Healthy Families America (OJJDP Model Program Guide)

Office of Justice Programs, Innovation - Partnerships – Safer Neighborhoods

Office of Juvenile Justice and Delinquency Prevention (OJJDP) Serving Children, Families and Communities

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Healthy Families America

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 Methodology:

Study 1
DuMont and colleagues (2010) utilized a seven-year longitudinal randomized controlled trial to evaluate the effectiveness of the Healthy Families America (HFA) model in New York (HFNY). The initial study that began in 2000 included 1,173 mothers randomly assigned to two groups (treatment group, n= 579; control group, n= 594). The 2010 follow-up included information on mothers and their children seven years after the initial assignment to one of the two study groups and consisted of 942 mothers (treatment group, n= 479; control group, n =463). The study looked at whether HFNY effectively prevented or reduced child maltreatment, limited the emergence of precursors to delinquency, and if the benefits outweighed the costs of the program. The study also explored the program's effects on child maltreatment for two analytic subgroups. The High Prevention Opportunity subgroup consisted of young first-time mothers who initiated home visiting services prenatally, while the Recurrence Reduction Opportunity subgroup consisted of women who had at least one substantiated Child Protective Services report prior to randomization.

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 recipients, 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 pre-established cutoff of 25.

The sample consisted mostly of African American women (45 percent), followed by White women (34 percent) and Latina women (18 percent). The study looked at families in inner city neighborhoods, as well as smaller suburban and rural cities. 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 made referrals based on needs identified at assessment, but did not refer women 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 1st, 2nd, and 7th 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, the mother and child had to still be living together. 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 prior to the year 7 interview. Along with in-depth participant interviews, evaluators looked at:

mother's earned income
risk assessment scores
frequency of program services
Child Protective Services investigation records
use of State-administered services such as welfare, Medicaid, food stamps, and public assistance
legal activities regarding child protective or foster care services
child birth weight

Unique to the 7-year 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.

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. Data analysis was conducted using Student’s t-tests and chi-square tests.

Evaluation Outcome:

Study 1
Child Maltreatment
DuMont and colleagues (2010) reported no program effects on prevalence or number of confirmed reports of child services for the sample. When authors looked into possible reporting bias, they found that mothers assigned to the Healthy Families New York (HFNY) intervention were significantly more likely to be detected for child maltreatment than mothers assigned to the control group (42.9 percent versus 22.2 percent).

Women in the Recurrence Reduction Opportunity (RRO) subgroup who received the HFNY intervention had significantly lower rates of initiating preventative, protective, and placement services as compared to RRO mothers in the control group. They also had lower rates of confirmed Child Protective Services reports for any abuse or neglect as well as physical abuse, although not significant. There were no significant differences found with women in the High Prevention Opportunity (HPO) subgroup.

Parenting Behaviors
Mothers in the HFNY group used serious physical abuse significantly less frequently and used non-violent discipline strategies significantly more frequently than mothers in the control group. Children reported significantly lower rates of minor physical aggression for HFNY mothers (70.8 percent versus 77.2 percent) than those in the control group. Authors found no differences in their reports of mothers' non-violent discipline practices. No program effects were found for prevalence of neglect, either.

Women in the HPO subgroup who received HFNY were less likely to engage in psychological aggression (79.7 percent versus 91.2 percent) and used minor physical aggression tactics less frequently, but these were not significant. No differences were found for reports of neglect. No findings were reported for women in the RRO group.

Precursors to Delinquency
Children in the HFNY group reported participating in gifted programs significantly more than children in the control group. While children in the intervention received special education services less often than those in the control group, it was not significant. No significant differences were found regarding problem behaviors, socio-emotional difficulties, and self-regulation.

Due 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 4th Edition than the HPO children in the control group. Children in the HPO subgroup were less likely to repeat a grade and more likely to participate in a gifted program; however, these findings were not significant. No differences were found regarding child functioning domains.

Other Information:

Costs: DuMont and colleagues (2010) reported that women in the Healthy Families New York intervention saved the Government an average of $628 in net costs when compared to women in the control group. When compared to the net program cost of $4,101, there was a return of $15 for every dollar invested.

References:

Bair–Merritt, Megan, Jacky M. Jennings, Rusan Chen, Lori Burrell, Elizabeth McFarlane, Loretta Fuddy, and Anne 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):243–258.

Caldera, Debra, Lori Burrell, Kira Rodriguez, Sarah Shea Crowne, Charles Rohde, and Anne Duggan. 2007. “Impact of a Statewide Home Visiting Program on Parenting and on Child Health and Development.” Child Abuse and Neglect 31(8):829–852.

Chaffin, Mark. 2004. “Is it Time to Rethink Healthy Start/Healthy Families?” Child Abuse and Neglect 28:589–595.

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, and others. 2005. Evaluation of The Healthy Families Alaska Program. Anchorage, Alaska: Alaska Department of Health and Human Services. http://hss.state.ak.us/ocs/publications/johnshopkins_healthyfamilies.pdf

Duggan, Anne, Debra Caldera, Kira Rodriguez, Lori Burrell, Charles Rohde, and Sarah Shea Crowne. 2007. “Impact of a Statewide Home Visiting Program to Prevent Child Abuse.” Child Abuse and Neglect 31(8):801–827. (This study was reviewed but did not meet the criteria for inclusion in the overall program rating.)

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.

Duggan, Anne, Elizabeth McFarlane, Loretta Fuddy, Lori Burrell, Susan M. Higman, Amy Windham, and Calvin 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 the 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, Loretta Fuddy, Lori Burrell, Susan M. Higman, Elizabeth McFarlane, Amy Windham, and Calvin Sia. 2004. “Randomized Trial of a Statewide Home Visiting Program to Prevent Child Abuse: Impact in Reducing Parental Risk Factors.” Child Abuse and Neglect 28:623–643.

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

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

DuMont, 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.

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.” The 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):149–179.

Healthy Families America. 2002. “Healthy Families America Reduces Child Maltreatment.” Fact Sheet. http://www.healthyfamiliesamerica.org/downloads/hfa_fact_a.pdf

Mitchell–Herzfeld, Susan, Charles Izzo, Rose Greene, Eunju Lee, and Ann Lowenfels. 2005. Evaluation of Healthy Families New York (HFNY): 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, M.L.; K. Dumont; S.D. Mitchell–Herzfeld; N.J. Walden; and R. 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 34:711–723.

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.

Windham, Amy M., Leon Rosenberg, Loretta Fuddy, Elizabeth McFarlane, Calvin Sia, and Anne K. Duggan. 2004. “Risk of Mother-Reported Child Abuse in the First 3 Years of Life.” Child Abuse and Neglect 28:645–667.

Program Specification:

New Rating:

Promising

Re-reviewed Date:

October 2011

Program Type:

Parent Training

Wraparound / Case Management

Ethnicity:

American Indian or Alaska Native

Asian

African American

Hispanic or Latino (of any race)

White

Gender:

Both

Age:

0 - 5

Problem Behaviors:

Aggression/Violence

Alcohol,Tobacco and Other Drug Use

Family Functioning

Sexual Activity/Exploitation

Risk & Protective Factors:

Risk

Family

Broken home

Child victimization and maltreatment

Family history of problem behavior / Parent criminality

Family management problems / Poor parental supervision and/or monitoring

Family transitions

Family violence

Having a young mother

Low parent education level / Literacy

Parental use of physical punishment / Harsh and/or erratic discipline practices

Pattern of high family conflict

Poor family attachment / Bonding

Sibling antisocial behavior

Individual

Life stressors

Teen parenthood

Protective

Family

Effective parenting

Good relationship with parents / Bonding or attachment to family

Having a stable family

High family expectations

Opportunities for prosocial family involvement

Rewards for prosocial family involvement

Individual

Perception of social support from adults and peers

Self-efficacy

Social competencies and problem solving skills

Additional Information:

OJJDP/CSAP: Strengthen Families

Status:

Program is in operation at this time.

Performance Measures:

Suggested OJJDP Performance Measures for the Program Types(s):

Delinquency Prevention
Parent Training
Logic Model: PDF
Performance Matrix:PDF
Mental Health Services
Parent Training
Logic Model: PDF
Performance Matrix:PDF

Contact Information:

Program Developer:
Lisa Schreiber, Director, State Systems Development
Healthy Families America
200 South Michigan Avenue, Suite 1700
Chicago, IL 60604
Phone: 3126633520
Fax: 3129398962
Email: Click Here
Website: Click Here

Training & TA Provider:
Helen Reif
Prevent Child Abuse America
200 South Michigan Avenue, Suite 1700
Chicago, IL 60604
Phone: 3123346830
Email: Click Here