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Intervention

Healthy Families America is a voluntary home visitation program designed to promote healthy families and children through a variety of services, including child development, access to health care, and parent education. The program targets families identified as at risk, with children ages prenatal to 5. Program goals include prevention of negative birth outcomes (low birth weight, substance abuse, criminal activity, child abuse, and neglect), increased parenting skills, healthy pregnancy practices, and the use of social systems. Assessments are conducted prenatally or at the time of birth.

All Healthy Families America sites must adhere to a set of critical program elements based on current knowledge about what constitutes a successful home visitation program. These elements provide each site the flexibility to adapt its program design to local needs and conditions and innovate where possible. Moreover, Healthy Families America’s credentialing process uses the elements to measure and improve the quality of services each site offers. The critical elements are as follows:

Initiating Services Prenatally or at Birth

• The sites use a standardized assessment tool to systematically identify families who most need services.
• Families voluntarily participate in the program. Caseworkers use positive outreach efforts to build family trust in the caseworker and the program.

Providing Services

• Home visitors offer participating families long-term services (usually 3 to 5 years), beginning intensively (at least one visit per week), and use well-defined criteria for determining whether the intensity of service should be increased or decreased.
• Services are culturally sensitive.
• Comprehensive services support parents, parent–child interaction, and child development.
• Families are linked to a medical provider (for timely inoculations and well-child care) and, if needed, financial assistance, food and housing assistance programs, school readiness programs, child care, job training programs, family support centers, substance abuse treatment programs, and domestic violence shelters.
• Home visitors carry a light caseload; the caseload varies from fewer than 10 families to as many as 15.

Selecting and Training Home Visitors

• Caseworkers are chosen based on their ability to establish trusting relationships with participating families.
• All service providers receive basic training in cultural competency, substance abuse, child abuse reporting, domestic violence, drug-exposed infants, and available services in their community.
• Service providers are trained so they understand the components of family assessment and home visitation.
  

Evaluation

The program has been evaluated in about 30 different studies. These evaluations used several different designs, including randomized experiments, quasi-experiments with comparison groups, and several single-group, pretest–posttest designs.

Two of the most comprehensive evaluations are Hawaii’s Healthy Start Program (HHSP) and Healthy Families New York (HFNY). In the HHSP study, families were randomly assigned to the Healthy Families America treatment group, the control group, or the testing control group. Whereas the first two groups were evaluated annually, the testing control group was evaluated only at 3 years, which controlled for a testing bias influencing the results. The treatment group consisted of 373 families; the mothers were 21 percent Native Hawaiian, 18 percent Filipina, 13 percent Pacific Islander, 11 percent white, 10 percent Asian, and 28 percent multiracial or unknown. Throughout the study the treatment program was run by three different community organizations: the Hawaii Family Support Center, Child and Family Service, and Parents and Children Together. The control group consisted of 270 families; the mothers were 20 percent Filipina, 19 percent Native Hawaiian, 14 percent Pacific Islander, 13 percent white, 7 percent Asian, and 26 percent multiracial or unknown. The testing control group had 74 families (ethnicities were not reported).

In the HFNY study, at-risk women who were pregnant or who had an infant less than 3 months in New York’s Erie, Rensselaer, and Ulster Counties were screened and assessed for risk of child abuse and neglect. A total of 1,296 women met the eligibility criteria for the program and agreed to participate in the study. Among those women, 1,157 (89 percent) completed an intake interview and became study participants. The sample is comparable with the population of families enrolled in HFNY programs across the State on a range of measures such as demographics, employment, prior child abuse reports, substance use, and depression. Almost 60 percent were first-time mothers; 22 percent had been physically abused in the previous year by a partner or spouse; and 8 percent had substantiated child-abuse or child-neglect reports prior to intake. The participants were randomly assigned to the treatment (n=568) or the control (n=589) group. The control group was given information and referrals to other appropriate services available in the community. Baseline statistics on the measures mentioned above showed no significant differences between the HFNY group and the control group.

Outcome

A summary of all the evaluations of Healthy Families America indicates that the program produces measurable benefits for participants in areas such as parent–child interaction and parental capacity. Most families receiving these services appear better able to care for their children, to access and effectively use health care services, to avoid reports of child abuse or neglect, and to resolve many personal and familial problems common among low-income, single-parent families. While many of these findings have emerged from the quasi-experimental designs, the randomized trials have produced similar findings.

The HHSP evaluation revealed that a well-implemented Healthy Families America program can achieve positive results. At 1 year, mothers in the treatment group were less likely to have poor general mental health, though this difference was not seen at 2 years. Treatment mothers increased their use of nonviolent strategies, and mothers experienced less stress related to parenting and felt more competent in their parenting skills. According to self-reports, control mothers were more likely to engage in neglectful behavior in the child’s 1st year of life; this difference also disappeared during the 2nd year. Overall, there were no group differences in the reported developmental status of children or use of physical assaults, and both groups had similar maternal life skills, social support, substance use, and depressive symptoms. The Hawaii Family Support Center site had a significant decrease in overall partner violence, while Child and Family Service had a significant positive effect on child development.

The HFNY study found overall positive program effects in terms of childbirth outcomes. HFNY mothers experienced better childbirth outcomes than control mothers. Specifically, among those in the sample who were randomized at least 2 months before the birth of their children, control group mothers were significantly more likely than HFNY group mothers to deliver low-birth-weight babies. The mean rate of low birth weight was 2½ times as high for the control group (8.3 percent) as for the HFNY group (3.3 percent).

The HFNY study also found overall positive program effects in terms of parenting practices. Compared with parents in the control group, HFNY participants were less likely to report neglecting their children and reported committing fewer acts of severe physical abuse, minor physical aggression, and psychological aggression against their children. Specifically, the study found that, compared with the control group parents,

• HFNY parents reported having engaged in significantly fewer acts of serious abuse and neglect (0.20 compared with 0.48), but the prevalence (whether a parent ever engaged in a behavior) of such serious abusive or neglectful practices did not differ significantly between the groups.
• HFNY parents had a significantly lower prevalence of self-reported neglect (5.4 percent compared with 8.5 percent), but the frequency of self-reported neglect did not differ significantly between the two groups.
• HFNY parents engaged in significantly fewer self-reported acts of severe/very severe physical abuse (0.06 compared with 0.42), but the prevalence of self-reported severe/very severe physical abuse did not differ significantly between the groups.
• HFNY parents engaged in fewer acts of minor physical aggression (2.34 compared with 3.27), but the prevalence of minor physical aggression was not significantly different between the two groups.
• HFNY parents engaged in fewer acts of psychological aggression (3.21 compared with 4.92). The prevalence of psychological aggression was not tested.
• However, no significant differences were observed between the HFNY and control groups with respect to the rate or average number of Child Protective Services–substantiated abuse and neglect reports.
  

Endorsements

• OJJDP/CSAP: Strengthen Families

References

Daro, Deborah, and Kathryn Harding. 1999. “Healthy Families America: Using Research to Enhance Practice.” The Future of Children Home Visiting: Recent Program Evaluations 9(1):152–76.

Díaz, Javier, Domarina Oshana, and Kathryn Harding. 2003. “Healthy Families America: 2003 Annual Profile of Program Sites.” Chicago, Ill.: National Center on Child Abuse Prevention Research, Prevent Child Abuse America. Available at http://www.healthyfamiliesamerica.org/downloads/hfa_site_survey.pdf/.

Duggan, Anne K., Elizabeth C. McFarlane, Amy M. Windham, Charles A. Rohde, David S. Salkever, Loretta Fuddy, Leon A. Rosenberg, Sharon B. Buchbinder, and Calvin C.J. Sia. 1999. “Evaluation of Hawaii’s Healthy Start Program.” The Future of Children Home Visiting: Recent Program Evaluations 9(1):66–90.

Duggan, Anne K., Amy M. Windham, Elizabeth C. McFarlane, Loretta Fuddy, Charles A. Rohde, Sharon B. Buchbinder, and Calvin C.J. Sia. 2000. “Hawaii’s Healthy Start Program of Home Visiting for At-Risk Families: Evaluation of Family Identification, Family Engagement, and Service Delivery.” Pediatrics 105 (1): 250–59.

Mitchell–Herzfeld, Susan, Charles Izzo, Rose Greene, Eunju Lee, and Ann Lowenfels. 2005. Evaluation of Healthy Families New York (HFNY): 1st Year Program Impacts. Rensselaer, N.Y.: New York State Office of Children and Family Services, Bureau of Evaluation and Research. Albany, N.Y.: Center for Human Services Research, University at Albany. Available at http://www.ocfs.state.ny.us/main/prevention/assets/HFNY_FirstYearProgramImpacts.pdf/.

Whipple, Ellen, and Laura Nathans. 2005. “Evaluation of a Rural Healthy Families in America (HFA) Program: The Importance of Context.” Families in Society 86 (1):71–82.

Contact

Lisa Schreiber, Director, State Systems Development
Healthy Families America
200 South Michigan Avenue, Suite 1700
Chicago, IL 60604
Phone: (312) 663-3520
Fax: (312) 939-8962
E-mail: lschreiber@preventchildabuse.org
Web site: http://www.healthyfamiliesamerica.org

Technical Assistance Provider

Helen Reif
Prevent Child Abuse America
200 South Michigan Avenue, Suite 1700
Chicago, IL 60604
Phone: (312) 334-6830
E-mail: hreif@preventchildabuse.org