Program Goals/Target Population
The goals of the Home-Visiting Program were to improve parenting beliefs and childrearing practices, promote school continuation, reduce repeat teen pregnancies and maternal depression, and improve connection to primary physicians among adolescent mothers through a home visitation, mentoring, and case management intervention.
The program was targeted toward adolescent mothers or mothers-to-be, particularly those living in urban, low- income communities. Eligible participants were between 12 and 18 years of age who were either in their third trimester of pregnancy (at least 24 weeks gestation) or had delivered a baby in the previous 6 months.
Eligible participants were recruited into the program and were involved until their children were 2 years old. Each program participant was paired with one volunteer home visitor. The home visitor made biweekly home visits to the adolescent mother for the first year of the child’s life, followed by monthly visits until the child was 2 years of age. Most visits occurred in the home of the adolescent mother, but these meetings could also take place elsewhere in the community if there were concerns about safety. During these in-person meetings, the home visitor provided mentoring to the participating youth, delivered the adolescent and parenting curricula, and monitored for depression, partner violence, and school status. With the mother’s consent, the child’s father was also invited to participate in the parenting sessions.
The parenting curriculum sessions were aimed at 1) improving adolescent mothers’ understanding of child development, 2) teaching/modeling positive parenting attitudes and skills, and 3) promoting appropriate health care use by making connections with primary health care providers. The adolescent curriculum was aimed at 1) increasing the likelihood of engaging in safer sexual practices, 2) preventing repeat teen pregnancy, 3) setting goals oriented toward school completion, and 4) fostering skills to improve communication and negotiation with the adolescents’ partners.
Multidisciplinary staff meetings were held biweekly. During these meetings, home visitors could discuss concerns about participants’ mental health. If needed, referrals were made to the program social worker for further evaluation and counseling. Home visitors also worked with school personnel and parents to actively promote school continuation or re-engagement. Additionally, home visitors connected adolescents with primary care for management of contraceptive needs, helping them select a primary care site based on insurance requirements, location, and preference.
Female home visitors were recruited from the communities served by the program. They received 2 days (16 hours) of initial training in the use of the curriculum as well as ongoing training throughout the intervention period in the topic areas of depression, contraception, substance use, and domestic violence. Additionally, home visitors completed criminal background checks and an extensive screening process that assessed their motivation. Each home visitor had a caseload of up to 15 adolescents whom they visited biweekly, and up to 10 adolescents whom they visited monthly.
Home visitors needed to have at least a high school degree and experience in health care, child development, or social work. Home visitors also needed to possess skills for empathy and communication, have the ability to connect with adolescents and their families, and have knowledge of the community. The program team also included a social worker, who consulted with home visitors regarding mental health concerns and then followed up with evaluation and further referral to mental health or primary care services if required.
The program was grounded in Bronfenbrenner’s (1979) ecological model of human development, which emphasizes the role of social and environmental contexts as contributors to youth development as well as the value of locating interventions within the immediate environment of adolescents. The two curricula were grounded in social cognitive theory (Bandura 1986), which emphasizes social influences on learning and reciprocal influences between an individual, the person’s environment, and the person’s behavior. Furthermore, the curriculum was developed by both a child developmental psychologist and an anthropologist with the aim of making it specifically relevant for the target population of urban, African American adolescent mothers.
The findings from the study by Barnet and colleagues (2007) showed that adolescent mothers who were assigned to the home-visiting intervention had significantly greater improvements at posttest on measures of parenting attitudes and belief and school continuation, compared with adolescent mothers assigned to the control condition. However, there were no significant differences between the intervention and control group mothers on measures of physical punishment avoidance, role reversal avoidance, depressive symptoms, use of contraceptives, and repeat pregnancies.
Adult-Adolescent Parenting Inventory (AAPI): Total Score
Adolescent mothers in the intervention group had significantly greater improvement in total scores on the AAPI scale at posttest, compared with those in the control group (the associated effect size indicated an impact of medium magnitude).
AAPI: Appropriate Expectations
Adolescent mothers in the intervention group had significantly greater improvement in their scores on the Appropriate Expectations subscale of the AAPI at posttest, compared with those in the control group (the associated effect size indicated an impact of medium magnitude).
Adolescent mothers in the intervention group had significantly greater improvements in their scores on the Empathy subscale of the AAPI at posttest, compared with adolescent mothers in the control group (the associated effect size indicated an impact of medium magnitude).
AAPI: Avoidance of Physical Punishment
The intervention and control groups did not differ significantly at posttest in their scores on the Avoidance of Physical Punishment subscale of the AAPI.
AAPI: Avoidance of Role Reversal
The intervention and control groups did not differ significantly at posttest in their scores on the Avoidance of Role Reversal subscale of the AAPI.
Adolescent mothers in the intervention groups were significantly more likely to be in school or to have graduated at posttest, compared with those in the control group (the associated effect size indicated an impact of medium magnitude).
The intervention and control groups did not differ significantly at posttest in the proportion of youth with CES-D scores greater than or equal to 21.
Contraceptive Use (Condoms)
The intervention and control groups did not differ significantly at posttest in their odds of consistent condom use in the last 12 months.
Contraceptive Use (Hormonal Contraception)
The intervention and control groups did not differ significantly at posttest in their odds of hormonal contraception use in the last 12 months.
Repeat Teen Pregnancy
The intervention and control groups did not differ significantly at posttest in their odds of having a repeat pregnancy during the follow up period.
Barnet and colleagues (2007) used a randomized experimental design to evaluate a home visiting program with a sample of pregnant adolescents recruited from three urban, university-affiliated prenatal care sites located in Baltimore, Maryland. Adolescent patients served by these clinics were predominantly African American and economically disadvantaged. Eligible adolescents (those with pregnancies at least 24 weeks gestation), identified from electronic scheduling databases, were approached during clinic visits and offered the opportunity to participate in the study. After obtaining informed consent from the adolescents and their parents or guardians, the adolescents completed baseline structured interviews and were randomly assigned to the intervention (home visitation) or control group. The intervention group received home visitation, mentoring, and case management from one of three African American women who were recruited from the communities served by the program and trained to deliver the intervention. The control group received usual care.
Outcome data on parenting attitudes and beliefs, depression, contraceptive behaviors, sexual relationships, repeat pregnancies, school status, and relationships with the child’s father were collected at baseline and when the child turned 1 and 2 years old. Parenting attitudes and beliefs were measured using the Adult-Adolescent Parenting Inventory (AAPI), a 32-item measure designed to assess high-risk parenting attitudes and child-rearing practices. The AAPI yields a total score as well as scores for 4 subscales: appropriate expectations, empathy, avoidance of physical punishment, and avoidance of role reversal. Higher scores reflect more positive parenting attitudes and behaviors. Participants were also asked about their use of condoms and other specific contraceptive methods in the previous 12 months (“never”, “sometimes”, “most times”, or “always”). Contraceptive methods were grouped into hormonal and non-hormonal types; responses were grouped into ‘”always” and “not always”. Mental health was measured using the Center for Epidemiologic Studies Depression (CES-D) scale, a 20-item measure asking about depressive symptoms experienced in the prior week; scores of 21 or higher were defined as reflecting moderate or severe levels of depressive symptoms. School status was assessed via adolescents’ self-reports and for purposes of analyses was dichotomized to indicate whether, as of the 2-year follow up, the adolescent was in school, had graduated (since study baseline), or had dropped out. Repeat pregnancies and births were also assessed by self-report.
Of 122 eligible adolescents targeted for recruitment, 84 consented to participate, completed the baseline assessment, and were randomized into the home visitation or the control conditions. Follow-up assessments were completed at 1 year by 62 adolescents and at 2 years by 63 adolescents. Fifty-six youths (67percent of the original sample) completed both assessments. Participants had a mean age of 16.9 years. The majority of the sample (91 percent) was African American, of low-socioeconomic status, and had a history of stressors that included physical violence, depression, school dropout, and abuse. The two groups were statistically similar at baseline, with the exception of the baseline score on measures of parenting attitudes and beliefs (AAPI total score). There was no differential attrition by group.
Intent-to-treat (ITT) analyses were conducted to evaluate program effectiveness. The impact of the home-visiting program on outcomes was assessed using Generalized Estimating Equations (GEE), adjusting for baseline differences, youth age, and baseline depressive symptoms.
There is no cost information available for this program.
It was considered important to recruit and train home visitors from the community, and to provide them with both training and ongoing support and supervision. Consistency in mentor-mentee relationships was also noted as a valuable aspect of implementing the curriculum in the context of an ongoing relationship. Home visitors may have the capacity to serve a similar role to that of care managers, in complementing services offered by primary health care providers.
Barnet and colleagues (2007) also found that the odds of having a repeat birth and having a regular personal doctor did not differ significantly at posttest between adolescent mothers in the intervention and control groups. Additional analyses indicated that adolescent mothers in the intervention group with high program exposure (attended 75 percent or more of planned sessions) scored more favorably at posttest than adolescent mothers in the control group on all of the Adult-Adolescent Parenting Inventory (AAPI) measures with the exception of the subscale for Avoidance of Role Reversal, where the difference approached significance (p = .06). No differences were observed between adolescent mothers in the intervention group with low program exposure and those in the control group.
Evidence-Base (Studies Reviewed)
These sources were used in the development of the program profile:Study 1
Barnet, Beth, Jiexin Liu, Margo DeVoe, Kari Alperovitz-Bichell, and Anne K. Duggan. 2007. “Home Visiting for Adolescent Mothers: Effects on Parenting, Maternal Life Course, and Primary Care Linkage.” Annals of Family Medicine
These sources were used in the development of the program profile:
Bandura, Albert. 1986. Social Foundations of Thought and Action: A Social Cognitive Theory.
Englewood Cliffs, N.J.: Prentice-Hall.
Barnet, Beth, Anne K. Duggan, Margo DeVoe, and Lori Burrell. 2002. “The Effect of Volunteer Home Visitation for Adolescent Mothers on Parenting and Mental Health Outcomes: A Randomized Trial.” Archives of Pediatrics and Adolescent Medicine
156:1216-22. (This study was reviewed but did not meet Crime Solutions' criteria for inclusion in the overall program rating.)
Bronfenbrenner, Urie. 1979. The Ecology of Human Development
. Cambridge, Mass.: Harvard University Press.
Stokols, Daniel. 1996. “Translating Social Ecological Theory into Guidelines for Community Health Promotion.” American Journal of Health Promotion