Promising - One study
The mission of Healthy Families America (HFA) is to promote child well-being and prevent the abuse and neglect of our nation’s children through home visiting services. The 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
- Enhance family functioning by reducing risk and building protective factors
The program targets expecting and new parents whose infants are less than 3 months old and who are identified as at risk of abusing or neglecting their children. Assessments are conducted prenatally or at the time of birth. Enrollment begins prenatally and continues to up to 3 months after birth.
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.
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.
Selecting and training home visitors
- 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.
- 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.
DuMont and colleagues (2010) reported no program effects on the prevalence or number of confirmed child Protective Services (CPS) reports of child maltreatment for the sample as a whole. The authors noted that the absence of a program impact on confirmed CPS reports may be attributable to greater surveillance of mothers assigned to the Healthy Families New York (HFNY) intervention. They found that HFNY mothers who self-reported committing acts of serious abuse or neglect were significantly more likely to have a CPS report than control mothers who self-reported serious abuse or neglect (42.9 percent versus 22.2 percent), suggesting that incidents of child maltreatment committed by HFNY parents were more likely to be detected and reported to CPS.
Women in the Recurrence Reduction Opportunity (RRO) subgroup who received the HFNY intervention had significantly lower rates of initiation of preventative, protective, or placement services, compared with RRO mothers in the control group (38 percent versus 60 percent). HFNY mothers had fewer confirmed CPS reports for any abuse or neglect as well as physical abuse (although this was not statistically significant). There were no significant differences found with women in the High Prevention Opportunity (HPO) subgroup.
Mothers in the HFNY group self-reported engaging in serious physical abuse significantly less frequently and using nonviolent discipline strategies significantly more frequently than mothers in the control group. Children in the HFNY group were significantly less likely to report that their mothers used minor physical aggression than children in the control group (70.8 percent versus 77.2 percent). The authors found no differences in children’s reports of their mothers’ nonviolent discipline practices. No program effects were found for the prevalence of neglect.
Women in the HPO subgroup who received HFNY were less likely to self-report engaging in psychological aggression (79.7 percent versus 91.2 percent) and using minor physical aggression tactics less frequently, but these were not statistically significant. No differences were found for maternal reports of neglect. Findings were not reported for women in the RRO group because of insufficient sample size.
Precursors to Delinquency
HFNY mothers were significantly more likely to report that their children participated in gifted programs than control group mothers. Children in the HFNY intervention received special education services less often than those in the control group, but these results were not statistically significant. No significant differences were found regarding problem behaviors, socioemotional difficulties, and self-regulation.
Owing to size and group representativeness, data analysis was only appropriate for the HPO group in this area. HFNY children in the HPO group were significantly less likely to score below average on the Peabody Picture Vocabulary Test Fourth Edition than the HPO children in the control group. No differences were found regarding child functioning domains.
DuMont and colleagues (2010) report the results of a 7-year follow-up of a randomized controlled trial (RCT) of Healthy Families New York (HFNY) initiated in 2000. The RCT included 1,173 mothers (treatment n=579, control n=594) at three HFNY sites that served inner-city neighborhoods as well as smaller cities and suburban and rural areas. Mothers were selected for the RCT based on the same criteria used to determine eligibility for HFNY. Eligibility criteria for HFNY included parents who were deemed high risk for 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 assessed risk of child abuse and neglect by using the Kempe Family Stress Checklist, and included parents who scored at or above the preestablished cutoff of 25.
The sample consisted mostly of African American women (45 percent), followed by white women (34 percent) and Latinas (18 percent). Study participants tended to be young (31 percent were younger than 19) first-time mothers (55 percent) who had never married (82 percent) and had not yet graduated high school or received a GED (47 percent). Treatment and control groups did not differ significantly at baseline.
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 in type, duration, and intensity to HFNY.
After baseline interviews, mothers were interviewed again at the participant child’s first, second, and seventh birthdays. Retention rates were high: 90 percent at year 1, 85 percent at year 2, and 80 percent at year 7. To participate in the year 7 interview, both the mother and child had to still be alive. For women in the control group to participate in the interview, they could not have received the HFNY intervention at any time between random assignment and 2 weeks before the year 7 interview. Data on parenting attitudes, parenting practices, child behavior, access to health care, employment status and earnings, and mental health was gathered at the years 1, 2, and 7 follow-up interviews. In addition, the following information was extracted and coded from the HFNY management information system and state administrative databases:
The 2010 follow-up included 942 mothers (Treatment n=479, Control n=463). Unique to the year 7 follow-up, evaluators interviewed 800 participant children. Children were interviewed if they lived within driving distance of the interviewer, and if the mother had custody of the child to grant consent. Nonparticipation was due to inability to locate the mother, mother’s refusal, separation of mother and child, or if the families had moved out of state.
- Types and frequency of program services
- Child Protective Services investigation records
- Preventive, protective, and foster care services
- Use of food stamps and public assistance
- Child birth weight
The study looked at whether HFNY effectively prevented or reduced child maltreatment, whether it limited the emergence of precursors to delinquency, and whether the benefits of the program outweighed its costs. The study also explored the program’s effects on child maltreatment for two analytic subgroups. The High Prevention Opportunity (HPO) subgroup consisted of first-time mothers under age 19 who were randomly assigned at a gestational age of 30 weeks or less (n=179), while the Recurrence Reduction Opportunity subgroup consisted of women who had at least one substantiated Child Protective Services report before randomization (n=104).
The evaluators used an intent-to-treat approach, meaning that the treatment mothers remained with their assigned group throughout the duration of the study even if they did not receive HFNY services. Dependent variables were analyzed using generalized linear models, and covariates were included as necessary to maximize the equivalence of the treatment and control groups overall or within subgroups.
DuMont and colleagues (2010) reported that women in the Healthy Families New York 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.
Evidence-Base (Studies Reviewed)
These sources were used in the development of the program profile:Study 1DuMont, Kimberly, Kristen Kirkland, Susan Mitchell–Herzfeld, Susan Ehrhard–Dietzel, Monica L. Rodriguez, Eunju Lee, China Layne, and Rose Green. 2010. Final Report: A Randomized Trial of Healthy Families New York (HFNY): Does Home Visitation Prevent Child Maltreatment? Final Research Report to the National Institute of Justice. https://www.ncjrs.gov/pdffiles1/nij/grants/232945.pdf
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.http://www.healthyfamiliesamerica.org/downloads/hfa_site_survey.pdf Duggan, Anne K., and others. 2005. Evaluation of Healthy Families AlaskaProgram. Anchorage, Alaska: Alaska Department of Health and Human Services. http://hss.state.ak.us/ocs/publications/johnshopkins_healthyfamilies.pdf 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. (This study was reviewed but did not meet CrimeSolutions criteria for inclusion in the overall program rating.)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. (This study was reviewed but did not meet CrimeSolutions criteria for inclusion in the overall program rating.)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.Healthy Families America. 2002. “Healthy Families AmericaReduces Child Maltreatment.” Fact Sheet. http://www.healthyfamiliesamerica.org/downloads/hfa_fact_a.pdf 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.: Center for Human Services Research, University at Albany. 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.