Healthy Families Arizona Evaluation Report 2002 Prepared by: Prepared for: LeCroy & Milligan Associates, Inc. 620 N. Country Club Road, Suite B Tucson, Arizona 85712 (520) 326-5154 FAX 326-5155 www.lecroymilligan.com The Department of Economic Security Division of Children, Youth & Families Office of Prevention and Family Support 1789 W. Jefferson, Site Code 940A Phoenix, Arizona 85007 December 2002 Table of Contents List of Exhibits ............................................................................................................... 2 Acknowledgements ........................................................................................................ 3 Executive Summary....................................................................................................... 4 Introduction.................................................................................................................... 8 In this Report ................................................................................................................. 9 The Healthy Families Arizona Program ....................................................................... 9 Converging Evidence: A Summary of Evaluation Results ........................................ 10 Implementation Update 2002...................................................................................... 14 Program Participants................................................................................................... 15 Service Delivery ........................................................................................................... 17 Program Outcomes for 2002 ........................................................................................ 19 Child Abuse and Neglect Outcomes....................................................................... 20 Maternal Life Course Outcomes ............................................................................ 24 Participant Satisfaction ............................................................................................... 25 Recommendations ........................................................................................................ 26 References .................................................................................................................... 28 Appendix A – List of Healthy Families Arizona Reports ........................................... 29 Appendix B – Parenting Stress Index Information .................................................... 30 Appendix C – Family Stress Checklist........................................................................ 34 Appendix D – Site Level Data ..................................................................................... 35 Age of Child at Entry ........................................................................................ 36 Days to Termination ......................................................................................... 37 Reason for Termination .................................................................................... 38 Mothers’ Education ........................................................................................... 39 Fathers’ Education ............................................................................................ 40 Health Insurance at Intake .............................................................................. 41 Late or No Prenatal Care or Poor Compliance at Intake ................................ 42 Ethnicity of Mother ........................................................................................... 43 Gestational Age ................................................................................................. 44 Low Birth Weight .............................................................................................. 45 Yearly Income.................................................................................................... 46 Family Stress Checklist Score .......................................................................... 47 Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 1 List of Exhibits Exhibit 1. Selected risk factors for Healthy Families mothers at intake.............................. 15 Exhibit 2. Ethnicity of Healthy Families Mothers ................................................................. 15 Exhibit 3. Percentage of Mothers and Fathers Rated Severe on the Family Stress Checklist Items.......................................................................... 16 Exhibit 4. Percentage of infants with high-risk characteristics ............................................ 16 Exhibit 5. Number of participants served by county, by site................................................. 17 Exhibit 6. Length of time in the program at termination for engaged families ................... 18 Exhibit 7. Major reasons for termination from the program ................................................. 18 Exhibit 8. Parenting Stress Index Findings ........................................................................... 20 Exhibit 9. Percent of child abuse and neglect cases in treatment and comparison groups . 21 Exhibit 10. Percent of safety practices implemented ............................................................. 21 Exhibit 11. Rate of immunization by Healthy Families participants ................................... 22 Exhibit 12. Percentage of children linked to a medical doctor at 6 months, 12 months, and 24 months ................................................................................................... 22 Exhibit 13. Percent of Healthy Families participants who make appropriate use of the emergency room ................................................................................ 23 Exhibit 14. Developmental delay from 4 to 36 months .......................................................... 23 Exhibit 15. Percentage of families who screened positive for alcohol and drug problems... 24 Exhibit 16. Mother’s employment status across three time periods ..................................... 24 Exhibit 17. School enrollment status of mothers at 6 months .............................................. 24 Exhibit 18. Responses to “The Healthy Families staff who offered me program services treated me with respect and dignity.” .............................................................. 25 Exhibit 19. Responses to: “How did you feel about the program so far?”.............................. 25 Exhibit 20. How would you describe the Healthy Families worker who first offered you program services? ............................................................................... 25 Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 2 Acknowledgements This evaluation report represents the efforts of many individuals and many collaborating agencies. Craig LeCroy, Ph.D. was the primary author of this report. The evaluation team was instrumental in the creation of this report. Cindy Jones conducted statistical analyses. Melanie Ruiz, Olga Urcadez, Veronica Urcadez and Vanessa Batt perform data entry and data cleaning. Allyson LaBrue helped with editing and formatting of the report. We are grateful to Rachel Whyte, Coordinator for the Child Abuse Prevention Fund and Healthy Families Arizona. Valerie Roberson continues to provide leadership and vision for the program. Kate Whitaker, Pauline Haas-Vaughn and Barbara Griffin provide quality assurance and training and help the sites to collect valid information. Jennifer Lopez and Bob Hoekstra provided administrative assistance for quality assurance for all the sites. Thank you to the program managers who have spent their time collecting and sending data. Staff at the sites have dutifully collected the data and answered endless questions to increase the accuracy of the data. Lastly, we acknowledge the families who have received Healthy Families Arizona services. Suggested Citation: LeCroy & Milligan Associates, Inc. (2002). Healthy Families Arizona Evaluation Report 2002. Tucson, AZ: LeCroy & Milligan Associates, Inc. Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 3 Executive Summary Imagine a community that exists at the top of a steep mountain. It is a thriving community where people have created a productive and satisfying life. There is only one problem in this community. Occasionally, the children fall off the steep mountain and slide down the hill becoming hurt and sometimes even die. The community came up with a practical solution. They built a hospital at the bottom of the mountain. The hospital was able to help care for the hurt children. A few leaders in the community protested that this was not a good enough solution to the problem. They got together and built a fence around the top of the steep mountain. Healthy Families Arizona is a child abuse prevention program that attempts to be part of the fence at the top of the steep mountain—before children fall off. As Neil Gutterman (2001, p.3) notes in his recent book, Stopping child maltreatment before it starts, “early intervention research have reignited the hope of stopping child abuse before it starts...Selected interventions under careful study and specific conditions have shown that the onset of child maltreatment can be averted.” Indeed, the early childhood years may provide a “window of opportunity” for early intervention that can impact critical and long lasting changes in parents and families. Major social and health organizations now advocate for home visitation services because of the belief in the potential it has to offer families. For example, Zero to Three, the National Research Council, American Academy of Pediatrics, the Freddie Mac Foundation, and Ronald McDonald Charities are only some of the groups that have supported the effort to promote home visitation. Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. The Healthy Families Arizona Program Healthy Families Arizona is a home visitation program designed to provide supportive services and education to parents of newborns who might benefit from support to strengthen their families at this crucial time. The goals of the program include: Promote positive parent/child interaction Improve child health and development Prevent child abuse and neglect All services are voluntary and assistance is typically provided for 12 to 18 months but may be provided for up to five years. Families enter the program based on a two level screening and assessment process. In the hospital after a child’s birth, the family can consent to an initial screening, which identifies family, parental, child and community risk factors associated with child abuse and neglect. If the screening is assessed as positive (indicating potential increased needs) the family is referred to a Family Assessment Worker who conducts a more detailed interview and assessment with the family. If the assessment is positive (family may be in need based on risk), the family is offered intensive home visiting services through the Healthy Families Arizona program. Any family who has had or receives a substantiated report of child abuse and/or neglect from Child Protective Services in Arizona will be excluded from the program, as required by law. Since the program is voluntary, the family can withdraw from the program at any time. After the family is referred to the program and accepts home visitation services, a Family Support Specialist visits the family in their home on a regular basis to provide supportive services and education. The Family Support Specialist seeks to develop a December 2002 4 trusting, open and constructive relationship with the family to meet their individual needs. The core Healthy Families Arizona services are: emotional support assistance in developing positive parenting skills education on child development and nutrition education and assistance in problem solving and coping skills education on preventive health care (immunizations, links to medical doctor) linkages to preschool resources referrals related to education, employment, and mental health and substance abuse services. This report focuses on aggregate data that is summarized across the 23 sites that make up the Healthy Families Arizona program. This report presents the evaluation data for the cohort of participants who received services in the Healthy Families Arizona program between the period of July 1, 2001 and June 30, 2002. This includes all families who received services at any time during the study period regardless of when they entered the program. Separate site reports are produced quarterly and provided to each site. In this year’s report, more extensive site level data can be obtained in the Appendices. Converging Evidence: A summary of Evaluation Results In this year’s report an examination of the converging evidence was provided to summarize what has been learned to date and reassess the overall impact of Healthy Families. Stress Index, replication of positive gains and positive results from a comparison group using the Child Abuse Potential Inventory, findings showing the comparison group getting worse on most measures while the Healthy Families participants were showing improvements, findings showing immunization rates higher than the statewide average, and findings that consistently show the Healthy Families participants had lower rates of child abuse and neglect when contrasted to a comparison group not receiving the program. Other outcomes that add to the cumulative evidence include the qualitative study that documented the perceived value the families report from being involved in the program and twelve years of experience in working toward program improvement showing gains in program implementation such as increased immunization and retention rates over time. Assessing program effectiveness is always a complex process, which requires a balance of good methodology, measures, and program implementation. In the end, a question of effectiveness requires a judgment be made based on an assessment of the data. Program Outcomes for 2002 The evaluation has assessed program outcomes in the following areas: health and development indicators, parenting effectiveness and competence, child safety, child abuse and neglect, and maternal life course indicators. The outcomes for families served in FY2002 are summarized graphically. The converging evidence for Healthy Families Arizona suggests that the program is effective. This conclusion is supported by the following findings: replicated evaluations showing improvement from baseline to post assessment periods, positive results when using a comparison group on the Parenting Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 5 Health Outcomes for Participants There was a 92.7% immunization rate for participants in the program at the 2-month assessment and at the 6-month assessment 97.3% of families were linked to a medical doctor. In terms of having received all 4 immunizations in the series, 83.9% obtained this compared with the state immunization rate for 2 year olds of 78%. Child Safety Enhanced quality of the home environment can be assessed by examination of child safety practices. At a 12-month assessment, almost all families practice many of the recommended child safety procedures. The results for two safety procedures are shown. Immunizations at 2 months 92.7% Link to Medical Doctor 97.3% 0.0% 50.0% 100.0% Percent of Participants Outlets Covered 72.8% Poisons Locked 92.8% 0.0% 50.0% 100.0% Percent of Participants at 12 months Parenting Stress & Competence Overall parenting effectiveness and competence is evaluated using a standardized parenting stress index. Assessment of participants from baseline to a 6 month, 1 year and 18 month follow up show statistically significant changes on all measures at each assessment period except distractibility which did not have adequate reliability to be used as a reliable measure. Results on the Parenting Stress Index Improvement Scale Sense of Competence Significant Parental Attachment Significant Feeling restricted in role Significant Depression Significant Isolation Significant Mood Significant Total Stress Significant Child Abuse and Neglect Child abuse and neglect incidents were examined for program participants and a small comparison group. As in previous years, child abuse and neglect rates continue to be low. In FY2002, 0.7% of program families had subsequent substantiated incidents of child abuse and neglect, meeting the program goal of having no higher than a 5% rate of child abuse and neglect. The comparison group rate of child abuse and neglect was 0.84%. Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 6 Maternal Life Course The Healthy Families Arizona program has also been shown to positively influence mothers’ life goals and actions. Specifically, many of the participants enroll in school, obtain their GED or seek gainful employment. Mothers’ employment outcomes at baseline, 6 and 12 months are shown to the right. Additionally, 17.3% of the mothers were enrolled full-time in school and 5.5% were enrolled part time in school. Participant Satisfaction Overall, program participants are very satisfied with the program services they receive. For example, 98.4% agreed or strongly agreed that they were treated with dignity and respect and 94.2% were somewhat satisfied or very satisfied with the program at a 2-month assessment. 15.9% Baseline 31.3% 6 Months 40.8% 12 Months 0.0% 25.0% 50.0% 75.0% 100.0% Percent of Participants Employed Treated me with dignity and respect 98.4% Satisfaction with the Program 94.2% 0.0% 50.0% 100.0% Percent of Participants Overall, results from multiple outcome indicators suggest the program is providing valuable services and improving the quality of life for participants. Positive changes in multiple outcome indicators point to the success of the Healthy Families Arizona home visitation program. Many social programs hope to impact only one model goal; Healthy Families Arizona demonstrates positive outcomes across Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. multiple goals: child health and development, quality of home life, reduction in parental stress, low rates of child abuse and neglect and increases in child safety practices. December 2002 7 Introduction Imagine a community that exists at the top of a steep mountain. It is a thriving community where people have created a productive and satisfying life. There is only one problem in this community. Occasionally, the children fall off the steep mountain and slide down the hill becoming hurt and sometimes even die. The community came up with a practical solution. They built a hospital at the bottom of the mountain. The hospital was able to help care for the hurt children. A few leaders in the community protested that this was not a good enough solution to the problem. They got together and built a fence around the top of the steep mountain. Healthy Families Arizona is a child abuse prevention program that attempts to be part of the fence at the top of the steep mountain—before children fall off. As Neil Gutterman (2001, p.3) notes in his recent book, Stopping child maltreatment before it starts, “early intervention research have reignited the hope of stopping child abuse before it starts...Selected interventions under careful study and specific conditions have shown that the onset of child maltreatment can be averted.” Indeed, the early childhood years may provide a “window of opportunity” for early intervention that can impact critical and long lasting changes in parents and families. Support for a national effort that suggests we can stop child abuse before it starts is converging from many sources. An early push came from the United States Advisory Board on Child Abuse and Neglect in 1991, which recommended a nationwide neonatal home visitation program. In 1992 Prevent Child Abuse America launched the Healthy Families America initiative to promote the expansion of home visitation services. Major social and health organizations now advocate for home visitation services because of the belief in the potential it has to offer families. Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. For example, Zero to Three, the National Research Council, American Academy of Pediatrics, the Freddie Mac Foundation, and Ronald McDonald Charities are only some of the groups that have supported the effort to promote home visitation. In line with the current emphasis at the Federal and state levels, “best practices” and science-based principles have been an important part of the Healthy Families effort. These principles are implemented through the assessment of “critical elements” believed essential for producing the best program outcomes. As the Healthy Families initiative evolved, the critical elements became a way to offer certification to programs that were adhering to practices that were the most likely to lead to positive outcomes. Arizona became the first statewide system to obtain the certification from Prevent Child Abuse America documenting adherence to “best practice” principles. This approach is recommended by Gutterman (2001, p.10) in his careful review of research literature on home visitation: “For application purposes, emphasizing best practice principles rather than whole program models enhances flexibility for programmatic adoption while minimizing overly prescriptive information that might constrain adaptation to specific needs and contexts.” This is a sound approach to building a scientific-based program. However, others have argued for the “model approach” which endorses strict adherence to specific intervention models rather than using research-based conclusions to inform best practice principles. For community-based programs, the best practice model allows for the inclusion of new scientific discoveries and becomes a more dynamic application of knowledge. December 2002 8 In this Report The Healthy Families Arizona program has been evaluated since 1991 by LeCroy & Milligan Associates, Inc. and several separate reports have been written (See Appendix A for a list of reports). This year’s report attempts to examine and summarize the cumulative evidence of the effectiveness of Healthy Families Arizona. Increasing emphasis is being placed on providing sitelevel data for program improvement and quality as the program evolves into a mature and established program. This report focuses on aggregate data that is summarized across the 23 sites that make up the Healthy Families Arizona program. Evaluation data are presented for the cohort of participants who received services in the Healthy Families Arizona program between the period of July 1, 2001 and June 30, 2002. This includes all families who received services at any time during the study period regardless of when they entered the program. Separate site reports are produced quarterly and provided to each site. In this year’s report, more extensive site level data can be obtained in the Appendices. The Healthy Families Arizona Program Healthy Families Arizona is a home visitation program designed to provide supportive services and education to parents of newborns who might benefit from support to strengthen their families at this crucial time. The goals of the program include: Promote positive parent/child interaction Improve child health and development Prevent child abuse and neglect All services are voluntary and assistance is typically provided for 12 to 18 months but may be provided for up to five years. Families enter the program based on a two level screening and assessment process. In the hospital after a child’s birth, the family can consent to an initial screening, which identifies family, parental, child and community risk factors associated with child abuse and neglect. If the screening is assessed as positive (indicating potential increased needs) the family is referred to a Family Assessment Worker who conducts a more detailed interview and assessment with the family. If the assessment is positive (family may be in need based on risk), the family is offered intensive home visiting services through the Healthy Families Arizona program. Any family who Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. has had or receives a substantiated report of child abuse and/or neglect from Child Protective Services in Arizona will be excluded from the program, as required by law. Since the program is voluntary, the family can withdraw from the program at any time. After the family is referred to the program and accepts home visitation services, a Family Support Specialist visits the family in their home on a regular basis to provide supportive services and education. The Family Support Specialist seeks to develop a trusting, open and constructive relationship with the family to meet their individual needs. The core Healthy Families Arizona services are: emotional support assistance in developing positive parenting skills education on child development and nutrition education and assistance in problem solving and coping skills education on preventive health care (immunizations, links to medical doctor) linkages to preschool resources referrals related to education, employment, and mental health and substance abuse services. December 2002 9 Converging Evidence: A Summary of Evaluation Results Each year an evaluation report is written that summarizes the service and demographic data for the program. This information is used extensively for purposes of program improvement. However, increasingly, policy makers and program staff want to know whether the program works or what the program outcomes are. This year’s report provides additional information about program outcomes by examining the converging evidence that can be summarized from past evaluation reports of the program. 1992-1993 Evaluation Report Methodology: descriptive analysis of program participants, screening and assessment data, pretest/posttest data on Parenting Stress Index, the HOME observation scale and child abuse and neglect rates. Results: Parenting Stress Index; Three of 9 subscales were significant at .05 level showing positive change, all of the subscales were significant at the .10 level. HOME scale; 2 of the 3 scales significant at the .05 level, one at the .10 level. Child abuse and neglect substantiated rates were 3% covering the years 1992-1993. Conclusions: Program is targeting at-risk families with a high percentage of past childhood abuse and neglect. Some promising results were obtained in the first year of implementation. This included significant pretest/posttest changes and attaining the program goal of child abuse and neglect rates below 5%. Low numbers affected the ability to document some outcomes. 1992-1994 Evaluation Report Methodology: descriptive analysis of program participants, screening and assessment data, pretest/posttest data on Parenting Stress Index, the HOME observation scale and child abuse and neglect rates. Design was strengthened with the addition of a comparison group for the Parenting Stress Index and child abuse and neglect reports. Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. Results: Parenting Stress Index scores from baseline to 6 months found 10 out of 11 subscales showed significant positive change. More importantly, when comparisons were made between the treatment and a comparison group, 5 of the 11 scales found significant positive differences favoring the Healthy Families participants. In fact, on all but one scale the comparison group got worse and the Healthy Families group got better. On the HOME measure, results found significant change from pretest to posttest on 3 of the 6 subscales and on the total score. Immunization data found that most immunization shots were up to date for over 50% of the Healthy Families group. The immunization rate for Arizona in 1993 was 46%. Substantiated child abuse and neglect reports were 2.8% for the treatment group and 3.7% for the comparison group which also included one child death. Conclusions: Results improved in that more Parenting Stress Index and HOME subscales were found to show significant pretest to posttest changes. A major methodological improvement was the addition of a comparison group that found significant improvement for the treatment group in contrast to the comparison group on some measures. The immunization rates were low for program participants and targeted as an important area for improvement. Child abuse and neglect rates were lower for the treatment group than the comparison group and met the stated program goal of less than 5 percent. December 2002 10 1992-1996 Evaluation Report Methodology: includes the same methodology as previous report. An addition is the use of the Child Abuse Potential Inventory and continued use of a matched comparison group for assessing outcomes in child abuse and neglect rates. Results: The Child Abuse Potential Inventory is primarily a screening tool for assessing child physical abuse. Results from this study found a statistically significant decrease in the average score from baseline to 12 months, indicating a reduced potential for physical abuse. Reductions in three subscales accounted for this change: parental distress, rigidity, and problems with others. Two subscales did not show significant change: problems with families of origin and problems with child and self. Positive results were also found with the Parenting Stress Index in that the total score and most of the subscales (e.g., parental attachment, sense of competence) showed significant improvements when assessed from baseline to 6 month and 18 month time periods. Similar to the last evaluation, positive changes were found on the HOME scale showing improvement in the total score from baseline to post assessment periods. Immunization data found that most immunization shots were up to date for over 90 to 99% of families enrolled at different time periods. Substantiated child abuse and neglect reports were studied for two groups, the original three sites (referred to as CAP sites) and the expansion sites (referred to as DES sites). For the CAP sites, the child abuse and neglect rate was 4.5% for the treatment group and 8.5% for a comparison group that did not receive services. This result favors the Healthy Families group at a statistically significant level of p <.10. For the DES sites, the child abuse and neglect rate was 0.7% for the Healthy Families participants and 2.0% for the comparison participants, a non-significant result. Given important methodological considerations (greater surveillance in treatment group, Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. greater likelihood of being tracked in the system) these results can be interpreted as positive. Although the numbers are small, a further study into the type of abuse that occurred revealed that physical abuse was more frequent for the comparison group than the Healthy Families group. Conclusions: Greater convergence of effectiveness data emerges from this evaluation. The Parenting Stress Index results of previous years is replicated but the additional finding from the Child Abuse Potential Inventory adds further evidence that program participants make improvements while in the program. Program implementation appears to improve as immunization rates increase considerably from last years’ assessment. Child abuse and neglect rates show significant decreases for the Healthy Families group when contrasted with a comparison group. The overall evaluation begins an increased focus on cross-site comparisons allowing enhanced quality assurance as data was more easily examined for each site. The report finds improvement in retention rates but there remains a need to continue improvements in retention. 1997 Qualitative Interview Study Methodology: A stratified random sample of 46 mothers was interviewed about their experiences in the program in order to understand program experience from the participants. Results: Participants reported that the program was seen as: helpful in addressing immediate family needs such as housing and food, providing emotional support with the multiple challenges parents face, and providing useful information about child health and development. Participants were also asked about their experiences with the screening process and it was found that participants perceive the screening as voluntary. Finally, participants reported a strong commitment to the program and December 2002 11 believe the program dramatically affected how they feel about themselves as mothers, feelings about their own sense of self, and their relationships with their children. Conclusions: This study provided additional data suggesting the participants benefited from what the program has to offer. Consistent with program theory, the participants reported value in the participant-worker relationship. This relationship appears to be the primary mechanism for achieving positive client outcomes. 1992-1998 Evaluation Report Methodology: descriptive analysis of program participants, screening and assessment data, pretest/posttest data on the Parenting Stress Index, the Child Abuse Potential Inventory and the HOME observation scale. Evaluation design is strengthened with the addition of a comparison group for the Child Abuse Potential Inventory. Because of a state-level change to the computerized CHILDS system of data collection, this report did not include an analysis of child abuse and neglect rates. Results: Assessment using the Child Abuse Potential Inventory showed some positive outcomes. In particular, baseline to post test at 12 months showed significant improvement in 4 of the 7 subscales: abuse, distress, rigidity, and problems with others. More importantly, an analysis was conducted to compare the change in scores between the Healthy Families participants and a comparison group of individuals who did not receive treatment. The Healthy Families group reduced their potential for abuse significantly more than the comparison group. Noteworthy was the finding that the comparison subjects actually increased their abuse potential as shown by an increase rather than a decrease on the abuse subscale. The Parenting Stress Index findings replicated the earlier reports showing 10 of 11 subscales had significant gains for the participants. This cohort was Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. also compared with the earlier comparison group using the Parenting Stress Index. Results found significance between group differences favoring the Healthy Families participants. The results for the HOME scale also found significant gains for participants at 12 month and 2 year assessments for the total score and most of the subscales. Immunization rates assessed at three time periods were again higher than what has been typically reported for statewide immunization rates. Conclusions: This report added to the evidence of effectiveness by finding improvements with the Child Abuse Potential Inventory. Especially significant was the greater between group differences in the Healthy Families group on abuse potential when compared to a no-treatment group. Also important was the replication of positive findings from the Parenting Stress Index. Critical program changes included the beginning efforts to systematically assess and intervene with families that have substance abuse problems. The program also showed improvement in the retention of families and that has been a major implementation issue. New efforts were also initiated to include fathers and expand outreach to strengthen the family focus of the program and the program began to collect participant satisfaction data. Healthy Families Evaluation Reports 2000 and 2001 Methodology: The last two reports from years 2000 and 2001 are combined because their methodology and results are quite similar. In these reports, the focus shifted from an extensive examination of outcomes to an examination on program improvement based on site-level data. After extensive analysis of multiple measures and outcomes, the program evaluation was refined using a smaller set of measures consisting primarily of the Parenting Stress Index, child safety in the home, and immunization rates. The program continues to monitor participant December 2002 12 data based on the screening tool, child development and referral for delays, links to medical doctors, maternal life outcomes such as employment and education and parent satisfaction with the program. These data are used primarily for program improvement. Results: Data from both years replicate the earlier findings from the Parenting Stress Index showing improvement from baseline to 6, 12 and 18-month assessments. Data on child safety show increases from baseline to assessment but increases are small because most parents are practicing safety habits prior to assessment. Immunization rates have remained stable and are consistently higher than comparable statewide data. In both years the rate of child abuse and neglect remained very low. For example, in 2001 the child abuse and neglect rate was 0.8% for the Healthy Families group and 1.7% for the comparison group. improvements, findings showing immunization rates higher than the statewide average, and findings that consistently show the Healthy Families participants had lower rates of child abuse and neglect when contrasted to a comparison group not receiving the program. Other outcomes that add to the cumulative evidence include the qualitative study that documented the perceived value the families report from being involved in the program, the cost benefit study which found that cost savings can be documented, and twelve years of experience in working toward program improvement showing gains in program implementation such as increased immunization and retention rates over time. Assessing program effectiveness is always a complex process, which requires a balance of good methodology, measures, and program implementation. In the end, a question of effectiveness requires a judgment be made based on an assessment of the data. Conclusions: Program results continue to be documented by the gains shown in the Parenting Stress Index, increases in immunization rates (and higher rates than statewide averages), small increases in child safety practices in the home, and low child abuse and neglect rates. What is the evidence for program effectiveness based on the evaluation studies completed? The converging evidence for Healthy Families Arizona suggests that the program is effective. This conclusion is supported by the following findings: replicated evaluations showing improvement from baseline to post assessment periods, positive results when using a comparison group on the Parenting Stress Index, replication of positive gains and positive results from a comparison group using the Child Abuse Potential Inventory, findings showing the comparison group getting worse on most measures while the Healthy Families participants were showing Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 13 Implementation Update 2002 There have been no new requirements added to the program during the last three years. However, the Healthy Families state system has developed new implementation strategies. First, a series of small focus groups was held to discover the barriers and challenges that hinder home visitors from focusing on parent-child relationships and child development. From these focus groups, a staff situational questionnaire was developed, implemented and analyzed identifying which situations occur the most frequently and are the most difficult to address. Training is being developed around each of these issues and will be implemented through the Training Institutes. Support for staff in dealing with these issues will be systemic and all aspects of the state system are being analyzed. Training efforts have been focused on developing the skills of the supervisors and program managers across the state. Advanced supervision training has been scheduled each quarter. Consultants have been included in the training to provide regional interim support monthly as supervisors integrate new supervisory skills into practice. Reflective, responsive supervision is seen as key to successful program outcomes. In order to integrate early intervention services for children with special needs, Healthy Families Arizona developed policies and procedures that were reviewed and agreed to by the Arizona Early Intervention Program (AzEIP). These procedures will facilitate the referral process to therapy and other services for children with special needs. Additionally, semi-annual training has been institutionalized for staff administering the Ages and Stages Questionnaire, a child developmental screen. Finally, in August 2002, Healthy Families Arizona applied for and was awarded the Western Regional Resource Center of Excellence. This center will provide training and technical assistance to the western states in all areas of Healthy Families program implementation. Arizona is one of two regions awarded the contract due to the quality of our statewide system. Thirdly, in an effort to reach out and include fathers in service delivery, a state Fatherhood Involvement Committee has been established. This committee defined active father/male involvement, methods staff could use to reach out to fathers, and training content to be included during the Training Institute and on site visits. Initial data were gathered to determine father/male involvement as a baseline and will be reviewed on a regular basis. Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 14 Program Participants What risk factors are associated with Healthy Families Arizona program participants? The graph shows that the kinds of families recruited to participate in the Healthy Families Arizona program are participants with clearly identifiable risk factors. These risk factors are associated with poor child development outcomes and child abuse and neglect. Important to any prevention program is the ability to target an at-risk population to deliver services. In examining the Healthy Families Arizona screening process, it is evident that the program is identifying a proper target population for services. Exhibit 1. Selected risk factors for Healthy Families mothers at intake Risk Factors Number Teen Births (<19 years old) 38.5% Births to single parents 70.8% Less than high school education 62.9% Not employed 17% No health insurance 4.8% Late or no prenatal care 38% Median yearly income $9,600 What is the ethnicity of the mothers served by the Healthy Families Arizona program? The Healthy Families Arizona program seeks to serve a culturally diverse number of participants in the state. Each site (see site level data in the Appendices) does an analysis of its community and ensures that staff are representative of the ethnic groups in the community. Staff are also trained in cultural competency. Exhibit 2. Ethnicity of Healthy Families Mothers Asian Native American American 1% 8% Other 4% Caucasian 21% Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. African American 7% Hispanic 59% December 2002 15 What percentage of mothers and fathers obtain a rating of severe on the Family Stress Checklist items? Exhibit 3. Percentage of Mothers and Fathers Rated Severe on the Family Stress Checklist Items Childhood Abuse Crime, substance abuse, mental illness Self-esteem, isolation CPS Involvement Current Life Stresses Violence Potential Expectations of Infant Discipline Attitudes Male Difficult Child Female Parental Attachment 0 10 20 30 40 50 60 70 Percent with Severe Rating During the initial assessment period, mothers and fathers are rated using the Family Stress Checklist. The above graph shows the three greatest stressors in families’ lives: coping with a history of child abuse, feeling low and isolated, and difficulty in coping with major stresses such as low income, poor housing, and relationship difficulties. What percentage of infants has high-risk characteristics? Exhibit 4. Percentage of infants with high-risk characteristics Risk Factor Percent Born <37 weeks gestation 15.1% Birth defects 1.1% Low birth weight 14.2% Positive alcohol screen 0.4% Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. The initial screening and assessment process identifies the risk characteristics of infants entering the program. Many of these risk characteristics are associated with increased risk for child abuse and neglect. The screening process helps workers provide tailored services to help families that have infants who may need special attention. December 2002 16 Service Delivery What number of participants does each county and site serve? Exhibit 5. Number of participants served by county, by site Site and Participants Served Cochise County Douglas/Bisbee Sierra Vista 112 111 Maricopa County Central Phoenix East Valley Phoenix Maryvale Mesa South Phoenix Southeast Phoenix Sunnyslope 95 79 89 110 78 120 119 Pinal County Pinal County Department Of Public Health Yuma County Yuma Site and Participants Served Coconino County Flagstaff Page Tuba City 82 50 60 Mohave County Lake Havasu City 129 Pima County Casa de los Niños CODAC Devereux La Frontera Pascua Yaqui 129 120 121 138 42 Santa Cruz County Nogales 122 110 Yavapai County Prescott Verde Valley TOTAL ALL SITES = 2,347 104 The number of participants served across all sites for the study time period (July 1, 2001 – June 30, 2002) totals 2,347. Sites serve different numbers of families depending on their funding level and number of Family Support Specialists at the site. Enrollment and participation in the program remains a program strength in that services are Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. 142 85 delivered to meet a broad range of needs such as child safety in the home, immunizations, and parenting skills to a large number of families. In spite of the volunteer nature of the program, recruitment and participation remains high (over 90% of the families who are offered the program, accept services). December 2002 17 What is the length of time in the program at termination for engaged families? In the home visitation field, a factor that has taken on increasing importance is the process of actively engaging families in the services. Families may enroll in the program but are not actively engaged until four home visits have been completed. In this year’s study, the percentage of families who were actively engaged was 89.4%, therefore only about 10% terminated the program prior to the four home visits. Exhibit 6 describes the actual length of time that families participated in the program before termination. Only 4% terminated the program at 3 months, which is a vast improvement over last year when 11.1% terminated at 3 months. Over half of the families participate for a year or longer. The average length of days in the program increased from 498 days in last year’s study to 595 days in this year’s study. In summary, Healthy Families Arizona has documented 3 years of steady improvement in the engagement and retention of families. Exhibit 6. Length of time in the program at termination for engaged families Up to 3 months 4% 3-6 months 14% 7-9 months 16% 1 year and beyond 56% 10-12 months 10% Exhibit 7. Major reasons for termination from the program Moved away 30.2% Unable to contact 29.3% Family refused further services 10.6% Completed program 10.5% All other reasons 8.3% Refused a change in worker 6.0% Achieved self-sufficiency 5.1% 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% Percent of Families In order to better understand how participants move in and out of the program, Healthy Families Arizona collects data on the reasons for termination in the program. Exhibit 7 presents this information. As can be seen, the main reasons for termination Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. are being unable to contact the family and family moved away. Noteworthy is that in last year’s study 5.7% had completed the program as a reason for termination and this year the percentage is up to 10.5%. December 2002 18 How do families who do not engage differ from those that do? This is an important question because it provides information about which families may need extra attention and help to stay engaged in the program. Several factors were examined to see if differences between the engaged and non-engaged families were present. The results reveal that most factors did not show a difference such as: age of the mother, Family Stress Checklist score, ethnicity of the mother, low birth weight of the infant, and household size. Only two factors could be considered to be meaningfully different: about 5% more early terminators where single parents and 5% of the early terminators were more likely to have had only a chart screen as opposed to a verbal screen at initial intake. Overall, it does not appear that any one set of risk factors are more likely to lead to early termination from the program. Program Outcomes for 2002 Healthy Families Arizona has continued to collect outcome data to examine program effectiveness. This section reports on multiple outcome indicators to study the overall impact of the program on parental stress and competence, child abuse and neglect, safety practices in the home, medical and social service use, and employment and educational attainment. Do Healthy Families Arizona participants show reductions in stress after participating in the program? One of the primary outcome indicators for the success of the Healthy Families Arizona program has been a measure of parental stress. This is because parental stress is related to increases in child abuse and neglect. The Parenting Stress Index (Abdin, 1995) is a reliable and valid measure used extensively in research and evaluation studies. This index provides data on the total amount of stress and information on Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. seven subscales: sense of competence, parental attachment, feeling restricted in one’s role, depression, isolation, distractibility, and mood. As the exhibit shows, significant pretest to posttest changes occurred for every subscale at 6 months and all but one subscale at 12 and 18 months. Furthermore, the total parenting stress score shows significant change across all time periods. December 2002 19 Exhibit 8. Parenting Stress Index Findings Subscale Sense of Competence Parental Attachment Feeling restricted in role Depression Isolation Distractibility Mood Total Stress Score Baseline to 6 months Significant Improvement Time Period Baseline to 12 months Significant Improvement Baseline to 18 months Significant Improvement t=9.28, p<.000 t=7.07, p<.000 t=3.25, p<.001 Significant Improvement Significant Improvement Significant Improvement t=5.83, p<.000 t=4.26, p<.000 t=2.97, p<.003 Significant Improvement Significant Improvement Significant Improvement t=3.60, p<.000 t=4.46, p<.000 t=3.57, p<.000 Significant Improvement Significant Improvement Significant Improvement t=4.85, p<.000 t=5.05, p<.000 t=3.93, p<.000 Significant Improvement Significant Improvement Significant Improvement t=4.57, p<.000 t=4.47, p<.000 t=3.20, p<.002 Significant Improvement No Significant Improvement No Significant Improvement t=2.66, p<.000 t=0.10, p>0.05 t=0.10, p>0.05 Significant Improvement Significant Improvement Significant Improvement t=11.88, p<.000 t=6.90, p<.000 t=3.06, p<.002 Significant Improvement Significant Improvement Significant Improvement t=9.63, p<.000 t=6.82, p<.000 t=4.48, p<.000 Note: See Appendix B for statistical details. Most reliabilities for the subscales were adequate, distractibility has an alpha of .47 which may explain why results were not significant for this scale. Definitions of each subscale can be found in Appendix B. Child Abuse and Neglect Outcomes Is there a difference in the rate of child abuse and neglect when comparing treatment and comparison groups? A common expectation of program impact is examination of the incidence of child abuse and neglect reports from the families who participate in the program. These data are presented in Exhibit 9, although reports of child abuse and neglect are unlikely to be a Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. good measure of program impact. This is because of several factors: child abuse and neglect are low occurring events, many incidents (perhaps up to one third) of child abuse and neglect go unreported, and increased community involvement with the family (e.g., mandatory reporting by physicians) may lead to increased reporting which can suggest the misleading conclusion that the program has no impact. December 2002 20 Exhibit 9. Percent of child abuse and neglect cases in treatment and comparison groups Group CPS Match Rate Healthy Families Participants 0.76% Comparison Group Participants 0.84% Exhibit 9 summarizes the percent of child abuse and neglect reports from two groups: the Healthy Families treatment group and a comparison group. The treatment group consists of families who have had at least four or more home visits (sufficient time to expect a program impact) and the comparison group consists of families who dropped out and did not complete at least four visits. The results are based on all families who entered the program during the study period of July 1, 2001 to June 30, 2002. Both groups had a very small percentage of matches when compared with the CHILDS registry. There were no significant differences between the groups and it is difficult to detect such differences when the rates are so small. Do Healthy Families Arizona participants show increases in child safety after participating in the program? Exhibit 10. Percent of safety practices implemented 100.0% 90.0% 89.7% 82.2% 80.0% 72.8% 70.0% Percent 92.8% 60.7% 60.0% 50.0% 46.7% 40.0% 30.0% 20.0% 10.0% 0.0% 2 months 6 months 12 months Since home visitors are in the parent’s home environment, they are in an excellent position to improve the safety of the family’s home. Data obtained from a child safety checklist show that most homes follow safety procedures and that on some indicators, child safety increases over time. This exhibit shows that on two safety measures, outlets covered and poisons being locked, increases can be detected from the 2 month, 6 month and 12 month assessment. Other safety indicators are also assessed including: smoke alarms, car seats, scissors and knives, lighters and matches, water safety, emergency phone numbers, outside supervision, and food storage. At the 2-month assessment, these other safety practices were all being actively used with over 90% of the participants. Outlets Covered Poisons Locked Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 21 Do Healthy Families Arizona child participants show increased levels of immunization after participating in the program? One goal of the Healthy Families program is to ensure that all families receive appropriate medical care. An assessment of this can be conducted by looking at the rate of immunizations that the children receive. Exhibit 11 shows the percentage of immunizations at different time periods. Exhibit 11. Rate of immunization by Healthy Families participants Immunization period Overall, program children do receive the required immunizations and, when compared with ADHS (2001) data, Healthy Families Arizona children do fairly well. This is especially noteworthy when considering that the program participants represent a high-risk group (less likely to get immunizations) and the state rate for immunization of 2 year olds is 78% (including both high-risk and low-risk groups). Percent immunized 2 month 92.7% 4 month 86.9% 6 month 76.6% 12 month 86.6% Received all 4 in the series 83.9% Immunization rate for 2year-olds in Arizona (OAG, 1999) 78% What percent of Healthy Families program children get linked to a medical doctor? Exhibit 12 shows the percentage of families that are linked to a medical doctor, a critical goal of the program. Exhibit 12. Percentage of children linked to a medical doctor at 6, 12, and 24 months 6 months 97.3% 12 months 96.2% 24 months 0.0% 94.8% 20.0% 40.0% 60.0% 80.0% 100.0% Percentage of Children Linked to Medical Doctor Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 22 What percent of Healthy Families participants make appropriate use of the emergency room? Data were also collected on emergency room use. A concern from health providers has been the inappropriate use of the emergency room for routine health care. Exhibit 13 shows a trend for an increasing number of participants who use the emergency room only when having obtained a doctors’ referral. Exhibit 13. Percent of Healthy Families participants who make appropriate use of the emergency room 6 months 12 months 24 months 30 months 36 months 42 months 48 months 54 months 60 months 0 10 20 30 40 50 60 70 80 90 100 Percent Using Emergency Room Appropriately What percent of families are detected to have children with developmental delays? The Healthy Families program seeks to monitor and promote healthy child development. Families that are in the program are offered developmental screening to assess their child’s developmental status. Both the parents and the home visitors are learning ways to encourage proper stimulation for growth and development and can then use this information. Home visitors attempt to administer the Ages and Stages Questionnaire to all their families. At the 4month time period, 55.8% of families had been administered the questionnaire, at the 6-month time period, 60.2% of the families had been administered the questionnaire. Exhibit 14. Developmental delay from 4 to 36 months Infants whose development is delayed are referred to early intervention services. Another major service that the program offers parents is early detection of such problems. Exhibit 14 shows the percent of developmental delays detected across four time periods. In almost all cases, children who were detected for delays were referred to appropriate followup services such as early intervention, AzEIP, or an intervention program. Developmental delay at 4 months 11.3% Developmental delay at 12 months 4.2% Developmental delay at 24 months 13.8% Developmental delay at 36 months 7.5% Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 23 High-risk families can have serious difficulties with alcohol and drug problems. The Healthy Families program is able to provide screening and referral for families who need to seek alcohol and drug treatment. Exhibit 15 shows the percentage of families who screened positive for alcohol and drug problems across four time periods. Exhibit 15. Percentage of families who screened positive for alcohol and drug problems 2 months (N=35) 6.8% 6 months (N=16) 3.7% 12 months (N=22) 5.7% 18 months (N=12) 4.5% While only a small number of participants are identified, those who are identified are referred to treatment. Given the strong connection between substance abuse and child abuse and neglect, getting even a few families into treatment could have a significant impact. Maternal Life Course Outcomes Although the Healthy Families program focuses on parent-child interaction as a primary goal, it can also bring benefits with regard to maternal life course outcomes such as subsequent pregnancies, education and employment. What percentage of mothers have subsequent pregnancies? Subsequent pregnancies were reported by 12.1% (N=254) of the participants while involved in the program. Of these mothers, 36% were 18 years or younger. In terms of how quickly they got pregnant, 36.1% did so within one year, the majority (43.4%) did so within 1-2 years. Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. Do Healthy Families Arizona participants show increases in employment after participating in the program? Exhibit 16 shows the percent change in employment status for mothers actively engaged in the program at baseline, 6 months and 12 months. Exhibit 16. Mother’s employment status across three time periods 100.0% 80.0% Percent What percent of families have alcohol and drug problems? 60.0% 40.8% 40.0% 20.0% 0.0% 31.3% 15.9% Baseline 6 months 12 months What percentages of Healthy Families Arizona participants become enrolled in school while participating in the program? Exhibit 17 shows small but consistent involvement in educational programs while participants are involved in the program. Exhibit 17. School enrollment status of mothers at 6 months 17% Enrolled full-time 6% Enrolled part-time 12% High school/GED Obtained 1% College Degree Obtained 0% 20% 40% 60% 80% 100% December 2002 24 Participant Satisfaction One aspect of program implementation, especially with a voluntary program like Healthy Families, is the satisfaction family members express about their participation. All Healthy Families program sites undertake an evaluation of both the program and staff after approximately 2 months of program involvement. Exhibit 18 shows that 98% of all participants returning a survey (N=557) agreed or strongly agreed that they had been treated with respect and dignity. In terms of program involvement, Exhibit 19 shows that 94% of the families were somewhat satisfied or very satisfied with the program. Exhibit 18. Responses to “The Healthy Families staff who offered me program services treated me with respect and dignity.” Exhibit 19. Responses to “How did you feel about the program so far?” Agree 20% Neutral 1% Strongly Disagree 1% Very Unsatisfied 1% Neutral 5% Somewhat Satisfied 13% Strongly Agree 78% Very Satisfied 81% Finally, Exhibit 20 describes various worker characteristics, such as polite or friendly, and the data show that almost 100% of workers are rated in a positive manner. Exhibit 20. How would you describe the Healthy Families worker who first offered you program services? (On a five point scale, shown are the two highest options for each characteristic) Characteristics Somewhat Polite to Very Polite 98.8% Somewhat Concerned to Concerned 93.7% Somewhat Patient to Patient 98.8% Friendly to Very Friendly 99.3% 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% Percent of Participants Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 25 Recommendations In order to continue to focus Healthy Families programming on factors that are likely to lead to the greatest outcomes, this year’s recommendations are based on an assessment of practice principles recently established by Neil Gutterman (2001) in his extensive review of home visitation research. Practice principle 1: To effectively serve families in their homes, workers must structure their work to clarify their focus with families. This practice principle concerns the implementation of the home visitation services. Because the evaluation has had a primary focus on outcome evaluation, not much attention has been paid in several years to the process of doing home visitation. However, an ongoing issue in implementation of services has always been clarifying the role of the home visitor. Therefore, a recommendation is to continue efforts at role clarification to help re-focus home visitors on their key functions with families. An additional assessment may be helpful in identifying any further issues around how to structure and clarify roles with families. Practice principle 2: Early home visitation programs should adapt and/or adopt parenting educational curricula with clear objectives, structured protocols that directly address those objectives and do so in ways that are compatible with and respectful of the families’ own cultural and individual contexts. It is encouraging to note that ongoing work has been done in the implementation of the Healthy Families Arizona program to refine and examine the use of curricula. In fact, a recent analysis of data attempted to examine the impacts of using the Growing Great Kids, Portage, and other varied curriculum. This practice principle suggests a further need to Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. assess the use of existing curricula in each site. Furthermore, whatever curricula are used should be evaluated for clear objectives and accompanying protocols for implementation. In areas where the curricula do not have clear protocols, they should be developed. Also, the recent study of difficult situations for home visitors in the Healthy Families Arizona program could be used as a starting point for developing clearer protocols to respond to those situations. Practice principle 4: Programs do not appear to increase their advantage by deploying multidisciplinary teams, either with regard to outcomes related to child maltreatment or with regard to cost efficiency. Healthy Families Arizona does not employ a multidisciplinary team by design so this practice principle is already in place. Practice principle 5: Programs that deliver, in practice, at least moderately intensive services–biweekly or more frequently–are linked with more favorable family participation and child maltreatmentrelated outcomes than those providing less intensive services. This trend holds for the frequency of services usually delivered, not for the frequency planned to be delivered. The Healthy Families Arizona program has continued to work on and has improved the engagement and retention rate of families. More intensive models of limited duration appear to hold greater promise for positive outcomes, where families are more likely to be engaged and involved in services, in comparison to approaches with less intensive services and longer service horizons. This practice principle suggests more effort might be made in ensuring an intensely delivered service. Since this is deemed an important practice principle, supervisors should December 2002 26 consider program intensity when addressing how workers can respond to families with greater needs. This practice principle also directs attention to prenatal initiated services that are associated with more favorable engagement and retention rates and reported outcomes. Furthermore, services initiated at the Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. prenatal stage hold the opportunity to address significant problems that shape the in-uterus environment and that later heighten risk for both maltreatment and for a host of poor developmental outcomes. Currently, prenatal initiated services by Healthy Families Arizona are legislatively restricted. December 2002 27 References Abdin, R. L. (1995). The parenting stress index. Odessa, FL: Psychological Assessment Resources. Gutterman, N. (2001). Stopping child maltreatment before it starts. Thousand Oaks, CA: SAGE Publications. Office of the Auditor General Report (1999). Department of Health Services: Bureau of Epidemiology and Disease Control Services. Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 28 Appendix A. List of Healthy Families Arizona Reports Prepared by LeCroy & Milligan Associates, Inc. (formerly LAM & Associates) 1) Implementation Study: Arizona Healthy Start/Families – (published 1993) 2) Arizona Healthy Families Outcome Evaluation Report for 1992-1993 Families – (published 1993) 3) Arizona Healthy Families: First Year Outcome Evaluation Report – (published 1994) 4) Healthy Families Arizona Evaluation Report for Tucson, Prescott and Casa Grande Sites 1992-1994 – (published 1996) 5) Qualitative Interview Study of Healthy Families Arizona – (published 1997) 6) Healthy Families Arizona Evaluation Report 1992-1996 (all sites) – (published 1997) 7) Healthy Families Arizona Evaluation Report, 1992-1998 (all sites) – (published 1999) 8) Healthy Families Arizona Evaluation Report, 2000 (published 2000) 9) Healthy Families Arizona Evaluation Report, 2001 (published 2001) Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 29 Appendix B Parenting Stress Index Information Reliabilities for Current Study Subscale Alpha Competence Attachment Restricted Role Depression Isolation Distractability Mood .73 .62 .72 .78 .73 .48 .69 Change in Parenting Stress Index Subscales Scores from baseline to 6 months Baseline Subscale 6 months Significance Mean SD Mean SD t Competence 31.6 6.2 29.6 6.1 9.28 Attachment 12.9 3.8 12.19 3.5 5.83 Restricted role 19.97 4.9 19.25 5.2 3.60 Depression 20.56 6.0 19.52 6.1 4.85 Isolation 14.58 4.5 13.82 4.6 4.57 Mood 10.65 3.2 9.15 2.9 11.88 Note: * p<.01, ** p<.001, *** p<.000, dependent t-tests, SD=Standard Deviation. Test are significant when applying a Bonferroni correction. N’s vary from 689 to 696. Change in Total Parenting Index Scores from baseline to 6 months Baseline Subscale Total Stress Score (N=684) Mean SD 6 months Mean SD Significance t 6.82 136.4 24.0 128.90 25.1 *** p<.000 Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 30 Appendix B Continued: Change in Parenting Stress Index from baseline to 12 months Baseline Subscale 12 months Significance Mean SD Mean SD t Competence 31.58 6.2 29.4 5.9 7.07 Attachment 13.04 3.9 12.30 3.7 4.26 Restricted role 19.98 5.0 18.77 5.6 4.46 Depression 20.82 6.3 19.38 6.2 5.05 Isolation 14.66 4.7 13.61 4.8 4.47 Mood 10.68 3.3 9.52 2.9 6.90 Note: * p<.01, ** p<.001, *** p<.000, dependent t-tests, SD=Standard Deviation. Test are significant when applying a Bonferroni correction. N’s range from 454-461. Change in Total Parenting Index Scores from baseline to 12 months. Baseline Subscale Total Stress Score (N=453) Mean SD 12 months Mean SD Significance t 6.82 136.44 24.0 128.9 25.1 *** p<.000 Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 31 Appendix B Continued: Change in Parenting Stress Index from baseline to 18 months Baseline Subscale 18 months Significance Mean SD Mean SD t Competence 31.08 6.2 29.66 6.2 3.25 Attachment 13.02 3.9 12.26 3.2 2.97 Restricted role 20.14 5.0 18.69 5.7 3.59 Depression 20.70 6.0 19.0 5.8 3.93 Isolation 14.4 4.5 13.34 4.6 3.20 Mood 10.62 3.3 9.72 3.2 3.06 Note: * p<.01, ** p<.001, *** p<.000, dependent t-tests, SD=Standard Deviation. Test are significant when applying a Bonferroni correction. N’s range from 239-242 Change in Total Parenting Index Scores from baseline to 18 months. Baseline Subscale Mean Total Stress Score (N=239) 136.76 SD 18 months Mean SD 127.78 25.47 Significance t 4.48 *** p<.000 Range and Reliability of the Parenting Stress Index (PSI) (Selected subscales for original reliabilities analysis) Alpha Administration Coefficient Subscales Rangea Sense of Competence 13 - 65 .77 Administered Parental Attachment 7 - 35 .64 at 3 weeks, 6 months, and 18 .74 Role Restriction 7 - 35 months Depression 9 - 45 .75 Social Isolation 6 - 30 .69 Mood 5 - 25 .70 Distractibility 9 - 45 .82 b Total Score 78-390 .85 a A higher score on each of the subscales represents a higher degree of stress in that area. b The total score on the Parenting Stress Index is computed by summing all of the subscales, with a higher score indicating more stress. Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 32 Appendix B Continued: Description of Parenting Stress Index Subscales Sense of Competence Subscale: Assesses the parent’s sense of competence in relation to his or her role as parent. It relates to knowledge of how to manage the child’s behavior and comfort in making decisions such as when and how to discipline the child. Parental Attachment Subscale: Assesses the intrinsic investment the parent has in the role of parent. This subscale was expected to determine the parent’s motivation level to fulfill the role of parent. Restrictive Role Subscale: Assesses the negative impact, losses, and sense of resentment associated with the parent’s perceptions of loss of important life roles. Depression Subscale: Assesses the extent to which the parent’s emotional availability to the child is impaired and the extent to which the parent’s emotional and physical energy is compromised. Isolation Subscale: Examines the parent’s social isolation and the availability of social support for the role of parent. Distractibility Subscale: Assesses the degree to which the child displays many of the behaviors associated with Attention Deficit Disorder with Hyperactivity and other behaviors which result in a continuous drain on the parents’ energy, which requires not only active parental management but also sustained high states of vigilance. Mood Subscale: Assesses child characteristics related to excessive crying, withdrawal, and depression. The parent usually experiences these behaviors as anxiety or anger provoking. Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 33 Appendix C Family Stress Checklist Family Stress Checklist Problem Areas and Interpretation (Mother & Father) Interpretation/ Problem Areas Range Administration I. Childhood history of The FSC is a 10 item physical abuse and rating scale. A score of 0 deprivation. 0, 5, or 10 represents normal, 5 represents a mild degree of II. Substance abuse, the problem, and a 10 mental illness, or criminal history. represents severe, on both 0, 5, or 10 the Mother and Father III. Previous or current Family Stress Checklist CPS involvement. items. The FSC is an 0, 5, or 10 assessment tool and is IV. Self-esteem, available lifelines, possible administered to the mother depression. 0, 5, or 10 through an interview by a Family Assessment Worker V. Stresses, concerns. from the Healthy Families 0, 5, or 10 Arizona Program. The VI. Potential for violence. 0, 5, or 10 interview takes place VII. Expectations of shortly after birth, or as infants milestones, 0, 5, or 10 near to that time as behaviors. possible. VIII. Discipline of infant, toddler, and child. IX. Perception of new infant. X. Bonding, attachment issues. 0, 5, or 10 0, 5, or 10 0, 5, or 10 Total Score 0 - 100 Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. A score over 25 is considered medium risk for child abuse and neglect, and a score over 40 is considered high-risk for child abuse. December 2002 34 Appendix D Site Level Data Age of Child at Entry Days to Termination Reason for Termination Mothers’ Education Fathers’ Education Health Insurance at Intake Late or No Prenatal Care or Poor Compliance at Intake Ethnicity of Mother Gestational Age Low Birth Weight Yearly Income Family Stress Checklist Score Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 35 Age of Child at Entry by Site (Age in days) Mean (Age in Days) Standard Deviation Number Douglas/Bisbee 17.88 17.81 104 Central Phoenix 27.10 21.58 88 Maryvale (Phoenix) 21.23 15.57 82 South Phoenix 21.95 21.21 73 East Valley (Phoenix) 21.75 18.16 64 Nogales 12.21 15.76 104 Page 21.18 19.41 49 Casa de los Niños (Tucson) 20.82 15.16 119 CODAC (Tucson) 17.90 20.12 105 La Frontera (Tucson) 17.04 14.23 131 Devereux (Tucson) 17.96 20.86 117 Sierra Vista 13.48 17.57 94 Tuba City 11.71 14.19 55 Verde Valley 10.17 10.74 75 Yuma 16.63 14.95 93 Pascua Yaqui 43.65 30.58 40 Lake Havasu City 25.06 19.14 120 Flagstaff 14.51 20.50 74 Sunnyslope (Phoenix) 24.79 19.82 94 Prescott 20.89 19.62 119 Casa Grande 18.82 19.97 93 Mesa 20.29 14.96 93 Southeast Phoenix 19.25 14.27 105 Total 19.37 18.75 2091 Site Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 36 Days to Termination by Site (For terminated clients) Mean (Days to termination) Standard Deviation Number Douglas/Bisbee 873.82 664.61 28 Central Phoenix 809.92 649.34 25 Maryvale (Phoenix) 555.08 497.03 25 South Phoenix 618.25 536.53 28 East Valley (Phoenix) 592.55 413.04 31 Nogales 909.23 655.79 26 Page 615.44 540.98 16 Casa de los Niños (Tucson) 585.84 431.97 49 CODAC (Tucson) 781.02 547.03 43 La Frontera (Tucson) 767.28 623.66 32 Devereux (Tucson) 662.39 457.02 28 Sierra Vista 378.48 289.30 50 Tuba City 607.54 553.26 13 Verde Valley 638.72 588.75 29 Yuma 765.89 540.81 27 Pascua Yaqui 310.71 477.37 7 Lake Havasu City 487.19 507.02 36 Flagstaff 421.91 345.67 23 Sunnyslope (Phoenix) 507.57 520.38 30 Prescott 328.11 285.15 27 Casa Grande 455.14 285.68 36 Mesa 401.64 350.81 28 Southeast Phoenix 346.34 200.03 32 Total 595.50 508.88 669 Site Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 37 Reason for Termination by Site (Number and Percent within Site) Moved Away Unable to contact Family refused further services Douglas/Bisbee 39.3% (11) 3.6% (1) 7.1% (2) Central Phoenix 44% (11) 20% (5) 0 Maryvale (Phoenix) 28% (7) 28% (7) 12% (3) South Phoenix 18.6% (8) 53.6% (15) 3.6% (1) East Valley (Phoenix) 12.9% (4) 41.9% (13) 6.5% (2) Nogales 38.5% (10) 11.5% (3) 26.9% (7) Page 43.8% (7) 18.8% (3) 18.8% (3) Casa de los Niños (Tucson) 26.5% (13) 36.7% (18) 2% (1) CODAC (Tucson) 16.3% (7) 30.2% (13) 11.6% (5) La Frontera (Tucson) 28.1% (9) 21.9% (7) 9.4% (3) Devereux (Tucson) 17.9% (5) 25% (7) 7.1% (2) Sierra Vista 36% (18) 42% (21) 6% (3) Tuba City 30.8% (4) 7.7% (1) 15.4% (2) Verde Valley 41.4% (12) 24.1% (7) 3.4% (1) Yuma 37% (10) 22.2% (6) 7.4% (2) Pascua Yaqui 14.3% (1) 0 0 Lake Havasu City 41.7% (15) 16.7% (6) 13.9% (5) Flagstaff 34.8% (8) 30.4% (7) 21.7% (5) Sunnyslope (Phoenix) 26.7% (8) 30% (9) 16.7% (5) Prescott 33.3% (9) 44.4% (12) 7.4% (2) Casa Grande 41.7% (15) 25% (9) 11.1% (4) Mesa 21.4% (6) 25% (7) 21.4% (6) Southeast Phoenix 12.5% (4) 59.4% (19) 21.9% (7) 30.2% (202) 29.3% (196) 10.6% (71) Site Total Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 38 Mothers’ Education by Site (Number and Percent within Site) Middle School (less than 9th) Some High School High School Graduate Post High School Douglas/Bisbee 23.1% (24) 46.2% (48) 22.1% (23) 8.7% (9) Central Phoenix 29.5% (23) 42.3% (33) 19.2% (15) 9% (7) 24% (18) 38.7% (29) 34.7% (26) 2.7% (2) 20.6% (14) 50% (34) 23.5% (16) 5.9% (4) 7.3% (4) 50.9% (28) 23.6% (13) 18.2% (10) Nogales 25.3% (20) 57% (45) 16.5% (13) 1.3% (1) Page 13.3% (4) 56.7% (17) 23.3% (7) 6.7% (2) Casa de los Niños (Tucson) 9.7% (10) 46.6% (48) 33% (34) 10.7% (11) CODAC (Tucson) 19.8% (20) 39.6% (40) 33.7% (34) 6.9% (7) La Frontera (Tucson) 23.4% (30) 46.9% (60) 24.2% (31) 5.5% (7) Devereux (Tucson) 18.2% (20) 37.3% (41) 36.4% (40) 8.2% (9) Sierra Vista 12.2% (11) 45.6% (41) 41.1% (37) 1.1% (1) 1.8% (1) 39.3% (22) 41.1% (23) 17.9% (10) Verde Valley 17.4% (12) 43.5% (30) 27.5% (19) 11.6% (8) Yuma 27.6% (24) 35.6% (31) 27.6% (24) 9.2% (8) Pascua Yaqui 28.6% (10) 48.6% (17) 20% (7) 2.9% (1) Lake Havasu City 17.1% (18) 35.2% (37) 41.9% (44) 5.7% (6) 21% (13) 33.9% (21) 33.9% (21) 11.3% (7) Sunnyslope (Phoenix) 15.3% (13) 40% (34) 35.3% (30) 9.4% (8) Prescott 15.7% (13) 50.6% (42) 21.7% (18) 12% (10) Casa Grande 20.7% (19) 54.3% (50) 23.9% (22) 1.1% (1) 6.3% (5) 45% (36) 26.3% (21) 22.5% (18) Southeast Phoenix 13.5% (13) 55.2% (53) 24% (23) 7.3% (7) Total 18.1% (339) 44.7% (837) 28.9% (541) 8.2% (154) Site Maryvale (Phoenix) South Phoenix East Valley (Phoenix) Tuba City Flagstaff Mesa Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 39 Fathers’ Education by Site (Number and Percent within Site) Middle School (less than 9th) Some High School High School Graduate Post High School Douglas/Bisbee 7.3% (6) 47.6% (39) 36.6% (30) 8.5% (7) Central Phoenix 19.3% (11) 42.1% (24) 35.1% (20) 3.5% (2) 8.6% (5) 56.9% (33) 31% (18) 3.4% (2) 29.1% (16) 38.2% (21) 30.9% (17) 1.8% (1) 2.4% (1) 47.6% (20) 33.3% (14) 16.7% (7) 20.6% (14) 54.4% (37) 19.1% (13) 5.9% (4) 4.2% (1) 54.2% (13) 37.5% (9) 4.2% (1) Casa de los Niños (Tucson) 12.8% (11) 39.5% (34) 40.7% (35) 7% (6) CODAC (Tucson) 18.2% (14) 40.3% (31) 37.7% (29) 3.9% (3) La Frontera (Tucson) 18.2% (20) 43.6% (48) 33.6% (37) 4.5% (5) 8.7% (8) 46.7% (43) 38% (29) 6.5% (6) Sierra Vista 7% (4) 38.6% (21) 50.9% (37) 5.3% (3) Tuba City 2% (1) 43.1% (22) 49% (25) 5.9% (3) Verde Valley 12.3% (7) 38.6% (22) 40.4% (23) 8.8% (5) Yuma 20% (15) 44% (33) 21.3% (16) 14.7% (11) Pascua Yaqui 16.7% (4) 62.5% (15) 20.8% (5) 0 Lake Havasu City 17.2% (16) 36.6% (34) 44.1% (41) 2.2% (2) Flagstaff 26.7% (12) 37.8% (17) 26.7% (12) 8.9% (4) Sunnyslope (Phoenix) 12.7% (8) 36.5% (23) 44.4% (28) 6.3% (4) Prescott 10.2% (6) 52.5% (31) 15.3% (9) 22% (13) Casa Grande 16.4% (12) 45.2% (33) 38.4% (28) 0 0 44.6% (25) 35.7% (20) 19.6% (11) 6.9% (4) 51.7% (30) 39.7% (23) 1.7% (1) 13.4% (196) 44.4% (649) 35.3% (516) 6.9% (101) Site Maryvale (Phoenix) South Phoenix East Valley (Phoenix) Nogales Page Devereux (Tucson) Mesa Southeast Phoenix Total Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 40 Health Insurance by Site at Intake (Number and Percent within Site) Site None AHCCCS Private Douglas/Bisbee 2.9% (3) 92.2% (95) 4.9% (5) Central Phoenix 4.5% (4) 83% (73) 11.4% (10) Maryvale (Phoenix) 3.7% (3) 84.1% (69) 9.8% (8) 0 64% (87.7) 9.6% (7) 4.6% (3) 80% (52) 15.4% (10) 15.2% (16) 81% (85) 1% (1) Page 6.1% (3) 91.8% (45) 2% (1) Casa de los Niños (Tucson) 1.7% (2) 74.8% (89) 18.5% (22) CODAC (Tucson) 2.9% (3) 83.3% (85) 11.8% (12) La Frontera (Tucson) 5.4% (7) 82.3% (107) 10.8% (14) Devereux (Tucson) 1.7% (2) 78.6% (92) 13.7% (16) Sierra Vista 2.1% (2) 76.8% (73) 16.8% (16) Tuba City 25% (14) 71.4% (40) 3.6% (2) 0 94.7% (71) 5.3% (4) 7.5% (7) 86% (80) 2.2% (2) 0 76.9% (30) 7.7% (3) Lake Havasu City 3.3% (4) 85% (102) 10.8% (13) Flagstaff 6.8% (5) 89.2% (66) 4.1% (3) Sunnyslope (Phoenix) 6.3% (6) 75.8% (72) 16.8% (16) 5% (6) 79.8% (95) 7.6% (9) Casa Grande 2.1% (2) 83% (78) 14.9% (14) Mesa 4.3% (4) 75.3% (70) 16.1% (15) Southeast Phoenix 4.8% (5) 83.7% (87) 11.5% (12) 4.8% (101) 82.3% (1720) 10.3% (215) South Phoenix East Valley (Phoenix) Nogales Verde Valley Yuma Pascua Yaqui Prescott Total Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 41 Late or No Prenatal Care or Poor Compliance at Intake by Site (Number and Percent within Site) The participant received no or late prenatal care or showed poor compliance with prenatal care Site True False Unknown Douglas/Bisbee 41.3% (43) 54.8% (57) 3.8% (4) Central Phoenix 39.1% (34) 57.5% (50) 3.4% (3) Maryvale (Phoenix) 33.7% (28) 63.9% (53) 2.4% (2) South Phoenix 35.6% (26) 61.6% (45) 2.7% (2) East Valley (Phoenix) 23.4% (15) 68.8% (44) 7.8% (5) 61% (64) 33.3% (35) 5.7% (6) Page 43.8% (21) 56.3% (27) 0 Casa de los Niños (Tucson) 29.2% (35) 58.3% (70) 12.5% (15) CODAC (Tucson) 38.1% (40) 56.2% (59) 5.7% (6) La Frontera (Tucson) 38.9% (51) 58% (76) 3.1% (4) Devereux (Tucson) 30.2% (35) 62.1% (72) 7.8% (9) Sierra Vista 41.5% (39) 57.4% (54) 1.1% (1) Tuba City 46.4% (26) 51.8% (29) 1.8% (1) Verde Valley 47.3% (35) 52.7% (39) 0 Yuma 41.3% (38) 58.7% (54) 0 Pascua Yaqui 21.1% (8) 76.3% (29) 2.6% (1) Lake Havasu City 32.5% (39) 67.5% (81) 0 Flagstaff 38.4% (28) 60.3% (44) 1.4% (1) Sunnyslope (Phoenix) 40% (38) 56.8% (54) 3.2% (3) Prescott 42% (50) 54.6% (65) 3.4% (4) Casa Grande 35.5% (33) 63.4% (59) 1.1% (1) Mesa 33.7% (31) 60.9% (56) 5.4% (5) Southeast Phoenix 34.3% (36) 62.9% (66) 2.9% (3) Total 38% (793) 58.4% (1218) 3.6% (76) Nogales Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 42 Ethnicity of Mother by Site (Number and Percent within Site) Caucasian Hispanic African American Asian American Native American Other Douglas/Bisbee 14.4% (15) 85.6% (89) 0 0 0 0 Central Phoenix 18.4% (16) 59.8% (52) 8% (7) 0 2.3% (2) 11.5% (10) Maryvale (Phoenix) 31.7% (26) 58.5% (48) 6.1% (5) 0 0 3.7% (3) 11% (8) 65.8% (48) 16.4% (12) 1.4% (1) 4.1% (3) 1.4% (1) 50.8% (33) 35.4% (23) 4.6% (3) 1.5% (1) 0 7.7% (5) 0 100% (105) 0 0 0 0 6.1% (3) 4.1% (2) 0 2% (1) 85.7% (42) 2% (1) Casa de los Niños (Tucson) 25.4% (30) 61% (72) 4.2% (5) 0.8% (1) 6.8% (8) 1.7% (2) CODAC (Tucson) 6.7% (7) 80% (84) 7.6% (8) 0 0 5.7% (6) La Frontera (Tucson) 12.2% (16) 78.6% (103) 3.8% (5) 0.8% (1) 3.1% (4) 1.5% (2) Devereux (Tucson) 24.8% (29) 64.1% (75) 2.6% (3) 1.7% (2) 3.4% (4) 3.4% (4) Sierra Vista 52.7% (49) 31.2% (29) 10.8% (10) 0 0 5.4% (5) 1.8% (1) 0 0 0 98.2% (55) 0 65.3% (49) 25.3% (19) 0 0 9.3% (7) 0 8.8% (8) 87.9% (80) 2.2% (2) 0 1.1% (1) 0 0 10.5% (4) 2.6% (1) 0 55.3% (21) 31.6% (38) 55% (66) 40.8% (49) 0.8% (1) 0 0.8% (1) 2.5% (3) Flagstaff 20.5% (15) 43.8% (32) 1.4% 91) 0 32.9% (24) 1.4% (1) Sunnyslope (Phoenix) 44.2% (42) 41.1% (39) 9.5% (9) 1.1% (1) 2.1% (2) 2.1% (2) Prescott 73.1% (87) 26.9% (32) 0 0 0 0 Casa Grande 27.7% (26) 56.4% (53) 8.5% (8) 0 3.2% (3) 4.3% (4) 57% (53) 24.7% (23) 5.4% (5) 0 5.4% (5) 7.5% (7) 16.2% (17) 51.4% (54) 24.8% (26) 0 1% (1) 6.7% (7) 28.5% (596) 53.4% (1115) 5.3% (111) 0.4% (8) 8.8% (183) 3.6% (75) Site South Phoenix East Valley (Phoenix) Nogales Page Tuba City Verde Valley Yuma Pascua Yaqui Lake Havasu City Mesa Southeast Phoenix Total Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 43 Gestational Age by Site (Number and Percent within Site) Was the gestational age less than 37 weeks? Site No Yes Douglas/Bisbee 89.2% (91) 10.8% (11) Central Phoenix 67.1% (57) 32.9% (28) Maryvale (Phoenix) 78.8% (63) 21.3% (17) South Phoenix 92.4% (61) 7.6% (5) East Valley (Phoenix) 79.7% (51) 20.3% (13) Nogales 92.3% (96) 7.7% (8) Page 87.2% (41) 12.8% (6) Casa de los Niños (Tucson) 80.4% (86) 19.6% (21) CODAC (Tucson) 88.8% (79) 11.2% (10) La Frontera (Tucson) 81.3% (100) 18.7% (23) Devereux (Tucson) 82.1% (87) 17.9% (19) Sierra Vista 91.8% (78) 8.2% (7) Tuba City 80.9% (38) 19.1% (9) Verde Valley 93.3% (70) 6.7% (5) Yuma 87.8% (79) 12.2% (11) Pascua Yaqui 97.1% (33) 2.9% (1) Lake Havasu City 85.9% (79) 14.1% (13) Flagstaff 84.6% (55) 15.4% (10) 83% (73) 17% (15) Prescott 91.5% (107) 8.5% (10) Casa Grande 81.5 % (75) 18.5% (17) 78% (71) 22% (20) 85.6% (83) 14.4% (14) 84.9% (1653) 15.1% (293) Sunnyslope (Phoenix) Mesa Southeast Phoenix Total Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 44 Low Birth Weight by Site (Number and Percent within Site) Did the child have low birth weight (less than 2500 grams or 88 ounces)? Site No Yes Douglas/Bisbee 82.7% (86) 17.3% (18) Central Phoenix 69.3% (61) 30.7% (27) Maryvale (Phoenix) 80.5% (66) 19.5% (16) South Phoenix 84.7% (61) 15.3% (11) East Valley (Phoenix) 76.9% (50) 23.1% (15) Nogales 91.4% (96) 8.6% (9) Page 85.7% (42) 14.3% (7) Casa de los Niños (Tucson) 85.7% (102) 14.3% (17) CODAC (Tucson) 84.8% (89) 15.2% (16) La Frontera (Tucson) 85.3% (110) 14.75 (19) Devereux (Tucson) 87.2% (102) 12.8% (15) Sierra Vista 87.4% (83) 12.6% (12) Tuba City 90.9% (50) 9.1% (5) Verde Valley 94.7% (71) 5.3% (4) Yuma 92.4% (85) 7.6% (7) Pascua Yaqui 97.5% (39) 2.5% (1) Lake Havasu City 87.4% (104) 12.6% (15) Flagstaff 79.5% (58) 20.5% (15) 83% (78) 17% (16) Prescott 95.7% (112) 4.3% (5) Casa Grande 87.2% (82) 12.8% (12) Mesa 75.3% (70) 24.7% (23) Southeast Phoenix 89.5% (94) 10.5% (11) 85.8% (1791) 14.2% (296) Sunnyslope (Phoenix) Total Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 45 Yearly Income by Site Mean Yearly Income Standard Deviation Number Douglas/Bisbee $9325.25 7438.07 93 Central Phoenix $11171.36 10529.50 56 Maryvale (Phoenix) $10534.60 8256.56 67 South Phoenix $9363.40 8103.32 60 East Valley (Phoenix) $18329.49 20597.03 41 Nogales $11250.45 8422.57 103 Page $8121.00 7492.00 44 Casa de los Niños (Tucson) $14422.49 11405.28 97 CODAC (Tucson) $13172.14 12958.05 79 La Frontera (Tucson) $10964.46 6514.70 96 Devereux (Tucson) $10814.11 7378.44 93 Sierra Vista $7242.98 14329.18 86 Tuba City $13602.98 18804.42 49 Verde Valley $8969.52 6440.61 66 Yuma $8079.90 5431.36 80 Pascua Yaqui $8618.50 6609.40 36 Lake Havasu City $13227.62 8987.39 105 Flagstaff $10672.45 11549.97 66 Sunnyslope (Phoenix) $12342.25 13631.41 71 Prescott $15080.18 10798.91 44 Casa Grande $10374.22 7951.74 54 Mesa $13320.76 12374.59 62 Southeast Phoenix $10911.32 11061.71 59 Total $11217.82 10749.18 1607 Site Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 46 Family Stress Checklist Score by Site Mean Score Percent of mothers whose FSC score was greater than 40 Number of mothers whose FSC score was greater than 40 Douglas/Bisbee 39.13 54.8% 57 Central Phoenix 36.21 38.6% 34 Maryvale (Phoenix) 38.86 56.6% 47 South Phoenix 37.95 47.9% 35 East Valley (Phoenix) 35.62 38.5% 25 Nogales 33.24 24.8% 26 Page 35.20 38.8% 19 Casa de los Niños (Tucson) 38.82 48.3% 58 CODAC (Tucson) 35.48 35.2% 37 La Frontera (Tucson) 37.25 44.3% 58 Devereux (Tucson) 39.36 53.8% 63 Sierra Vista 40.63 52.6% 50 Tuba City 30.71 12.5% 7 Verde Valley 35.60 34.7% 26 Yuma 38.28 43% 40 Pascua Yaqui 34.38 30% 12 Lake Havasu City 35.25 32.5% 39 Flagstaff 38.38 44.6% 33 Sunnyslope (Phoenix) 38.74 49.5% 47 Prescott 43.74 58.8% 70 Casa Grande 33.56 34% 32 Mesa 33.68 38.7% 36 Southeast Phoenix 37.10 45.7% 48 Total 37.15 42.8% 899 Site Healthy Families Arizona Evaluation Report LeCroy & Milligan Associates, Inc. December 2002 47