Healthy Families Longitudinal Evaluation Annual Report

              Healthy Families Arizona
Longitudinal Evaluation
1st Annual Report
January 2006
Prepared by: Prepared for:
LeCroy & Milligan Associates, Inc. The Arizona Department of Economic Security
620 N. Country Club Road Division of Children, Youth & Families
Tucson, Arizona 85716 Office of Prevention and Family Support
(520) 326-5154 1789 W. Jefferson, Site Code 940A
www.lecroymilligan.com Phoenix, Arizona 85007
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Table of Contents
List of Tables.................................................................................................................................3
Acknowledgements.....................................................................................................................4
Executive Summary......................................................................................................................5
Significance of the Healthy Families Arizona Longitudinal Evaluation........................11
Introduction to Planning the Healthy Families Arizona Longitudinal Evaluation ..........12
Program Theory and Research .................................................................................................14
Exploratory Study of Perceived Healthy Families Arizona Long-Term Outcomes..........17
Recruitment to Healthy Families Arizona ..........................................................................17
Areas of Program Impact ......................................................................................................19
Improving the Parent/Child Relationship .........................................................................19
Promoting Child Development ............................................................................................20
Increasing Economic Self-Sufficiency..................................................................................22
Preventing Child Abuse and Neglect ..................................................................................24
Improving Child Health ........................................................................................................24
Improving Parent Health and Mental Health ....................................................................25
Promoting Family Stability ...................................................................................................25
Increasing Social Support ......................................................................................................26
Improving Parental Competence .........................................................................................27
Participant Retention..............................................................................................................27
Staff Retention........................................................................................................................29
Characteristics of the FSS.......................................................................................................29
Retrospective Study of the Factors Related to Child Abuse and Neglect in Healthy
Families Arizona .........................................................................................................................32
Model of Change.........................................................................................................................44
Blueprint for the Healthy Families Arizona Longitudinal Evaluation ...............................49
References ...................................................................................................................................61
Appendix A: Summary of the Literature Related to the Theory of Change .....................68
Appendix B: Definition and Codes for Variables...................................................................85
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List of Tables
Table 1. Risk and Protective Factors Identified in the Literature.........................................15
Table 2. Selected Risk Factors for Healthy Families Arizona Participants and Those Who
Dropped Out Prior to 4 Home Visits .......................................................................................33
Table 3. Percent of CPS Reports for Healthy Families Arizona Participants .....................34
Table 4. Parent Characteristics by CPS report ........................................................................35
Table 5. Percentage with mental health risk factors by CPS report.....................................36
Table 6. Percentage of participants with substance abuse histories ....................................37
Table 7. History of severe childhood maltreatment ..............................................................37
Table 8. Risk Characteristics for Infants ..................................................................................38
Table 9. Familial risk factors......................................................................................................39
Table 10. Societal Factors ...........................................................................................................40
Table 11. Logistic Regression Predicting the Probability of Child Abuse and Neglect....42
Table 12. Participating Healthy Families Arizona Sites ........................................................50
Table 13. Schedule of Standardized Measures .......................................................................55
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Acknowledgements
We would like to thank the Arizona Department of Economic Security (ADES) for their
vision and commitment to this study. Our special thanks go to Ms. Rachel Whyte, Healthy
Families Arizona (HFAz) Coordinator, and Ms. Valerie Roberson, Manager, Office of
Prevention and Family Support, ADES. Always instrumental in the evaluation of HFAz and
deserving of great praise for her role is Ms. Kate Whittaker, the Quality Assurance
Coordinator. We would also like to acknowledge the support of those who generously agreed
to involve the HFAz sites they manage in the longitudinal evaluation: Ms. Mary Hauk and
Ms. Julie Dale of Child and Family Resources, Tucson, and Ms. Maria Paisano, Pascua
Yaqui Health Department, Tucson. Our heartfelt gratitude goes out to the FAW supervisors
and staff who work with us on a daily basis to recruit families for the evaluation. Thank you
also to the many families who have shared their time and their stories with us so that we
might advance our learning and ultimately program effectiveness.
Members of the LeCroy and Milligan Associates, Inc., evaluation team who were
primary contributors to this report include Judy Krysik, Ph.D.; Hilary Smith, M.S.; Craig
LeCroy, Ph.D.; Kerry Milligan, M.S.W.; and Allyson LaBrue, BA.
Suggested Citation: LeCroy & Milligan Associates, Inc. (2005). Healthy Families Arizona
Longitudinal Evaluation – 1st Annual Report. LeCroy & Milligan Associates, Inc. Tucson,
AZ.
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Executive Summary
More convincingly than in the past, research suggests that the effects of child maltreatment
are immense, and can follow children throughout their lives (Felitti, 2004). Regardless of the
severity, child maltreatment poses serious risks to the immediate and long-term physical and
psychological health of children. Furthermore, the financial costs associated with child abuse
and neglect are enormous, costing an estimated $56 billion annually (Cicchetti, 2004). There
is no uncertainty that child maltreatment is a dire problem that exerts a major toll on its
victims, affected families, and society – therefore, prevention is key.
Many of the programs developed to prevent child abuse and neglect in the past three decades
involve home visitation. As of December 2004 there were an estimated 430 Healthy Families
America-type sites in 36 different states and Washington DC serving an estimated 47,500
families (Diaz, Oshana, & Harding, 2004). The budget for these programs was $232 million,
a substantial investment in the prevention of child abuse and neglect and the healthy
development of children. The rapid expansion of home visitation and its associated costs has
focused attention on the effectiveness of this strategy. To date, the evidence of effectiveness
on home visitation has been mixed (e.g., Duggan et al., 2000, Kitzman et al., 1997, Larson,
1980; Gray et al., 1979; Barth, 1991; Siegel et al, 1991). The purpose of this report is to
outline the planning for the longitudinal controlled evaluation of Healthy Families Arizona.
The Healthy Families Arizona longitudinal evaluation is designed to:
1. provide evidence of the program’s effectiveness;
2. examine program impacts on parents and children over a five-year period to
determine if any early differences between those receiving the Healthy Families
Arizona program and those not receiving the program are maintained;
3. examine the critical elements related to success, e.g., study the variation in outcomes
based on mother and child characteristics, client/worker relationship, and site
characteristics; and
4. examine the cost of offering the program to families over a 5-year period.
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The Healthy Families Arizona longitudinal evaluation will follow the same families over five
years. This covers the period in which children are the most vulnerable to child abuse and
neglect and allows for an assessment of school readiness as children approach kindergarten.
It will compare a group of 95 families receiving Healthy Families Arizona to a group of 95
families not receiving the program (the control group). The analysis will track changes within
the families and compare across the two groups over time.
The longitudinal evaluation of Healthy Families Arizona differs from the ongoing evaluation
that has been conducted annually since 1991 in three important ways:
1. The evaluation is long-term – it follows the same families for five years regardless of
whether or not they remain enrolled in the program. This is different from the
ongoing annual evaluation of Healthy Families Arizona that does not follow families
once they leave the program.
2. The evaluation uses a randomized control group as opposed to a comparison group as
a means to determine program effectiveness. Random assignment to the control group
and the intervention group, the Healthy Families Arizona program, allows for the
assumption that the groups are equivalent prior to entry into the program. The
ongoing evaluation cannot provide insight into whether or not the outcome would
have been any different in the absence of Healthy Families Arizona.
3. The longitudinal evaluation employs additional measures that are not currently used
in the ongoing evaluation. The purpose of these additional measures is to test a full-range
of potential program risk and protective factors and outcomes. For example,
domestic violence, substance abuse, mental health, and parental discipline of children
will be measured systematically.
The Role of Evaluation in Healthy Families Arizona
Evaluation plays two important roles with regard to Healthy Families Arizona. First is a
formative role. Since the inception of the Healthy Families Arizona program in 1991;
evaluation has been used to provide timely and relevant information to be used in a quality
improvement process. The second role of evaluation is an important summative role in which
evaluation is used to determine overall effectiveness and accountability.
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The state of Arizona has long been committed to a process of program improvement driven
by the information gained through the ongoing formative evaluation of Healthy Families
Arizona. Since the inception of Healthy Families Arizona in 1991, LeCroy & Milligan
Associates, Inc. has conducted an annual evaluation of Healthy Families Arizona that is
summarized in a report to the state at the end of each calendar year. Throughout the history
of Healthy Families Arizona, the information generated through evaluation has been used in
conjunction with quality assurance and training to ensure that the program is achieving its
goals and producing the expected outcomes.
Early in the life of the evaluation it was recognized that the sites needed information beyond
the aggregation of data that was presented in the annual evaluations. The initial response to
this realization was to provide site-specific information in the appendices of the annual
reports. In an effort to respond to the sites in a timelier manner, and to make the data useable
for quality assurance visits and technical assistance to the sites, LeCroy & Milligan
Associates, Inc. moved to providing site-level data on a quarterly basis. Since 1999, quarterly
evaluation reports to the sites provide immediate feedback to ensure that processes that are
not working well and outcomes that are less than expected receive immediate attention.
Program specialists from the quality assurance team conduct a minimum of two visits to each
site per year to provide follow-up on concerns highlighted in the quarterly evaluation reports.
Problem areas identified through the quarterly reports are also followed-up by targeted
training and technical assistance.
The evaluators have worked closely with the quality assurance and training staff to ensure
that the site-level evaluation findings are useful to the sites and are used to influence practice.
For instance, the reports include information on a range of process issues including the
percentage of assessments completed, compliance with the required number of home visits
and supervision standards, and worker retention and training. The reasons eligible families
provide for declining the program are tracked and the sites receive quarterly data on
acceptance rates that can be used in program improvement. The focus of the quarterly reports
change from time to time as new problem areas are identified and new practices are
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implemented. For instance, the most recent quarterly evaluation report tracks the enrollment
of prenatal participants, a new component of Healthy Families Arizona implemented in 2004.
There is plenty of evidence to suggest from the controlled evaluation of other home visitation
programs that in the absence of a quality improvement process informed by evaluation, i.e.,
the formative evaluation role, services will not be of sufficient quality, intensity, and fidelity
to lead to the desired benefits for children and families (see for example Duggan et al., 2004).
Summative evaluation methods such as this controlled longitudinal evaluation should not be
attempted until it is demonstrated through formative evaluation that the program is being
implemented as planned, that there is sufficient attention to process, and that the program
demonstrates the promise of effectiveness. Only then is it worthwhile to spend the time,
effort, and money on summative evaluation.
The longitudinal evaluation of Healthy Families Arizona marks a commitment to embark on
the summative evaluation function. What state legislators, funders, advocates, and program
personnel want from the evaluation is evidence of effectiveness. This is the purpose of the
controlled longitudinal evaluation of Healthy Families Arizona.
Planning for the Longitudinal Evaluation
The evaluators have spent a full year planning and preparing the Healthy Families Arizona
program for the longitudinal evaluation. The planning and preparation was centered around
four sub-studies:
(1) a literature review on the theory and research related to the goals of Healthy Families
Arizona;
(2) an exploratory study of the long-term outcomes of Healthy Families Arizona as
perceived by the staff, supervisors, and participants of the program;
(3) an examination of the program structure and logic model of the program; and
(4) a retrospective study of factors related to substantiated incidents of child abuse and
neglect for program participants from 1997 to 2004.
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In addition to informing the specific roadmap for the Healthy Families Arizona longitudinal
evaluation, these four sub-studies resulted in recommendations to strengthen the program in
the areas of program development and training – assisting the program to prepare for the
controlled longitudinal evaluation.
Recommendations
From 1997 through 2004 there were 305 families with substantiated reports of child abuse
and neglect, 5,092 families with no CPS involvement, and another 754 families with
unsubstantiated CPS reports. In some way, this proportionately small group of 305 families
with substantiated CPS reports represents the failure of Healthy Families Arizona, and there
is much to be learned from them. Nine factors were identified as significant predictors of
substantiated child abuse and neglect in the retrospective study of Healthy Families Arizona
participants. These nine factors can be used to identify children who are at increased risk.
These factors also have implications for training and supervision. It is important that
assessment tools, program activities, and referrals address the factors that are related to child
abuse and neglect and that are amenable to change. Of the nine factors that were statistically
significant predictors of substantiated child abuse and neglect, six are amenable to change
including: substance abuse, isolation that results from living alone, reconciliation of issues
related to a childhood history of abuse and neglect, potential for violence, an acceptance of
discipline strategies that include spanking, and shouting, and the lack of a secure attachment
to the child. The odds of child abuse and neglect are about 54% greater for mothers who
report difficulty attaching with their child, and 66% greater for mothers with histories of
abuse in their own childhoods than those without such histories.
The recommendations that result from the retrospective study of Healthy Families
Arizona participants are consistent with the recommendations resulting from the exploratory
study. For instance, the Family Support Specialists reported needing additional support and
information in the areas of:
  nonviolent discipline in a cultural context where spanking and yelling are commonly
accepted. The Family Support Specialists need tools they can give parents to work
with extended family in the area of discipline.
  strategies for stress reduction with parents;
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  involving fathers and promoting father involvement when the family environment is
less than supportive. Interestingly, the retrospective study showed that CPS
involvement, including unsubstantiated and substantiated reports are more likely to
occur when the father is unemployed. The Family Support Specialists might engage
fathers in working on life course goals, much the same way that they have had
success in working with Healthy Families mothers.
Parents also indicated several areas of the parent/Family Support Specialist (FSS)
relationship that should continue to be addressed. These include:
  Staff retention: parents find it difficult to transition to new Family Support Specialists
and reportedly feel like they are starting over and have to tell their story all over
again. Easing transitions when an FSS terminates their work with a family and a new
staff takes her place are important to the participant’s continued engagement in the
program.
  Just as endings are important to the Healthy Families participant, so are beginnings.
The comments of the participants interviewed for the exploratory study suggest that
the explanation of Healthy Families Arizona at the time of recruitment should address
why the parent is being recruited. Some parents reported speculating about the
reasons they were recruited to the program. For example, they reportedly wondered if
the reasons they were offered the program were because they were on AHCCCS,
young, or because someone thought they were going to be a bad parent. This suggests
that there is stigma associated with the program. The parents suggested that it would
be helpful if public awareness of the Healthy Families Arizona program was
increased to reduce the stigma that some women feel as a result of being recruited by
Healthy Families Arizona. Parents also suggested that broader awareness would
increase accessibility to the program for other parents who could potentially benefit.
  The hiring of new Family Support Specialists should consider what Healthy Families
Arizona parents describe as experience. Parents appreciate Family Support Specialists
with direct hands-on experience versus “book smart” experience.
  Hiring should target increasing the pool of bilingual Family Support Specialists.
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  Family Support Specialists need to be continually reminded about the importance to
families of punctuality and keeping appointments. Not only do they inconvenience
and disappoint families when they are late or do not show for appointments, but they
are modeling important behaviors. When necessary, parents need to be informed of
canceled appointments and appointments need to be rescheduled.
Significance of the Healthy Families Arizona Longitudinal Evaluation
The longitudinal evaluation is highly significant, especially since Healthy Families Arizona
has grown in size and cost. The Governor’s office, state legislators, and child advocates are
calling for evidence of program accountability. Second, other controlled studies of home
visitation, although few in number, have produced mixed results and some have been
damaging to the reputation of the Healthy Families program model. This has put pressure on
Healthy Families programs across the nation to demonstrate program effectiveness. Arizona
has long been recognized as a leader in the Healthy Families model of home visitation.
Therefore, the outcome of this evaluation has national, as well as local significance.
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Introduction to Planning the Healthy Families Arizona Longitudinal
Evaluation
The 2005 fiscal year has been a year of planning and start-up for the longitudinal evaluation
of Healthy Families Arizona. The approach to the evaluation can be described as a layered-study
approach including four substudies. These four studies are outlined below.
Theory of Change. This substudy summarizes the theory and empirical evidence related to
the three major goals of the Healthy Families Arizona program: (1) the prevention of child
abuse and neglect, (2) the enhancement of parent/child interaction, and (3) the promotion of
child health and development. The significance of this substudy is that it is unreasonable to
expect change if the Healthy Families Arizona program is not working to affect change in the
major risk and protective factors related to the program goals.
Exploratory Study of Healthy Families Arizona Long-term Outcomes. An exploratory
study that included a survey of 18 established Healthy Families Arizona sites and interviews
with 16 current and former Healthy Families Arizona participants was conducted to identify
perceptions of long-term impacts beyond those identified in the literature on home visitation.
This study was conducted with the intent of informing the range of outcome measures to
fully test the boundary of the Healthy Families Arizona program.
Retrospective Study on Child Maltreatment. This substudy examines eight years of data
collected on all Healthy Families Arizona program participants from 1997 through 2004.
Child abuse data collected prior to 1997 were not available for analysis. The total Healthy
Families Arizona target child and dependent sibling database was run against the Department
of Economic Security (DES)-Child Protective Services (CPS) CHILDS database to identify
families with substantiated incidents and unsubstantiated reports of child abuse and neglect.
The statistical analysis for this substudy allowed a determination of the factors predictive of
substantiated child abuse and neglect in the Healthy Families Arizona population.
Critical Examination of the Program Logic Model. A program logic model is an articulated
description of the program goal, objectives, activities, measurements, and resources. It
outlines the program’s operations in terms of administration, personnel, training and
supervision practices, and the major decision points in the course of participation in the
program. The concurrent examination of program theory and conceptualization of the
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Healthy Families Arizona program as represented by the program logic model helped
promote an ongoing discussion on program improvement in a critical and guided manner.
The critical examination of the program logic model served two purposes. The first was to
help the program look critically at implementation issues prior to engaging in the outcome
evaluation. For instance, did the program objectives address the salient risk and protective
factors identified in the examination of program theory? Second, was the program logic
model an accurate representation of the program and was it front and center in guiding
decision-making related to the program? It is important that the program logic model be both
of these things as it will be used as a basis for measuring program fidelity in the longitudinal
evaluation, i.e., measuring if the program was implemented as intended. LeCroy & Milligan
Associates, Inc. conducted activities throughout the planning year to promote the use of the
program logic model as a basis for understanding the program and as a guide in decision-making.
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Program Theory and Research
The causes of child abuse and neglect are complex. Most theories of child maltreatment
recognize that the root causes can be organized into a framework of four principal systems:
1) the individual parent and child, 2) the family, 3) the community, and 4) the larger societal
system or macrosystem. Within each of these four systems numerous factors have been found
to increase a child’s risk for maltreatment while other factors have been found to protect
against maltreatment. Researchers studying the etiology and effects of child maltreatment
argue for a simultaneous study of multiple risk and protective factors, suggesting that it is
more than just one factor that makes certain segments of the population more likely to report
child abuse histories or experiences (Belsky, 1993; Brown et al., 1998; Cicchetti & Lynch,
1993).
Studies have found that as the number of risk factors for maltreatment increases, a child’s
likelihood for abuse and neglect also increases (Brown et al., 1998). For instance, Brown et
al., (1998) discovered that the prevalence of child abuse or neglect increased 3% when no
risk factors were present to 24% when four or more risk factors were present. This finding
suggests that in order to effectively identify children who are at a greater risk for child
maltreatment, and consequently developmental difficulties, a significant number of risk
factors need to be considered and addressed. Given these findings, researchers and
practitioners need to consider the multitude of personal, family, and environmental factors
that strengthen families, reduce the risk of abuse and neglect within families, and improve
child outcomes. Table 1 presents the risk and protective factors, as well as the consequences
of child maltreatment identified in the literature. These items should be considered for
inclusion in the longitudinal evaluation. The full literature review is presented in Appendix
A.
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Table 1. Risk and Protective Factors Identified in the Literature
Individual Child
Prenatal Period
• genetic endowment
• stress in pregnancy
• exposure to violence in
pregnancy
• nutritional deficiency
• infectious disease (STD,
etc.)
• neurotoxins (alcohol,
drugs, tobacco)
• prenatal care
Birth and beyond
• premature birth
• low birth weight
• stimulation/play
• routines for basic care
• nutrition
• sleep and rest
• health care
• sense of security
• age
• gender
• disability
• intelligence
• easy temperament
• consistent and preventive
medical care
(immunization)
Individual Parent
• personality
• substance abuse
• race/ethnicity
• age
• education
• employment
• history of childhood
maltreatment
• reconciliation with history
of abuse
• mental health (self-esteem,
depression, social
isolation, loneliness)
• stress
• anger
• impulsivity
• tendency to interpersonal
conflict
• age at birth of child
• educational attainment
• attachment to child
• knowledge of child
development
• perception of child
Family
• discipline strategies
• income
• household rules
• supervision/monitoring
• communication
• flexible and adaptable to change
• household size
• number of children
• family structure
• domestic violence
• chaotic home environment
• parental absence
• healthy relationships
• family support
• expectations of pro-social
behaviors
• participation in religious faith
• adequate housing
Community
• neighborhood
poverty
• parental perception
of safety
• availability of
medical care
• availability of
social services
• preventive medical
care
• economic
opportunities
• housing
Larger Society
• access to
medical care
• access to
mental health
and other social
services
• income support
• child care
• support for
education/
employment
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The literature also identifies the following outcomes associated with child maltreatment.
Assessment of some of the outcomes would be based on the child’s age. For example,
relationship with peers and school readiness are measures geared to a 5 or 6 year old child.
Outcomes associated with child maltreatment
• child fatality
• sexual abuse
• physical abuse
• neglect
• emotional abuse
• developmental delay
• behavior problems
• social withdrawal
• self-regulation
• independence from parent
• brain development
• empathy
• demonstration of compassion and love
• toileting behavior
• need for special education
• educational outcomes
• literacy skills
• learning
• intellect
• good peer relationships
• plays well with others
• follows simple directions and rules
• ability to resolve conflict
• concentration
• speech
• disabilities (FAS, FAE, etc.)
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Exploratory Study of Perceived Healthy Families Arizona Long-Term
Outcomes
An exploratory study to examine perceptions of the range of Healthy Families Arizona
program effects and the long-term impacts of the program was conducted in the spring of
2005. The purpose of the exploratory study was to guide the design of the longitudinal
evaluation. Two groups were surveyed for the exploratory study. First, Healthy Families
Arizona staff including supervisors and Family Support Specialists (FSS) from the 24
established Healthy Families Arizona sites were requested to respond to a mailed survey. Of
the 24 sites surveyed, Healthy Families Arizona supervisors and staff from 18 sites
participated, representing a 75% response rate. Secondly, 16 current and former Healthy
Families Arizona participants were recruited through referrals from the Healthy Families
Arizona staff participating in the mailed survey.
Six of the participating Healthy Families Arizona sites referred participants including1:
Central Phoenix, Sunnyslope, Nogales, Prescott, Lake Havasu, and Tucson. Sixteen Healthy
Families Arizona participants, all mothers, were interviewed using a semi-structured
interview guide. The interviews were approximately 30-45 minutes each and interviewees
received $25 in appreciation for their time and information. Participation in the Healthy
Families Arizona program for the 11 current participants ranged from 18 to 58 months with
an average of 30 months. The five former Healthy Families Arizona participants had all
graduated between June 2004 and March 2005 after completing five years in the program.
Recruitment to Healthy Families Arizona
The 16 participants were asked to think back to how they felt about starting the Healthy
Families Arizona program and to describe their lives at that time. Five participants expressed
“chaotic” or “hectic” home environments at the time they were recruited to Healthy Families
Arizona; four other participants characterized their lives as “crazy” and reported feeling
stressed, anxious and overwhelmed about raising their children. One mother noted she was
1 A seventh site, Yuma, also referred participants for the study and attempts to make contact were not
successful.
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“at a crazy point” in her life stating: “I didn’t want to admit I needed help.” In addition to
their own life stressors, several participants mentioned that their child was born with
complications, or that they had experienced problems during childbirth. The mothers
mentioned that they were especially nervous about their ability to parent; consequently, they
reported feeling afraid and expressed the need to have someone to talk to. Only one of the 16
mothers interviewed noted that things in her life were “normal” at the time she was
introduced to Healthy Families Arizona; yet she also reported feeling inexperienced and
scared about caring for her child: “My life was normal; I had a happy marriage. The only
thing is I was really stressed because I didn’t know how to care for a newborn. I was really
scared.”
Four participants expressed the opinion that there is not enough awareness of Healthy
Families Arizona and this may limit the program’s ability to attract families who might
otherwise need the program’s services. “I think it’s wonderful and should be offered to more
moms.” Another participant commented: “I wished they advertised it more. Several people at
my work haven’t heard of it and for some it would’ve been helpful.”
Five mothers suggested that the approach to offering Healthy Families Arizona made them
“nervous” and “unsure” about why they were being offered the program. For instance, one
mother revealed: “I didn’t know if I was approached because I was on AHCCCS. Is it
because I was poor? I wasn’t sure.” Another mother noted, “I thought they thought I was
going to be a bad mother because I was young. I wasn’t sure why they were asking me. I
guess I was intimidated.” Another mother indicated: “Having a nurse hand me a flyer made
me feel nervous. I didn’t know why I was being told about it.” These mothers suggested that
greater sensitivity and more information as to why they were being offered the program
could help generate more interest in Healthy Families Arizona.
The majority of the 16 mothers noted that although they were unsure about what to expect
from Healthy Families Arizona they were also excited about enrolling. For example, one
mother stated: “I was looking forward to learning about my baby and have someone there. I
was excited.” Another participant noted that although she felt a bit “naïve and nervous,” she
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also felt “excited about learning new things.” The ability to enroll in a free program that
provides help, support, information and services was a significant factor in the mothers’
decisions to start and ultimately continue their involvement with Healthy Families Arizona.
Areas of Program Impact
There was a great deal of congruence in the responses of supervisors, staff, and participants
as to the range of Healthy Families Arizona program effects and long-term impacts. The
perceived program effects have been summarized into nine major themes. Each theme is
described below and is illustrated with quotes from the survey.
They include:
  improving the parent/child relationship
  promoting child development
  increasing economic self-sufficiency
  preventing child abuse and neglect
  improving child health
  improving parent health and mental health
  promoting family stability
  increasing social support
  and improving parental competence.
Improving the Parent/Child Relationship
Healthy Families Arizona program staff noted attempts to promote healthy parent/child
relationships, and increase attachment, parental empathy, and parental involvement with an
emphasis on father involvement. The staff reported the perception that the program is
generally effective in promoting healthy parent/child relationships due in large part to the
number of activities and resources that Healthy Families Arizona provides to families in this
area. These include, for example, encouragement, reinforcement, modeling, direct teaching,
flexibility in scheduling so fathers can be involved, community referrals, handouts with
relevant information, consistent contact, listening, supportive play, activities, floor time, the
Individual Family Service Plan (IFSP), and the Growing Great Kids and Everyday Matters
curriculums.
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The one outcome that program personnel expressed the least confidence in influencing in this
area was father involvement. Although several Healthy Families Arizona sites expressed
support for this outcome, some reported that family members sometimes oppose father
involvement.
Consistent with the comments from the Healthy Families Arizona staff, the 16 Healthy
Families Arizona participants recognized the impact that the program had on their
relationships with their children. Eight mothers suggested that Healthy Families Arizona
focuses on enhancing communication within the family. For example, one mother said:
“They have taught me how to communicate with my daughter by singing, reading and talking
to her.” These mothers felt such things as praise and patience helped establish a positive,
stable home environment and good relationships with their children. Statements that reflect
these sentiments include:
“I remember to praise my child. That’s important. I try and remember that.”
“I’m a more patient parent.”
“The program shows parents that nothing should bother you. Children don’t all learn
at the same time and that’s ok. They remind you that you have to be patient when
raising a baby.”
“She [FSS] gives me information that I can apply to being a parent. And the
activities, they’re wonderful. I couldn’t think of these things on my own. I think it has
really improved communication with my child.”
Promoting Child Development
A second theme in the staff and participant responses was related to child development. This
theme includes activities such as helping parents understand their babies, teaching parents
about child development, demonstrating appropriate developmental expectations of children,
and making community referrals. These activities were viewed by Healthy Families Arizona
staff as a means for creating better outcomes in subsequent family births, and encouraging
development consistent with the child’s age. Program personnel felt that Healthy Families
Arizona is generally effective in promoting child development outcomes in the long-term.
Healthy Families Arizona Longitudinal Evaluation 21
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They also recognized that long-term demonstrations of appropriate developmental
expectations of children were limited due to the lack of resources for families with children
between 5 and 10 years of age.
The 16 Healthy Families Arizona participants spoke about child development with
knowledge and confidence. Program participants recognized the promotion of healthy child
development as a key focus of Healthy Families Arizona. This is reflected in the following
quote: “(Name of FSS) asks questions to see how she is developing. It helps to make sure my
daughter is growing properly.” Mothers noted that one primary resource that Healthy
Families Arizona uses to promote child development is the developmental questionnaire
called Ages and Stages. For instance: “The program helps me see how my baby is
developing.” “Kids change every year, it’s nice to have tools for each stage.” The
participants noted that the questionnaire provides an opportunity to understand key
developmental milestones of their children as they move through the program.
Participants’ comments reflected the perception that Healthy Families Arizona is influential
in child development and they were overall satisfied with their knowledge and understanding
of their child’s development. For instance, one mother suggested that Healthy Families
Arizona provides “information on what you can expect from babies at developmental stages
and age groups. You learn how to distinguish cries, and at what age your child should start
crawling.” Similarly, another mother said the program would “help me pay a lot of attention
to my daughter, such as her development and how to treat her.” Another mother stated that
she now had a “better understanding of my child and I feel I am a better mother. The
program helped me advance.”
Participants also noted the program’s focus on identifying potential developmental delays.
These mothers reported that the emphasis on delays led to early identification that might
otherwise have been overlooked. For instance, one mother with older children stated: “I have
a 5-year-old son with developmental problems. Had I known about the program earlier, I
think we could’ve caught his problems.” Mothers reported that delays were often identified
in the areas of speech and language. Interestingly, mothers noted developmental
Healthy Families Arizona Longitudinal Evaluation 22
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improvements among their children as the most common positive change in their child as a
result of Healthy Families Arizona. These mothers mentioned that once the FSS identified
developmental difficulties they were subsequently referred to appropriate community
services and received extra attention during home visits. For instance, one mother said, “His
speech is improving because of the tools and reading we’ve been doing.” Consequently,
these mothers viewed one of the primary goals of Healthy Families Arizona as providing
developmental information and community resources to help identify and provide services
for needed care. The information mothers receive from Healthy Families Arizona on
development and developmental stages was frequently mentioned as one of the greatest
strengths of this home visitation program. The goal of promoting child development was
often mentioned as an initial expectation of the program’s purpose and was reinforced
throughout participation in the program.
In addition, five mothers emphasized the program’s impact on enhancing their child’s
cognitive ability. For instance, one mother stated, “He’s intelligent. Our visitor brings me
books so I can read to him.” Another mother noted, “My daughter is very intelligent, not just
because she’s my daughter but because she has learned a lot from the program. For
example, since they teach parents to read to their children, she [my FSS] always seems to
bring me different books so I can read to her [my daughter].”
Increasing Economic Self-Sufficiency
A third theme that surfaced in the survey of Healthy Families Arizona sites and participants
was economic self-sufficiency. This theme is broad and includes such objectives as parents
pursuing their educations, families receiving assistance with job training, employment, and
finances and budgeting. Responses from the Healthy Families Arizona sites suggest the
program is generally effective in meeting these outcomes, and yet staff experience problems
encouraging some aspects of budgeting and economic self-sufficiency due to parent’s limited
job skills, life stressors, and an absence of community resources to address financial,
education, and health issues.
Healthy Families Arizona Longitudinal Evaluation 23
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Half of the Healthy Families Arizona participants also reported that the program was helpful
in assisting them with finding appropriate resources in their communities and ultimately
impacted their becoming self-sufficient. This included finding community services to assist
them with their immediate financial and educational needs, as well as those that might help
them in the future. Several participants noted major achievements such as:
“I am full time in school now.”
“I own my own house and went and finished some school.”
The participants also noted the relationship between economic self-sufficiency and family
relationships. For example, one mother indicated the program helped her improve relations
with her husband where they went from “living on the street to owning their own home. I am
now a better parent and a better wife.” Similarly, two mothers commented:
“I feel like I am a better parent and wife.”
“I am healthier, wealthier, and wise. I’m more well-rounded with income and
budgets. The quality of life for my son is better.”
A special emphasis on “self” sufficiency was noted as is reflected in the following comment:
“I thought it would do for me. It doesn’t. The program is out to help teach. Not do for you,
but teach you.” Only one participant suggested that Healthy Families Arizona should directly
provide her with resources: “Another thing is if I need something, like diapers, they need to
get it to us. They need to always have access to diapers and milk.”
Generally, as the mothers’ self-sufficiency increased, they reported they relied upon and
needed Healthy Families Arizona less. One mother stated, “I have less visits now because I
am not relying on it as much. I’m gaining my independence.” Another mother replied, “I
don’t need as much help now so I don’t see (name of FSS) as much.” These comments
indicate that participants understand the level-system used by Healthy Families Arizona and
support this practice.
Healthy Families Arizona Longitudinal Evaluation 24
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Preventing Child Abuse and Neglect
The fourth theme, the prevention of child abuse and neglect, is an area that was alluded to in
the three previous themes including parent/child relationships, child development, and
economic self-sufficiency. Both Healthy Families Arizona staff and participants explicitly
mentioned preventing child abuse and neglect as an area of program impact. For Healthy
Families Arizona staff, this included promoting positive discipline through modeling and
education, improving parenting skills, and decreasing parental stress. This was an area where
Healthy Families Arizona staff mentioned two challenges to the attainment of positive
program impact. First, some staff reported that the use of positive discipline methods is at
times offset by the influence of extended family members and cultural practices. Second, it
was stated that there is currently not enough information for parents on stress management.
One site also reported that more should be done to help families avoid CPS involvement.
Two of the 16 Healthy Families Arizona participants reported the potential for the program to
reduce child abuse. One mother noted this was especially likely among “single moms who
are already so stressed out about caring for their baby.” Another mother reported: “If more
families got involved, the state would see less child abuse and neglect.” Seven participants
expressed the opinion that Healthy Families Arizona reduced parental stress by providing
resources and referrals, parenting information, and support that helps enhance families ability
to effectively care for their children. For instance, “I would not be the parent I am now if it
wasn’t for Healthy Families. I am an advocate of Healthy Families. I believe it helps reduce
abuse and ignorance about parenting. I would recommend it to all parents.”
Improving Child Health
The fifth area of program impact is child health, including healthy, immunized children
living in safe home environments. Staff reported that the activities that lead to the attainment
of these outcomes are teaching about infant and child care, educating families on child safety
and nutrition, and encouraging routine immunization and medical care of children. Healthy
Families Arizona staff reported the perception that the program was largely effective in this
area. The outcome is reportedly hindered at times due to limited health resources and a lack
of wellness checks among participating families.
Healthy Families Arizona Longitudinal Evaluation 25
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Improving Parent Health and Mental Health
The sixth category is somewhat of a catchall for a number of outcomes related to parent
health and mental health. These outcomes include decreasing domestic violence, substance
use and abuse, and supporting identification and treatment of mental health problems. Noted
program services that target these outcomes include domestic violence, substance abuse, and
mental health screens; community referrals; collaboration with other programs;
reinforcement and encouragement. Healthy Families Arizona personnel reported the
perception that the program is able to meet these goals effectively. However, one site noted
the difficulty with knowing whether parents discontinue their use of drugs and alcohol in the
long-term as there is limited awareness of substance use among past program participants.
The participants did not mention program impacts in the areas of substance abuse and
domestic violence. Two participants, however, reported that the program was able to help
them deal with their disabilities.
“It’s the best program I’ve been in and they did a good job, excellent job with me. I’m
disabled and they did an excellent job with my kids. They did real good. Put an A
down and a smiley face.”
“I’m really impressed and grateful for the way my FSS has helped me. I suffered a
very serious car accident and am now disabled. My FSS has helped me in this area.
She has given me advice and information on how to deal with it and how to explain to
my son why and how I am disabled.”
Promoting Family Stability
Additional areas of program impact identified by staff included the parent’s resolution of
their own childhood issues, improved family communication, future family planning (e.g.,
discussions about future pregnancies), children becoming more independent, families
advocating for themselves and others, families referring others to Healthy Families Arizona
and providing resources to those who may need help with parenting issues, and decreased
incarcerations of family members. Participants suggested that the emphasis on
communication was focused on both the child, and, where applicable, a significant other,
thus improving relationships with a spouse or partner.
Healthy Families Arizona Longitudinal Evaluation 26
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Increasing Social Support
Many mothers reported a major purpose of Healthy Families Arizona is to provide “support”
and “offer help and needed services” to families throughout the first few years of their child’s
life. This sentiment was particularly common among mothers who felt they were “alone”
when they learned about the program and among those who were first time mothers. Mothers
reported that the program, primarily the FSS, acts as a “crutch” by providing them with
information, resources and referrals, and economic and emotional support. For instance, one
mother felt the primary purpose of the program was to “help young moms so they won’t be
stressed out.” Another mother felt the program would “give me someone to talk to.” These
mothers felt it was important to have someone to turn to and “be there when you need
someone.” These sentiments indicate that the program acts as a form of support that these
families may otherwise be lacking. Their comments in this area included:
“She (FSS) counsels me on issues. Helps keep me sane.”
“They are just always there. They help you with financial things, food boxes, just
getting you on your feet. I can always call (name of FSS), tell her anything.”
“This is my first child and I really didn’t know what to expect. (Name of FSS) helped
me understand.”
“As a first time parent, I have support.”
Aside from the emotional and financial support and resources Healthy Families
Arizona provides, participants discussed the program gatherings as another means of support
and an opportunity for socializing with other families involved with Healthy Families
Arizona. Similarly, these outings provide children with an opportunity to play and interact,
which was mentioned as a positive change for many enrolled children. One mother remarked,
“They had a Christmas party. And they did this ‘Dress a Child.’ Families who can’t afford
nice things were able to get a nice outfit for their child. That really is important.” Similarly,
one mother commented, “I really like the gatherings they have with the Healthy Families
Arizona clients. This is really good for my daughter so she can play with other kids.
Sometimes we go to the pool. They also play music for the kids and this gives kids the
opportunity to socialize with one another.”
Healthy Families Arizona Longitudinal Evaluation 27
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Improving Parental Competence
Participants especially emphasized the program’s ability to help them feel better about
themselves, particularly improving their self-esteem, making their lives more “stable,” and
enhancing their confidence and ability to be a good parent. Several mothers mentioned that
this was an emphasis of Healthy Families Arizona. For instance, one mother indicated she
felt better about herself and stated she now had “confidence in being a great mom even
though I’m single.” Similarly, another mother suggested “our life is more stable because I am
learning how to take care of myself and my children.”
Participant Retention
In order to fully benefit from Healthy Families Arizona, participants have to remain in the
program long enough to receive what they need from the program. Accordingly, we asked
current and former participants why they remain(ed) involved as well as the strengths and
limitations of the Healthy Families Arizona program. When asked the question, “What has
kept you involved in Healthy Families Arizona?” the mother’s comments included:
“They find ways to get you help where you need it.”
“It’s a good program. I receive a lot of help.”
“Learning different things.”
Aside from the help they receive, participants reported that the Family Support Specialists
were one of the major strengths of Healthy Families Arizona and a primary reason they
remain(ed) involved. While the services including developmental assessments, parenting
information, and emotional and economic support helped induce initial interest in the
program; it was the relationships with the Family Support Specialists that often influenced
participants’ to continue in the program. Participants generally reported the perception that
their Family Support Specialists were “nice,” “supportive,” and “caring.” The FSS was often
noted as having a “positive influence” on mothers and how they parent, and many mothers
indicated that they were “comfortable” with their FSS and “respect their comments and
feedback.”
Healthy Families Arizona Longitudinal Evaluation 28
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For example,
“She calls often to see how my son is doing. She cares a lot about him and our
family.”
“I feel fortunate to have her.”
“She helps me be a better mother because of the feedback she provides.”
“I didn’t feel like a case.”
“The home workers… She comes and plays with my son. That is good for him and for
me.”
“I have mommy brain. I can’t remember when my daughter does things. I say, ‘When
did she do this?” (Name of FSS) has it recorded and knows.”
“She helps me a lot. She brings toys, books, and lots of things to do with my son. I
learn a lot from the things she does with us.”
Despite the friendly, respectful characteristics of the Family Support Specialists, many
mothers discussed the difficult process of building relationships. Participants reported that it
often took a little time before establishing the rapport that allowed them to open up and trust
their FSS. For example, one mother said she was “more comfortable now than at the
beginning of the program because I am now more comfortable with my worker.” Another
mother echoed the sentiment of comfort with her FSS by stating, “At first, it was awkward
because we didn’t really know each other, but after getting to know each other it has really
helped.” Other examples of this sentiment include:
“I am more confident and trust her now. I’m not embarrassed anymore to talk to
her.”
“I was worried about having someone in my home. But the more we met I became
comfortable with her. I knew she was there to help me.”
These comments suggest that the relationship between the FSS and family is central to
program effectiveness by promoting family and child well-being.
Healthy Families Arizona Longitudinal Evaluation 29
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Staff Retention
Many mothers mentioned that a change in their relationship with their FSS had impacted
their level of involvement in Healthy Families Arizona. Participants reported that their
relationships with the Family Support Specialists also created some difficulties when they
experienced more than one FSS throughout their involvement with Healthy Families
Arizona. This was particularly true when a mother felt comfortable with a FSS who
terminated her employment, leaving the family to build a new relationship with a new FSS.
For instance, one mother responded: “There was some inconsistency among the family
workers. I think there is such a high turnover and it impacts our relationship. We’ve had a
couple and it’s hard to rebuild relationships and feel comfortable again. It takes time. And
then they seem to leave.”
Many mothers echoed this concern over the high turnover among Healthy Families Arizona
Family Support Specialists. Five of the participants interviewed had between three and six
Family Support Specialists. Participants mentioned this created a problem for them since it
produced the need to readjust to a new relationship and get comfortable. For instance, one
mother indicated she had “several workers quit so I had trouble adjusting to each one. I’ve
had this one for a while now so I’m more comfortable with her.” Similarly, three mothers felt
there was a little “setback” when they had a new FSS. For instance, “It seemed like we
started all over again. She didn’t know where we left off or what I had shared, so we
basically started over.”
Characteristics of the FSS
Four participants discussed the experience level of the Family Support Specialists as a
limitation of Healthy Families Arizona. This was attributed to the lack of hands-on
experience among some Family Support Specialists. Comments that indicate this theme
include:
“I feel as if they were reading on the Internet or had a child development class but
that is not the same thing as hands on experience. The program needs more people
who have experience with children for modeling.”
Healthy Families Arizona Longitudinal Evaluation 30
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“My relationship was different from my sister’s. My family worker was younger, had
a different experience level. She didn’t do some of the same activities my sister told
me about. I didn’t feel like I was getting what I wanted from the program.”
A few participants talked about some practices of their home visitor that created problems for
them. For instance:
“There is not enough staff. And when one of my workers didn’t call or show up when
it was planned, that is really stressful for a family.”
“…They need to be on time. There has been three times when she never calls when
she can’t show up for an appointment. Sometimes, I also experience attitude from
them. She also needs to get back to me more promptly.”
It is also important to participants to have home visitors that can speak their language. In
some places there is a shortage of bilingual staff as illustrated in this comment:
“I think there’s like two here (referring to bilingual Spanish-speaking Family Support
Specialists). We need more. I talk and can listen better in Spanish; it’s hard.”
Program participants and Healthy Families Arizona staff align closely with the objectives
outlined by Healthy Families Arizona program. These objectives include such child and
parent outcomes as appropriate developmental expectations, identification of developmental
delays and early intervention, a better sense of support and access to community services,
positive parent-child interaction, fewer incidents of child abuse and neglect, healthier
children and parents, enhanced parental self-esteem and competence, improved family
stability, and economic self-sufficiency. The comments were also suggestive of additional
outcomes including: enhanced cognitive skills and the social and emotional development of
children, both related to school readiness; improved relationships with significant others
including spouses and partners; and reduced involvement with the justice system. Overall,
the 16 mothers felt extremely benefited by Healthy Families Arizona in ways that closely
support the intended outcomes. Program staff and Healthy Families Arizona participants
view the program as generally effective in meeting the many outcomes mentioned, with a
few exceptions noted by program staff in the areas of father involvement and nonviolent
Healthy Families Arizona Longitudinal Evaluation 31
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discipline that can be impeded by extended family. Resources were also considered lacking
in the areas of health care and stress management.
The 16 participants interviewed had a strong commitment to Healthy Families Arizona. The
participants initially grew interested in Healthy Families Arizona as a result of the
informational services and support the program provided, but they expressed continued
participation in the program largely as a result of their relationships with their Family
Support Specialists. These relationships are perceived as helpful and significant in achieving
successful program effects. Overall, both current and former participants of the program
reported that they were very satisfied with their experience in Healthy Families Arizona.
Healthy Families Arizona Longitudinal Evaluation 32
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Retrospective Study of the Factors Related to Child Abuse and Neglect
in Healthy Families Arizona
This section utilizes eight years of retrospective data (1997 through 2004) collected on
Healthy Families Arizona program participants to identify the risk factors most strongly
associated with child abuse and neglect. This study is limited by two factors. One, the study
is restricted to those variables for which data are available in the database. Second, this study
relies upon a definition of child abuse and neglect that is equivalent to a substantiated report
as determined by Child Protective Services (CPS). Reliance on official CPS reports is limited
since CPS substantiated cases are low occurring events, and many incidents of child abuse
and neglect go unreported.
Selected Risk Factors for Child Abuse and Neglect
Families that enroll in Healthy Families Arizona often have many stresses in their lives.
Stress is associated with an increased risk for child abuse. Table 1 highlights selected risk
factors for two groups – Healthy Families Arizona program families (N = 4,432) and a group
of families eligible for the program but who dropped out before completing at least four
home visits (N = 1,755). The results are based on Healthy Families Arizona data from 1997
to 2004. What the information in Table 2 shows is that the typical Healthy Families Arizona
participant, regardless of whether or not they engage in the program after four home visits, is
likely not to have had prenatal care, is likely to be a single parent but not likely to be living
alone with their child; about 30% are teenagers and the majority are not employed, and many
are not high school graduates at the time of enrollment. The majority of participants, around
60%, reported severe childhood histories of abuse and neglect.
Healthy Families Arizona Longitudinal Evaluation 33
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Table 2. Selected Risk Factors for Healthy Families Arizona Participants and Those
Who Dropped Out Prior to 4 Home Visits
Selected risk factors at the time of
program enrollment
Healthy Families
Arizona Participants
N = 4,432
Families Who
Dropped Out Prior
to 4 Home Visits
N = 1,755
Late or no prenatal care, or poor
compliance
37.9%
40.3%
Baby born with birth defects 1.0% 0.4%
Baby born <37 weeks gestation 13.1% 13.4%
Low birth weight (88 ounces or less) 12.5% 12.7%
Mother was single, separated, or divorced 78.7% 86.4%
Maternal age (18 or younger) 30.3% 32.8%
Unstable housing 17.5% 16.7%
Living alone with baby 10.4% 10.7%
Median household income $9,300 $8,400
Marital or family problems 28.0% 27.0%
Mother unemployed 81.8% 78.3%
Mother less than 12 years of education 56.5% 57.3%
Mother has history of substance abuse 18.5% 19.0%
Mother has a history of psychiatric care 11.6% 9.5%
History of or current depression 29.0% 23.6%
Mother reported severe childhood history
of abuse
59.8%
59.7%
Family Stress Checklist> 40 (considered
high-risk for child abuse)
29.6%
27.1%
Healthy Families Arizona Longitudinal Evaluation 34
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Incidence of Child Abuse and Neglect
Table 3 presents data regarding substantiated and unsubstantiated child abuse and neglect
reports. The results are based on CPS data reported on Healthy Families Arizona families
from 1997 through 2004. Table 3 shows similar percentages of CPS reports, substantiated or
not, for families that engage and those who do not.
Table 3. Percent of CPS Reports for Healthy Families Arizona Participants
Group No CPS Report
Substantiated
CPS Report
CPS Report –
Not
Substantiated
Healthy Families Arizona
Participants
N = 4,432
83.1%
4.8%
12.2%
Those Who Dropped Out Prior to
4 Home Visits
N = 1,755
82.1%
5.4%
12.5%
Note. Thirty-six Healthy Families Arizona participants have CPS reports with status unknown. As a result, these
36 participants are excluded from this table.
Individual Risk Factors for Child Abuse and Neglect
Table 4 provides demographic risk factor data for the Healthy Families Arizona population,
both those who stayed in the program for four or more home visits and those who had fewer
than four visits, among those with substantiated child abuse and neglect reports (N = 305) as
compared to those with unsubstantiated reports (N = 754) and those with no CPS reports (N =
5,092) 2. These factors include young maternal age, race/ethnicity, poor education, and
unemployment.
These data illustrate notable risk factors for child abuse and neglect. As illustrated, mothers
with substantiated and unsubstantiated CPS reports (versus no CPS report) are more likely to
report they are Caucasian. Additionally, participants with substantiated reports of child abuse
and neglect are more likely to have lower educational attainment (i.e., less than 12 years of
education). Most notable is the difference in the employment status of the father among
2 Thirty-six respondents have CPS reports but the status of the report is unknown and therefore excluded from
data analysis.
Healthy Families Arizona Longitudinal Evaluation 35
1st Annual Report
participants with substantiated CPS reports, unsubstantiated reports, and no reports. Families
experiencing CPS involvement are more likely to have a father who is not employed.
Table 4. Parent Characteristics by CPS report
Characteristics
No CPS Report
N = 5,092
Substantiated CPS
Report
N = 305
Unsubstantiated
CPS Report
N = 754
Young maternal age (18 or
younger)
31.3%
30.3%
29.5%
Average age of mother 22.18 years 21.75 years 22.16 years
Mother’s race/ethnicity
Caucasian
Hispanic
African American
Asian American
Native American
Other
26.5%
54.8%
5.2%
0.4%
10.1%
3.0%
42.1%
34.5%
8.9%
1.3%
6.9%
6.3%
46.7%
34.6%
8.3%
0.1%
4.8%
5.5%
Less than 12 years of
education
55.8%
61.6%
59.4%
Average grade completed 10.56 10.29 10.36
Mother unemployed at time
of program enrollment
80.3%
80.7%
84.2%
Father unemployed at time of
program enrollment
28.9%
(N = 4,224)
40.2%
(N = 239)
32.7%
(N = 594)
Table 5 presents mental health-related risk factor data linked to child abuse and neglect.
These factors include depression, self-esteem problems, life stressors, potential for violence,
attitude towards discipline, and past histories of pregnancy and abortion. As indicated,
mothers with substantiated CPS reports reported higher rates of depression, histories of
psychiatric care, more severe self-esteem problems, and greater stressors than those without
child abuse reports and substantiated incidents. These findings are consistent with other
research on child maltreatment that suggests that parents with self-esteem problems,
including depression, place their children at an increased risk for child abuse and neglect.
Maternal depression and psychiatric problems often lead to compromised parenting as
depressed, withdrawn mothers may offer their babies poor stimulation and may have trouble
Healthy Families Arizona Longitudinal Evaluation 36
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connecting with their babies emotionally (Kaplan, 1999). Furthermore, mothers who scored
high on the Family Stress Checklist for their potential for violence and for their discipline
attitudes have a greater likelihood of CPS involvement.
Interestingly, the average number of pregnancies was higher among participants with
substantiated and unsubstantiated child maltreatment reports than participants without CPS
reports. A participant’s history of abortion was also higher among those with any CPS
involvement, including those with unsubstantiated CPS reports.
Table 5. Percentage with mental health risk factors by CPS report
Personality Risk Factors at
Time of Program Enrollment
No CPS Report
N = 5,092
Substantiated
CPS Report
N = 305
Unsubstantiated
CPS Report
N = 754
History of psychiatric care 9.6% 16.7% 18.0%
History of or current
depression
25.8%
36.7%
33.2%
Mother’s self-esteem,
available life-lines (noted as
severe problems by Family
Stress Checklist)
45.6%
60.3%
54.0%
Mother’s stressors (noted as
severe by Family Stress
Checklist)
55.0%
67.9%
64.5%
Mother’s potential for violence
(severe risk)
12.6%
27.2%
22.1%
Mother’s discipline attitude 3.8% 7.9% 4.8%
Average number of
pregnancies
2.03
2.60
2.57
History of abortions 6.9% 7.9% 11.4%
Healthy Families Arizona Longitudinal Evaluation 37
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Table 6 shows the percentage of mothers with a history of substance abuse. As indicated,
mothers with substantiated or unsubstantiated reports of child abuse and neglect are more
likely to report a history of substance abuse, a finding consistent with research on child
maltreatment.
Table 6. Percentage of participants with substance abuse histories
History of Substance Abuse
No CPS Report
N = 5,092
Substantiated
CPS Report
N = 305
Unsubstantiated
CPS Report
N = 754
History of substance abuse 16.8% 32.1% 24.8%
A history of maltreatment in one’s own childhood is another risk factor that has been
identified in association with abusive and neglectful parenting behavior (Belsky, 1993).
Table 7 illustrates significantly higher rates of childhood abuse and neglect among
individuals with substantiated and unsubstantiated CPS reports than individuals with no CPS
involvement. This relationship holds for both mothers and fathers.
Table 7. History of severe childhood maltreatment
History of Childhood Abuse
and Neglect
No CPS Report
N = 5,092
Substantiated CPS
Report
N = 305
Unsubstantiated
CPS Report
N = 754
Childhood Abuse – Mother 56.7% 75.1% 73.2%
Childhood Abuse – Father 36.7% 41.9% 42.1%
Common child risk factors for maltreatment often include factors related to perinatal effects
(i.e., premature birth, low birth weight), child disability, and child demographics (Belsky,
1993). Child risk factors are presented below in Table 8.
As illustrated, gestational age, low birth weight, positive drug screens, and intermediate
intensive nursery care are more common among participants with CPS reports of child abuse
and neglect and substantiated incidents than participants without CPS involvement. This is
consistent with the child maltreatment literature. In contrast with some findings in the
literature on child maltreatment (e.g., Jones & McCurdy, 1992; Margolin, 1990), there was
Healthy Families Arizona Longitudinal Evaluation 38
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little difference between having a CPS report and having no involvement with CPS and the
child’s gender. Interestingly, participants with unsubstantiated CPS reports were more likely
to have babies who were born early, and with lower birth rates than both participants with no
CPS reports and those with substantiated reports of child abuse and neglect.
Table 8. Risk Characteristics for Infants
Risk Factors for infants at
time of program enrollment
No CPS Report
N = 5,092
Substantiated CPS
Report
N = 305
Unsubstantiated
CPS Report
N = 754
Born <37 weeks gestation 12.4% 14.5% 17.3%
Low birth weight (88 ounces
or less)
11.9%
13.1%
17.1%
Positive alcohol screen 0.2% 0.3% 0.0%
Positive drug screen 0.4% 3.0% 0.7%
Birth defects 0.7% 1.0% 1.1%
Intermediate or intensive
nursery care
11.2%
15.8%
15.8%
Mother had late or no prenatal
care, or poor compliance
38.1%
43.3%
37.9%
Attachment issues as reported
by mother
11.6%
23.0%
14.7%
Male child 50.2% 51.5% 51.9%
Family-level Risk Factors
Research demonstrates that family dynamics and parental involvement are related to a child’s
potential for maltreatment. Characteristics of abusive families often include single parenting,
low family income (i.e., less than $15,000 per year), large family size (i.e., more than four
children), and family conflict. Table 9 highlights the risk factor data at the family level.
As illustrated with the data, maltreating participants (those with substantiated CPS reports)
report slightly more children on average, are more likely to live below $15,000 per year, live
alone, have unstable housing, report marital or family problems and are more likely to be
Healthy Families Arizona Longitudinal Evaluation 39
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single parents. This is consistent with literature on child maltreatment which often reports
differences between abusing and non-abusing families in terms of low income, large number
of children or large household size, living alone, single parenthood, and conflict among
family members.
Table 9. Familial risk factors
Familial risk factors at time
of program enrollment
No CPS Report
N = 5,092
Substantiated CPS
Report
N = 305
Unsubstantiated
CPS Report
N = 754
Single, divorced, or separated 80.1% 84.3% 83.8%
Living alone 9.3% 16.4% 14.9%
Unstable housing 16.6% 22.3% 19.9%
Median yearly income $9,600 $7,200 $7,200
Income <$15,000 76.6% 87.8% 81.8%
Average household size 4.79 4.48 4.73
Four or more living children 8.8% 14.8% 13.8%
Average number of living
children
1.75
2.19
2.09
Marital or family problems 25.2% 41.6% 37.8%
Societal and Environmental Factors
Societal factors play an important role in creating conditions that can contribute to childhood
abuse and neglect. Such factors often identified in the literature on child maltreatment
include neighborhood poverty and reduced social connectedness (Gillham et al., 1998). Table
10 shows differences among those with CPS reports and those with unsubstantiated and
substantiated reports.
The support families receive outside of the home can be an important factor in the potential
for child abuse and neglect. As illustrated by the data, participants with unsubstantiated and
substantiated CPS reports were more likely to feel alone and without friends or adequate
emergency contacts than those without CPS involvement.
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Table 10. Societal Factors
Societal risk factors
at time of program
enrollment
No CPS Report
N = 5,092
Substantiated CPS
Report
N = 305
Unsubstantiated CPS
Report
N = 754
Inadequate
emergency contacts
11.6%
17.4%
15.3%
Societal risk factors
at time of program
enrollment
No CPS Report
N = 2,494
Substantiated CPS
Report
N = 124
Unsubstantiated CPS
Report
N = 378
Feel alone and
without friends
23.2%
35.5%
27.7%
Note. There is a significantly reduced number of participants for “feel alone and without friends” due to the
number of participants who completed the Parenting Stress Index, upon which this measure was taken.
Predictors of Child Abuse and Neglect
In order to investigate which risk factors were significantly associated with official reports of
child abuse and neglect while controlling for other factors, logistic regression analyses were
conducted. Logistic regression is used to predict a discrete outcome (e.g., substantiated child
abuse and neglect versus no substantiated report of neglect or abuse) from a set of predictor
variables (Menard, 2001).
After running each variable independently, final models were run on the dependent variables
in which all variables were entered simultaneously. Only those variables found to be
statistically significant predictors of group membership in the bivariate logistic regression
analyses, and only those variables that were consistently reported (i.e., had no more than 15%
of missing data)3, were included in the final models.
Table 11 summarizes the results of the logistic regression equations containing the significant
variables predicting the odds of CPS status for two separate models. The first model uses any
CPS involvement as compared to those without CPS involvement; the second model predicts
child maltreatment using substantiated CPS reports as compared to those without CPS
3 The following variables were excluded in logistic regression analyses due to the extent of missing data: history
of psychiatric care, marital/family conflict, history of depression, household income, and household size.
Healthy Families Arizona Longitudinal Evaluation 41
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reports. The table presents only the direction and statistical significance of the relationships.
The statistical information including coefficients (b), standard errors (se) and odds ratios
(Exp(b)) for these models can be found in Appendix B (Tables B3 & B4).
Table 11 indicates six factors that significantly predict the likelihood of any CPS
involvement. Nine factors increase one’s odds for substantiated CPS reports. The variables
that were significant for both models include mother’s age, mother lives alone, mother’s
race/ethnicity, mother has a history of childhood abuse, and mother has a strong potential for
violence. The age of the mother significantly predicts the likelihood of CPS involvement as
the odds of child maltreatment decreases as mother’s age increases. The likelihood of CPS
involvement increases among mothers living alone, mothers identifying as Caucasian, those
with a history of childhood abuse and neglect, and mothers with a strong potential for
violence as measured by the Parent Survey (Family Stress Checklist).
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Table 11. Logistic Regression Predicting the Probability of Child Abuse and Neglect
Variable Probability of Any CPS
Involvement (Model 1)
Probability of a
Substantiated CPS Report
(Model 2)
Mother single, separated,
divorced
  Increases with single
mother*
Not significant
Mother’s age   Decreases as
mother’s age
increases***
  Decreases as
mother’s age
increases***
History of substance abuse
Not significant
  Increases with
mother’s history of
substance abuse
Number of living children
Not significant
  Increases as number
of living children
increases**
Mother lives alone   Increases with mother
living alone*
  Increases with mother
living alone*
Mother’s race/ethnicity   Increases with white
mother***
  Increases with white
mother***
Childhood history of abuse
and neglect
  Increases with history
of abuse*
  Increases with history
of abuse*
Violence potential   Increases as potential
increases***
  Increases as potential
increases***
Discipline attitudes
Not significant
  Increases with more
severe attitudes*
Attachment
Not significant
  Increases with lower
attachment levels*
Note. ***p<.001, **p<.01, *p<.05. n.s. = not significant. Any CPS involvement (Model 1: N
= 3,110); Substantiated CPS report (Model 2: N = 3,147).
Variables that were significant for one model but not the other include single parenting for
those with any CPS involvement; among those with substantiated CPS reports, a history of
substance abuse, the number of living children, a mother’s attitude towards discipline, and
difficulty attaching to one’s child were significant factors. As such, in Model 1, the
likelihood of CPS involvement increases among mothers who are single than among those
who are not when holding all other variables constant. When predicting a substantiated CPS
report, there is an increase in the odds of abuse and neglect among mothers with a history of
substance abuse, families with large numbers of living children, mothers who rate severe
Healthy Families Arizona Longitudinal Evaluation 43
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their attitude towards discipline, and mothers who report difficulty attaching with their
children.
The second model predicting substantiated CPS reports yields a significantly better fit to the
data. The second model classified 94.9% of cases correctly while the first model correctly
predicted 83.4% of the cases. Furthermore, the goodness of fit test is used to choose the
model that does the best job of prediction with the fewest predictors and is larger in the
second model (3072.63) than the first model (3005.38). Looking at the model chi-square, we
can conclude that the variables, when taken together, differentiate the two categories of the
dependent variable (e.g., those with any CPS involvement versus those without involvement,
and those with substantiated CPS reports versus those without any CPS involvement) (model
1: x2 = 277.69, df = 24, p <.001) (model 2: x2 = 139.44, df = 19, p <.001).
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Model of Change
Figure 3 presents the model of hypothesized relationships for the longitudinal evaluation. It is
based on the review of the literature, the exploratory study, and the retrospective study
findings. The model can be described as an ecological transactional model. It is ecological in
the sense that it includes three levels: the micro (individual), mezzo (family) and macro
(community), and suggests that no single risk factor places or protects any child from risk of
poor outcomes, but rather it is the interaction of factors that is important. The model is
transactional in the sense that these factors are believed to mutually influence and determine
the amount of risk that an individual faces (Belsky, 1993). Sameroff and Chandler (1975)
offered a transactional model of child development, suggesting that biological risk factors
and environmental stresses are involved in a synergistic process that shape outcomes. This
model guides the measurement, hypotheses, and analyses for the longitudinal evaluation.
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Evaluation of the Program Logic Model
The Healthy Families Arizona program logic model lists 10 outcome objectives. A substudy
was conducted to evaluate how the objectives are currently measured, with the philosophy
that when an outcome is measured, it attracts focus and is more likely to be attained. Each
objective is presented below with an assessment of how it is currently measured, or not
measured, in the Healthy Families Arizona program. As noted from the list below, a number
of the program objectives rely on measurement using the Healthy Families Parenting
Inventory (HFPI). This newly developed instrument designed by LeCroy & Milligan
Associates, Inc. is for use in the Healthy Families Arizona program. The Healthy Families
Arizona longitudinal evaluation will not use the HFPI as a measure because it is so new and
the validation study is currently in progress.
Based on the findings from the retrospective study of Healthy Families Arizona participants
from 1997 to 2004, it would appear that the greatest gaps in measurement are in the areas of
reconciliation of childhood history of abuse, violence potential, attitudes towards discipline,
and attachment difficulties. Ongoing assessment of these difficulties is essential to providing
support and assessing change in these areas.
Measured Not Measured
Increase the support
network
• HFPI (social support subscale)
• Family and Social Support
services referred and received
(FSS-23)
• Community Service
living situation, i.e.,
lives alone with child
Improve mental health
• HFPI (depression, personal care
subscales)
• Counseling and supportive
services referred and received –
FSS-23; referral for domestic
violence, substance abuse, and
mental health
Healthy Families Arizona Longitudinal Evaluation 47
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Measured Not Measured
Increase health behaviors
• Alcohol screen (CRAFFT)
• Subsequent birth FSS20
• Parents health provider
• Parents health insurance
No tracking of tobacco
use, and the
information gained
from the CRAFFT is
minimal on alcohol
and tobacco. Ongoing
assessment of these
factors is required
Increase problem solving
skills
• HFPI (problem solving and
mobilizing resources subscales)
Improve family stability
• Public assistance referral (FSS-
23)
• Employment, training and
education referral (FSS-23)
• Income
• Education
• Employment
There is no tracking of
housing, budgeting,
family planning and
length of interval to
subsequent pregnancy,
or the receipt of
TANF,WIC, other
benefits (cash or in-kind),
child support, or
literacy resources.
Increase parental
competence
• HFPI-accepting the parent role,
parent competence, parenting
efficacy subscales
Increase positive parent-child
interaction
• HFPI -parent child behavior
subscale
There is no recording
of discipline strategies,
father involvement,
child’s contact and
relationship with
father, child support,
living with or married
to father of baby.
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Measured Not Measured
Improve child health
• Immunization
• Medical home
• Health insurance
• ER visits for routine matters
• Home safety checklist
• Health care referral (FSS-23)
• Well-child checkups
There is no tracking of
nutrition, dental health,
injuries and ingestions,
days hospitalized, or
ER use.
Optimize child development
• ASQ – screen for developmental
delays
• HFPI-home environment
subscale
• Referral for developmental
delay (FSS-20)
There is no school
readiness measure.
Prevent child abuse and
neglect
• CPS Substantiated reports for
target child and all dependent
children in the home.
Physical discipline
strategies
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Blueprint for the Healthy Families Arizona Longitudinal Evaluation
The Healthy Families Arizona longitudinal evaluation was designed to deal with the
criticisms of previous longitudinal and experimental evaluations, as well as evaluations of
home visiting programs in general. As such it:
1. uses random assignment to treatment and control groups to look at the program as the
cause for any observed changes between the two groups;
2. tests a series of hypothesis and calculates significant effect sizes, i.e., the difference
needed in order to claim success;
3. is designed to provide adequate statistical power, i.e., the sample size is large enough
to have confidence that if the null hypothesis is rejected the alternative hypothesis is
likely true given the likelihood of moderate effect sizes;
4. examines established and stable Healthy Families Arizona sites that provide adequate
variation across the program in participants, communities, and Healthy Families
Arizona administration; 6 metro sites and 1 semi-rural tribal site leading to diversity
in geographic area and population served.
5. specifies the program theory in advance; the longitudinal evaluation is guided by a
theory of change based on a review of theoretical and empirical literature on child
maltreatment and home visitation
6. measures fidelity to the program model (e.g., intensity of the home visits, content of
the home visits and supervisory sessions);
7. measures the services received by the control group; hence it recognizes that this
group are non-participants who may receive services through other means, thus the
Healthy Families Arizona program is being compared to available community
services without the benefit of home visitation;
8. uses measures with good validity and reliability, and where possible measures that go
beyond self-report; in addition to substantiated child abuse and neglect the evaluation
examines method of discipline, exposure to domestic violence, and childhood injuries
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9. employs evaluation across sites to determine if treatment effects can be replicated.
Replication of treatment effects is one standard for judging the validity of the causal
claim that the program is responsible for the outcome. The importance of replication
is based on the notion that no single realization will ever be sufficient for
understanding a phenomenon with validity;
10. to the extent possible, employs blind data collection.
11. follows a true experimental design with intent to treat, meaning that families are
tracked even after leaving the program
Participating Healthy Families Arizona Sites
The evaluation team established a set of criteria to target site selection. The Healthy Families
Arizona quality assurance (QA team) provided information on the 23 established Healthy
Families Arizona sites and it was decided that the best choice for sites in a metro area would
be Tucson, based on stability of staff and number of participant openings. Tucson has six
established sites in the metro area. A seventh site in the rural Tucson area was selected to
increase diversity among the sites studied. The selected sites are well-established sites with
minimum staff turnover and demonstrated success in engaging and retaining participating
families. The seven Healthy Families Arizona sites included in the longitudinal evaluation
are presented in Table 12.
Table 12. Participating Healthy Families Arizona Sites
1. Blake
2. Casa De Los Niños
3. CODAC
4. La Frontera (1)
5. La Frontera (2)
6. Parent Connection
7. Pascua Yaqui Health Department
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Target Participants
The participants in the longitudinal evaluation include the mothers of target children. The age
of the participants will include anyone able to bear children. Based on data from previous
years, approximately 20 to 30% of participants are expected to be teenagers. Based on
demographic data from the sites selected for the longitudinal evaluation, participation should
include a significant number of ethnic minority women, especially Hispanic, African
American, and Native American women. Inclusion criteria include becoming a new parent,
and scoring above a standardized threshold on two assessment instruments as well as
consenting to participate in the program.
There are also four exclusion criteria. The longitudinal evaluation will exclude from
recruitment:
• Families referred to Healthy Families Arizona by CPS
• Families who self-refer
• Families for which the hospital social worker makes a referral to Healthy
Families Arizona
• Families that are particularly crisis ridden as determined by the FAW staff in
consultation with their supervisor.
Recruitment
A total sample size of 190 participants is needed for the longitudinal evaluation, allowing for
a 20% attrition rate over the life of the evaluation. Split evenly between the two groups, the
desired size of the experimental and control groups is approximately 95 families each.
Recruitment for the longitudinal evaluation will follow the standard Healthy Families
Arizona recruitment process that currently exists at the sites. Following the birth of a child at
one of the referral hospitals, the Healthy Families Arizona 15-item screen will be conducted.
Families who screen positive will be asked if a Family Assessment Worker (FAW) from
Healthy Families Arizona can contact them. If the family consents to contact, the parent(s)
will be asked if they are interested in participating in a randomized study referred to as the
Arizona Child Development Project. If the family is not interested they will be provided
Healthy Families Arizona Longitudinal Evaluation 52
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with information on Healthy Families Arizona without the longitudinal evaluation and an
outline of services in their community. If the family is interested in participating they will be
randomly assigned to one of two groups.
Families will be informed that participation in the study on child development includes free
developmental assessments of their children at regularly spaced intervals, referral to
community resources, and monetary incentives that increase in value on an annual basis.
They will also be advised of the time commitment of the study - a maximum commitment of
90 minutes per in-home visit. Families will also be informed that if they move or decide not
to continue with Healthy Families Arizona they can still participate in the study on child
development and receive monetary incentives as promised. In some instances, if the family
moves out of state, participation would be by telephone.
Those participants who agree to participate in the Arizona Child Development Project will
be asked to sign an informed consent form outlining a description of the Healthy Families
Arizona longitudinal evaluation and any potential benefits and risks. The consent will also
outline the incentives for participation and the responsibility of the participant and
researcher. One copy of the signed consent will be left with the participant and a second copy
will be kept on file at LeCroy & Milligan Associates, Inc.
Recruitment for the longitudinal evaluation began November 1, 2005. Recruitment was
delayed from the target of summer 2005 due to the number of openings in the participating
Healthy Families Arizona sites, which discouraged directing potential participants toward the
control group for financial reasons. Recruitment for the evaluation will end when the desired
number of families has been enrolled. Based on current enrollment, this is likely to be
approximately a six-month period.
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FAW conducts 15-item screen
following birth
screen is positive
family is invited to
participate in a study where
they could receive one of
two things?
FAW conducts
parent survey
based on HFAz
opening available
either parent
scores > 25?
Yes
Family is told that they
may still be eligible for
some services and is
offered contact with HFAz
Refusal
No
Procedure for Random Assignment
enrolled in HFAz
and the Arizona
Child Development
Study
(E1)
enrolled in the
Arizona Child
Development Study
(C1)
No
Parent consents to
random assignment ,
assigned to one of two
conditions
Case closed, list of
resources offered
screen is
negative
No additional
contact
FAW conducts
parent survey,
family not included
in study
Yes
enrolled in the
Arizona Child
Development Study
(C2)
E1 = experimental group (HFAz)
C1 = equivalent control group not
receiving HFAz services
C2 = nonequivalent control group,
not eligible, and not receiving HFAz
L & M conducts
parent survey
either parent
scores > 25?
Yes
No
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Data Collection
The outcome portion of the longitudinal evaluation will collect two sets of data independent
of the ongoing Healthy Families Arizona program operations. Maternal demographic data
and risk factor data will be collected on a questionnaire that includes items that are subject to
change such as education and health insurance. Outcome data will be collected on the effects
of the home visitation services.
Data collection will occur in the home and each visit will average 90 minutes. In the first
year there are three data collection visits. Data collection visits will be annual in years two
through five (for a total of seven visits over a period of five years). Data collectors masked
with respect to the participants’ treatment assignment will gather the data. That is, the data
collectors will not be aware of whether or not the family is enrolled in Healthy Families
Arizona and will not ask any questions about participation in Healthy Families Arizona. All
questionnaires will be read to participants to ensure that they properly understand all items.
Charts that depict the response categories for questions with ordinal level responses will be
used as visual aids.
Data Collection Staff
A trained data collection team unaware of the specific hypotheses and uninvolved in Healthy
Families Arizona program implementation will collect all data. Three individuals employed
by LeCroy and Milligan Associates, Inc. will collect the data for the Healthy Families
Arizona Longitudinal evaluation. The data collectors will carry the title of Research
Assistant. The data collectors will be female because the majority of Healthy Families
Arizona participants are women and data collection requires that participants respond to
sensitive questions on mental health, depression and domestic violence.
Qualities of the data collectors include a bachelor or associate degree in a related field (social
work, psychology, nursing, etc.), the ability to speak Spanish, good communication and
interviewing skills, and a reliable means of transportation. Data collection staff will have to
submit to a criminal record check and must have proof of a valid driver’s license with current
insurance and registration. Data collectors will not for any reason transport participants.
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Commitment to the five-year longitudinal evaluation is a plus, although that cannot be
guaranteed or expected.
Schedule of Standardized Measures
The following table presents a list of standardized measures that will be implemented at
different observation points in the longitudinal evaluation. The standardized measures are
integrated into the overall questionnaires that have been developed for each data collection
point.
Table 13. Schedule of Standardized Measures
Measure Baseline 6 mo. 12 mo. 24 mo. 36 mo. 48 mo. 60 mo.
Mental Health
Inventory
x x x x
CES-D (Depression
Index)
x x
Parent Survey Control only
Being a Parent x x x x x
Adult-Adolescent
Parenting Inventory
2
x x x x
Eyberg (behavior) x x x
Bracken (school
readiness)
x
Goals Scale x x x x
Social Support
(ESLI)
x x x
Mobilizing
Resources
x x x
Safety checklist x x x x x
HOME x x
ASQ
(developmental
delay)
x x x x x x
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Data Analysis
Differences in those who agree to participate and those who do not will be analyzed in terms
of demographics and scores on the Family Stress Checklist. Between group differences will
be analyzed at baseline. Multivariate analysis will follow the model of change and the
particular method of statistical analysis will depend on the scale of measurement on the
particular outcome variable examined. For instance, factors accounting for the difference in
outcomes that are categorical such as child abuse and neglect or no CPS involvement will be
analyzed using logistic regression. Effect sizes will be calculated on significant differences
and highlighted if meaningful (d > .33).
Study Retention Efforts
The success of any longitudinal study is reliant upon participant recruitment and retention.
Losing participants from a project can have detrimental effects to the success of studies that
extend over long periods of time. Studies with high drop out rates can yield biased findings
and lack integrity and validity. Maintaining participation over the life of a study is essential
to informing valid conclusions about the impact of program services. The goal of the Healthy
Families Arizona longitudinal evaluation is to lose no more than 20% of participating
families to attrition. To reach this goal, LeCroy & Milligan Associates, Inc. will implement a
comprehensive retention and incentive strategy. As part of our retention efforts, this project
will utilize the following procedures:
• A history of repeated contacts with families that are positive in nature. Research
Assistants will emphasize and respect families’ rights to privacy and confidentiality,
assume a nonjudgmental approach, be flexible and punctual, and establish good
rapport by contacting participants by mail at least once during each quarter (e.g.,
personalized reminder letters, birthday cards). Research Assistants will also
encourage participants to contact them through the project’s 1-800 number4 when
they have questions, know about changes in their location, or need service referrals.
4 A 1-800 number for participants to call the program at no cost or hassle that is involved in placing a collect
call will be maintained throughout the life of the project.
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• LeCroy & Milligan Associates, Inc. will retain project personnel to the extent
possible so that the same Research Assistant acts as the primary and continuing
contact for their assigned families over the life of the project.
• At each interview, the Research Assistants will stress the importance of the
evaluation and the benefits of continued participation (i.e., developmental
information, referral to resources, and participant incentives).
• Participant burden in the project will be minimized (e.g., interview length will not exceed
90 minutes and only 7 interviews are required over five years). Furthermore, families’
scheduling needs will be accommodated through convenient appointment times and
locations.
• A project identity (the Arizona Child Development Project) will be created and
promoted through the use of a project logo that can reduce concerns about the
credibility of the project and help facilitate recognition of correspondence related to
the project.
• Project staff will establish associations with Healthy Families Arizona program staff
as well as community agencies that may have contact with participants (e.g.,
educational institutions, treatment programs). These associations are for the purpose
of tracking participants and efforts will begin early in the evaluation to establish these
relationships by advertising the evaluation.
• Detailed participant contact information will be collected and updated at every
interview or as soon as participant location changes are made.
• Confirmation letters will be mailed once interviews are scheduled (approximately one
to two months before the next interview period).
• Project staff will make reminder phone calls two days before an interview and a
personalized letter will be sent two weeks prior.
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• Participants will be asked to inform project staff of changes in contact information
and will be provided with change of address cards, business cards, and a refrigerator
magnet that display project phone numbers and timelines for follow-up assessments.
The project’s 1-800 number will also be on all project materials and correspondence.
• Project staff will send birthday cards to immediate family members.
• Contact information of participant’s relatives, friends, neighbors, or coworkers who
are likely to know the family’s whereabouts will be secured at each interview. If
relatives and friends are contacted regarding participant’s whereabouts, staff will ask
to send them a business and change of address card to give to the participant if they
see them.
• A wide variety of tracking sources (e.g., family and friends, Internet locator sites,
directory assistance, phone books, license providers) will be tapped to locate missing
participants.
• All contact information, including the nature and results of attempted and successful
contacts will be maintained in the Healthy Families Arizona longitudinal evaluation-tracking
database. This database will include ongoing, comprehensive notes
documenting any and all family contacts and contact attempts.
Incentives
Cash incentives for participation will be discussed with participants at each interview.
Participants will receive $60 for Year 1 ($20 for each data collection period including initial,
six and 12 months), $30 for Year 2 (24 months), $40 for Year 3 (36 months), $50 for Year 4
(48 months), and $60 for Year 5 (60 months). Incentives ($10 cashier’s check) will also be
provided to families who inform project staff of changes in contact information (i.e.,
relocation or change in telephone number). Families participating in the longitudinal
evaluation will be eligible for four $125 drawings – two midway and two at the end of the
five-years.
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Informed Consent
Healthy Families Arizona Family Assessment Workers will explain the longitudinal
evaluation to participants. The Research Assistants will administer the informed consents.
The Informed Consent will be read to participants and their questions will be answered.
Upon consenting to participate in the longitudinal evaluation, participants will be asked to
sign the informed consent form. A copy of the consent form will be provided to participants.
Participants may refuse to participate or withdraw from the longitudinal evaluation at any
time without consequence and may refuse to answer any questions they do not want to
answer. There will be no impact on the services participants can use or will be offered by the
state or other service providers among participants who change their mind about participating
or answering any specific question(s). Participants may also stop using or refuse services
from Healthy Families Arizona and still participate in the Healthy Families Arizona
longitudinal evaluation.
Protection – Data Security, Storage, and Confidentiality
A separate database from the ongoing Healthy Families Arizona evaluation will be developed
for the longitudinal evaluation. The data entry staff at LeCroy and Milligan Associates, Inc.
will enter the data and file the hard copy records. In order to preserve the confidentiality of
all subjects the following procedures will be followed:
• Each family will be assigned a unique identification number.
• Each assessment rating form will be coded with the ID number rather than a name to
protect confidentiality.
• Names or other identifying information will not be noted in reports to the Arizona
Department of Economic Security, published papers, or within other written reports.
• The data will be stored in file folders in the LeCroy and Milligan office in one
lockable cabinet. The file cabinet will be for the exclusive use of the Healthy Families
Arizona longitudinal evaluation.
• Only the principal investigator, co-principal investigators, data collection and data
entry staff will have access to the data and the list of names associated with the
unique identifiers.
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• Data collectors will not store data in their cars or brief cases.
• The hard copy data will be destroyed one-year following completion of the Healthy
Families Arizona longitudinal evaluation.
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Appendix A: Summary of the Literature Related to the Theory of
Change
Child Development
A great deal of evidence now points to the early years in a child’s life as the most important
in terms of human growth and development. If a child’s development does not proceed
normally, or if it is not nurtured along a positive path, it may be near impossible to reverse
the negative impact. The early years also present greater risk for child abuse and neglect,
including death. Children age three years and younger are the most frequent victims of child
fatalities (National Clearinghouse on Child Abuse and Neglect Information, 2004). In 2002,
infants accounted for 41% of child fatalities resulting from abuse and neglect, while children
under age four accounted for 76%. The following review looks at critical periods of
children’s growth and development, and the risk and protective factors associated with
resilience and risk at various stages of development from conception until five years of age.
Prenatal to Birth. Prenatal development is divided into three trimesters. During the first two
months the developing human is called an embryo. The embryo has three layers from which
all body organs develop. During the second trimester the developing human is called a fetus.
During the third trimester the individual is a baby that if born prematurely is likely to survive
with extra support.
The prenatal environment and the child’s genetic endowment are associated with risk for
child abuse and neglect, developmental delay, behavior problems, and the need for special
education in kindergarten. Two recent studies show the impact of low birth weig