Healthy Families America (HFA) (HFA)

1  — Well-Supported by Research Evidence
Medium
4  — Evidence Fails to Demonstrate Effect
Medium

About This Program

Target Population: Families who are at-risk for child abuse and neglect and other adverse childhood experiences; home visiting services are initiated prenatally or within three months after the birth of the baby

For parents/caregivers of children ages: 0 – 5

Program Overview

HFA is a home visiting program model designed to work with families who may have histories of trauma, intimate partner violence, mental health issues, and/or substance abuse issues. HFA services are offered voluntarily, intensively, and over the long-term (3 to 5 years after the birth of the baby).

HFA is theoretically rooted in the belief that early, nurturing relationships are the foundation for life-long, healthy development. Building upon attachment, bio-ecological systems theories, and the tenets of trauma-informed care, interactions between direct service providers and families are relationship-based; designed to promote positive parent-child relationships and healthy attachment; services are strengths-based; family-centered; culturally sensitive; and reflective.

The HFA model is based upon 12 Critical Elements. These Critical Elements are operationalized through a series of standards that provide a solid structure for quality, yet offer programs the flexibility to design services specifically to meet the unique needs of families and communities.

HFA’s Vision: All children receive nurturing care from their family essential to leading a healthy and productive life.

HFA’s Mission: To promote child well-being and prevent the abuse and neglect of our nation’s children through home visiting services.

Program Goals

The goals of Healthy Families America (HFA) are:

  • 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

Essential Components

The essential components of Healthy Families America (HFA) include:

o The 12 Critical Elements: Initiate services prenatally or at birth

o Use standardized screening and assessment tools to systematically identify and assess families most in need:

 The Parent Survey (formerly the Kempe Family Stress Checklist) or other HFA-approved tool is used to assess the presence of various factors associated with increased risk for child maltreatment or other adverse childhood experiences.

o Offer services voluntarily and use positive, persistent outreach efforts to build family trust

o Offer services intensely and over the long-term, with well-defined criteria and a process for increasing or decreasing frequency of service

o Take into account the culture of families in the services offered such that staff understands, acknowledges, and respects cultural differences of families:

 Staff and materials used by the site reflect to the greatest extent possible the cultural, language, geographic, racial, and ethnic diversity of the population served.

o Focus on supporting the parent(s) as well as the child through services that cultivate the growth of nurturing, responsive parent-child relationships and promote healthy childhood growth and development

o Link all families to a medical provider to ensure optimal health and development

 Depending on the family’s needs, they may also be linked to additional services related to: finances, food, housing assistance, school readiness, child care, job training, family support, substance abuse treatment, mental health treatment, and domestic violence resources.

o Ensure Family Support Specialists have an adequate amount of time to spend with each family to meet their unique and varying needs and to plan for future activities by providing services in accordance with principles of ethical practice and with limited caseloads

o Select service providers based on:

 Their personal characteristics

 Their willingness to work in, or their experience working with, culturally diverse communities

 Their knowledge and skills to do the job

o Provide intensive training to service providers specific to their role to understand the essential components of family assessment, home visiting, and supervision.

o Ensure service providers have a framework, based on education or experience, for handling the variety of experiences they may encounter when working with at-risk families

 All service providers receive basic training in areas such as culture, reporting child abuse, determining the safety of the home, managing crisis situations, and responding to mental health, substance abuse, or intimate partner violence issues, drug-exposed infants, and services in their community.

o Give service providers ongoing, effective supervision so they are able to develop realistic and effective plans to empower families

Program Delivery

Parent/Caregiver Services

Healthy Families America (HFA) (HFA) directly provides services to parents/caregivers and addresses the following:

  • Expectant or new parents screened and/or assessed as moderate to high risk for child maltreatment and/or poor early childhood outcomes (e.g., mental health issues, domestic violence, substance abuse, poverty, housing, lack of education, lack of social support, etc.).
Services Involve Family/Support Structures:

This program involves the family or other support systems in the individual's treatment: While the focus is on the primary caregiver and index child, HFA welcomes all interested family members in home visits, and works to engage fathers in particular. In addition, parents are linked to other services in the community as needed, as detailed under the service content section.

Recommended Intensity:

Families are offered weekly home visits for a minimum of six months after the birth of the baby. Home visits typically run 50-60 minutes. Upon meeting the defined criteria for family functioning, visit frequency is reduced to biweekly visits, monthly visits, and quarterly visits and services are tapered off over time. Typically, during pregnancy, families receive 2-4 visits per month. During times of crisis families may be seen 2 or more times in a week.

Recommended Duration:

Services are offered prenatally or at birth until the child is at least three years of age and can be offered until they are five years of age.

Delivery Setting

This program is typically conducted in a(n):

  • Birth Family Home

Homework

This program does not include a homework component.

Languages

Healthy Families America (HFA) (HFA) has materials available in a language other than English:

Spanish

For information on which materials are available in this language, please check on the program's website or contact the program representative (contact information is listed at the bottom of this page).

Resources Needed to Run Program

The typical resources for implementing the program are:

  • A local implementing agency or a collaboration of host agencies that provide office space with confidentiality related to participant files/records
  • Computer and email
  • Data or tracking system
  • Cell phones
  • Program Manager
  • 1 FTE Supervisor per 5-6 FTE direct services staff (home visitors and/or assessment staff)
  • Travel expense reimbursement (mileage) for home visitors
  • A community advisory board
  • Diversified, and sustainable funding

Education and Training

Prerequisite/Minimum Provider Qualifications

Program staff is selected because of a combination of personal characteristics, experiential, and educational qualifications.

Direct Service Staff should have qualifications including, but not limited to:

  • Experience in working with or providing services to children and families
  • An ability to establish trusting relationships
  • Acceptance of individual differences
  • Experience and willingness to work with the culturally diverse populations that are present among the program’s target population
  • Knowledge of infant and child development
  • Open to reflective practice (i.e. has capacity for introspection, communicates awareness of self in relation to others, recognizes value of supervision)
  • Minimum of a high school diploma or equivalent
  • Infant Mental Health endorsement preferred

Supervisors should have qualifications including, but not limited to:

  • A solid understanding of and experience in supervising and motivating staff, as well as providing support to staff in stressful work environments
  • Knowledge of infant and child development and parent-child attachment
  • Experience with family services that embrace the concepts of family-centered and strength-based service provision
  • Knowledge of maternal-infant health and dynamics of child abuse and neglect
  • Experience in providing services to culturally diverse communities/families
  • Experience in home visiting with a strong background in prevention services to the 0-3 age population
  • Master’s degree in human services or fields related to working with children and families, or Bachelor’s degree with 3 years of relevant experience
  • Experience with reflective practice preferred
  • Infant Mental Health endorsement preferred
  • Program managers should have qualifications including, but not limited to:
    • A solid understanding of and experience in managing staff
    • Administrative experience in human service or related program(s), including experience in quality assurance/improvement and program development
    • Master’s degree in public health or human services administration or fields related to working with children and families, or a Bachelor’s degree with 3 years of relevant experience

Education and Training Resources

There is a manual that describes how to implement this program , and there is training available for this program.

Training Contact:
Training is obtained:

Training is provided in person either in state or regionally

Number of days/hours:
  • 4 full days for direct service staff, 5 days for supervisors
  • Two tracks: Parent Survey (assessment) and Integrated Strategies (home visiting)
  • Three day advanced clinical and reflective practice training for Supervisors

Implementation Information

Pre-Implementation Materials

There are pre-implementation materials to measure organizational or provider readiness for Healthy Families America (HFA) (HFA) as listed below:

The HFA model is supported by 12 research-based critical elements and a series of corresponding best practice standards. At the time a provider seeks to affiliate with HFA, they are required to submit an implementation plan that discusses how they intend to carry out model requirements. It is not unusual at this stage for sites to be uncertain of some areas, and a structured consultation phone call occurs to help the organization determine its level of readiness to begin implementation. Prior to implementation, HFA sites are also provided a copy of the HFA Site Development Guide.

Formal Support for Implementation

There is formal support available for implementation of Healthy Families America (HFA) (HFA) as listed below:

The HFA National Office provides ongoing implementation support, including a 3-day in-person Implementation Training that focuses intensely on what is expected to deliver HFA services in accordance with the HFA Best Practice Standards. Technical assistance (provided both in-person and remotely), staff training, and periodic accreditation site visits to measure each site’s ability to implement the model with fidelity are also components of the formal implementation support offered to sites. The National Office also provides CQI guidance as needed on how to address best practice standards not in adherence. Some materials are available at the HFA website: www.healthyfamiliesamerica.org

Fidelity Measures

There are fidelity measures for Healthy Families America (HFA) (HFA) as listed below:

HFA requires implementing sites to utilize the HFA Best Practice Standards and to demonstrate fidelity to the standards through periodic accreditation site visits. The HFA Best Practice Standards serve as both the guide to model implementation, as described above, and as the tool used to measure adherence to model requirements. There are 153 standards and each is coupled with a set of rating indicators to assess the site’s current degree of fidelity to the model. All HFA affiliated sites are required to complete a self-study that illustrates current site policy and practice, and an outside, objective peer review team uses this in conjunction with a multi-day site visit to determine the site’s rating (of exceeding, meeting or not yet meeting) for each standard.

Implementation Guides or Manuals

There are implementation guides or manuals for Healthy Families America (HFA) (HFA) as listed below:

HFA has a Site Development Guide and State Systems Development Guide that are accessible via the HFA website. The HFA Best Practice Standards is an extensive model-specific implementation document provided to all HFA affiliated sites. HFA Site Development Guide is a comprehensive planning guide to support prospective sites and new sites. It provides expert guidance and practical tips related to community planning, organizational infrastructure, budgeting, staffing, local advocacy, etc. The HFA State Systems Development Guide provides similar guidance as the Site Development Guide but is geared toward state leaders who want to strengthen state-level infrastructure to support HFA home visiting in their state. The HFA Best Practice Standards is the go-to document for purposes of understanding the required elements of model implementation and expectations related to all aspects of policy and practice.

Research on How to Implement the Program

Research has not been conducted on how to implement Healthy Families America (HFA) (HFA).

Relevant Published, Peer-Reviewed Research

Child Welfare Outcome: Child/Family Well-Being

Note regarding Child Welfare Outcomes: Healthy Families America is rated a "1 - Well-Supported by Research Evidence" on the Scientific Rating Scale in the Home Visiting for Child Well-Being topic area, based on the published, peer-reviewed research available for child well-being outcomes.

All of the research below has outcomes related to the Home Visiting for Prevention of Child Abuse and Neglect topic area, not the Home Visiting for Child Well-Being topic area.

Duggan, A., McFarlane, E., Fuddy, L., Burrell, L., Higman, S. M., Windham, A., & Sia, C. (2004). Randomized trial of a statewide home visiting program: Impact in preventing child abuse and neglect. Child Abuse and Neglect, 28, 597-622.

Type of Study: Randomized controlled trial
Number of Participants: 643

Population:

  • Age — Children: Birth-3 years, Adults: Not specified
  • Race/Ethnicity — Children: Not specified; Adults: 32% Native Hawaiian, 23% Asian, 20% Other Pacific Islander, 7% Caucasian, and 18% other
  • Gender — Children: Not specified; Adults: 100% Females
  • Status — Participants were families at risk for child maltreatment.

Location/Institution: Three regional community agencies on Oahu, Hawaii

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Families were randomly assigned to the Healthy Start Program (HSP) [now called Healthy Families America] or to a control group. Measures used included the Parent-Child Conflict Tactics Scale (CTS-PC) and the Home Observation for Measurement of the Environment (HOME) Inventory. Hospitalizations, substantiated child protective services reports, and mother’s relinquishment of care were also tracked. Results indicated that the treatment and control groups did not differ on most measures of maltreatment. HSP mothers were less likely to use common methods of corporal/verbal punishment, but this effect was traced to only one agency. HSP mothers reported less neglectful behavior, related to decreased preoccupation with problems and improved access to medical care at one agency studied. It should be noted that the study was conducted prior to implementation of HFA’s national accreditation system. Limitations include high dropout rate of initial sample and study did not show impact on child abuse and neglect.

Length of postintervention follow-up: 3 years.

*Duggan, A., Fuddy, L., McFarlane, E., Burrell, L., Windham, A., Higman, S., & Sia, C. (2004). Evaluating a statewide home visiting program to prevent child abuse in at risk families of newborns: Fathers’ participation and outcomes. Child Maltreatment, 9(1), 3-17.

Type of Study: Randomized controlled trial
Number of Participants: 643

Population:

  • Age — Adults: Mean = 25.9-26.3 years; Children: Birth-3 years
  • Race/Ethnicity — Adults: Intervention: 32% Native Hawaiian, 22% Asian, 15% Other Pacific Islander, 6% Caucasian, and 24% Other; Control: 34% Native Hawaiian, 22% Asian, 14% Other Pacific Islander, 8% Caucasian, and 23% Other. Children: Not specified
  • Gender — Adults: 100% Male, Children: Not specified
  • Status — Participants were families at risk for child maltreatment.

Location/Institution: Three regional community agencies on Oahu, Hawaii

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Note: This study uses data from the same study as Duggan, Fuddy, Burrell et al. (2004). Families were randomly assigned to either the Healthy Start Program (HSP) (same as Healthy Families America) or the control group. Data were collected through interviews with mothers, HSP record reviews, and surveys of home visitors. Data concerning fathers included fathers’ participation in home visits and factors influencing their participation, role in parenting as identified by maternal reports, accessibility, responsibility, and engagement. Analysis showed no program effects on accessibility, engagement in parenting activities, or sharing responsibility for the child’s welfare. HSP fathers who were non-violent and living with the child’s mothers showed increased parenting involvement, as did HSP fathers who were violent and had little contact at baseline.

Length of postintervention follow-up: 3 years.

Barlow, A., Varipatis-Baker, E., Speakman, K., Ginsburg, G., Friberg, I., Goklish, N., … Walkup, J. (2006). Home-visiting intervention to improve child care among American Indian adolescent mothers: A randomized controlled trial. Archives of Pediatrics & Adolescent Medicine, 160, 1101-1107.

Type of Study: Randomized controlled trial
Number of Participants: 53

Population:

  • Age — 14-20 years
  • Race/Ethnicity — 100% American Indian
  • Gender — 100% Females
  • Status — Participants were pregnant adolescents recruited from American Indian health service catchment areas.

Location/Institution: One Apache and Three Navajo Communities

Summary: (To include comparison groups, outcomes, measures, notable limitations)
The study evaluated the short-term impact of a paraprofessional-delivered home-visiting intervention (Healthy Families America [HFA]) among rural Navajo and Apache pregnant teens. Main outcome measures included child care knowledge, skills, and involvement. Participants assigned to the control arm were scheduled to receive home visits covering breastfeeding lessons. Data collected included child care knowledge and skills test scores and maternal self-reports at baseline, 2 months, and 6 months postpartum. Results indicated that mothers in the HFA group compared with the control group had significantly higher parent knowledge scores at 2 months and 6 months postpartum. HFA group mothers scored significantly higher on maternal involvement scales at 2 months postpartum and scores approached significance at 6 months postpartum. No between-group differences were found for child care skills. Limitations included the inability to study teen mothers’ child care capacity, a notable number of dropouts particularly in the HFA group, most measures were a type of self-report, and the study lacked evaluators blind to the HFA group

Length of postintervention follow-up: None.

Caldera, D., Burrell, L., Rodriguez, K., Crowne, S. S., Rohde, C., & Duggan, A. (2007). Impact of a statewide home visiting program on parenting and on child health and development. Child Abuse & Neglect, 31, 829-852.

Type of Study: Randomized controlled trial
Number of Participants: 325

Population:

  • Age — Adults: Mean=23.4-23.7 years, Children: Birth-2 years
  • Race/Ethnicity — Adults: 22% Alaska Native, 55% Caucasian, 8% Multiracial, and 15% other, Children: Not specified
  • Gender — Adults: 100% Female, Children: Not specified
  • Status — Participants were families at risk for child maltreatment.

Location/Institution: Healthy Families Alaska (HFAK)

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Families were randomly assigned to Healthy Families or to a control group. Mothers completed interviews to determine baseline demographic and risk variables; measures used included the Center for Epidemiological Studies Depression Scale (CES-D), Mental Health Index (MHI-5), CAGE scores (which ask about alcohol use), and the Revised Conflict Tactics Scale (CTS). Child outcomes were measured using incidences of injuries requiring medical care. Children were assessed using the Bayley Scales of Infant Development (BSID), Child Behavior Checklist (CBCL), and the Nursing Child Assessment Satellite Teaching Scale (NCAST). Parent outcomes at follow-up were assessed using the Knowledge of Infant Development Inventory, the Maternal Self-Efficacy Scale, Adult-Adolescent Parenting Index, Infant Caregiving Inventory, Parent-Child Conflict Tactics Scale (CTS-PC), and maternal recognition of developmental issues and linkage to medical care and other community services was evaluated. The study found no impact on child health, but home-visited children showed more favorable behavioral and developmental outcomes. Mothers in the intervention group had higher self-efficacy and provided a better environment for learning and were also more likely to use parenting services.

Length of postintervention follow-up: 2 years.

Lee, E., Mitchell-Herzfeld, S. D., Lowenfels, A. A., Greene, R., Dorabawila, V., & DuMont, K. A. (2009). Reducing low birth weight through home visitation: A randomized controlled trial. American Journal of Preventive Medicine, 36(2), 154-160.

Type of Study: Randomized controlled trial
Number of Participants: 501

Population:

  • Age — 22% under 18 years
  • Race/Ethnicity — 45% Black, 22% Hispanic, 30% Caucasian, and 3% Other
  • Gender — 100% Females
  • Status — Participants were pregnant women and adolescents and their infants 3 months of age or younger at high risk for low birth weight and infant mortality.

Location/Institution: Healthy Families New York (HFNY)

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Mothers in the Healthy Families NY program received home visits focused on social support, prenatal education, and links to community services. Analysis showed that after the intervention, mothers in the Healthy Families group were significantly less likely to have babies categorized as low birth weight than control group mothers.

Length of postintervention follow-up: None.

Sandy, J. M., Anisfeld, E., & Ramirez, E. (2009). Effects of a prenatal intervention on breastfeeding initiation rates in a Latina immigrant sample. Journal of Human Lactation, 25(4), 404-411.

Type of Study: Randomized controlled trial
Number of Participants: 238

Population:

  • Age — 16-41 years
  • Race/Ethnicity — 87% Dominican, 5% Other Latin American, 4% Puerto Rican, 2% Mexican, 2% Salvadoran, and 1% African American
  • Gender — 100% Females
  • Status — Participants were mothers who participated in the Best Beginnings program for breastfeeding support.

Location/Institution: Washington Heights, New York City, NY

Summary: (To include comparison groups, outcomes, measures, notable limitations)
The purpose of the present study was to evaluate the effectiveness of a prenatal health education intervention aimed at increasing breastfeeding rates in an urban, low-income, predominantly Dominican immigrant sample. Program group families received services based on the Healthy Families America model along with certain enhancements to promote breastfeeding. Family support workers visited program group families on a weekly basis while mothers were pregnant. Results indicated that exposure to the intervention did not affect mother report of any breastfeeding (ABF) during the first week postpartum, but it did affect mother report of exclusive breastfeeding (EBF). Consistent with findings from numerous prior studies, breastfeeding outcomes in the present study were significantly positively associated with a measure of household income (ABF and EBF) and significantly negatively associated with maternal acculturation level (ABF). Limitations included the lack of double blinding and possible systematic experimenter bias, and minimal follow-up.

Length of postintervention follow-up: None.

Rausch, J. C., McCord, M., Batista, M., & Anisfeld, E. (2012). Latino immigrant children's health: Effects of sociodemographic variables and of a preventive intervention program. International Journal of Population Research, 2012, Article ID 250276, 8 pages. doi:10.1155/2012/250276

Type of Study: Randomized controlled trial
Number of Participants: 535

Population:

  • Age — Mean=26.3 years
  • Race/Ethnicity — 88% Dominican
  • Gender — 100% Female
  • Status — Participants were participating in the Best Beginnings home prevention home visitation program.

Location/Institution: Washington Heights, New York

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Note: This study used data from the same study as Sandy, Anisfeld, & Ramirez (2009). This study examined to what extent immigrant status and other factors play a role in determining measures of their children's health and well-being, and finally to investigate whether a home visiting intervention modified any of these factors. Families were randomized to the Healthy Families America (HFA) Home Visiting program or a control group. Measures utilized include the Ages and Stages Questionnaire (ASQ), the Kempe Family Stress Inventory (KFSI), pediatric intake forms, and other standardized questionnaire forms. Results showed that prenatal participation in HFA was significantly associated with more exclusive breastfeeding postdelivery. Participation in HFA was significantly positively associated with both overall and urgent pediatric visits. By 24 months, among prenatally enrolled mothers significantly more HFA than control group mothers had primary care providers. Participation in HFA did not have a significant impact on ASQ scores at 12 months but it did by 24 months. Male infants in the HFA group performed significantly better than male infants in the control group at 24 months. Limitations include generalizability due to the limited ethnicity and gender of the subjects and the small number of health indicators investigated for immigrant children.

Length of postintervention follow-up: None – program services were on-going.

McFarlane,E., Burrell, L., Crowne, S., Cluxton-Keller, F., Fuddy, L., Leaf, P., & Duggan, A. (2013). Maternal relationship security as a moderator of home visiting impacts on maternal psychosocial functioning. Prevention Science, 14(1), 25-39.

Type of Study: Randomized controlled trial
Number of Participants: 843

Population:

  • Age — Adults: Mean age =23 years, Children: 1-9 years
  • Race/Ethnicity — Adults: 32.5% Native Hawaiian or Pacific Islander, 28% Asian or Filipino, 12% Caucasian, 27.5% Unknown; Children: Not specified
  • Gender — Adults: 100% Females, Children: Not specified
  • Status — Participants were mothers with children at risk for child maltreatment at program sites in Hawaii.

Location/Institution: Six program sites on Oahu, Hawaii

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Note: This study uses data from the same study as Duggan, Fuddy, Burrell, et al. (2004). The study evaluated whether and how maternal attributes, including relationship security, moderate short- and long-term home visiting impacts on maternal psychosocial functioning. Families were randomly assigned to Healthy Families America (HFA) and control groups. Measures utilized include the Attachment Style Questionnaire (ASQ), The Center for Epidemiological Studies-Depression Scale (CES-D), the Mental Health Index 5-Item Short Form (MHI-5), The Revised Conflict Tactics Scale (CTS2), the CAGE, the Addiction Severity Index (ASI), and the Parenting Stress Index-Short Form (PSI-SF). Results indicate that there was little evidence of overall positive impacts on maternal psychosocial functioning. There was a significant program impact on only one outcome indicator when children were 1–3 years old, and no significant impacts when children were 7–9 years old. Results also found that maternal relationship security did moderate short- and long-term program impacts on maternal psychosocial functioning. Limitations include issues with the use and timing of measures and small sample size for subgroup analyses.

Length of postintervention follow-up: Varies – approximately 4-6 years.

Duggan, A., Fuddy, L., Burrell, L., Higman, S., McFarlane, E., Windham, A., & Sia, C. (2004). Randomized trial of a statewide home visiting program: Impact in reducing parental risk factors. Child Abuse & Neglect, 28, 623-643.

Type of Study: Randomized controlled trial
Number of Participants: 643

Population:

  • Age — Children: Not specified, Adults: Not specified
  • Race/Ethnicity — Children: Not specified; Adults: 34% Native Hawaiian/Pacific Islander, 28% Asian/Filipino, 12% Caucasian, and 27% Other
  • Gender — Children: Not specified, Adults: 100% Females
  • Status — Participants were families at risk for child maltreatment.

Location/Institution: Three regional community agencies on Oahu, Hawaii

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Note: This study utilizes information from Duggan, McFarlane, et al. (2004). The study assessed the impact of the Healthy Start Program (HSP) [now called Healthy Families America] in reducing malleable parental risk factors for child abuse in families of newborns identified, through population-based screening, as at-risk of child abuse. Measures used included the Center for Epidemiological Studies Depression Scale (CES-D), Parenting Stress Index (PSI), Conflict Tactics Scale (CTS), and CAGE questions (which ask about alcohol use). Results indicated that malleable parental risks for child abuse were common at baseline. There was no significant overall program effect on any risk or on at-risk mothers’ desire for and use of community services to address risks. There was a significant reduction in one measure of poor mental health at one agency and a significant reduction in maternal problem alcohol use and repeated incidents of physical partner violence for families receiving ≥75% of visits called for in the model. Limitations included home visitors often failed to recognize parental risks and seldom linked families with community resources, and HSP training programs were under-developed in preparing staff to address risks and to link families with community resources. Overall, the home visiting program did not reduce major risk factors for child abuse that made families eligible for service.

Length of postintervention follow-up: 3 years.

Duggan, A., Caldera, D., Rodriguez, K., Burrell, L., Rohde, C., & Crown, S. S. (2007). Impact of a statewide home visiting program to prevent child abuse. Child Abuse & Neglect, 31, 801-827.

Type of Study: Randomized controlled trial
Number of Participants: 325

Population:

  • Age — Children: Prenatal or Birth-2 years, Adults: Not specified
  • Race/Ethnicity — Children: Not specified, Adults: 55% Caucasian, 22% Alaska Native, 8% Multiracial, and 15% Other
  • Gender — Not specified
  • Status — Participants were families at risk for child maltreatment.

Location/Institution: Healthy Families Alaska (HFAK)

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Families were randomly assigned to the Healthy Families [now called Healthy Families America] program or to a control group who were referred to other services. Families were measured at baseline on maternal mental health, substance abuse, and partner violence by interview. Measures used included the Center for Epidemiological Studies Depression Scale (CES-D), Mental Health Index (MHI-5), CAGE scores (which ask about alcohol use), Revised Conflict Tactics Scale (CTS), and the Home Observation of the Environment (HOME) Inventory. Mother-child interactions were also observed. At follow up, maternal depression and partner violence were reassessed and parenting attitudes were measured with the Adult-Adolescent Parenting Index. Results indicated no program effects on maltreatment reports and most measures of potential maltreatment. Mothers who received home visits reported using mild forms of discipline less often. There was no program impact on parental risks and home visitors often failed to address caregiver risks and link to community resources. Limitations include biased self-reported outcome measures, too few families had services that met some of more stringent definitions, and measures that incorporated discussion of risks for abuse did not reflect the quality of discussion.

Length of postintervention follow-up: 2 years.

DuMont, K., Mitchell-Herzfeld, S., Greene, R., Lee, E., Lowenfels, A., Rodriguez, M., & Dorabawila, V. (2008). Healthy Families New York (HFNY) randomized trial: Effects on early child abuse and neglect. Child Abuse & Neglect, 32, 295-315.

Type of Study: Randomized controlled trial
Number of Participants: 1173

Population:

  • Age — Children: Birth to 2 years, Adults: Not specified
  • Race/Ethnicity — Children: Not specified; Adults: 35% Caucasian, 46% African American, and 19% Hispanic
  • Gender — Children: Not specified, Adults: 100% Female
  • Status — Participants were families at risk for child maltreatment.

Location/Institution: Healthy Families New York (HFNY)

Summary: (To include comparison groups, outcomes, measures, notable limitations)
The study evaluated the effects of Healthy Families NY, a home visiting program modeled after Healthy Families America on parenting behaviors in the first 2 years of life. Families were randomly assigned to receive the Healthy Families NY program or standard services. Participants were interviewed at baseline, 1 and 2 years follow-up. Mothers reported on parenting behaviors using the Parent-Child Conflict Tactics Scale (CTS-PC) and official CPS report data was also examined for the intervention period. At one-year follow-up, mothers in the Healthy Families NY program reported fewer acts of very serious abuse, minor physical aggression, and psychological aggression in the past year, as well as fewer acts of harsh parenting in the last week. At year 2, Healthy Families NY mothers reported significantly fewer acts of serious physical abuse. There was trend toward lower levels of neglect at both times for Healthy Families NY program mothers, as well, although it did not reach significance. No group differences were found for substantiated CPS reports. Limitations include generalizability due to gender, high attrition rate, and lack of follow-up.

Length of postintervention follow-up: None.

Cullen, J. P., Ownbey, J. B., & Ownbey, M. A. (2010). The effects of the Healthy Families America Home Visitation Program on parenting attitudes and practices and child social and emotional competence. Child & Adolescent Social Work Journal, 27, 335-354.

Type of Study: One group pretest-posttest design
Number of Participants: 64

Population:

  • Age — Children: Prenatal or Birth-5 years, Adults: Not specified
  • Race/Ethnicity — Children: Not specified; Adults: 78% Caucasian, 17% African American, 2% Hispanic, and 3% Other
  • Gender — Children: Not specified; Adults: 86% Female and 14% Male
  • Status — Participants were under-resourced families at risk for child maltreatment who were referred from human service organizations.

Location/Institution: Healthy Families in rural Western North Carolina

Summary: (To include comparison groups, outcomes, measures, notable limitations)
The study evaluated the effectiveness of the Healthy Families America program in a rural setting for families at risk for maltreatment. Intervention length ranged from 2.5 to 5 years for families. Measures used included the Kempe Family Stress Inventory (KFSI), Adult-Adolescent Parenting Inventory-Revised (AAPI-R, AAPI-2), and the Ages and Stages Questionnaire Social-Emotional (ASQ-SE) completed by the parent every 1 to 3 weeks. Results indicated that highly significant positive changes were noted between pre- and postintervention assessments on all attitudinal and behavioral factors, parental attitudes, and children’s social and emotional competence. Limitations include lack of randomization, lack of control group, and lack of follow-up.

Length of postintervention follow-up: None.

Rodriguez, M. L., Dumont, K., Mitchell-Herzfeld, S. D., Walden, N. J., & Greene, R. (2010). Effects of Healthy Families New York on the promotion of maternal parenting competencies and the prevention of harsh parenting. Child Abuse & Neglect, 34, 711-723.

Type of Study: Randomized controlled trial
Number of Participants: 522

Population:

  • Age — Children: 2.9-3.9 years, Adults: Not specified
  • Race/Ethnicity — Children: Not specified; Adults: 42% Caucasian, 39% African American, 16% Hispanic, and 3% Other
  • Gender — Children: Not specified; Adults: 100% Females
  • Status — Participants were mothers at risk for child maltreatment.

Location/Institution: Healthy Families New York sites

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Note: The study used microlevel observational assessments of mother-child interactions in a three-year follow-up of the DuMont et al. (2008) study. The study evaluated the effectiveness of the Healthy Families New York [now called Healthy Families America] home visiting program in promoting parenting confidence and preventing maladaptive parenting behaviors in mothers at risk for child maltreatment. Participants were randomly assigned during pregnancy or shortly after the birth of the target child to an intervention group that was offered home visiting services or a control group that was given referrals to other services. Results indicated that Healthy Families NY was effective in fostering positive parenting, such as maternal responsivity and cognitive engagement. With respect to negative parenting, Healthy Families NY mothers in the High Prevention Opportunity subgroup were less likely than their counterparts in the control group to use harsh parenting, while no differences were detected for the Limited Prevention Opportunity subgroup. Limitations include generalizability due to gender and high attrition rates.

Length of postintervention follow-up: 3 years.

Bair-Merritt, M. H., Jennings, J. M., Chen, R., Burrell, L., McFarlane, E., Fuddy, F., & Duggan, A. K. (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 & Adolescent Medicine, 164(1), 16-23.

Type of Study: Randomized controlled trial
Number of Participants: 643

Population:

  • Age — Children: Birth-9 years, Adults: Not specified
  • Race/Ethnicity — Children: Not specified; Adults: 34% Native Hawaiian/Pacific Islander, 28% Filipino, 12% Caucasian, and 27% Other
  • Gender — Children: Not specified, Adults: 100% Female
  • Status — Participants were families with an infant at high risk for maltreatment.

Location/Institution: Three regional community agencies on Oahu, Hawaii

Summary: (To include comparison groups, outcomes, measures, notable limitations)
Note: This study uses data from the same study as Duggan, Fuddy, Burrell, et al. (2004). Using data collected to evaluate the Hawaii Healthy Start Program (same as Healthy Families America), the study estimated over two 3-year intervals (during program implementation and over long-term follow-up) whether home visitation beginning after the birth of a child was associated with changes in (1) average rates of mothers’ IPV victimization and perpetration and (2) rates of specific IPV types (physical assault, verbal abuse, sexual assault, and injury). Caregivers in the intervention and control groups participated in interviews at baseline following the child’s birth and at follow-up when the child was 1 to 3 years of age and then annually when the child was 7 to 9 years of age. Measures used included the Conflict Tactics Scale and the Mental Health Index 5-item short form. Results indicated that intervention group women reported consistently lower unadjusted rates of maternal victimization and perpetration across all specific IPV types compared with control women. There was a general decline in overall rates of IPV over time for both groups. However, when the children were 7 to 9 years of age, the intervention group did not report significantly lower rates of IPV victimization or perpetration than the control group. Verbal abuse may have increased for the intervention group. Limitations included minimal actual IPV program content, Healthy Start Program home visitors struggled to maintain visit frequency and retain families, and women self-reported their own and their partner’s IPV.

Length of postintervention follow-up: 3 years.

LeCroy, C. W., & Krysik, J. (2011). Randomized trial of the Healthy Families Arizona home visiting program. Children and Youth Services Review, 33, 1761-1766. doi:10.1016/j.childyouth.2011.04.036

Type of Study: Randomized controlled trial
Number of Participants: 195

Population:

  • Age — Mean=24 years
  • Race/Ethnicity — 60% Hispanic, 21% Caucasian, and 19% not specified
  • Gender — 100% Females
  • Status — Participants were mothers with children at risk for child maltreatment at an Arizona program site.

Location/Institution: Arizona

Summary: (To include comparison groups, outcomes, measures, notable limitations)
The study evaluated the effectiveness of the Healthy Families Arizona [now called Healthy Families America] home visitation program for families at risk for child maltreatment. Participants were randomly assigned to a treatment or to Child Development control group. Mothers were assessed at intake, 6- and 12-month follow-ups using the Kempe Family Checklist, Revised Parent-Child Conflict Tactics Scale, Adult-Adolescent Parenting Inventory-2 (AAPI), and the Emotional/Social Loneliness Inventory. Results indicated that significant results favoring the experimental group in contrast to the control group were found on some measures in each of five domains including violent parenting behavior; parenting attitudes and practices; parenting support; mental health and coping; and maternal outcomes. Looking specifically at abusive parenting behaviors, the program found results on two of nine behaviors: shouted, yelled, or screamed at child; and slapped child's hand. Limitations include significant differences between the HFA and control groups at baseline (generally indicating the HV group was at higher risk, and addressed through statistical control), small sample size, and lack of information on service that may have been received by the control group families.

Length of postintervention follow-up: None – services were on-going.

Green, B. L., Tarte, J. M., Harrison, P. M., Nygren, M., & Sanders, M. B. (2014). Results from a randomized trial of the Healthy Families Oregon accredited statewide program: Early program impacts on parenting. Children and Youth Services Review, 44, 288-298.

Type of Study: Randomized controlled trial
Number of Participants: 803

Population:

  • Age — Mean=24 years
  • Race/Ethnicity — 60% Hispanic, 21% Caucasian, and 19% Not Specified
  • Gender — 100% Females
  • Status — Participants were mothers with children at risk for child maltreatment at an Arizona program site.

Location/Institution: Oregon

Summary: (To include comparison groups, outcomes, measures, notable limitations)
The study evaluated the effectiveness of Healthy Families, Oregon (HFO), [now called Healthy Families America] through a telephone survey. Participants were randomly selected group of mothers to assess early outcomes at their child's 1-year birthday. Participants were randomly assigned (402 HFO and 401 control) to assess the effects of the program on service utilization and on early parenting and child risk and protective factors associated with abuse and neglect. Measures utilized include the Adult Adolescent Parenting Inventory, Corporal Punishment Subscale (AAPI-CP), the Parent–Child Activities Scale (PCAS), the Protective Factors Survey (PFS), the Parenting Stress Index — Short Form (PSI-SF), and the Pregnancy Risk Assessment Monitoring System. Results found that mothers assigned to the Healthy Families program group read more frequently to their young children, provided more developmentally supportive activities, and had less parenting stress. Children of these mothers were more likely to have received developmental screenings, and were somewhat less likely to have been identified as having a developmental challenge. Families with more baseline risk had better outcomes in some areas; however, generally there were not large differences in outcomes across a variety of subgroups of families. Limitations include that the findings may not be generalized to parents with more than one child, reliance on parent self-report data for all key outcomes, and generalizability due to gender.

Length of postintervention follow-up: None – HFO services were on-going.

Dew, B., & Breakey, G. F. (2014). An evaluation of Hawaii’s Healthy Start Program using child abuse hospitalization data. Journal of Family Violence, 29(8), 893-900.

Type of Study: Quasi-experimental
Number of Participants: 4,774 families

Population:

  • Age — Children: Mean=10.6 months, Adults: Not specified
  • Race/Ethnicity — Not Specified
  • Gender — Children: Not specified, Adults: 100% Females
  • Status — Participants were mothers with children at risk for child maltreatment at an Oahu program site.

Location/Institution: Oahu, Hawaii

Summary: (To include comparison groups, outcomes, measures, notable limitations)
The goals of this study were to (1) assess efficacy of Hawaii’s Healthy Start Program [now called Healthy Families America] program in implementation of the screening and assessment process, and (2) assess the effectiveness of the home visiting services in preventing serious abuse and neglect. Data were drawn from the Healthy Start statewide data system and from the records of Kapiolani Medical Center for Women and Children. Participants were assigned to either a high-risk group or a low-risk category. The measure utilized was the Family Stress Checklist (FSC). Results revealed hospitalization was nonrandomly distributed across service categories. Results suggest the screening and assessment procedure differentiated between parents with greater and lesser degrees of risk for being abusive or neglectful. In addition, the results support the idea that an intervention as modest in scope as Healthy Start can prevent child abuse or neglect. Limitations include looking retrospectively and only at families with a serious form of abuse or neglect and non-randomization of participants.

Length of postintervention follow-up: None – Healthy Start services were on-going.

Additional References

Daro, D., & Harding, K. A. (1999). Healthy Families America: Using research to enhance practice. The Future of Children, 9(1), 152-176.

Galano, J., Credle, W., & Perry, D. (2001). Developing and sustaining a successful community prevention initiative: The Hampton Healthy Families Partnership. Journal of Primary Prevention, 21(4), 495-509.

Harding, K., Galano, J., Martin, J, Huntington, L., & Schellenbach, C. J. (2007). Healthy Families America effectiveness: A comprehensive review of outcomes. Journal of Prevention and Intervention in the Community, 34(1/2), 149-179.

Contact Information

Kathleen Strader, MSW, IMH-E® (IV)
Agency/Affiliation: Healthy Families America at Prevent Child Abuse America
Website: www.healthyfamiliesamerica.org
Email:
Phone: (248) 988-8990

Date Research Evidence Last Reviewed by CEBC: September 2018

Date Program Content Last Reviewed by Program Staff: February 2019

Date Program Originally Loaded onto CEBC: June 2015