Program Profile: Healthy Families America

This is a home-visitation program for expectant and new parents, which was designed to prevent child abuse or neglect. The program is rated No Effects. Treatment group mothers showed statistically significant improvements on some outcomes, such as parental stress and discipline strategies, compared with control group mothers. However, there were no statistically significant differences between the groups in neglect, foster care placement, or substantiated child protective services reports.

A No Effects rating implies that implementing the program is unlikely to result in the intended outcome(s) and may result in a negative outcome(s).

This program's rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Goals/Target Population

Healthy Families America (HFA) was designed to promote child well-being and prevent the abuse and neglect of children through home-visiting services. The program specifically targets expectant and new parents who are identified as being at high risk of abusing or neglecting their children. Parents are identified as “high risk” through assessments conducted by various collaborative agencies, such as prenatal care providers and hospitals. Generally, assessments are conducted before or at the time of a child’s birth, and enrollment in the program can begin anywhere from before to 3 months after birth. The overall goals of the program are to build and sustain community partnerships to systematically engage overburdened families in home visiting services prenatally or at birth; cultivate and strengthen nurturing parent–child relationships; promote healthy childhood growth and development; and enhance family functioning by reducing risk and building protective factors.

Program Theory

The HFA model uses a strengths-based approach, which promotes parent–child bonding and positive interactions, educates parents about child health and development, helps parents access community resources, and uses family and community supports to assist parents in addressing problems such as substance abuse or mental health issues.

Program Components

All HFA 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 to innovate where possible. Moreover, HFA’s credentialing process uses the elements to measure and improve the quality of services that 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 15 families who are currently being seen weekly to no more than 25.

Selecting and training home visitors

• Caseworkers are chosen on the basis of 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 to understand the components of family assessment and home visitation.

Study

Green and colleagues (2016) conducted a randomized controlled trial of the Healthy Families Oregon (HFO) program, which was officially initiated in 2007. Seven of the 35 operational HFO programs were selected based on whether they met state and national performance standards. The program used the New Baby Questionnaire (NBQ) to identify at-risk first-time parents with an infant under 90 days old. Families with two or more risk factors were eligible for the home-visiting services. Because there were limited program slots, all eligible parents (n = 2,727) were entered into a lottery and then randomly assigned to either the HFO treatment group (n = 1,438) or the control group (n = 1,289). The treatment group received HFO home visitation services, and the control group received community services as usual.

Families in the treatment group were 57.3 percent white, 27.0 percent Hispanic/Latino, and 15.7 percent identified as other. The average age of first-time parents was 21.9 years, with 36.5 percent of parents having at least two baseline risk factors, 29.0 percent having three baseline risk factors, and 34.5 percent having four or more baseline risk factors. Eighty-one percent of HFO first-time mothers were unmarried, 30.6 percent were teen mothers (19 years or younger), and 33.2 percent did not have a high school diploma or GED. Control group families were 60.4 percent white, 24.2 percent Hispanic, and 15.4 percent identified as other. The average age of first-time parents was 22.0 years, with 36.6 percent of parents having two or fewer baseline risk factors, 28.9 percent with three baseline risk factors, and 34.5 percent with four or more baseline risk factors. Control parents were mostly unmarried (81.2 percent), 30.4 percent of mothers were teen mothers, and 31.3 percent did not have a high school diploma or GED. There were no statistically significant differences between mothers in the treatment and control groups in demographic characteristics at baseline.

Outcomes of interest were reports of maltreatment, out-of-home placements, and parental substance abuse treatment at the 24-month follow up. Outcomes data were retrieved from the statewide service database and a data warehouse managed by the Oregon Department of Human Services and Oregon Health Authority. Logistic regression was used for dichotomous outcome variables, such as “ever had any maltreatment report (yes or no)” and multiple linear regression for continuous outcomes such as days in out-of-home placement. A subgroup analysis determined whether child welfare outcomes differed for families with different baseline characteristics.

Study

Jacobs and colleagues (2015) conducted a randomized controlled trial to examine the impact of the Healthy Families Massachusetts (HFM) program on first-time mothers. Eligibility criteria for the study included mothers who were between 16 and 20 years of age and had not received HFM services in the past. The final sample consisted of 704 mothers. The treatment group (n = 433) received home-visiting services (HVS) through HFM, and the control group (n = 271) received referrals to other services and were provided information about child development.

The treatment and control group mothers were white (37 percent), Hispanic (36 percent), Black (19 percent), or identified as non-Hispanic other (8 percent). The average age of mothers at enrollment was 18.6 years. Sixty-five percent of mothers were pregnant at enrollment, 35 percent were parenting during enrollment, and 4 percent had at least one Department of Children and Families (DCF) maltreatment report prior to enrollment in HFM. There were statistically significant differences between the treatment and control groups on baseline characteristics. Specifically, treatment group mothers were more likely to be Hispanic (39 percent) than control group mothers (31 percent), and treatment group mothers were less likely to be born in the United States (9 percent were born in Puerto Rico, 13 percent were born outside of the continental United States), compared with mothers in the control group (4 percent were born in Puerto Rico, 10 percent were born outside of the continental United States). To adjust for these differences, the study authors controlled for the background characteristics in all analyses.

Outcomes of interest included at least one substantiated report of abuse, nonviolent discipline practices, parental stress, child social-emotional/behavioral problems and competencies, high school/GED completion, mothers’ current employment status, repeat pregnancy, and whether the mother engaged in three or more risky behaviors. Reports of at least one substantiated report of abuse was measured by whether there was sufficient evidence to justify DCF intervention after investigation of child maltreatment. Nonviolent discipline practices were measured using Conflict Tactics Scale–Parent-Child (CTS–PC). Child behavioral skills was measured using the Brief Infant–Toddler Social and Emotional Assessment (BITSEA), which generates children’s social-emotional and behavioral problems and competencies by summing 31 items that then indicate problematic behavior. High school/ GED completion, repeat pregnancy, and maternal employment status were self-reported through phone interviews. Whether the mother engaged in three or more risky behaviors was measured through self-reports of engaging in any of the 12 risky behavior indexes in the past 30 days (i.e., rode with a driver drinking alcohol, smoked at least one cigarette every day, and engaged in unprotected sex).

Data were retrieved from Participant Data System (PDS), state public agencies (i.e., DCF, Department of Elementary and Secondary Education, Department of Public Health, and Department of Transitional Assistance), and the 2010 U.S. Census. Follow-up interviews were conducted at 1 month, 12 months, and 24 months after enrollment. Ordinary logistic regression and ordinary least squares regression were used to examine group differences in the outcomes. An ITT approach was used to examine data. The study authors conducted subgroup analyses based on 16 various mother experiences and characteristics.

Study

DuMont and colleagues (2011) conducted a randomized controlled trial of Healthy Families New York (HFNY), which was initiated in 2000. The study included 1,173 mothers (treatment group n = 579, control group n = 594) at three HFNY sites that served inner-city neighborhoods, smaller cities, and suburban and rural areas. Mothers were selected for the study based on the same criteria used to determine eligibility for HFNY, which included those who were deemed as high risk for perpetrating child abuse or neglect and lived in communities with high rates of teen pregnancy, infant mortality, welfare dependency, and late or no prenatal care. Family assessment workers evaluated risk of child abuse and neglect by using the Kempe Family Stress Checklist and included parents who scored at or above the pre-established cutoff of 25. Families in the treatment group were offered the HFNY program, which followed the traditional Healthy Families America model. Families in the control group were provided with information about other services in the community and were given referrals based on needs identified at assessment but were not referred to other home-visiting programs that were similar to HFNY in type, duration, and intensity.

The treatment and control group mothers were 45.4 percent Black, 34.4 percent white, and 18.0 percent Latina. The average age was 22.45 years (31 percent of mothers were younger than 19), and 55 percent were first-time mothers. Most were unmarried (82 percent), and nearly half had not graduated from high school or received a GED (47 percent). The women also had a high number of risk factors for child abuse and neglect, with an average of 6 to 10 risks assessed as moderate to severe. Similar to the sample of mothers, 49.0 percent of children in the study sample were Black, 34.1 percent were white, and 15.1 percent were Latino/a. A slight majority of the children were male (52.7 percent). There were no statistically significant differences between mothers in the treatment and control groups in demographic characteristics at baseline.

After baseline interviews, mothers were interviewed again at the participant child’s first, second, and seventh birthdays. To participate in the year 7 interview, treatment group mothers and their children had to both still be living. Control group mothers could participate in the interview if they had not received the HFNY intervention at any time between random assignment and 2 weeks before the year 7 interview. At the 7-year follow up, a total of 942 mothers were interviewed (treatment group n = 479, control group n = 463), and 800 children were interviewed (treatment group n = 408, control group n = 392). Children were interviewed if they lived within driving distance of the interviewer, to facilitate a face-to-face assessment, and if the mother had custody of the child and could grant consent. Nonparticipation was usually due to inability to locate the mother, the mother’s refusal, separation of mother and child, or the families had moved out of state.

Outcomes of interest included maternal physical abuse, nonviolent discipline strategies, maternal neglect, having substantiated CPS reports; and child foster care placement, attention problems, rule-breaking behavior, aggressive behavior, social problems, and deviant activities. Reports of maternal abuse, nonviolent discipline practices, and neglect were measured through a 27-item revised parent-child Conflict Tactics (CTS-PC), self-report scale. Substantiated CPS reports and foster care placements were measured from information in the Child Care Review Service (CCRS) database. Child attention problems, rule-breaking behavior, aggressive behavior, and social problems were measured through the Child Behavior Checklist for Ages 6-18 (CBLC/6-18), a 112-item, open-ended scale. Child deviant activities were measured through an adapted version of the Seattle Social Development Project and the Dominic-R assessment, in which one scale represented bullying activities and the second represented deviant activities.

Outcomes were analyzed using generalized linear models, and covariates were included as necessary to maximize the equivalence of the treatment and control groups overall. An intent-to-treat (ITT) analysis was used to examine the outcomes, indicating that the treatment group mothers remained with their assigned groups throughout the duration of the study even if they did not receive HFNY services. The study also explored the program’s effects on child maltreatment for two subgroups: 1) the high prevention opportunity (HPO) subgroup, and 2) the recurrence reduction opportunity (RRO) subgroup.

DuMont and colleagues (2010) reported that women in the Healthy Families New York (HFNY) intervention saved the government an average of $628.00 in net costs, compared with women in the control group. When compared with the net program cost of $4,101.00, there was a return of $0.16 for every dollar invested. Among women in the Recurrence Reduction Opportunity subgroup, HFNY produced savings in the net cost to government of $12,699.00, which translates into a return of $3.24 for every dollar invested. For the High Prevention Opportunity subgroup, the savings in the net cost to government was $813.00, with a return of $0.20 for every dollar invested. <br><br> In addition, Green and colleagues (2016) reported that the average cost per child in the Healthy Family Oregon (HFO) program was $3,766.96 per year. However, depending on the site, costs ranged from $2,502.97 to $5,956.33 per child per year.

Subgroup Analysis

With regard to subgroup analyses, Dumont and colleagues (2010) found that among women in the recurrence reduction opportunity subgroup, HFA women had statistically significant lower rates of initiation of new CPS services, compared with the control group. In addition, Jacobs and colleagues (2015), comparing 16 baseline characteristics (such as maternal age at child’s birth and trauma exposure), found that HFA mothers with high or medium levels of trauma exposure were less likely to smoke frequently/daily, compared with the control group. Finally, Green and colleagues (2016) found that Hispanic/Latino parents in the HFA group (but not the control group) had a statistically significant lower likelihood of having a founded report for any type of maltreatment, compared with non-Hispanic/Latino parents in the HFA group. Additional findings from the subgroup analyses can be found in each of the reviewed studies of HFA.

These sources were used in the development of the program profile:

These sources were used in the development of the program profile:

Bair–Merritt, Megan, Jacky M. Jennings, Rusan Chen, Lori Burrell, Elizabeth McFarlane, Loretta Fuddy, and Anne K. Duggan. 2010. “Reducing Maternal Intimate Partner Violence After the Birth of a Child: A Randomized Controlled Trial of the Hawaii Healthy Start Home Visitation Program.” Archives of Pediatrics and Adolescent Medicine 164(1):16–23.

Blunt Bugental, Daphne, Patricia Crane Ellerson, Eta K. Lin, Bonnie Rainey, Ana Kokotovic, and Nathan O’Hara. 2002. “A Cognitive Approach to Child Abuse Prevention.” Journal of Family Psychology 16(3):243–58.

Caldera, Debra, Lori Burrell, Kira Rodriguez, Sarah Shea Crowne, Charles A. Rohde, and Anne K. Duggan. 2007. “Impact of a Statewide Home Visiting Program on Parenting and on Child Health and Development.” Child Abuse and Neglect 31(8):829–52.

Chaffin, Mark. 2004. “Is It Time to Rethink Healthy Start/Healthy Families?” Child Abuse and Neglect 28:589–95.

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.

Duggan, Anne K., and others. 2005. Evaluation of Healthy Families Alaska Program. Anchorage, Alaska: Alaska Department of Health and Human Services.

https://clinicaltrials.gov/ct2/show/NCT00216710

Duggan, Anne K., Debra Caldera, Kira Rodriguez, Lori Burrell, Charles A. Rohde, and Sarah Shea Crowne. 2007. “Impact of a Statewide Home Visiting Program to Prevent Child Abuse.” Child Abuse and Neglect 31(8):801–27.

Duggan, Anne K., Loretta Fuddy, Lori Burrell, Susan M. Higman, Elizabeth C. McFarlane, Amy M. Windham, and Calvin C.J. Sia. 2004. “Randomized Trial of a Statewide Home Visiting Program to Prevent Child Abuse: Impact in Reducing Parental Risk Factors.” Child Abuse and Neglect 28:623–43.

Duggan, Anne K., Elizabeth C. McFarlane, Loretta Fuddy, Lori Burrell, Susan M. Higman, Amy M. Windham, and Calvin C.J. Sia. 2004. “Randomized Trial of a Statewide Home Visiting Program: Impact in Preventing Child Abuse and Neglect.” Child Abuse and Neglect 28:597–622.

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.

DuMont, Kimberly, Susan D. Mitchell–Herzfeld, Rose Greene, Eunju Lee, Ann Lowenfels, and Monica L. Rodriguez. 2006. Healthy Families New York Randomized Trial: Impacts on Parenting After the First 2 Years. Albany, N.Y.: New York State Office of Children & Families Services Working Paper Series: Evaluating Healthy Families New York.

http://www.ocfs.state.ny.us/main/prevention/assets/HFNYRandomizedTrialWorkingPaper.pdf

DuMont, Kimberly, Susan D. Mitchell–Herzfeld, Rose Greene, Eunju Lee, Ann Lowenfels, Monica Rodriguez, and Vajeera Dorabawila. 2008. “Healthy Families New York Randomized Trial: Effects on Early Child Abuse and Neglect.” Child Abuse and Neglect 32:295–315.

Ericson, Nels. 2001. Healthy Families America. Washington, D.C.: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention.

http://www.ncjrs.gov/pdffiles1/ojjdp/fs200123.pdf

Falconer, Mary Kay, M.H. Clark, and Don Parris. 2011. “Validity in an Evaluation of Healthy Families Florida—A Program to Prevent Child Abuse and Neglect.” Children and Youth Services Review 33(1):66–77.

Galano, Joseph, Walter Credle, Douglas Perry, S. William Berg, Lee Huntington, and Elizabeth Stief. 2001. “Report From the Field: Developing and Sustaining a Successful Community Prevention Initiative: The Hampton Healthy Families Partnership.” Journal of Primary Prevention 21(4):495–509.

Harding, Kathryn, Joseph Galano, Joanne Martin, Lee Huntington, and Cynthia J. Schellenbach. 2007. “Healthy Families America® Effectiveness.” Journal of Prevention and Intervention in the Community 34(1–2):149–79.

LeCroy, Craig Winston, and Judy Krysik. 2011. “Randomized Trial of the Healthy Families Arizona Home Visiting Program.” Children and Youth Services Review 33:1761–66.

Mitchell–Herzfeld, Susan D., Charles Izzo, Rose Greene, Eunju Lee, and Ann Lowenfels. 2005. Evaluation of Healthy Families New York: First Year Program Impacts. Albany, N.Y.: University at Albany, Center for Human Services Research.

http://www.ocfs.state.ny.us/main/prevention/assets/HFNY_FirstYearProgramImpacts.pdf

Rodriguez, Monica L., Kimberly DuMont, Susan D. Mitchell–Herzfeld, N.J. Walden, and Rose Greene. 2010. “Effects of Healthy Families New York on the Promotion of Maternal Parenting Competencies and the Prevention of Harsh Parenting.” Child Abuse and Neglect 34:711–23.

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

Windham, Amy M., Leon A. Rosenberg, Loretta Fuddy, Elizabeth C. McFarlane, Calvin C.J. Sia, and Anne K. Duggan. 2004. “Risk of Mother-Reported Child Abuse in the First 3 Years of Life.” Child Abuse and Neglect 28:645–67.

Following are CrimeSolutions-rated programs that are related to this practice:

Preventive Child Maltreatment Programs

Preventive child maltreatment programs are designed to prevent physical child abuse or neglect by educating expectant and new parents in parenting skills, coping with stressors, and stimulating child development. This practice is rated Effective for preventing child abuse, neglect, and maltreatment.

Evidence Ratings for Outcomes

Victimization - Child abuse/neglect/maltreatment

Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?