Child Adolesc Soc Work J (2011) 28:439458

DOI 10.1007/s10560-011-0235-z

The Effects of a Healthy Families Home Visitation

Program on Rapid and Teen Repeat Births
Mark Ownbey Jeannie Ownbey Joseph Cullen

Published online: 21 June 2011

Springer Science+Business Media, LLC 2011

Abstract The prevention of Rapid Repeat Births (RRBs) and Teen Repeat Births
(TRBs) is an important indicator of the effectiveness of home visitation programs
that serve mothers who are at-risk for child maltreatment. This study examined the
effects on RRBs and TRBs of a rural/small town home visitation program based on
the Healthy Families America (HFA) model. The participants in this study were
referred between 1999 and 2007 and included a Treatment Group of 140 at-risk
mothers who met minimum engagement criteria and a Comparison Group of 241 atrisk mothers who were referred for services but not enrolled due to limits on
program capacity. In addition, county-wide TRB data was used as the basis for a
static group comparison. With regard to RRBs, the rates for the Treatment (18%)
and Comparison (30%) groups were compared using a Chi-Square test of homogeneity. The null hypothesis that there would be no difference between the rates for
the two groups was rejected at the .05 level. Similarly, with regard to TRBs, the null
hypothesis that there would be no difference between the rates for the Treatment
(9%) and Comparison (27%) groups was rejected at that .01 level. Furthermore,
using a Chi-Square test of independence, this investigation tested the null hypothesis
that the rates for the two groups would not differ from the county-wide rate (24%).
This hypothesis was also rejected at the .01 level. Overall, these results of this
inquiry support the conclusion that participants in a rigorously implemented HFA
program show significantly lower rates of RRB and TRB when compared to a
comparable group of at-risk nonparticipants. They also appear to have a significantly lower incidence of TRB than teen mothers in the general population.

M. Ownbey
J. Ownbey
Catawba Valley Healthy Families, Barium Springs Home for Children, Statesville, NC, USA
J. Cullen (&)
Institute for Health and Human Services, ASU Box 32102, Boone, NC 28608, USA
e-mail: cullenjc@appstate.edu

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Keywords
America

M. Ownbey et al.

Rapid repeat birth
Adolescent birth
Home visiting
Healthy families

Introduction
The U.S. Department of Health and Human Services (USDHHS 2000) defines
Rapid Repeat Births (RRBs) as births that occur in intervals of less than 24 months.
It uses the term Teen Repeat Births (TRBs) to refer to multiple births to a teen
mother regardless of birth interval. Preventing RRBs and TRBs among at-risk
mothers has been a key public health objective over the past 40 years. The emphasis
given to this objective is well justified by a substantial body of research on the
negative effects of short birth intervals and/or multiple births during the teen years,
particularly among mothers at-risk for child maltreatment. The following sections
will review this body of research along with the evidence base that supports the use
of home visitation as a primary prevention strategy.

Review of the Literature

Several lines of research have contributed to our understanding of the effects of
multiple births on the quality of caregiver-child relationships. These lines have
included research on: (a) the effects of newborns on caregiver relationships with
first-born children; (b) the relationship between birth interval and child maltreatment, caregiver stress, and healthy child development; and (c) the effects of teen
repeat births on child health and development and maternal life course. The
following sections will discuss these lines of research, describe the Healthy Families
America (HFA) home visitation program, and review studies of the effectiveness of
the HFA model.
The Effects of a Newborn on a Caregivers Relationship
with the First-Born Child
Research on the effects of a newborn on the relationship between a mother and her
first-born child has been extensive. Dunn and Kendrick (1980), who studied
maternal-firstborn child interactions before and after the birth of a second child,
found decreases in maternal attention and play, increases in confrontation, and
changes in the balance of responsibility for initiating interactions. Similarly, Trause
(1978), in a study of the responses of firstborn children to separation from their
mothers due hospitalization for childbirth, observed significantly more behavior
problems in the post-hospitalization period relative to the pre-hospitalization period.
In addition, Stewart et al. (1987) observed a dramatic decline in mothers
interactions with firstborn children and an increase in confrontations with them
during a 12-month period following the birth of a sibling. These results were
replicated by Baydar and Greek (1997) who, in a longitudinal study on the effects of
the birth of a sibling during the first 6 years of life, found that mothers emotional

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resources decreased significantly following the birth of a new baby and that positive
interactions with the older child diminished. In particular, the authors found that
parental warmth diminished, controlling parenting styles became more prevalent,
and physical discipline increased. These conclusions were extended to at-risk
mothers by El-Kamary et al. (2004) who, in a study of Hawaiis Healthy Start
program, found that mothers who had a subsequent birth within 3 years of the birth
of the index child were more likely to show poor warmth to the index child.
Research on families with short birth intervals has been especially consistent in
documenting changes in family dynamics associated with subsequent births.
Specifically, studies have found that positive interactions between primary
caregivers and eldest children are especially likely to diminish in families with
short birth intervals (Baydar and Greek 1997; El-Kamary et al. 2004). In addition, a
number of studies have found a higher incidence of child maltreatment in families
with closely spaced children. Groothuis et al. (1982), for example, found that
families with twins, the most extreme example of closely spaced births, had a higher
incidence of child abuse than families with a single child. Similarly, Benedict et al.
(1985), in a study of the relationship between maternal peri-natal risk factors and
child abuse, found a inverse relationship between birth interval and incidence of
maltreatment. These results were replicated by Zuravin (1988) who, in a study of the
connection between fertility patterns and child maltreatment, found that closely
spaced births increased the risk of physical abuse and neglect. Closely spaced births
have also been found to be associated with a higher risk of childhood injury
(Nathens et al. 2000). Based on these findings, many child welfare organizations
have concluded that helping mothers adequately space births will have a positive
effect on child safety and well-being.

The Relationship Between Birth Interval, Child Maltreatment, Caregiver Stress,

and Healthy Child Development
In the search for causes of the relationship between birth interval and child
maltreatment, research has focused on the role of caregiver stress. The relationship
between family stress and parentchild physical aggression and child physical abuse
is well established in the literature (Black et al. 2001; DePanfilis and Zuravin 2002;
Sprang et al. 2005). However, this relationship appears to be especially strong in
families with children that are closely spaced. For example, Groothuis et al. (1982)
attributed the higher incidence of child abuse in families with twins to the stress
involved in raising twins as opposed to individual children. Similarly, others have
attributed the higher incidence of child maltreatment in families with RRBs to the
effects of caregiver stress (Benedict et al. 1985; Zuravin 1988).
In addition to contributing to caregiver stress, RRBs appear to create conditions
unfavorable to healthy child development. With regard to physical development,
research has identified a number of pre-natal health difficulties resulting from short
inter-pregnancy intervals to mothers of all ages. They include congenital
malformations, neural tube defects, low birth weight, small size for gestational
age, and prematurity (Brody and Bracken 1987; Conde-Agudelo et al. 2006;

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DeFranco et al. 2007; Fuentes-Afflick and Hessol 2000; Grisaru-Granovsky et al.

2009; Miller 1991; Todoroff and Shaw 2000; Zhu et al. 1999).
With regard to cognitive development and educational attainment, Baydar et al.
(1993) found that subsequent births in close succession after the first birth may have
long term negative effects on childrens levels of literacy. These findings are
consistent with a number of studies that have found a relationship between close
age-spacing and poor academic performance (Downey et al. 1999; Powell and
Steelman 1990; Steelman et al. 2002; Zajonc 2001). In addition, Powell and
Steelman (1993) found that the close spacing of siblings increases the possibility of
dropping out of high school and decreases the likelihood of acquiring a postsecondary education. These conclusions appear to be especially applicable to underresourced families. Specifically, Hayes et al. (2006) investigated the effect of short
birth intervals on school readiness in a low-income population and found that
children born with intervals of less than 24 months were less likely to be ready for
school compared to children born with adequate spacing.
With regard to long term mental health, a population-based study in Denmark by
Smits et al. (2004) found that individuals born within birth intervals up to
26 months, particularly those born within 1520 months, had an elevated risk of
developing schizophrenia relative to individuals born after birth intervals of
45 months or longer. In light of these results and a thorough review of data from the
United States and other western countries, Zhu et al. (1999, 2001) concluded that
spacing children at least 3 years apart dramatically reduces the incidence of
negative health outcomes and assures optimal opportunities for cognitive and social
development, especially in families with financial and social challenges.
The Effects of Teen Repeat Births on Child Health and Development
and Maternal Life Course
In addition to the effects of RRBs, the effects of TRBs have been identified as a
significant public health challenge. Teenage parenthood has been associated with
higher incidence rates of a variety of prenatal and perinatal conditions including
small for gestational age, preterm delivery, low birth weight, birth defects, and
sudden infant death syndrome (Gortzak-Uzan et al. 2001). In addition, teen mothers
are more likely to have infants that are born with infections and/or chemical
dependence due to maternal substance abuse (Gilbert et al. 2004; MalamitsiPuchner and Boutsikou 2006; Menacker et al. 2004). These conditions appear to
contribute to the significantly higher first-year and long-term morbidity and
mortality rates that have been found among the children of teenage mothers
(Maynard 1996; Moore et al. 1998).
Nonetheless, others have argued that the relationship between teen motherhood
and negative perinatal outcomes may be spurious. Gueorguieva et al. (2001), for
example, in a study of educational disabilities and problems, found that when they
controlled for race, poverty level, level of education, and marital status, detrimental
effects disappeared and some protective effects were observed. They concluded that
the higher incidence of educational problems among the children of teenage mothers
most likely results not from the effects of youthful mothering but from the influence

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of socio-demographic factors. Despite this conclusion, Dangal (2005) writes that,

regardless of the specific cause, early child bearing has multiple consequences in
terms of maternal health, child health and the overall well-being of society (p. 1).
The risk of negative health outcomes among the children of teenage mothers
increases with subsequent pregnancies during adolescence. Specifically, Blankson
et al. (1993) found that teen mothers who had a poor outcome during their first
pregnancy were at least three times more likely to have a subsequent pregnancy that
was problematic. Similarly, Smith and Pell (2001) found that the risk of preterm
delivery and stillbirth was approximately three times higher during second births to
adolescent mothers. These findings were consistent with Reime et al. (2008) who
found that perinatal and neonatal mortality rates were significantly higher among
adolescent mothers who had a previous birth.
In addition to their effects on childrens physical health and well-being, TRBs
have been found to have potentially negative effects on childrens intellectual,
academic, and social development and maternal life course. Specifically, Dubow
and Luster (1990) and Furstenberg et al. (1987) found that the children of teenage
mothers were more likely to score lower on measures of cognitive competence and
behavioral adjustment (Dubow and Luster 1990; Furstenberg et al. 1987). With
regard to maternal life course, subsequent births to teen mothers, especially closely
spaced ones, make it difficult for the mothers to move out of poverty (Harris 1996;
Horwitz et al. 1991; Stewart and Dooley 1999). In addition, adolescent mothers who
have closely spaced births are more likely to have lower levels of educational
attainment, drop out of high school, and depend upon public assistance (Dailard
2000; Furstenberg et al. 1987; Manlove et al. 2000). These findings, along with
research on the negative outcomes of early child rearing in general, support an
emphasis on the prevention of TRBs as a key public health policy initiative.
The HFA Model
Several models of home visitation have emerged over the past 20 years as a primary
strategies for preventing RRBs and TRBs. Healthy Families America (HFA) is one
such model. The HFA approach centers on providing comprehensive home
visitation services to first-time, highly stressed care givers who are at-risk for child
maltreatment. The overall goals of HFA are to promote positive parenting, enhance
child health and development, and prevent child abuse and neglect (Diaz et al.
2004).
Healthy Families is not a strict replication model in that it offers sites the
option of tailoring program operations to suit local needs and interests. However,
certified HFA programs are expected to implement a set of 12 critical elements
that guide program development. These elements include the following (Frankel
et al. 2000):
1.
2.

Intervening early to facilitate warm, secure and nurturing child/caregiver

relationships.
Using standardized assessments to identify families who are most in need of
services.

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3.

Relying on voluntary participation and trust-building to engage and retain

families.
Offering intensive services entailing weekly home visits for minimally the
first 6 months after the birth of the baby and then tapering off to a leaner
schedule and lasting for a period of 35 years.
Assuring that services are respectful of differences in cultural values and
tradition.
Focusing services on three areas: (a) Stress reduction; (b) Positive parent
child interaction; and, (c) Stimulating child social, cognitive, and physical
development.
Linking all families to appropriate services in the community.
Maintaining limited caseloads so that practitioners can devote sufficient time
to meeting the unique and varying needs of each family.
Selecting service providers based primarily upon personal qualities, openness
to cultural diversity, and skills for performing key job functions.
Giving home visitors a sound professional framework that includes knowledge
of cultural differences, infant and child development, mandated reporting,
domestic violence, mental health conditions, substance abuse issues, and
community resources.
Providing home visitors with intensive training specific to their role, including
principles of (a) family assessment and home visitation, (b) preventive health
care and home safety, (c) trust building with consumers, (d) individualized
family support plans, (e) behavioral observation, (f) basic teaching skills, and
(g) crisis intervention skills.
Providing home visitors with ongoing, effective supervision.

4.

5.
6.

7.
8.
9.
10.

11.

12.

In an effort to meet its program goals and minimize family stress that can result
in child abuse and neglect, one focus of HFA is to help mothers delay subsequent
births and, in the case of teen mothers, multiple births during the teen years. By
helping overburdened mothers space their children, HFA seeks to improve the
likelihood of positive parentchild interactions by avoiding the increase in negative
mother-firstborn child interactions often associated with the birth of a second child
and protecting the mothers available time to attend to her firstborn child.

Effectiveness of Home Visitation Programs in Preventing RRBs and TRBs

Research on the effectiveness of home visitation programs in preventing RRBs and
TRBs is mixed. This statement applies both to home visitation programs in general
and the HFA in particular. Encouraging findings were presorted by Black et al.
(2006), Field et al. (1982), Key et al. (2008), Kitzman et al. (1997), Klerman et al.
(2003), Olds (2002), Olds et al. (1988, 1998), and Sangalang et al. (2006). The
results of these studies are summarized in Table 1.
However, less encouraging results were reported by Barnet et al. (2007), ElKamary et al. (2004), Koniak-Griffin et al. (2002, 2003), Norr et al. (2003), and
Stevens-Simon et al. (2001). The results of these studies are summarized in Table 2.

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Table 1 Studies of home visitation programs that found positive treatment effects for RRB and TRB
Study

Findings

Black et al. (2006)

At 2 years postpartum, mothers in the control group were 2.5 times

more likely to have had a subsequent birth than mothers in the
intervention group

Field et al. (1982)

Home visited teen mothers had significantly lower rates of

subsequent pregnancies than did adolescent mothers in a control
group

Key et al. (2008)

School-based prevention program reduced subsequent births to

participating mothers relative to mothers in a matched
comparison group

Kitzman et al. (1997)

At 24 months postpartum, home visited mothers reported fewer

second pregnancies and births than mothers in the comparison
group

Olds et al. (1988)

Recipients of home visitation services exhibited 43% fewer

subsequent pregnancies than controls. In addition, when
participants did have subsequent children, they delayed the birth
of the second child by an average of six months relative to the
comparison group.

Klerman et al. (2003), Olds (2002),

Olds et al. (1998)

The Nurse-Family Partnership model was found to be effective in

reducing or delaying the occurrence of repeat pregnancies

Sangalang et al. (2006)

Mothers in the treatment group significantly delayed the timing of

second births relative to the comparison group mothers

Table 2 Studies of home visitation programs that did not find positive treatment effects for RRB and
TRB
Study

Findings

Barnet et al. (2007)

Home visitation had no impact on subsequent pregnancy and birth rates of

adolescent mothers served by a community-based home visiting program at
1 or 2 years following the birth of the index child

El-Kamary et al. (2004)

Mothers served by Hawaiis Healthy program did not differ in their rates of
rapid repeat pregnancies from mothers in a control group

Koniak-Griffin et al.
(2002, 2003)

In a study of teen mothers, authors failed to find any significant difference in

repeat pregnancy rates between home visited mothers and mothers in a
control group

Norr et al. (2003)

In a study of the nurse-health advocate program, authors found no significant

impact of the program on the incidence of repeat pregnancy one year after
the birth of the index child

Stevens-Simon et al.
(2001)

In a study of teen mothers, authors failed to find any statistically significant

difference in repeat pregnancy rates between home visited mothers and
mothers in a control group

Critique
While studies of the effects of home visitation on rates of RRB and TRB have not
consistently shown positive results, a number of authors have commented that these

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findings may be due, in part, to methodological limitations. El-Kamary et al. (2004),

for example, noted that shortcomings in the design and implementation of the
Hawaii Healthy Start program most likely undermined the programs effect on
RRBs and TRBs. In addition, the results of several promising investigations were
limited by small sample sizes. Specifically, Koniak-Griffin et al. (2002, 2003), due
to small sample sizes, failed to achieve statistically significant results despite finding
a nearly 50% reduction in rates of RRB and TRB among participants. Similarly,
Norr et al. (2003) reported that their results may have been distorted by a basal
effect in that repeat pregnancy rates were so low across all intervention and control
groups that they left little room for improvement.
Other authors have commented that participation and attrition rates are key
factors affecting program outcomes. The relationship between participation rates
and program success in preventing RRBs and TRBs was established by Black et al.
(2006) who found that the number of completed sessions was positively correlated
with greater reductions in the risk of a second birth. Building on these results was
the work of Barnet et al. (2007) who reported that their program may have limited
effects due to the high percentage (39%) of mothers in the home visiting group that
received less than 75% of planned sessions. Likewise, Stevens-Simon et al. (2001)
suggested the possibility that high attrition rates and lack of program fidelity may
have undermined the effects of home visiting services on subsequent fertility rates
among participants in their study.
Overall, the mixed results found in the literature on the effects of home visitation
programs on rates of RRB and TRB suggest the need for further inquiry in this area.
In addition, a critique of this literature suggests that there is a need for studies that
include: (a) rigorous controls on treatment, (b) larger samples, and (c) high rates of
participation and retention. This study will address these gaps in the evidence base.

Methods
This study is based upon an analysis of data collected by an HFA credentialed
program in rural Western North Carolina from 1999 through 2007. The following
narrative will describe the participants, treatment model, research design, sampling,
instrumentation, and data analysis procedures that support the defensibility of this
investigation and inspire confidence in its results.
Research Design
While this investigation utilized a comparison group, it was not a true control group
due to an inability to randomly assign subjects. It also focused on dependent
variables that could only be measured post-intervention. Therefore, it is properly
considered a post-test only, non-equivalent control group design which authoritative
sources (Campbell and Stanley 1963; Fraenkel and Wallen 2009) describe as
defensible but with threats to internal validity associated with group equivalence;
e.g., selection, regression, maturation, and/or mortality. External validity treats

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associated with this design include interaction of selection and treatment and
multiple treatment interference.
To control effectively for the rival hypotheses of selection, regression, and
maturation, this inquiry collected key risk and demographic information on subjects
to evaluate group equivalence. Statistical tests, including t-test and Chi-square
procedures, were used to evaluate the significance of group differences and assure
that the Treatment and Comparison groups were similar with regard to age, risk
level, and ethnicity. In addition, the low attrition rate (13%) in the treatment group
strongly suggests that mortality would not is not a viable alternative explanation for
the results of this investigation.
Regarding external validity threats, the threat of interaction between selection
and treatment is minimized by the fact that the Treatment and Comparison groups
were closely matched on the salient treatment factors of age, risk level, and
ethnicity. However, given that this investigation was field-based and that the
participants had exposure to a range of human service options, it is impossible to
rule out the threat of multiple treatment interference. The implications of this threat
will be explored in the Discussion section.
Sampling
Participants for this investigation were referred to a rural/small town Healthy
Families America (HFA) program between 6/01/2000 and 7/6/2007. Expectant
parents and parents with an infant under 3 months of age were identified, screened,
and referred by Maternal Care Coordinators from the county Health Department, the
Nursing staffs of local hospitals and two local Obstetrics practices, and Social
Workers from the county Department of Social Services.
Referrals were prioritized based on the results of an informal pre-screening
checklist (Frankel et al. 2000) that included the following indicators of risk for child
maltreatment: (a) Late or no prenatal care or poor compliance, (b) Abortion/
adoption unsuccessfully sought or attempted during pregnancy, (c) Inadequate
income, (d) Single parent, (e) No telephone, (f) Unstable housing, (g) History of
sexual abuse, (h) History of substance abuse, (i) History of abortions, (j) History of
psychiatric care, (k) Employment problems, (l) Marital or family problems,
(m) Education under 12 years, (n) History of or current depression, (o) Inadequate
emergency contacts, and (p) Child protective services history. The priority status of
a referral depended upon (a) the number of at-risk indicators they exhibited and
(b) their responses to the most critical indicators (i.e., items that are known to have
the strongest relationship with abusive and/or neglectful parenting behaviors).
Minimum requirements for a positive screen were an affirmative response to either
item a or item b, affirmative responses to two or more indicators, or unknown
responses to seven or more indicators.
To receive services, families who screened positive on the referral questionnaire
were further evaluated on the Kempe Family Stress Inventory (KFSI; Murphy et al.
1985; Orkow 1985), an established indicator of parental risk for child maltreatment.
To be eligible, families had to score in the at-risk range based on the normative
standards of the KFSI. Because the participants were referrals from human service

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agencies, the sampling approach for this study is most accurately described as
convenience sampling. This method of sampling, while not ideal, is defensible when
dealing with participants that cannot be accessed through randomized procedures
(Fraenkel and Wallen 2006).
Participants
Study participants included 402 pregnant or new mothers, 232 of whom were in
their teens when they were referred to the program. Due to limited service capacity,
161 of these mothers, including 90 teen mothers, were enrolled in the program
during the time of the study while 241 mothers, including 142 teen mothers, could
not be enrolled. Of the 161 mothers enrolled, 21 (13%) withdrew before they met
the minimum engagement criteria (defined by HFA as participation in 75% of home
visits over the first 3 months of service). A profile of key demographic
characteristics (age, risk factors, and ethnicity) of the 161 enrolled, 21 drop-out
and 241 non-enrolled mothers can be found in Table 3. As these data indicate, the
three groups appear to be fairly similar in terms of age, risk factors, and ethnic
distribution. Nonetheless, to eliminate the problem of small sample size and create
the most parsimonious design for this inquiry, the drop out group was not included
in further analyses.
To establish the comparability of the remaining two groupsa Treatment Group
consisting of 140 at-risk mothers (90 teen mothers) who met minimum engagement
criteria and a Comparison Group of 241 at-risk mothers (130 teen mothers) who
could not be enrolled due to full caseloadsthe examiners used pooled variance ttests to evaluate comparisons based on interval and ratio-level data and a Chi-square
test of homogeneity to evaluate points of comparison that were based on nominal
Table 3 Demographic characteristics of enrolled, not enrolled and drop-out groups
Attributes

Enrolled
(n = 140)

Not enrolled
(n = 241)

Dropout
(n = 21)

20.37

20.89

19.90

Range

13.8340.5

14.8535.5

15.0829.58

SD

4.73

3.96

3.88

Age

Risk factors
X

5.9

5.0

5.2

Range

214

213

211

SD

2.20

2.54

2.49

Teen % (N)

64 (90)

54 (130)

57 (12)

White % (N)

81 (113)

81 (196)

86 (18)

African American % (N)

14 (20)

13 (30)

9.4 (2)

Hispanic % (N)

1.5 (2)

2 (5)

0 (0)

Asian % (N)

2.8 (4)

4 (10)

4.6 (1)

Native American % (N)

.7 (1)

0 (0)

0 (0)

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data. The results of these analyses are profiled in Tables 4 and 5. As these data
indicate, t-test results revealed a significant difference between the Treatment Group
and the Comparison Group with respect to mean at-risk factors (5.9 vs. 5.0,
p = .001). However, when a Chi-square test of homogeneity was used to compare
observed demographic frequencies in the Comparison Group to expected frequencies in the Treatment Group, the results indicate that the null hypothesis of no group
differences can be accepted (v2 = 8.083, p = .1517 at 5 df); that is, that the two
groups do not differ with respect to ethnic composition or proportion of adolescent
mothers. Based on these findings, it was concluded that the two groups were
sufficiently similar to treat them as equivalent for the purposes of this investigation.
Nonetheless, the implications of group dissimilarity in risk factors will be explored
in the Discussion section.
Data Collection
Birth information was gathered in a number of ways. For the Treatment Group,
information on the birth of the index child and all subsequent children was gathered
by Family Support Workers on referral forms and during home visits as long as
Table 4 Demographic characteristics of Treatment and Comparison groups with pooled variance t-test
results
Group

Mean
Age

SD
Age

Mean
Risk factors

SD
Risk factors

Treatment

140

20.37

4.73

5.9

2.54

T
Probability
p = .25
Accept Ho

Comparison

241

20.81

3.94

5.0

2.46

p = .001
Reject Ho

Ho Groups will not differ with respect to age or risk factors

Table 5 Chi-Square test for homogeneity of demographic characteristics of comparison and treatment
groups
Observed
(comparison)

Expected (based
on treatment group)

O-E

(O - E)2

(O - E)2/E

Adolescent

130

154.2 (64%)

-24.2

585.64

3.80

White

196

195.2 (81%)

.8

.64

.003

30

33.7 (14%)

-3.7

13.69

.406
.544

African American
Hispanic
Asian
Native American
Totals

3.6 (1.5%)

1.4

1.96

10

6.7 (2.8%)

3.3

10.89

1.63

1.7 (.7%)

-1.7

2.89

1.70

241

v2 = 8.083, p = .1517 at 5 df

241

Accept Ho
Ho The ethnic profiles of the comparison group will not differ from the ethnic profile of the treatment
group

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mothers were enrolled in the program. Additional information on births to mothers

who exited the program was obtained from county birth records. For the
Comparison Group, information on the birth of the index child and all subsequent
births was collected from referral forms and county birth records. The examiners
obtained demographic information and data on county-wide rates of TRB from the
U.S. Census Bureau (2000) and the Carolina State Center for Health Statistics
(20012007), respectively.
Analyses
Given that the dependent variables for this investigationrates of RRB and TRB
are frequency variables, Chi-square procedures were used to test for differences
between groups. These procedures were of two types: (a) tests of homogeneity,
which established whether or not observed frequencies of RRB and TRB
distribution differed significantly from an assumption of homogeneity; and (b) a
test of independence, which assessed whether or the distribution of TRBs in the
Comparison and Treatment groups was independent of the county-wide rate.
Statistical significance was defined as p \ .05 and a statistical trend as
.05 \ p \ .10. All tests were two-tailed. All statistical tests were performed in
MS Excel.
Treatment
Intervention for this investigation consisted of the HFA in-home early intervention
program for at-risk families. Services were provided by Family Support Workers
(FSWs), some of whom were non-degreed and none of whom held more than a
bachelors degree. FSWs served caseloads of 1520 families. All Treatment Group
participants started the program during their childrens prenatal period or shortly
after birth and continued in services for at least 6 months. Service delivery goals
varied by family but typically included achieving specified participation rates,
maintaining stability in the home, being responsive to parentchild interventions,
developing a support network, establishing a medical home, and attaining goals on
the Individual Family Service Plan (IFSP).
The services delivered to families in this study conformed to the HFA Home
Visitation Model as described in the literature review. This means that they
emphasized: (a) the development of a strong, trusting parentvisitor partnership;
(b) education in child development and parenting; (c) assistance with coordinating a
wide range of community resources; and (d) linking families with healthcare as a
means of increasing protective factors that have been shown to reduce the risk of
child abuse and neglect. Treatment fidelity was assured through the rigorous
application of HFA standards to four key implementation drivers described by
Fixsen et al. (2005); i.e., staff recruitment, training, supervision, and evaluation.
Regarding staff recruitment, the program, in accordance with HFA standards,
actively sought employees from diverse backgrounds who had experience serving
culturally and ethnically diverse clients. These efforts resulted in a staff that was
89% white and 11% African-American. While these ratios do not reflect a high

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degree of ethnic diversity, they closely matched the ethnic composition of the
county and the clientele of the program. In addition, all staff members had work
experience in human services when they were hired, ranging from 6 to 20 years,
with an average of 14.5 years. Furthermore, careful attention was given to personal
qualities that would enable FSWs to address difficult topics with their clients.
Specifically, FSWs were screened for their ability to confidently and sensitively
address the subjects of family planning, domestic violence, substance abuse, and
parental depression. Degree status was not a significant factor in personnel
selection. As a result, the educational backgrounds of the seven FSWs who
participated in this study were quite varied, including one high school graduate, two
with associate degrees, and four with bachelor degrees.
Regarding training, all FSWs participated in an extensive regimen of rigorous,
outcome-based training and development activities. These activities included:
(a) Connecting with Families: Family Support in Practice, a 6-day training program
that teaches essential intervention and treatment practices that are respectful to such
factors as gender, age, race, ethnicity, religion, geographical region, family
traditions, and lifestyle; (b) Family-Centered Practice in Family Preservation
Programs, a second 6-day training program focused on principles of partnership,
relationship-building, and strengths-based intervention; (c) HFA Role-Specific Core
Training, a pre-service curriculum that addresses principles of home visitation,
family assessment, and/or program management; (d) HFA mandated continuing
education, which includes a set of advanced training modules on maternal health,
child development and parenting skills that all staff members are required to
complete within their first year of employment; and (e) On-going in-service training
on various topics through staff meetings, seminars, workshops, and conferences. In
addition, to supplement formal training, supervisors provided opportunities for
FSWs to shadow experienced practitioners and observe them apply the skills they
had learned in training sessions.
Regarding supervision and evaluation, the FSWs who participated in this study
received weekly one-on-one reflective supervision and regular supervised co-visits
throughout their tenure in the program. In addition, the performance of FSWs was
routinely evaluated via direct observation and the collection of consumer
satisfaction surveys. These data sources were used to assure program quality and
fidelity to treatment goals and methods.

Hypotheses
The following sections with discuss the results of this inquiry with respect to the
following three null hypotheses:
Ho 1 The distribution of RRBs in the treatment group will not differ from the
distribution of RRBs in the Comparison group.
Ho 2 The distribution of TRBs in the treatment group will not differ from the
distribution of TRBs in the Comparison group.

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M. Ownbey et al.

Ho 3 The distributions of TRBs in the Treatment and Comparison groups will not
differ from those that would be expected based on county-wide census and public
health data.

Results
Results of this study are profiled in Tables 6, 7, and 8. As Table 6 indicates, the
results of a Chi-square test of homogeneity reveals that the difference between the
RRB rates for the Treatment Group (18%) and the Comparison Group (30%) was
statistically significant .05 level (v2 = 5.07, p = .0243at 1 df). Based on these
findings, Ho 1 can be rejected. Specifically, they demonstrate that at-risk mothers
who participate in a rigorously implemented HFA program exhibit significantly
lower rates of RRB than a comparable group of nonparticipants.
With regard to TRBs, the results of a Chi-square test of homogeneity profiled in
Table 7 reveals that the differences in the distributions of TRBs in Treatment Group
(9%) and Comparison Group (27%) were statisticallysignificant at the .01 level
(v2 = 8.87, p = .0029 at 1 df). Based on these findings, Ho 2 can be rejected.
Specifically, they demonstrate that at-risk teen mothers who participate in a
rigorously implemented HFA program exhibit significantly lower rates of TRB than
a comparable group of teen mother nonparticipants. Similarly, as Table 8 indicates,
the results of a Chi-square test of independence revealed that the distribution of
rates of TRB in the Treatment and Control groups differed markedly from the
county-wide rate of TRB (24%) at p \ .01 level (v2 = 8.02, p = .0027 at 1 df).
These data indicate that Ho 3 can also be rejected; that is, that the distributions
conform to county-wide norms. Upon inspection it is evident that the data are
skewed by a lower frequency of TRB among the Treatment Group participants.
Table 6 v2 Test of homogeneity for RRB using mean rate for both groups (26%) as the expected rate
N

% Observed

F observed

F expected

O-E

(O - E)2

(O - E)2/E

Treatment

140

18

25

35.6

-10.6

112.36

3.16

Comparison

241

30

72

61.2

10.8

116.64

1.91

Total

281

25.2

97

v2 = 5.07, p = .0243 at 1 df; Reject Ho

Table 7 v2 Test of homogeneity for TRB using mean rate for both groups (20%) as the expected rate
N
Treatment

% Observed

F observed

F expected

O-E

(O - E)2

(O - E)2/E

90

17.6

-9.6

92.16

5.24

Comparison

130

27

35

25.4

9.6

92.16

3.63

Total

220

19.55

43

v2 = 8.87, p = .0029 at 1 df; Reject Ho

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Table 8 v2 Test of independence for TRB using county-wide rate (24%) as the expected rate
N
Treatment

% Observed

F observed

F expected

O-E

(O - E)2

(O - E)2/E

90

21.6

-13.6

184.96

8.56

Comparison

130

27

35

31.2

3.8

14.44

.46

Total

220

19.55

43

v2 = 8.02, p = .0027 at 1 df; Reject Ho

Discussion
Relative to the Comparison Group and the community at large, clients of the HFA
program examined in this study exhibited significantly reduced rates of RRB and
TRB. These results provide evidence that well designed Healthy Families programs
implemented with fidelity can have significant positive effects on a key indicator of
the effectiveness of home visitation programs that serve mothers at-risk for child
maltreatment. Specifically, relative to the Treatment Group, rates of RRB were 60%
higher in Comparison Group. Similarly, teen mothers in the Comparison Group
were three times more likely to have a second birth during adolescence than were
teen mothers in the Treatment Group. Furthermore, teen mothers who participated
in the program were more than 67% less likely to have a TRB than nonparticipants
and 63% less likely to have a TRB than teens in the community at large. These
findings are especially noteworthy in light of the fact that the Treatment Group
consisted of at-risk mothers who, on average, exhibited a significantly higher
number of risk factors than participants in the Comparison Group.
While favorable, these results must be considered in light of the limitations of
this inquiry. Specifically, it relied, in effect, on a convenience sample and lacked
random assignment. In addition, the treated and untreated conditions were not
carefully controlled, leading to the question of multiple treatment interference. This
question is especially critical in light of the fact that the model of intervention used
was highly individualized and encouraged participants to access a full range of
services in the community, resulting in differences across clients in the level and
type of services provided. Furthermore, since RRB and TRB data on the
Comparison Group were gathered from public records, there were no opportunities
to follow up with these participants to determine what, if any, services they received
from other programs.
Nonetheless, the results are rather striking and somewhat out of synch with the
results of similar studies of home visitation programs. The authors propose four
specific factors that may account for these outcomes. The first is that the HFA
program in this study, as discussed previously, was rigorously implemented and
incorporated many characteristics found in effective prevention programs (Klerman
2004; and Omar et al. 2008).
Secondly, the HFA program described in this study exhibited low rates of staff
turnover throughout the intervention period. Specifically, the mean length of service
for the employees who participated in this investigation was 4.7 years. This feature
circumvented many of the implementation challenges described in previous studies
of HFA and of home visitation in general.

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Thirdly, the mothers in this study were enrolled prenatally whenever possible.
The programs emphasis on this feature was based on the conviction that it is
essential to offer services when mothers are most open and receptive to assistance
(Frankel et al. 2000). It is the authors observation that early engagement was
instrumental in facilitating a strong bond between the mother and the FSW. This
bond provided clients with opportunities to revise their working models of
attachment and, as a result, establish a foundation for building closer and more
functional bonds with their children (Rutter and OConnor 1999; Sroufe et al. 1999).
The strength of these bonds may have provided the motivation for participants to
delay subsequent births.
Finally and most importantly, it is the authors belief that the success of this
program in preventing RRB and TRB was mostly due to the depth and intensity of
the services provided. Specifically, services to mothers and other caregivers focused
on the development of life skills. In this regard, FSWs used home visits to engage in
frank discussion aimed at assisting clients to improve their judgment and change
counter-productive ways of thinking. Specific intervention techniques included
solution-focused problem solving and providing mothers with individualized
rationales about the benefits and costs of their choices.
Beyond individual work, FSWs helped mothers develop social supports, find
stable housing, and find economic supports as needed. Mothers were also given
assistance in accessing needed educational resources so that they could return to or
continue in school or work after giving birth. This assistance often included
adequate and affordable childcare. In addition, Family Support workers endeavored
to: (a) establish and maintain mutually respectful therapeutic relationships with
parents, (b) deliver services within a flexible framework to allow for individualization to meet the specific needs of each family; and (c) remain involved with
families over a long period of time. Collectively, these interventions contributed to
feelings of security, purpose, and hopefulness; all of which supported their decisions
to delay subsequent births.
With regard to family planning, FSWs educated parents in a culturally sensitive
manner on available contraceptive methods helped them decide which ones were
best for them. They also offered frequent, ongoing information on their consistent
and proper use. In addition, motivational interviewing was used to encourage
parents to delay subsequent births (Britt et al. 2004; Petersen et al. 2007; StevensSimon et al. 1991). Furthermore, FSWs responded to parental resistance with
encouragement and support for their self-efficacy. Other evidence based features of
the program included a strength-based philosophy, voluntary enrollment, regularly
scheduled home visits, and the use of tested curricula to structure home visits
(Heaman et al. 2006).

Conclusions
Participation in a rigorously implemented, early intervention home visitation
program for at-risk mothers based on the Healthy Families America Model was
associated with a significantly reduced frequency of RRB and TRB among the

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mothers it served. It is the authors contention that these findings provide valuable
direction for the future development of home visiting programs in general and for
Healthy Families programs in particular. Based on the results of this study, the
examiners would offer the following conclusions:
1.

2.
3.

Theory-driven, research-supported design and implementation with fidelity are

essential to the development of effective home visitation programs. Support
systems to ensure ongoing fidelity of implementation should address the key
implementation divers of recruitment, training, supervision, and evaluation as
described by Fixsen et al. (2005).
Home visitors who are not highly credentialed can, nonetheless, be highly
effective at providing in-depth services and achieving excellent outcomes.
In order to succeed, home visitation programs must consider a primary focus on
life skills, including: (a) cognitive interventions to improve reasoning,
judgment. Problem-solving, and goal-setting; (b) strategies for meeting security
needs including housing, social support, and economic support; (c) methods for
confronting learned helplessness including support for self-efficacy, hopefulness, and a sense of purpose; and (d) direct, culturally sensitive discussions of
family planning.

Finally, this investigation points to a need for further research. Future inquiry
into the effects of home visitation should examine such factors as effective staff
training and supervision strategies, reliable program replication, traditional and
nontraditional program outcomes, and identification of active program ingredients.
Acknowledgment The authors gratefully acknowledge Shanna Carswell-Worley, Lisa Ross, and Janice
Atkinson for their dedicated service and commitment to the mothers served by the Catawba Valley Health
Families program. This article would not have been possible without their efforts.

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