraining program success or failure is essential for informing policy and practice. We propose the use of realist theory to identify the underlying mechanisms of home visitation programs. While realist theory has been used broadly in the social sciences, its uptake in nursing has been slow. Despite its limited use in nursing, realism's primary function, seeking to identify the underlying mechanisms in complex social programs, makes it suitable for investigating many complex phenomena that are of interest to nurse scientists. Here we discuss the theoretical foundations for home visitation programs, the recent evidence for program effectiveness, significant home visitation program components, and we propose a realist model for home visitation program evaluation that may aid in identifying how, for whom, and under what conditions home visitation programs work when these programs are implemented to address child maltreatment.