Promoting First Relationships®—Home Visiting Options

Entries in this row combine information across all versions of Promoting First Relationships that are used with parents in the home.

Model effectiveness research report last updated: 2021

Model overview

Theoretical approach

Promoting First Relationships® (PFR), based on attachment theory, posits that developing strong early relationships with parents and other caregivers* is the key to healthy social, emotional, behavioral, language, and cognitive development in children. The model aims to promote parent/caregiver-child relationships by helping parents/caregivers read and understand children’s cues and the unmet needs behind challenging behaviors, and by supporting parents’/caregivers’ use of sensitive and responsive caregiving behaviors.

PFR can be used in multiple settings. The PFR-Home Visiting Options include two versions of PFR that are used with parents in the home: (1) PFR-Home Visiting Promotion Model and (2) PFR-Home Visiting Intervention Model. The only difference between the versions is that in the PFR-Home Visiting Intervention Model, home visitors must have a master’s degree. The PFR-Early Learning Model is used with caregivers responsible for group child care. The PFR-Pediatric Primary Care Model can be used one-on-one with parents during pediatric well-child visits for children from birth through age 2 years. The information in this profile describes the PFR-Home Visiting Promotion Model, but the information also applies to the PFR-Home Visiting Intervention Model unless specified otherwise.

*In this profile, the term “caregiver” refers to child care providers.

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Model services

The PFR-Home Visiting Promotion Model involves home visitors providing feedback to parents based on video recordings of the parent’s interactions with the child. The home visitor makes video recordings of the parent interacting with the child at home, and the home visitor and parent view and reflect on the recordings. The home visitor highlights positive interactions observed and offers instructive comments to enhance caregiving. The home visitor also helps the parent reflect on their own behavior, feelings, and needs during the interaction, as well as on those of the child. In addition, the PFR-Home Visiting Promotion Model provides parents with information, including handouts, on the social and emotional needs of young children, and strategies to meet these needs. The home visitor and the parent discuss ways to handle challenging behaviors and explore the parent’s own social-emotional development and how that influences caregiving.

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Intended population

The PFR-Home Visiting Promotion Model serves parents of children from birth through age 5 years.

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Where to find out more

Jennifer Rees
Director, Promoting First Relationships Home Visiting
Parent-Child Relationship Programs, Barnard Center
School of Nursing, University of Washington
Box 357231
Seattle, WA 98195
Phone: (206) 616-5380 
Email: rees@uw.edu
Website: http://pfrprogram.org/

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Effects shown in research & outcome measure details

Positive parenting practices

Findings rated high

Promoting First Relationships®—Home Visiting Intervention Model
Show findings details
Outcome measure Effect Follow-up timing Sample Sample size Intervention group Comparison group Group difference Effect size Statistical significance Notes

Dyadic synchronicity

FavorableUnfavorable or ambiguousNo Effect

12 months of age

PFR vs. comparison, Washington 2015-2020, full sample

252 mother/child dyads Adjusted mean = 6.45 Adjusted mean = 5.98 Difference = 0.43 Study reported = 0.19

Not statistically significant, p= 0.15

Adjusted to control for preferred language and baseline measure.

Dyadic synchronicity

FavorableUnfavorable or ambiguousNo Effect

12 months of age

PFR vs. comparison, Washington 2015-2020, full sample

225 mother/child dyads Unadjusted mean = 6.45 Unadjusted mean = 5.98 Mean difference = 0.47 = 0.21

Not statistically significant, p = 0.12

Unadjusted mean.

Dyadic synchronicity

FavorableUnfavorable or ambiguousNo Effect

6 months of age

PFR vs. comparison, Washington 2015-2020, full sample

239 mother/child dyads Unadjusted mean = 5.43 Unadjusted mean = 5.31 Mean difference = 0.12 = 0.05

Not statistically significant, p = 0.68

Unadjusted mean.

Dyadic synchronicity

FavorableUnfavorable or ambiguousNo Effect

6 months of age

PFR vs. comparison, Washington 2015-2020, full sample

252 mother/child dyads Adjusted mean = 5.43 Adjusted mean = 5.31 Difference = 0.01 Study reported = 0.00

Not statistically significant, p= 0.98

Adjusted to control for preferred language and baseline measure.

Maternal confidence

FavorableUnfavorable or ambiguousNo Effect

12 months of age

PFR vs. comparison, Washington 2015-2020, full sample

243 mothers Unadjusted mean = 4.40 Unadjusted mean = 4.36 Mean difference = 0.04 = 0.11

Not statistically significant, p = 0.38

Unadjusted mean.

Maternal confidence

FavorableUnfavorable or ambiguousNo Effect

12 months of age

PFR vs. comparison, Washington 2015-2020, full sample

252 mothers Adjusted mean = 4.40 Adjusted mean = 4.36 Difference = 0.02 Study reported = 0.05

Not statistically significant, p= 0.52

Adjusted to control for preferred language and baseline measure.

Maternal confidence

FavorableUnfavorable or ambiguousNo Effect

6 months of age

PFR vs. comparison, Washington 2015-2020, full sample

244 mothers Unadjusted mean = 4.44 Unadjusted mean = 4.36 Mean difference = 0.08 = 0.23

Not statistically significant, p = 0.07

Unadjusted mean.

Maternal confidence

FavorableUnfavorable or ambiguousNo Effect

6 months of age

PFR vs. comparison, Washington 2015-2020, full sample

252 mothers Adjusted mean = 4.44 Adjusted mean = 4.36 Difference = 0.05 Study reported = 0.12

Not statistically significant, p= 0.10

Adjusted to control for preferred language and baseline measure.

Parenting sensitivity

FavorableUnfavorable or ambiguousNo Effect

12 months of age

PFR vs. comparison, Washington 2015-2020, full sample

225 mothers Unadjusted mean = 36.73 Unadjusted mean = 35.32 Mean difference = 1.41 = 0.32

Statistically significant, p = 0.02

Unadjusted mean.

Parenting sensitivity

FavorableUnfavorable or ambiguousNo Effect

12 months of age

PFR vs. comparison, Washington 2015-2020, full sample

252 mothers Adjusted mean = 36.73 Adjusted mean = 35.32 Difference = 1.28 Study reported = 0.26

Statistically significant, p= 0.03

Adjusted to control for preferred language and baseline measure.

Parenting sensitivity

FavorableUnfavorable or ambiguousNo Effect

6 months of age

PFR vs. comparison, Washington 2015-2020, full sample

238 mothers Unadjusted mean = 33.86 Unadjusted mean = 32.38 Mean difference = 1.48 = 0.30

Statistically significant, p = 0.02

Unadjusted mean.

Parenting sensitivity

FavorableUnfavorable or ambiguousNo Effect

6 months of age

PFR vs. comparison, Washington 2015-2020, full sample

252 mothers Adjusted mean = 33.86 Adjusted mean = 32.38 Difference = 1.24 Study reported = 0.25

Statistically significant, p= 0.05

Adjusted to control for preferred language and baseline measure.

Understanding of toddlers

FavorableUnfavorable or ambiguousNo Effect

12 months of age

PFR vs. comparison, Washington 2015-2020, full sample

252 mothers Adjusted mean = 51.84 Adjusted mean = 48.67 Difference = 2.32 Study reported = 0.45

Statistically significant, p <0.001

Adjusted to control for preferred language and baseline measure.

Understanding of toddlers

FavorableUnfavorable or ambiguousNo Effect

12 months of age

PFR vs. comparison, Washington 2015-2020, full sample

243 mothers Unadjusted mean = 51.84 Unadjusted mean = 48.67 Mean difference = 3.17 = 0.64

Statistically significant, p = 0.00

Unadjusted mean.

Understanding of toddlers

FavorableUnfavorable or ambiguousNo Effect

6 months of age

PFR vs. comparison, Washington 2015-2020, full sample

252 mothers Adjusted mean = 52.07 Adjusted mean = 50.17 Difference = 1.06 Study reported = 0.21

Statistically significant, p= 0.03

Adjusted to control for preferred language and baseline measure.

Understanding of toddlers

FavorableUnfavorable or ambiguousNo Effect

6 months of age

PFR vs. comparison, Washington 2015-2020, full sample

244 mothers Unadjusted mean = 52.07 Unadjusted mean = 50.17 Mean difference = 1.90 = 0.38

Statistically significant, p = 0.00

Unadjusted mean.

Show outcome measure summary
Outcome measure Outcome measure description Collection method Properties

Dyadic synchronicity

The Infant CARE-Index (ICI) assesses parent-infant interaction during play on one dyadic scale, three parent scales, and four child scales.

Videotaped parent-child interaction

Intraclass correlation = 0.69

Maternal confidence

The Maternal Confidence Questionnaire (MCQ) is a 14-item scale that measures mothers' perceptions of their ability to care for and understand their infants.

Caregiver questionnaire

Cronbach's α range from 0.66 to 0.76 across the three study time points

Parenting sensitivity

The Nursing Child Assessment Teaching Scale (NCATS) is a binary scale that includes 73 items measuring maternal and child contributions to dyadic interactive quality. This subscale reflects the 50 items measuring maternal contributions.

Videotaped parent-child interaction

Cronbach's α = 0.72

Understanding of toddlers

The Raising a Baby Scale (RAB) is a 16-item questionnaire that measures caregiver knowledge of infants' and toddlers' social-emotional needs.

Caregiver questionnaire

Cronbach's α range from 0.68 to 0.71 across the three study time points

Promoting First Relationships®—Home Visiting Intervention Model
Show findings details
Outcome measure Effect Follow-up timing Sample Sample size Intervention group Comparison group Group difference Effect size Statistical significance Notes

Commitment: This Is My Baby (TIMB)

FavorableUnfavorable or ambiguousNo Effect

Post-intervention

PFR vs. EES, one county in Washington state, 2007-2010, full sample

169 caregivers Not reported Not reported Not reported Not available

Not statistically significant, p= >0.10

Finding estimated with hierarchical linear model (HLM).

Commitment: This Is My Baby (TIMB)

FavorableUnfavorable or ambiguousNo Effect

Post-intervention

PFR vs. EES, one county in Washington state, 2007-2010, full sample

169 caregivers Adjusted mean = 4.10 Adjusted mean = 4.21 Mean difference = -0.11 Study reported = -0.17

Not statistically significant, p= 0.35

Engagement: Indicator of Parent-Child Interaction (IPCI, 9 item subscale)

FavorableUnfavorable or ambiguousNo Effect

Post-intervention

PFR vs. EES, one county in Washington state, 2007-2010, full sample

173 children Adjusted mean = 2.08 Adjusted mean = 2.15 Mean difference = -0.07 Study reported = -0.15

Not statistically significant, p= 0.39

Engagement: Indicator of Parent-Child Interaction (IPCI, 9 item subscale)

FavorableUnfavorable or ambiguousNo Effect

Post-intervention

PFR vs. EES, one county in Washington state, 2007-2010, full sample

173 children Not reported Not reported Not reported Not available

Not statistically significant, p= >0.10

Finding estimated with hierarchical linear model (HLM).

Sensitivity: Nursing Child Assessment Teaching Scale (NCATS, without 6 items on child distress)

FavorableUnfavorable or ambiguousNo Effect

Post-intervention

PFR vs. EES, one county in Washington state, 2007-2010, full sample

167 caregivers Adjusted mean = 13.26 Adjusted mean = 11.76 Mean difference = 1.50 Study reported = 0.41

Statistically significant, p= 0.02

Support: Indicator of Parent-Child Interaction (IPCI, 15 items)

FavorableUnfavorable or ambiguousNo Effect

Post-intervention

PFR vs. EES, one county in Washington state, 2007-2010, full sample

173 caregivers Adjusted mean = 2.18 Adjusted mean = 2.14 Mean difference = 0.04 Study reported = 0.11

Not statistically significant, p= 0.49

Support: Indicator of Parent-Child Interaction (IPCI, 15 items)

FavorableUnfavorable or ambiguousNo Effect

Post-intervention

PFR vs. EES, one county in Washington state, 2007-2010, full sample

173 caregivers Not reported Not reported Not reported Not available

Not statistically significant, p= >0.10

Finding estimated with hierarchical linear model (HLM).

Understanding of toddlers: Raising a Baby (RAB, 16 items)

FavorableUnfavorable or ambiguousNo Effect

Post-intervention

PFR vs. EES, one county in Washington state, 2007-2010, full sample

175 caregivers Adjusted mean = 52.16 Adjusted mean = 50.92 Mean difference = 1.24 Study reported = 0.36

Statistically significant, p= 0.04

Understanding of toddlers: Raising a Baby (RAB, 16 items)

FavorableUnfavorable or ambiguousNo Effect
Post-intervention

PFR vs. EES, one county in Washington state, 2007-2010, full sample

175 caregivers Not reported Not reported Not reported Not available

Statistically significant, p= <0.01

Finding estimated with hierarchical linear model (HLM).

Show outcome measure summary
Outcome measure Outcome measure description Collection method Properties

Commitment: This Is My Baby (TIMB)

The TIMB consists of interview questions that assess the caregiver's commitment to supporting the child's growth and development.

Interview responses rated by two trained coders

Interrater agreement: r = 0.89

Engagement: Indicator of Parent-Child Interaction (IPCI, 9 item subscale)

The IPCI is an observational screening and monitoring tool for early intervention use in the home.

Observations scored by two trained coders

Interrater agreement: r = 0.81 at baseline, r = 0.79 at post-intervention, and r = 0.82 at 6-month follow-up

Sensitivity: Nursing Child Assessment Teaching Scale (NCATS, without 6 items on child distress)

The NCATS is a videotaped interaction to assess caregiver sensitivity, stimulation of the child, and emotional responsiveness.

Videotaped interaction scored by a trained coder

Cronbach's α: 0.74 at baseline, 0.79 at post-intervention, 0.71 at 6-month follow-up

Support: Indicator of Parent-Child Interaction (IPCI, 15 items)

The IPCI is an observational screening and monitoring tool for early intervention use in the home.

Interaction rated by two trained coders and averaged across three activities: free play, reading, and a distraction task

Interrater agreement: r = 0.84 at baseline, 0.76 at post-intervention, and 0.80 at 6-month follow-up

Understanding of toddlers: Raising a Baby (RAB, 16 items)

The RAB is a measure of caregiver knowledge of infant and toddler social emotional needs and developmentally appropriate expectations.

Self-administered survey of caregivers

Cronbach's α: 0.71 at baseline, 0.73 at post-intervention, and 0.77 at 6-month follow-up

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Child development and school readiness

Findings rated high

Promoting First Relationships®—Home Visiting Intervention Model
Show findings details
Outcome measure Effect Follow-up timing Sample Sample size Intervention group Comparison group Group difference Effect size Statistical significance Notes

Difficultness

FavorableUnfavorable or ambiguousNo Effect

12 months of age

PFR vs. comparison, Washington 2015-2020, full sample

225 infants Unadjusted mean = 2.23 Unadjusted mean = 2.71 Mean difference = -0.48 = -0.22

Not statistically significant, p = 0.11

,

Unadjusted mean.

Difficultness

FavorableUnfavorable or ambiguousNo Effect

12 months of age

PFR vs. comparison, Washington 2015-2020, full sample

252 infants Adjusted mean = 2.23 Adjusted mean = 2.71 Difference = -0.49 Study reported = -0.16

Not statistically significant, p= 0.09

Adjusted to control for preferred language and baseline measure.

Dysregulation

FavorableUnfavorable or ambiguousNo Effect

12 months of age

PFR vs. comparison, Washington 2015-2020, full sample

243 infants Unadjusted mean = 54.82 Unadjusted mean = 55.33 Mean difference = -0.51 = -0.04

Not statistically significant, p = 0.77

,

Unadjusted mean.

Dysregulation

FavorableUnfavorable or ambiguousNo Effect

12 months of age

PFR vs. comparison, Washington 2015-2020, full sample

252 infants Adjusted mean = 54.82 Adjusted mean = 55.33 Difference = -0.56 Study reported = -0.04

Not statistically significant, p= 0.75

Adjusted to control for preferred language.

Externalizing behavior

FavorableUnfavorable or ambiguousNo Effect

12 months of age

PFR vs. comparison, Washington 2015-2020, full sample

243 infants Unadjusted mean = 59.24 Unadjusted mean = 62.54 Mean difference = -3.30 = -0.28

Statistically significant, p = 0.03

,

Unadjusted mean.

Externalizing behavior

FavorableUnfavorable or ambiguousNo Effect

12 months of age

PFR vs. comparison, Washington 2015-2020, full sample

252 infants Adjusted mean = 59.24 Adjusted mean = 62.54 Difference = -3.27 Study reported = -0.28

Statistically significant, p= 0.03

Adjusted to control for preferred language.

Internalizing behavior

FavorableUnfavorable or ambiguousNo Effect

12 months of age

PFR vs. comparison, Washington 2015-2020, full sample

243 infants Unadjusted mean = 53.64 Unadjusted mean = 54.93 Mean difference = -1.29 = -0.12

Not statistically significant, p = 0.37

,

Unadjusted mean.

Internalizing behavior

FavorableUnfavorable or ambiguousNo Effect

12 months of age

PFR vs. comparison, Washington 2015-2020, full sample

252 infants Adjusted mean = 53.64 Adjusted mean = 54.93 Difference = -1.22 Study reported = -0.11

Not statistically significant, p= 0.39

Adjusted to control for preferred language.

Show outcome measure summary
Outcome measure Outcome measure description Collection method Properties

Difficultness

The Infant CARE-Index (ICI) assesses parent-infant interaction during play on one dyadic scale, three parent scales, and four child scales.

Videotaped parent-child interaction

Intraclass correlation = 0.55

Dysregulation

Subscale from 126-item normed assessment of child behaviors, the Infant Toddler Social Emotional Assessment (ITSEA).

Caregiver report

Cronbach's α = 0.80

Externalizing behavior

Subscale from 126-item normed assessment of child behaviors, the Infant Toddler Social Emotional Assessment (ITSEA).

Caregiver report

Cronbach's α = 0.81

Internalizing behavior

Subscale from 126-item normed assessment of child behaviors, the Infant Toddler Social Emotional Assessment (ITSEA).

Caregiver report

Cronbach's α = 0.68

Promoting First Relationships®—Home Visiting Intervention Model
Show findings details
Outcome measure Effect Follow-up timing Sample Sample size Intervention group Comparison group Group difference Effect size Statistical significance Notes

Attachment security: Toddler Attachment Sort-45 (TAS45, modified version of Attachment Q-Sort, using trilemmas)

FavorableUnfavorable or ambiguousNo Effect

Post-intervention

PFR vs. EES, one county in Washington state, 2007-2010, full sample

175 children Not reported Not reported Not reported Not available

Not statistically significant, p= >0.10

Finding estimated with hierarchical linear model (HLM).

Attachment security: Toddler Attachment Sort-45 (TAS45, modified version of Attachment Q-Sort, using trilemmas)

FavorableUnfavorable or ambiguousNo Effect

Post-intervention

PFR vs. EES, one county in Washington state, 2007-2010, full sample

175 children Adjusted mean = 0.58 Adjusted mean = 0.54 Mean difference = 0.04 Study reported = 0.16

Not statistically significant, p= 0.41

Competence: Brief Infant Toddler Social and Emotional Assessment (BITSEA, 11 item subscale)
FavorableUnfavorable or ambiguousNo Effect

Post-intervention

PFR vs. EES, one county in Washington state, 2007-2010, full sample

175 children Not reported Not reported Not reported Not available

Not statistically significant, p= >0.10

Finding estimated with hierarchical linear model (HLM).

Competence: Brief Infant Toddler Social and Emotional Assessment (BITSEA, 11 item subscale)

FavorableUnfavorable or ambiguousNo Effect

Post-intervention

PFR vs. EES, one county in Washington state, 2007-2010, full sample

163 children Adjusted mean = 17.35 Adjusted mean = 16.38 Mean difference = 0.97 Study reported = 0.42

Statistically significant, p= 0.03

Problem behavior: Brief Infant Toddler Social and Emotional Assessment (BITSEA, 31 item subscale)

FavorableUnfavorable or ambiguousNo Effect

Post-intervention

PFR vs. EES, one county in Washington state, 2007-2010, full sample 175 children Not reported Not reported Not reported Not available

Not statistically significant, p= >0.10

Negative effect is favorable to the intervention. Finding estimated with hierarchical linear model (HLM).

Problem behavior: Brief Infant Toddler Social and Emotional Assessment (BITSEA, 31 item subscale)

FavorableUnfavorable or ambiguousNo Effect

Post-intervention

PFR vs. EES, one county in Washington state, 2007-2010, full sample

163 children Adjusted mean = 10.81 Adjusted mean = 10.72 Mean difference = 0.09 Study reported = -0.02

Not statistically significant, p= 0.92

Show outcome measure summary
Outcome measure Outcome measure description Collection method Properties

Attachment security: Toddler Attachment Sort-45 (TAS45, modified version of Attachment Q-Sort, using trilemmas)

The TAS45 is a modified version of the Attachment Q-Sort, a standard attachment measure, and measures child attachment behaviors.

Observations scored by two trained observers

Interrater reliability: r = 0.66 at baseline, r = 0.80 at post-intervention, and r = 0.96 at 6-month follow-up

Competence: Brief Infant Toddler Social and Emotional Assessment (BITSEA, 11 item subscale)

The BITSEA assesses children's social or emotional behavior problems and competencies based on the Infant Toddler Social Emotional Assessment (ITSEA).

Self-administered survey of caregivers

Cronbach's α: 0.69 at baseline and post-intervention and 0.70 at 6-month follow-up

Problem behavior: Brief Infant Toddler Social and Emotional Assessment (BITSEA, 31 item subscale)

The BITSEA assesses children's social or emotional behavior problems and competencies based on the Infant Toddler Social Emotional Assessment (ITSEA).

Self-administered survey of caregivers

Cronbach's α: 0.79 at baseline, 0.75 at post-intervention, and 0.77 at 6-month follow-up

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In brief

Evidence of model effectiveness

This model does not meet the criteria established by the Department of Health and Human Services (HHS) for an “evidence-based early childhood home visiting service delivery model” for the general population or for tribal populations because the findings from high- or moderate-rated effectiveness studies of the model do not meet all required criteria.

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Model description

The Promoting First Relationships (PFR)-Home Visiting Options include two versions that are used with parents in the home: (1) PFR-Home Visiting Promotion Model and (2) PFR-Home Visiting Intervention Model. The only difference between the versions is that in the PFR-Home Visiting Intervention Model, home visitors must have a master’s degree. PFR can also be used one-on-one with parents in a health clinic and with caregivers responsible for group child care. The HomVEE review is based on the PFR-Home Visiting Options. The PFR-Home Visiting Options seek to promote children’s social-emotional development by helping parents read and understand children’s cues and the unmet needs behind challenging behaviors, and supporting parents’ use of sensitive and responsive caregiving behaviors. Both of the PFR-Home Visiting Options serve parents of children from birth through age 5 years. A trained home visitor video records the parent interacting with their child at home, and the home visitor and parent view and reflect on the recordings. In addition, the PFR-Home Visiting Options provide parents with information, including handouts, on the social and emotional needs of young children, and strategies to meet these needs. The PFR-Home Visiting Options provide weekly hour-long home visits for 10 to 14 weeks but can be extended based on a family’s needs.

For more information on the PFR-Home Visiting Options, please read the Model Overview.

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Extent of evidence

Promoting First Relationships®—Home Visiting Promotion Model
Results of search and review
Number of manuscripts
At least one finding was eligible for review…
2
  …and at least one finding rated high
0
  …and at least one finding rated moderate (but none rated high)
0
  …and all findings that were eligible for review rated low
1
  …but manuscript is additional source2
1
Promoting First Relationships®—Home Visiting Intervention Model
Results of search and review
Number of manuscripts
At least one finding was eligible for review…
9
  …and at least one finding rated high
3
  …and at least one finding rated moderate
0
  …and all findings that were eligible for review rated low
6
  …but manuscript is additional source2
0

For more information, see the research database. For more information on the criteria used to rate research, please see details of HomVEE’s methods and standards.

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Summary of findings

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Criteria established by the U.S. Department of Health and Human Services

Information based on comprehensive review of all high- and moderate-rated manuscripts
Promoting First Relationships®—Home Visiting Promotion Model

This model has no manuscripts that report high- or moderate-rated findings.

Promoting First Relationships®—Home Visiting Intervention Model
CriterionCriterion descriptionCriterion met?
1High- or moderate-quality impact study?Yes
2Across high- or moderate-quality studies, favorable impacts in at least two outcome domains within one sample OR the same domain for at least two non-overlapping samples?Yes
3Favorable impacts on full sample?Yes
4Any favorable impacts on outcome measures sustained at least 12 months after model enrollment?
Reported for all research but only required for RCTs.
No
5One or more favorable, statistically significant impact reported in a peer-reviewed journal?
Reported for all research but only required for RCTs.
Yes
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