Healthy Families Arizona Annual Evaluation Report FY2010 July 2009 – June 2010 Prepared by: LeCroy & Milligan Associates, Inc. 4911 E. Broadway Blvd., Suite 100 Tucson, Arizona 85711 (520) 326-5154 www.lecroymilligan.com Prepared for: The Arizona Department of Economic Security Division of Children, Youth and Families Office of Prevention and Family Support 1789 W. Jefferson, Site Code 940A Phoenix, Arizona 85007 Acknowledgements This evaluation report represents the efforts of many individuals and many collaborating organizations. The evaluation team for Healthy Families Arizona that contributed to this year’s report includes evaluators Darlene Lopez, Ph.Dc., Kerry Milligan, MSSW, Lena Malofeeva, Ph.D., Olga Valenzuela, B.A, and Craig W. LeCroy, Ph.D., and data management staff, Veronica Urcadez, Eloina Cardenas, and Delcia Barcelo. We are grateful to Karen Bulkeley, Manager, and Jenna Shroyer, Program Coordinator, in the Office of Prevention and Family Support, for their guidance and support. Thank you to the Healthy Families Arizona program managers and supervisors, who have worked diligently to ensure data are collected, submitted, and shared with staff for program improvement. Family Assessment Workers, Family Support Specialists and support staff at the sites have dutifully collected the data, and have participated in the evaluation process--all of whom help to tell an accurate story about Healthy Families Arizona. Lastly, we acknowledge the families who have received Healthy Families Arizona services. Suggested Citation: LeCroy & Milligan Associates, Inc. (2010). Healthy Families Arizona Annual Evaluation Report 2010. Tucson, AZ: LeCroy & Milligan Associates, Inc. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 1 Table of Contents Executive Summary ............................................................................................................ 4 Introduction....................................................................................................................... 10 Current Issues in the Evaluation of Home Visitation programs ............................... 10 Program Reductions in 2010......................................................................................... 14 Credentialing Update ................................................................................................... 16 In this Report ..................................................................................................................... 18 Evaluation Methodology .............................................................................................. 18 Healthy Families Arizona Participant Characteristics ................................................... 19 Characteristics of the Target Population ..................................................................... 21 Assessment of Risk Factors .......................................................................................... 23 Infant Characteristics .................................................................................................... 25 Summary........................................................................................................................ 25 Key Healthy Families Arizona Services .......................................................................... 27 Developmental Screens and Referrals for Children ................................................... 27 Outcomes for Families ...................................................................................................... 29 Parent outcomes ............................................................................................................ 29 Healthy Families Parenting Inventory Reveals Positive Parent Change .............. 29 Healthy Families Parent Inventory (HFPI) Subscales ................................................ 30 Total Change Score on the HFPI .................................................................................. 31 Child Abuse and Neglect.............................................................................................. 31 Child Development and Wellness ............................................................................... 33 Immunizations........................................................................................................... 33 Safety Practices in the Home .................................................................................... 34 Mothers’ Health, Education, and Employment .......................................................... 34 Subsequent Pregnancies and Birth Spacing ............................................................ 35 School, Educational Enrollment, and Employment................................................ 36 Substance Abuse Screening .......................................................................................... 37 Conclusions and Recommendations ............................................................................... 38 References ……………………………………………………………………………………40 Appendix A: Site Level Data ........................................................................................... 43 Appendix B. Parent Survey ............................................................................................. 57 Appendix C. Healthy Families Arizona Prenatal Logic Model .................................... 58 Appendix D. Healthy Families Arizona Postnatal Logic Model .................................. 59 Healthy Families Arizona Annual Evaluation Report 2010 FINAL 2 List of Exhibits Exhibit 1. Healthy Families Arizona DES Program Sites as of June 2010................................... 15 Exhibit 2. Participants Included in the Evaluation for July 2009 – June 2010 ............................ 20 Exhibit 3. Most Frequent Reasons for Termination 2010.............................................................. 21 Exhibit 4. Selected Risk Factors for Mothers at Intake - 2010 ....................................................... 22 Exhibit 5. Mother’s Ethnicity ......................................................................................................... 22 Exhibit 6. Father’s Ethnicity .......................................................................................................... 23 Exhibit 7. Percentage of Parents Rated Severe on Parent Survey Items PRENATAL………... 24 Exhibit 8. Percentage of Parents Rated Severe on Parent Survey ItemsPOSTNATAL .............. 24 Exhibit 9. Risk Factors for Infants - 2010 ...................................................................................... 25 Exhibit 10. ASQ Screening --2010................................................................................................... 27 Exhibit 11. ASQ Follow-up Services – 2010................................................................................... 28 Exhibit 12. Change in Subscales of the HFPI................................................................................ 30 Exhibit 13. Overall Change in Healthy Families Parenting Inventory Outcomes ...................... 31 Exhibit 14. Percent of Families Showing no Child Abuse and Neglect Incidences –2007, 2008, 2009, 2010 .................................................................................................................... 32 Exhibit 15. Immunization Rate of Healthy Families Arizona Children ...................................... 33 Exhibit 16. Percent of all Postnatal Families Implementing Safety Practices .............................. 34 Exhibit 17. Percentage of Mothers who Reported Subsequent Pregnancies ............................... 35 Exhibit 18. Length of Time to Subsequent Pregnancy for Those Families with Subsequent Births ........................................................................................................................... 35 Exhibit 19. Percent of Mothers Enrolled in School – 2010 ............................................................ 36 Exhibit 20. Mother’s Employment Status ...................................................................................... 37 Exhibit 21. Percent Screened and Assessed Positive on the CRAFFT ......................................... 37 Healthy Families Arizona Annual Evaluation Report 2010 FINAL 3 Executive Summary There is broad recognition that there are many unmet needs among children and families in this country. Many of the most pervasive and intractable problems experienced by children can be found in homes with insufficient income, poor child care, poor parenting skills, and stressful conditions that interfere with effective child rearing and parenting. The long-term consequences of poor care take a toll on many of America’s children, among these are: infant mortality, low birth weight, neurodevelopmental impairments, child abuse and neglect, and accidental childhood injuries. The severity of the child abuse and neglect problem alone is evidence of the ongoing problems in many American homes. In 2008, there were nearly 2 million investigations or assessments (involving 3.7 million children) conducted by CPS regarding incidences of alleged maltreatment. Of these, approximately 24 percent found that at least one child was the victim of abuse or neglect (U.S. Department of Health and Human Services, 2010a). While there are many potential methods for addressing some of these factors, increasingly the home visitation model has been selected as a way for communities and states to reach out to families. Home visitation programs share several common beliefs: the importance of children’s early years, a focus on the pivotal role parents can play in shaping the healthy development of children’s lives, and a perspective that service delivery works better when bringing services to families rather than expecting them to seek and find assistance in their communities. One study estimated that 400,000 to 500,000 families with young children now receive home visitation services each year (Gomby, 2005). This number is likely to increase as more federal dollars are now being put toward these programs. As a national audience focuses increasing attention on home visitation, the issue of which programs to fund has been brought into question. For example, when President Obama announced his plan to spend up to 8 billion dollars over the next ten years on home visitation—he made it clear that evidence-based programs were a priority. The issue of which programs had enough “evidence,” however, has been controversial. While some experts define “evidence-based practice” as hinged on positive outcomes from a randomized clinical trial, many understand evidence-based practice as a set of guidelines and practices that transcend that narrow definition. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 4 An important element in the evidence-based program debate has been the evaluation of the home visitation programs. Although home visitation can be traced back to the 1800s, full understanding of its effectiveness remains somewhat elusive. It still unclear exactly which elements of home visitation programs are most likely to impact which outcomes, and some findings suggest all programs are not effective at impacting these outcomes. However, research suggests that home visitation programs help families with young children during a critical period, the first three years of a child’s life, and suggests the effectiveness of early intervention services in areas such as avoiding child maltreatment, influencing a child’s development, and building positive parent-child relationships (Daro, 2009). The Healthy Families Arizona (HFAz) program is one model for home visitation, designed to impact these and other outcomes. Findings from the evaluation of this program, included in this report, continue to contribute to the research-base on the effectiveness of home visitation programs and document the impact this program has on families in Arizona. The Healthy Families Arizona Program Healthy Families Arizona (HFAz) serves families experiencing multiple stressors that can put their children at risk for child abuse and neglect. HFAz began in 1991 under the auspices of the Arizona Department of Economic Security (DES). Like many states, budget decisions in Arizona over the last several years have reduced the health and human service system capacity. Over many years Arizona has developed an array of home visiting services which have been steadily reduced due to the current economic environment. The HFAz program was one of the programs dramatically impacted by the reduction. DES is hopeful that the funding level for the HFAz program is sustainable at its new reduced level. Funding to support the HFAz program from DES totaled over $6.0 million in state fiscal year 2010. First Things First (FTF) provided $6.3 million through their RFGA process. In spite of the financial shortfall, HFAz continues to be a visible and viable program across Arizona. There is a strong commitment to provide families with the necessary supports, education and information to promote the healthy development of their children. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 5 HFAz is a national home visitation program model that requires their providers to be accredited. DES and FTF are working together on the reaccreditation of the HFAz program. In order to establish a Healthy Families Program, providers must complete an initial accreditation process with Healthy Families America. To maintain the accreditation, established Healthy Families programs are required to complete a reaccreditation process every four years. For Arizona’s multi-site accreditation, DES serves as the central administration office for all HFAz programs. Arizona was due for reaccreditation through Healthy Families America in 2008, but was granted an extension due to the significant DES budget cuts. The reaccreditation process began in the summer of 2010 with the national site visit scheduled for Central Administration and 60% of the programs. DES worked with FTF to coordinate and prepare the information for the accreditation process. DES and FTF had established an Interagency Service Agreement to ensure a collaborative relationship and to share the costs and resources for the administration of the HFAz program. An evaluation of Healthy Families Arizona has been conducted yearly since the program’s inception. The scope of this evaluation report, as in past years, focuses only on the DES-funded Healthy Families sites. Who Does Healthy Families Arizona Serve? A total of 1,743 families were reached by DES funded Healthy Families programs between July 1, 2009 and June 30, 2010. However, the evaluation covers only families that are within the first 24 months after the birth of the baby (n=1,416). In addition, in order to have a meaningful evaluation of the program effects we include only the families where the most complete information on the effectiveness is available. This further restricts our dataset to include only those families where we have full data showing that they have received at least 4 home visits (n=901). The average length of time families remained in the program is just over one year. About 76% of the engaged families entered the program after the birth of their child, with 24% entering during the prenatal phase. Healthy Families Arizona program participants reported a significant number of risk factors at entry into the program compared to the overall state rates. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 6 Risk Factors of Mothers Teen Births (19 years or less) Births to Single Parents Less Than High School Education Not Employed No Health Insurance Receives AHCCCS Late or No Prenatal Care Median Yearly Income HFAz Prenatal Families 14% 75% 62% 80% 6% 87% 27% $8,700 HFAz Postnatal Families 17% 72% 58% 83% 3% 90% 29% $12,000 Arizona state Rates - 2009 12% 45% 24% NA* 3% 54% 20% $48,745 *Employment figures for Mothers are not available at the state level. Additionally, families reported the following risk factors at intake: • Premature birth—11% of the infants who entered prenatally were born with less than 37 weeks gestation compared to 19% of infants who entered postnatally; • Low Birth weight— 10% of the infants who entered prenatally had low birth weight (less than 5.5 pounds) whereas 15% of the infants who entered postnatally had low birth weight. Outcomes for Families and Children Participating in Healthy Families The economic recession experienced in the United States throughout this report year undoubtedly impacted many of the at-risk families served by Healthy Families Arizona. While this study does not address the specific impact of economic insecurity on the health outcomes for children and families, continued awareness of the potential impacts are warranted. Unemployment remains high, health insurance becomes more difficult to attain and maintain, and education and supportive services for families are increasingly cut throughout the state, and all of these factors potentially impact HFAz families and their outcomes. Despite these challenges, participants in Healthy Families Arizona did show significant positive change in a number of areas related to parenting practices, as shown in the following figure. Parents in Healthy Families report significant changes in: • Increased social support • Increased problem solving • Increased personal care • Increased use of resources • Improved home environment • Increased parenting efficacy • Decreased depression Healthy Families Arizona Annual Evaluation Report 2010 FINAL 7 The Healthy Families Parenting Inventory (HFPI) revealed statistically significant improvement on 7 of 9 subscales and on the total HFPI score at either the 6 or 12 month time point, suggesting that participation in the program reduced risk factors related to child abuse and neglect. Although the evaluation lacks a comparison group to study program effects, these findings (consistent over 2 years) continue to show that participants report improvements in healthy parenting behaviors. Child Health, Development, and Safety Timely immunizations remain an important component for positive child health and development outcomes. There continue to be positive results in this area among HFAz participants. For example, there was a reported 85% immunization rate for the children of Healthy Families Arizona participants at 18 months. This is in comparison to a 76.4% immunization rate for children between the ages of 19 months and 35 months in the state of Arizona as a whole. HFAz also helps families adopt and maintain home safety practices. Results show over 98% of participants are using car seats, 95% have poisons locked, and 90% have working smoke alarms. This compares favorably with national trends among the general population (e.g., national estimates of 90% car seat usage and 75% “working” smoke detectors). The program also screens for developmental delays at 6 month intervals and assures that children who need further services are referred appropriately. Child Abuse and Neglect Records of child abuse and neglect incidents (substantiated) were examined for program participants. The results showed that the percent of families with no child abuse or neglect incidences was 97.4%, slightly lower than the previous year, but still above the program performance goal of 95%. There were 23 HFAz families with a substantiated case of child abuse and neglect out of 878 families that had participated in HFAz for at least 6 months. Mothers’ Health, Education, and Employment In addition to the parenting outcomes noted earlier, the HFAz model also seeks to improve the health, education, and employment outcomes among mothers so that they are better equipped to meet their families’ needs. Research shows that spacing births has positive health benefits for the mother. Results for HFAz show only 3.3% of mothers with a subsequent pregnancy waited over 24 months before they got Healthy Families Arizona Annual Evaluation Report 2010 FINAL 8 pregnant with their next child, while more than half the mothers with subsequent pregnancies waited a year or less. This means that a smaller percentage of women are spacing their births in spite of the health benefits, and the program needs to put more emphasis in this area. The number of mothers enrolled in school has increased significantly in this reporting year, from 10% in 2008-2009 to 22% in 2009-2010 enrolled within 1 year of program participation. HFAz provides initial screening and referrals for substance abuse problems, and substance abuse continues to be a difficult problem for families. Just under 30% of the participants (compared to 34% in the prior year) were screened as having potential substance abuse problems during the first 2 months of the program. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 9 Introduction The Healthy Families Arizona program was established in 1991 as an initiative of the Department of Economic Security to develop and implement home visitation services with at-risk families. The program is modeled after the Healthy Families America initiative and is accredited by Prevent Child Abuse America. Healthy Families America began under the auspices of Prevent Child Abuse America (formerly known as the National Committee to Prevent Child Abuse) in partnership with Ronald McDonald House Charities and was designed to promote positive parenting, enhance child health and development, and prevent child abuse and neglect. Healthy Families America grew to over 440 communities in the United States and Canada by 2008. As described by Prevent Child Abuse America, the Healthy Families program model is designed to help expectant and new parents get their children off to a healthy start. Families are screened according to specific criteria and participate voluntarily in the program. Participating families receive home visits and referrals from trained staff. By providing services to under-resourced, stressed, and overburdened families, the Healthy Families Arizona program fits into a continuum of services provided to Arizona families. Initially, Healthy Families America drew largely from existing research, and knowledge and experiences gained through the Hawaii Healthy Start program to design the program. Healthy Families America is built on a set of 12 research-based critical elements that provide a benchmark used to measure quality. Healthy Families Arizona (HFAz) is now considered a nationally credentialed, communitybased voluntary home visitation program designed to: • Promote parent/child interaction • Promote child health and development • Prevent child abuse and neglect. Current Issues in the Evaluation of Home Visitation programs The growing demand for evidence-based home visitation is astonishing. A Google search on “evidence-based home visiting programs” provides over 500,000 entries. In addition, one study estimated that 400,000 to 500,000 families with young children now receive these home visitation services each year (Gomby, 2005). This number is likely to increase as more federal dollars are now being put toward these programs. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 10 Although home visitation can be traced back to the 1800s, full understanding of its effectiveness remains elusive. Studies of home visitation to date have examined a range of outcomes with mixed evidence of program effects. Generalization of these studies is made more difficult given the variation in programming, the diversity of target populations and communities, and the fact that the studies examine different outcomes with different measures over different time periods. A sample of findings from some of these studies is included below. These studies are included to highlight the variation and complexity in the assessment of home visitation effectiveness, but should not be taken as a comprehensive literature review on the subject or to ascertain the effectiveness of any one model:  A randomized study of Hawaii’s Healthy Start Program (HSP), including six sites operated by three community-based agencies found more positive parenting attitudes and improved parent/child interactions at six and 12 months for program participants in contrast to the control group . There were, however, no differences found in children’s cognitive development (McCurdy, 1996).  Taylor & Beauchamp (1988) found a positive program impact of a home visitation program on attitudes toward discipline (Olds et al., 2002; 2004a; 2004b).  Barth (1991) reported no advantages on self-report measures or reports of child abuse for families participating in the Child Parent Enrichment Project, compared to a randomized control group, although some indication of greater success with families with less serious problems was observed.  Macdonald et al. (2007) assessed the effectiveness of five home-visiting programs directed at teenage mothers. All studies were randomized controlled trials with 1838 participants. Findings from this study suggest there is only limited evidence that home-visiting programs of the kind described in this review can impact positively on the quality of parenting of teenage mothers on child development. Authors assert that this does not amount to a conclusion that home-visiting programs are ineffective but rather indicate a need to think carefully about improvements in the conduct and reporting of outcome studies in this area.  One study of a home visitation program utilizing nurses found these programs were able to reduce subsequent pregnancies, child abuse and neglect, welfare receipt, substance abuse, crime, and increasing labor force Healthy Families Arizona Annual Evaluation Report 2010 FINAL 11 participation (Olds et al., 1997). A replication of this study showed results that were less expansive, but nonetheless positive including reducing pregnancyinduced hypertension, subsequent pregnancies, and childhood injuries and hospitalizations (Kitzman et al., 1997).  McDonald Culp et al. (2004) compared 156 Oklahoma mothers enrolled before 28 weeks of gestation through the infant’s first birthday to 107 mothers not receiving the Healthy Families program. She found greater utilization of community resources, safer homes, more appropriate developmental expectations, better understanding of non-corporal punishment, and behaviors that were more respecting and accepting of their infants among mothers in the intervention group compared to the control group.  Gessner (2008) in an evaluation of Healthy Families Alaska (HFAK) which included 325 families, found no overall program effect on maltreatment reports, and most measures on potential maltreatment. Home visited mothers reported using mild forms of physical discipline less often than control mothers. The groups were similar in their use of more severe forms of physical discipline. There was no program impact on parental risks.  Other recent studies (such as Duggan et al., 2007) suggest that Healthy Families Alaska (HFAK) may have produced somewhat better results than those produced in the Hawaii Healthy Starts evaluation – at least with respect to children’s development (Gomby 2007). From these studies, it is apparent that the debate on the effectiveness of home visitation programs continues. The debate gathered strength when President Obama announced his plan to spend up to 8 billion dollars over the next ten years on home visitation—but only for programs that had the strongest evidence of effectiveness. The issue of which programs had enough “evidence” heated up and eventually the policy was reshaped to declare that the majority of funding would go to programs that had the most evidence and programs with modest evidence could get some, but less funding (See Haskins, Paxson, & Brooks-Gunn, 2009). Remaining in the legislation is the intent that all programs be subjected to continuous evaluation. For example a July 2010 announcement was made about the release of $88 million by U.S. Department of Health and Human Services to support evidence-based home visiting programs (U.S. Department of Health and Human Services, 2010). Healthy Families Arizona Annual Evaluation Report 2010 FINAL 12 The Healthy Families Arizona (HFAz) program is in the middle of the evidencebased revolution; the program model was on the forefront in 1993 when it was recognized as a “promising program,” in part because of its strong evaluation component. Although a randomized trial had not been conducted at that time, the program was focused on continuous program improvement. While some experts define “evidence-based practice” as hinged on positive outcomes from a randomized clinical trial, many understand evidence-based practice as a set of guidelines and practices that transcend that narrow definition. Many experts claim evidence-based practice is best thought of as a systematic approach to improving the quality of services (Gray, 2001; Sackett et al., 2000). Thus, HFAz has taken into consideration the breadth of this definition since its inception, and has worked to establish itself as an evidence-based program. Over the years, the HFAz evaluation effort has conducted several special studies in order to improve the quality of services and program implementation, in addition to focusing on outcome findings. For example, the “problematic situations” study (LeCroy & Whitaker, 2005) sought to identify very specific problematic situations for home visitors. It was designed to shed additional understanding on what situations were difficult and provide a framework for improving supervision and training to respond to those difficult situations. The overall evaluation model of the Healthy Families Arizona program focuses on quarterly and annual reports in order to meet legislative requirements, measure participant outcomes, describe evolving program components, and provide basic accountability. Furthermore, the ongoing evaluation seeks to provide information for strategic growth and planning by examining program theory and logic as it evolves and ask critical questions to inform progress and growth. Some action steps in this process include: 1. Working with program directors, program administrators, supervisors, and direct care home visitors to learn about evidence-based processes; 2. Involving participants of home visitation services as informed participants; 3. Reviewing Healthy Families Arizona management and administrative practices and policies that influence practice; and 4. Addressing implementation challenges including the implications of scarce resources. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 13 All of this information also contributes to the evidence base for the Healthy Families program. The evaluation of the Healthy Families Arizona program continues today, necessarily scaled back because of budget constraints, but still a significant aspect to the program. Furthermore, in this time of fewer resources, programs will need to take more initiative to rigorously investigate their program operations and data to keep the process of using evidence active and part and parcel of program improvement. Some key ways in which all programs can engage in evidence review includes: 1. Searching for ongoing research to answer questions about program operations; 2. Critically examining the existing data on the program; 3. Using the program report, quarterly reports and process of data collection to inform ongoing practices; and 4. Evaluating the process for improving the program and seeking ways to implement improvements. As the field continues to build on the home visitation programming and evidencebase in this country, increasingly program experts, researchers, and policymakers, are beginning to acknowledge that a systemic approach to understanding and improving outcomes for youth and families may be merited. In addition to home visitation programs, other important elements in this systemic approach might include: early access to basic health and reproductive care, a broad risk assessment, and linkages to childcare and early education programs (Daro, 2009). Continued evaluation of these home visitation programs, as well as the systems in which they operate, will help inform our understanding about the best ways to help children and families attain optimal outcomes. Program Reductions in 2010 Healthy Families Arizona began in 1991 with 2 sites and increased to 58 sites serving over 150 communities around the state by 2006. Budget reductions at DES and at the program level in 2009 decreased the number of sites. Many sites have had to reduce the level of services they provide, and some communities will not be served by the Healthy Families Arizona Annual Evaluation Report 2010 FINAL 14 program due to limited capacity, resources, and funding. See Exhibit 1 for a list of currently funded sites. Exhibit 1. Healthy Families Arizona DES Program Sites as of June 2010 Maricopa County Santa Cruz County Central Phoenix Maryvale Nogales Graham County South Phoenix Safford East Valley Pascua Yaqui Tribe Sunnyslope Lake Havasu Mesa Coconino County West Phoenix Page LaPlaza Vieja Pima County CODAC Kinlani La Frontera Flagstaff Pima Main Tuba City Mojave County Yavapai County Kingman Bullhead City Prescott Navajo County Winslow Cochise County Douglas Yuma Sierra Vista Excel DES provides just over $6 million annually to agencies around the state to deliver the HFAz program. These dollars come from designated Lottery Funds, and The Federal Community-Based Child Abuse Prevention Grant. This is a reduction from over $18 million in 2008. In April 2009, First Things First (FTF) responded to the state’s urgent needs by releasing emergency dollars to agencies providing services consistent with the identified goals of FTF to promote early childhood health and development. In state fiscal year 2010 FTF provided $6.3 million to HFAz programs around the state, enabling some sites to be increased in size and 8 additional sites to be funded. The families funded through FTF are not included in this report, but an interagency agreement is in process to include FTF funded families in next year’s report. For the 2010 state fiscal year, there are 11 programs and 40 sites (16 DES funded, 9 FTF funded, and 15 receiving funding from both). Healthy Families Arizona Annual Evaluation Report 2010 FINAL 15 In addition to the reduction in sites and numbers of families being served, funding cuts in early 2009 resulted in the temporary suspension of the HFAz Quality Assurance and Training Services, which was responsible for ongoing training, policy development, technical assistance, site visits, and credentialing preparation since 1991. Significant reductions in evaluation services for the state also took place in 2009 and required modifications to the evaluation design. The impact of the cuts includes: decreases in quality assurance site visits; fewer training workshops; fewer support materials being distributed; reduced evaluation data quality checks; a reduction in data collected, entered, and analyzed; and a re-focusing and reduction in the evaluation in order to ensure assessment of basic outcomes and credentialing data. Credentialing Update Healthy Families Arizona programs worked diligently to prepare for accreditation during 2009 and 2010, after being granted a one-year extension due to the changes occurring with the 2009 funding cuts. There are two sets of accreditation standards. One set of standards is designed specifically for the statewide system to assure that the system is performing to best practice measures. The other set of standards is designed to be completed by the individual Healthy Families Arizona (HFAz) programs. In order for Healthy Families Arizona programs to be accredited, both the state system and the programs within the system must meet standards of best practice. The HFAz state system accreditation criteria include five functional areas. These functional areas include: 1) adherence to a system of statewide policies, 2) provision of both training and technical assistance, 3) monitoring and quality assurance services, 4) utilization of evaluation results to improve practice, and 5) administration services that assure appropriate oversight of service implementation. The individual programs follow the best practice standards that operationalize the Healthy Families America 12 Critical Elements. These Critical Elements are broken into three major service activities: 1) initiation of services, 2) home visiting services, and 3) administration. There are 119 standards that indicate best practice based upon over 30 years of research. There are three major steps in the accreditation process. First, both the HFAz state system and the individual programs prepare a written self-study that enables HFAz Healthy Families Arizona Annual Evaluation Report 2010 FINAL 16 to take a critical look at the services offered and improve practice as needed. This written self-study is submitted to the Healthy Families America national office. The second step requires site visits by nationally trained peer reviewers. The HFAz state system receives a site visit first, followed by visits to individual program sites. The peer reviewers come to Arizona from other states and serve as outside, objective observers. Following the site visit, each program will receive an Accreditation Site Visit Report that will detail the strengths of the program as well as areas in which services can be improved. Finally, each program can demonstrate improvement in their practices and formally respond to the Healthy Families America Accreditation Panel, who will make the final decision to accredit. Peer review site visits were completed in July 2010 for the statewide system, and in August through October 2010 for the individual program sites. While the final results of accreditation have not yet been released the initial feedback on these documents was positive. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 17 In this Report This annual program evaluation report for Healthy Families Arizona focuses on annual participant outcomes, process information, and evaluation information useful for program improvement for the time period July 1, 2009 - June 30, 2010. The process evaluation describes the characteristics of families participating in the program. The outcome (or summative) evaluation examines program outcomes and looks at the program’s impact across a number of measures. Detailed appendices provide specific site data on process and outcome variables. The description of evaluation methodology explains the methods used for each part of the report. Due to reduced funding for the program evaluation, the 2010 Annual Report is limited to reporting of data for basic accountability and credentialing and is limited to only those families within 24 months of the birth of the infant. Currently, the Healthy Families Arizona evaluation also includes the creation and distribution of quarterly reports for ongoing program monitoring, but detailed process and outcome studies are no longer included in these documents. Evaluation Methodology This evaluation includes both a basic process evaluation component and an outcome evaluation component. The primary questions for the process evaluation are: Who participates in the program and what are the services provided? The primary question for the outcome evaluation is: What are the short and long term outcomes of the program? For the process evaluation, evaluation activities focus on obtaining and describing the program “inputs” such as numbers served, participant characteristics, and services received. The goal is to describe the participants involved in the Healthy Families Arizona program and document the services they receive. Also, information relative to Critical Elements and expected standards from Healthy Families America is provided as a benchmark for assessing some aspects of the implementation. The primary data for the process evaluation comes from the management information system developed to process data for Healthy Families Arizona. Sites are required to submit data that captures enrollment statistics, number of home visits, administration of assessment and outcome forms, descriptions of program participants, types of services provided, etc. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 18 The overall aim for the outcome study is to examine program effects or outputs, at both the parent and child level on a number of different outcomes. The evaluation team has worked together with program staff to develop and select key program measures that are used to provide feedback and to measure the program’s ability to achieve specific outcomes. The primary activities of the outcome evaluation are to: examine the extent to which the program is achieving its overarching goals, examine the program’s effect on short term goals, and examine the extent to which participant characteristics, program characteristics, or community characteristics moderate the attainment of the program’s outcomes. For most of the outcome measures, Healthy Families home visitors collect baseline (pretest) data and follow-up data at different time points of program participation: 6 months, 1 year, 18 months, and 24 months. Evaluation funding in prior years allowed for the collection and analysis of follow-up data through 60 months. Part of the outcome evaluation also includes examination of substantiated cases of child abuse and neglect obtained through the Department of Economic Security’s CHILDS database. The process and outcome components of the evaluation were developed and guided by the logic models for both the prenatal and postnatal programs. Logic models for the prenatal and postnatal components of Healthy Families Arizona are presented in the Appendices. Healthy Families Arizona Participant Characteristics During the current study year, July 2009 through June 2010, the total number of families served by the DES-funded programs was 1,743. This is a 60% decrease from the number of families served last year prior to the full budget cuts. The evaluation covers only families that are within the first 24 months after the birth of the baby (n=1,416). For the purposed of a meaningful evaluation of the program effects we include only the families where the most complete information on the effectiveness is available. This further restricts our dataset to include only those families where we have full data showing that they have received at least 4 home visits (n=901). The remaining 515 families all received a first home visit, but include both families that closed prior to receiving 4 home visits (81 families), that went on outreach before receiving 4 home visits (23 families), or for whom data had not yet been received so it was not possible to determine the number of home visits they have received (411 families). Thus, the data for this report focuses on participants who were within the first 24 months after the birth of the infant and “actively engaged” (received 4 or Healthy Families Arizona Annual Evaluation Report 2010 FINAL 19 more home visits) in the Healthy Families program regardless of when they entered the program. About one quarter (24%) of the families enter the program in the prenatal period (prenatal participants) and about three quarters (76%) of the families enter the program after the birth of the child (postnatal participants). For the July 2009 to June 2010 evaluation cohort, there were 212 prenatal families and 689 postnatal families. Exhibit 2 presents the total numbers of prenatal and postnatal participants actively engaged from July 2009 to June 2010. Exhibit 2. Participants Included in the Evaluation for State Fiscal Year 2010 County Cochise Coconino Graham Maricopa Mohave Navajo Pima Santa Cruz Yavapai Yuma Total Site Douglas/Bisbee Sierra Vista Flagstaff (La Plaza Vieja) Page Tuba City Wellspring Williams (Kinlani) Safford Central Phoenix Maryvale South Phoenix East Valley Sunnyslope Mesa West Phoenix Bullhead City Kingman Lake Havasu City Winslow Child & Family Resources CODAC La Frontera Pascua Yaqui Nogales Prescott Yuma Prenatal 6 2 22 7 10 15 20 3 9 9 2 13 3 12 6 1 3 16 6 5 5 14 15 3 2 3 212 Postnatal 17 20 23 13 12 24 11 13 44 44 47 42 46 61 48 11 9 19 6 15 34 57 9 13 34 17 689 Total 23 22 45 20 22 39 31 16 53 53 49 55 49 73 54 12 12 35 12 20 39 71 24 16 36 20 901 Length of Time in Program and Reasons for Termination It is difficult to draw conclusions or make comparisons with last year regarding the length of time families stayed in the program due to the fact that the majority of terminations (55%) last year were caused by program closure. For all families (N=400) who closed: • The median number of days in the program was 305 days; • The average length of time in the program was 385 days; and Healthy Families Arizona Annual Evaluation Report 2010 FINAL 20 • Forty percent (40%) of families were in the program one year or longer. Exhibit 3 shows the most frequent reasons families left the program during this year. A breakout by site is presented in Appendix A. Exhibit 3. Most Frequent Reasons for Termination State Fiscal Year 2010 Reason Moved away Did not respond to outreach efforts Family refused further services Refused worker change Other Self-sufficiency Unable to contact No longer has custody Prenatal Postnatal 33.7% 22.9% 8.4% 10.8% 10.8% 1.2% 6.0% 3.6%* 28.7% 21.5% 16.6% 8.1% 6.9% 8.5% 3.2% 3.6% * This is families that entered the program during the prenatal period, but lost custody after the birth of the infant. Characteristics of the Target Population The Healthy Families Arizona program targets expectant parents and parents with newborn infants who live in high risk communities—those communities with high rates of teen pregnancies, child abuse and neglect reports, poverty, and low birthweight babies. Furthermore, the program seeks to offer services targeted to factors that are consistently correlated with maltreatment—specifically to parents at high risk for parenting difficulties including those with high stress, single parents, low income parents, or parents with mental health, substance abuse and/or domestic violence issues. Exhibit 4 presents selected risk factors for both prenatal and postnatal mothers at intake compared with state rates. As the data show, mothers participating in Healthy Families are at higher risk than the overall population in Arizona. HFAz mothers are teens in about 14% of all prenatal families and in over 16% of postnatal families. Single parents make up the vast majority of participants—over 71% of the mothers at intake. Over 80% of the mothers are unemployed and receive AHCCCS. With a median annual income of $11,000-$14,000, it can be seen that many participants are living in poverty. In relation to the state rates, these data confirm that Healthy Families participants do represent an “at-risk” group of mothers. The program has Healthy Families Arizona Annual Evaluation Report 2010 FINAL 21 been successful in recruiting families with multiple risk factors associated with child abuse and neglect and poor child health and developmental outcomes. Exhibit 4. Selected Risk Factors for Mothers at Intake State Fiscal Year 2010 Risk Factors of Mothers Teen Births (19 years or less) Births to Single Parents Less Than High School Education Not Employed No Health Insurance Receives AHCCCS Late or No Prenatal Care Median Yearly Income Prenatal Families 13.8% 74.9% 62.0% 79.8% 5.9% 87.1% 26.9% $8,700 Postnatal Families 16.5% 71.5% 57.6% 83.4% 3.1% 90.4% 29.3% $12,000 Arizona state Rates - 2009 11.8%* 45.2%* 23.9%* NA*** 2.7%* 53.5%* 19.7%* $48,745 ** *Source: 2009 data from the Arizona Department of Health Services Vital Statistics records. Percent does not include “unknown.” **U.S. Census Bureau, American Community Survey, 2009 *** Employment figures for Mothers are not available at the state level. Note: Percentages for the combined total for prenatal and postnatal families can be found in Appendix A. The Healthy Families Arizona program continues to serve a culturally diverse population. In the following two exhibits, ethnicity is examined from enrollment data for mothers and fathers, with prenatal and postnatal participants combined. Just over 50% of mothers and fathers enrolled in the program are Hispanic. Site level data is available in Appendix A. Exhibit 5. Mother’s Ethnicity* (N=892) State Fiscal Year 2010 White/Caucasian 28% African American 5% Native American 13% Other/Mixed 3% Hispanic 51% Asian American 0% *This includes all mothers who entered the program either prenatally or postnatally. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 22 Exhibit 6. Father’s Ethnicity* (N=793) State Fiscal Year 2010 White/ Caucasian 24.9% African American 8% Native American 10% Other/Mixed 2% Hispanic 53% Asian American 1% *This includes all fathers who entered the program either prenatally or postnatally. Assessment of Risk Factors Both mothers and fathers are assessed initially using an interview with the Parent Survey1. The Parent Survey helps the program learn about the family’s circumstances and life events that place them at risk for child maltreatment and other adverse outcomes. During the intake process, the Family Assessment Worker evaluates each family across the 10 domains of the Parent Survey. The survey is administered in an interview format and the items are then rated by the worker according to level of severity. The percentage of parents scoring severe on each of the scales is presented for prenatal mothers and fathers and for postnatal mothers and fathers in Exhibits 7 and 8. The Family Stress Checklist was revised by the original developer and renamed the Parent Survey to impart a more strengths based perspective, however, the rating scale remains unchanged. More information on this instrument is provided in Appendix B. 1 Healthy Families Arizona Annual Evaluation Report 2010 FINAL 23 Exhibit 7. Percentage of Parents Rated Severe on Parent Survey Items PRENATAL * Parental Attachment Difficult Child Discipline Attitudes Expectations of Infant Violence Potential Current Life Stresses Social Support, Isolation CPS Involvement Mom Crime, Substance Abuse, Mental Illness Dad Parent Childhood Abuse 0 10 20 30 40 50 60 70 80 90 100 *Note: The Ns ranged from 205 – 212 for mothers and from 64 – 150 for fathers depending on the item. Exhibit 8. Percentage of Parents Rated Severe on Parent Survey Items POSTNATAL* Parental Attachment Difficult Child Discipline Attitudes Expectations of Infant Violence Potential Current Life Stresses Social Support, Isolation CPS Involvement Mom Crime, Substance Abuse, Mental Illness Dad Parent Childhood Abuse 0 10 20 30 40 50 60 70 80 90 100 *Note: the Ns ranged from 668 – 685 for mothers and from 313 – 589 for fathers depending on the items Healthy Families Arizona Annual Evaluation Report 2010 FINAL 24 As in previous years, the four factors rated most severe by both mothers and fathers are: history of childhood abuse (for the parent); current life stressors; social support and isolation; and a history of crime, substance abuse, or mental illness. There are no major differences between prenatal participants and postnatal participants. Overall, participants in the Healthy Families Arizona program are families that are impoverished, stressed, socially disadvantaged, and lacking in resources to manage the demands of parenting. Infant Characteristics In addition to family risk factors, information about infant risk factors is collected at intake for postnatal families and at birth for prenatal families. This information helps to indicate the level of need of the families served by the program. The following exhibit displays the high-risk characteristics of the newborns who entered prenatally and postnatally. Exhibit 9. Risk Factors for Infants - State Fiscal Year 2010 Risk Factors for Infants Prenatal Families* Born < 37 weeks gestation Birth Defects Low Birth Weight Positive Alcohol/Drug Screen 10.5% 0.7 % 9.8% 1.4% Postnatal Families** 19.2% 1.9% 15.4% 6.8% Arizona State percent*** 10.0% 0.6% 7.1% 1.1% *The Family Support Specialist collects this information either from the family or from a CPS referral form for prenatal families. **Family Assessment Workers collect this information from hospital records for postnatal families. ***2009 data from the Arizona Department of Health Services Vital Statistics records. The overall risk factors for infants have remained about the same as last year. The percentage of postnatal Healthy Families Arizona program infants born early (less than 37 weeks gestation) is 9% higher than the overall state rate, suggesting that the families being identified for service have a significant level of need. The percentage of low birth weight infants in the program also remains high in comparison to the state rate. Summary Data suggests the Healthy Families Arizona program is reaching parents and babies who have greater risks of child maltreatment and other unhealthy outcomes. Healthy Families Arizona home visitors have the opportunity to help mothers Healthy Families Arizona Annual Evaluation Report 2010 FINAL 25 prevent having pre-term or low birth weight babies by encouraging parents to attend regular prenatal visits; to adopt healthy behaviors such as good nutrition habits; and to stop alcohol, drug, and tobacco use. The recent Healthy Families New York randomized control study reported that in a control group, mothers were significantly more likely to deliver low birth weight babies than were the mothers engaged in the Healthy Families program (Mitchell-Herzfeld et al., 2005). Both low birth weight children and children born at less than 37 weeks gestation are at more risk for child maltreatment and present special challenges for parents. Taken together, this information suggests that the infants in the Healthy Families Arizona program are at significant risk and can benefit from early support that is offered by the Healthy Families program. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 26 Key Healthy Families Arizona Services To reach the overall goals of reducing child abuse and neglect, it is important that families stay engaged in the program and receive the services and resources they need. An important aspect of the Healthy Families program model is linking families with needed community resources. While much of the home visitor’s assistance is provided in the home, home visitors connect families with education, employment, and training resources, counseling and support services, public assistance and health care services. Based on the 2008 evaluation, nutrition and child development services are the most fully accessed services among families at all data collection time periods (LeCroy & Milligan Associates, 2008). The provision of and referral to developmental screening is focused on in this report. Developmental Screens and Referrals for Children Developmental screens are regularly provided by home visitors and are used to measure a child’s developmental progress and to identify potential developmental delays requiring specialist intervention. The home visitor administers the Ages and Stages Questionnaire (ASQ) for physical development and the ASQ-Social Emotional (SE) which focuses on social and emotional difficulties. The program goal is to screen 80% of the children in families served by the program. As Exhibit 10 shows, approximately two-thirds of children are receiving the ASQ at each interval. Rates of screening for this year are approximately 10% higher than the previous year and similar to rates from 2008. While the screening rate has increased back to the level prior to funding cuts, it is still below the program goal. It will be important to follow this trend in future years, as the program sites stabilize. Exhibit 10. ASQ Screening State Fiscal Year 2010 Interval ASQ Screening 6-month 12-month 18-month 24-month Percent of children Screened with ASQ 2010 68.1% 78.1% 69.3% 66.2% Percent screened as delayed 2010 2.6% 8.2% 19.1% 26.0% Healthy Families Arizona works to ensure that children who may have development delays can obtain needed interventions. Program data tracks what happens after a family’s ASQ is scored as follows: 1) the child is screened as having no delays, 2) the Healthy Families Arizona Annual Evaluation Report 2010 FINAL 27 child is referred for further assessment and is determined to have no delays upon a more extensive assessment, 3) families are referred to different services such as the Arizona Early Intervention Program (AzEIP) or other early intervention or therapy, or 4) the home visitor may provide developmental intervention or education to the family. Although 3-26% of children (depending on their age) are initially screened as delayed in their development, up to 43% of the children who initially screen as delayed on the ASQ are determined to be “not delayed” upon further assessment (see Exhibit 11 below). For example, of the families at 12 months who screened as delayed on the ASQ and were referred for more assessment, 6 families showed no delay, 3 families were referred to the AzEIP, 2 families were referred to an early intervention program, 9 families received developmental intervention, 1 family received specialized therapy, and 1 declined further referral. The ASQ screening provides a valuable service to families because it enables them to access appropriate services to meet their child’s particular needs. The following exhibit shows the outcome of these follow-up assessments that are completed with families at the different time intervals. Exhibit 11. ASQ Follow-up Services State Fiscal Year 2010 Continued Assessment shows “no delay” % (n) Referred to AzEIP % (n) Referred to other Early Intervention % (n) Provided Developmental Intervention % (n) Referred to Therapy % (n) 6-month 0% (0) 57.1% (3) 0% (0) 85.7% (6) 0% (0) Screen 12-month 42.9%(6) 21.4% (3) 14.3% (2) 64.3% (9) 7.1% (1) Screen 18-month 9.1%(2) 18.2% (4) 4.5% (1) 95.5% (21) 4.5% (1) Screen 24-month 16.0% (4) 64.0% (16) 4.0% (1) 72.0% (18) 12.0% (3) Screen Note: Percents do not equal 100% as multiple referrals can happen for s single child. Healthy Families Arizona Annual Evaluation Report 2010 FINAL Parent Declined Referral % (n) 0% (0) 7.1% (1) 13.6% (3) 12.0% (3) 28 Outcomes for Families The Healthy Families Arizona program focuses the evaluation on the following primary outcome indicators: • Parent outcomes • Child development and wellness • Mother’s health, education, and employment • Child abuse and neglect Parent outcomes One of the primary intermediate goals of the Healthy Families Arizona program is to have a positive influence on parenting attitudes and behaviors. While reducing child abuse and neglect is the ultimate outcome, intermediate objectives such as changes in parenting behaviors can inform us about progress toward the ultimate goal. The intermediate goals of the Healthy Families program revolve around a few key factors known to be critical in protecting children from maltreatment (Jacobs, 2005): • providing support for the family; • having a positive influence on parent-child interactions; • improving parenting skills and abilities and sense of confidence; and • promoting the parents’ healthy functioning. Healthy Families Parenting Inventory Reveals Positive Parent Change In order to evaluate critical intermediate goals the evaluation team developed the Healthy Families Parenting Inventory (HFPI) in 2004. The development of the HFPI was guided by several perspectives and sources: the experience of the home visitors in the Healthy Families Arizona program; data gathered directly from home visitors, supervisors, and experts; information obtained from previous studies of the Healthy Families program; and examination of other similar measures. The process included focus groups with home visitors, the development of a logic model, and an extensive review of relevant literature. The final instrument includes 9 scales: Social Support, Problem-solving, Depression, Personal Care, Mobilizing Resources, Role Satisfaction, Parent/child interaction, Home Environment and Parenting Efficacy. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 29 The following section describes the results obtained for each subscale of the HFPI. The level of significance is reported along with the effect size which estimates the magnitude of the change. These findings are based on data reported from the sites and represent participants who completed both instruments at the baseline and 6 month intervals (n=459) and participants who also had matched instruments at the 12 month interval (n=230). Healthy Families Parent Inventory (HFPI) Subscales Exhibit 12. Change in Subscales of the HFPI Sub- scale Social support Problem solving Depression Personal care Mobilizing resources Commitment To Parent Role Parent/child Behavior Home Environment Parenting Efficacy Significant Significant improvement improvement Effect Effect from Significance from Significance size size baseline to baseline to 6 months 12 months  .003 (.12) None - (.02)  .001 (.15)  .017 (.15)   .028 .002 (-.12) (.13) None  .011 (-.10) (.16)  .000 (.23)  .000 (.23) None - -(.13) None - (-.09) None - (.01) None - (-.05)  .000 (.28)  .000 (.45) None - (.08)  .037 (.14) From baseline to 6 months, there were significant changes in social support, problem solving, depression, personal care, mobilizing resources, and the home environment. From baseline to 12 months, however, significant gains were lost in the areas of social support, and depression, while parenting efficacy did significantly improve. The largest changes occurred in the home environment and mobilizing resources scales indicating that the Healthy Families programs are effective at connecting parents to resources and improving the atmosphere of the home. Overall, the results from this year’s study cohort are different than seen in the prior years, with more of the Healthy Families Arizona Annual Evaluation Report 2010 FINAL 30 subscales failing to show significant improvement from baseline to post-testing. This may be an artifact of the reduced number of families served this year compared to prior years or other changes in program or capacity with the reductions in funding. For example, some programs might have decided to focus their efforts on higher risk families. The continuing challenges presented by the slow economic recovery both statewide and nationally may also have played a role. Total Change Score on the HFPI In order to provide a more comprehensive understanding of changes in parenting observed during participation in the Healthy Families program, it is also useful to examine the total score on the Healthy Families Parenting Inventory and overall significance of change across all subscales. As the exhibit below shows, there were significant changes from baseline to 6 months and from baseline to 12 months on the HFPI. This finding supports the conclusion that program participants changed during the course of the program. Overall, the percent of individuals who showed positive change on the total score from baseline to 6 months was 57.1% and from baseline to 12 months was 59.1%. Exhibit 13. Overall Change in Healthy Families Parenting Inventory Outcomes Significant Significant Sub- improvement Effect improvement Effect Significance Significance scale from baseline size from baseline size to 6 months to 12 months Total  .000 (.17)  .000 (.27) Scale Child Abuse and Neglect This report includes data from CHILDS, the Arizona DES CPS data system, on the rates of child abuse and neglect for Healthy Families Arizona participants. It is important to acknowledge that using official child abuse data as an indicator of program success is complex and is unlikely to fully answer the question about the effectiveness of Healthy Families in preventing child abuse. The shortcomings in using official child abuse rates to assess the effectiveness of home visiting programs have been discussed in numerous journal articles (see for example, The Future of Children, 2009). Healthy Families Arizona Annual Evaluation Report 2010 FINAL 31 There are several reasons the use of child abuse data is believed to have limitations. First, child abuse is an event that occurs infrequently and, therefore, changes are difficult to detect with statistical methods. Second, using official incidents of child abuse and neglect does not necessarily reflect actual behavior—there are many variations in what constitutes abuse and neglect and using only reported and substantiated incidents of abuse only captures incidents that rise to that level of severity. Some incidents of child abuse or neglect are undetected or may not meet some definitional standard minimizing the accuracy of the count. Third, using official data requires a process whereby cases are “matched” on available information such as mother’s name, social security number, and date of child’s birth. When any of this information is missing, the accuracy of the match decreases. Finally, because home visitors are trained in the warning signs of abuse and neglect and are required to report abuse or neglect when it is observed, there is a “surveillance” effect—what might have gone unreported had there been no home visitor shows up in the official data. Because of these issues, many programs are beginning to not only count on actual rates of child abuse and neglect as the standard, but instead rely on measures that document reducing risk factors and increasing protective factors—factors shown to predict child maltreatment (Howard and Brooks-Gunn, 2009). These factors were also evaluated for HFAz and findings are noted throughout this report. This year, 97.4% of the Healthy Families matched cases were without a substantiated report, as can be seen in Exhibit 14. A substantiated finding means that “Child Protective Services has concluded that the evidence supports that an incident of abuse or neglect occurred based upon a probable cause standard” (see DES substantiation guidelines for further detail). Although 97.4% of the HFAz families that participate for at least six months have no substantiated reports, 23 families did have a substantiated report of abuse or neglect (2.6% of families), an increase over the previous years. Exhibit 14. Percent of Families Showing no Child Abuse and Neglect Incidences –2007, 2008, 2009, 2010 Group All Families Percent Without Substantiated Report 2006-2007 (n = 3,301) Percent Without Substantiated Report 2007-2008 (n = 3,885) Percent Without Substantiated Report 2008-2009 (n = 4,247) Percent Without Substantiated Report 2009-2010 (n = 878) 99.7% 98.9% 98.8% 97.4% Healthy Families Arizona Annual Evaluation Report 2010 FINAL 32 Child Development and Wellness While it is challenging to find ways to accurately measure child abuse and neglect, researchers do point to the benefits and impact that home visitors and home visiting can have on promoting optimal child growth and development in the families served. Home visitors are in a strategic position to help families obtain access to health resources and promote wellness. Immunizations and safety practices in the home are two indicators of child development and wellness reported this year. Immunizations The Arizona Department of Health Services set a Healthy People 2010 goal to have at least 90% of all Arizona children immunized. As of 2009, the Arizona rate was 76.4%, and the U.S. rate was 78%. (www.AZDHS.gov) Healthy Families Arizona supports children obtaining all their necessary immunizations as a key step in preventing debilitating diseases. HFAz home visitors regularly check each family’s immunization booklet to assess completion of immunizations. Exhibit 15 presents the past four years of data on immunization rates for the 2, 4, 6, and 12 month immunization periods. For the 2010 study year, nearly 80% of the children in the Healthy Families Arizona program, for whom we had data on immunizations, were reported to have received all 4 immunizations in the recommended series given by 18 months of age. This percentage exceeds the immunization rate for 2-year olds in Arizona and nationally. Overall, this finding suggests the program is successfully promoting immunizations for the children served by Healthy Families Arizona. Exhibit 15. Immunization Rate of Healthy Families Arizona Children Percent Immunization Immunized Period 2007 2 month 4 month 6 month 12 month Received all 4 in the series by 18 months of age Percent Immunized 2008 Percent Immunized 2009 Percent Immunized 2010 91.3% 88.4% 77.7% 87.4% 91.3% 88.5% 75.9% 90.2% 80.3% 78.0% 65.9% 88.6% 92.9% 89.9% 74.0% 85.3% 87.5% 87.4% 85.0% 79.8% Immunization Rate for 2-year-olds in Arizona (2009)* 76.4% *Source: 2009 data from the Arizona Department of Health Services Healthy Families Arizona Annual Evaluation Report 2010 FINAL 33 Safety Practices in the Home Unintentional injuries are the leading cause of death for children and adolescents ages 1 to 19. Each year over 13,000 children die from unintentional injuries. A recent report, What works for children, 2008, concluded that home visits can reduce the risk of accidental injuries in the home by approximately 26 percent. Safety practices help prevent accidents and promote injury prevention—important steps toward promoting child health and wellness. Healthy Families Arizona assesses and promotes safe environments for children through education about safety practices and by monitoring safety in the home through the completion of the safety checklist. The following exhibits show results for families that had data in these areas. Exhibit 16 reports the use of four key safety practices across five time points for postnatal participants. As the data show, safety practices increase over time spent in the program and reach high rates. For example, at 12 months, 98% use car seats and 95% lock their poisons properly. Car seat use has been estimated to be 90% for a similar age group not participating in the program (Glassbrenner & Ye, 2007) and the data reported for the Healthy Families program exceeds this percent. Furthermore, studies have found that smoke alarms are present in only 69% of homes with reported fires and one fifth of those alarms do not work properly (Ahrens, 2009). Similarly, one study in an inner city (Rowland, et al., 2002) reports that 54% of Americans have “working alarms” and this is much lower than the 90% working alarm finding reported by the Healthy Families program. Exhibit 16. Percent of all Postnatal Families Implementing Safety Practices Outlets Covered Poisons Locked Smoke Alarms Car Seats 2-Month (n = 344) 6-Month (n = 497) 12-Month (n = 260) 18-Month (n = 214) 24-Month (n = 143) 45.1% 56.4% 77.5% 85.9% 82.4% 91.2% 92.9% 94.7% 96.8% 96.9% 86.9% 89.7% 90.0% 94.1% 90.9% 100.0% 99.1% 98.7% 100.0% 97.7% Mothers’ Health, Education, and Employment The Healthy Families’ model extends beyond parenting outcomes and also attempts to influence maternal life course outcomes. The Healthy Families program has the opportunity to encourage families to seek new educational opportunities, complete Healthy Families Arizona Annual Evaluation Report 2010 FINAL 34 their high school education, obtain greater economic self-sufficiency, and obtain better paying and better quality jobs. Subsequent Pregnancies and Birth Spacing The goal of promoting the health of mothers is addressed by efforts to prevent repeat pregnancies and to promote longer birth spacing. Multiple births for some families can lead to increased stress and parenting difficulties, especially if the birth is unwanted or unplanned. The following exhibit shows that the percent of HFAz mothers who reported subsequent pregnancies has decreased from last year. Exhibit 17. Percentage of Mothers who Reported Subsequent Pregnancies State Fiscal year 2009 –2010 Percent of mothers with subsequent pregnancies 2006 2007 2008 2009 2010 11.8% 10.4% 11.5% 9.9% 7.1% Mothers with greater birth spacing have fewer pregnancy complications and are less likely to give birth to low birth weight or premature babies (Kallan, 1997). The health benefits of birth spacing are considerable and Healthy Families can support the new public campaign about birth spacing that says, “three to five years saves lives” by educating families about the benefits of longer time periods between births. The following exhibit shows the length of time to subsequent pregnancy for those mothers who do have subsequent births. The most important data is the percent of mothers who waited over 24 months between births. There has been a persistent downward trend in the number of women waiting 2 years between subsequent births, which means that a smaller percentage of women are adhering to the “three to five years saves lives” philosophy. Exhibit 18. Length of Time to Subsequent Pregnancy for Those Families with Subsequent Births Length of Time to Subsequent Pregnancy 2006 Percent of Mother 2007 Percent of Mother 2008 Percent of Mother 2009 Percent of Mother 2010 Percent of Mother 1 to 12 mos. 13 to 24 mos. Over 24 mos. 37.7% 42.1% 40.2% 49.3% 54.1% 38.1% 39.3% 43.9% 46.8% 42.6% 24.2% 18.6% 15.9% 4.0% 3.3% Healthy Families Arizona Annual Evaluation Report 2010 FINAL 35 School, Educational Enrollment, and Employment School and educational obtainment are also important to consider when examining the program’s potential impact on maternal life course outcomes. Increased education is associated with better overall well-being and greater family stability. As the following exhibit shows, at each interval, 14-22% of the mothers are enrolled in school either full- or part-time. Fulltime school enrollment is much lower than in 2008, but has increased since 2009. While there has been a slight rebound, the continued economic issues could be a relevant factor. Parents may have additional challenges in accessing or affording childcare, affording school, or having the time available away from work (or seeking employment) to attend school. Exhibit 19. Percent of Mothers Enrolled in School – State Fiscal Year 2010 Percent enrolled full-time (2008 prior report) Percent enrolled part-time (2009 prior report) Percent enrolled full-time (2009 prior report) Percent enrolled part-time (2010) Percent enrolled full-time (2010) 6 month 21.2% 5.8% 9.3% 6.2% 12.3% 12 month 24.9% 5.2% 10.4% 7.2% 14.8% 18 month 30.8% 6.1% 10.6% 6.2% 12.4% 24 month 31.7% 5.4% 7.3% 4.6% 10.0% Mothers who are actively engaged in the program show an increasing rate of employment from initial assessment to 12 months of program participation. Just over 32% of the mothers are employed at 24 months and this is lower than previous national estimates of employment for mothers of young children, which was approximately 50%. While increasing employment and income is fundamental for family well-being there are complex realities facing families as they begin to increase their earnings. One concern is that as mothers increase their income, there is the potential for families to become ineligible for AHCCCS health insurance and also not be covered by employers. Furthermore, the importance of home visitors working with families in obtaining quality child care is critical given the limited child care options for families with low incomes. The rate of employment for HFAZ mothers this year is lower than in the previous year when it was 40%. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 36 Exhibit 20. Mother’s Employment Status 35% 30% 25% 20% Part-time 15% Full-time 10% 5% 0% Baseline 6 mon ths 12 months 18 mo nths 24 months Substance Abuse Screening Research finds a strong relationship between substance abuse and risk for child maltreatment (Pan, et al., 1994; Windom, 1992; Wolfe, 1998). When a family member suffers from substance abuse, it is not surprising to find that the individual is not able to adequately care for and supervise children. Successful treatment of substance abuse often requires intensive treatment, but home visitors can play a critical role in the initial screening, in educating families about substance abuse, and in making referrals for treatment services. Exhibit 21 presents data on the percent of families screened with the CRAFFT substance abuse screening tool and the percent of those families who screened positive for drug use. The percent screened at the 2 month interval showed steady increases over the past several years, but decreased this year from nearly 95% last year to approximately 85% this year. The percentage of screens that were conducted at the 6 and 12 month time periods increase from 68% and 66% to 82% and 80% respectively. However, a 29.5% positive screen at 2 months is high and suggests a large number of families are screened as positive and are potentially in need of substance abuse information or treatment. The New York Healthy Families study, using the AUDIT for assessment, found 16% of the Healthy Families participants reported drug use. Exhibit 21. Percent Screened and Assessed Positive on the CRAFFT 2 months (lifetime) Percent Screened 84.8% Percent Assessed Positive 29.5% 6 months 82.1% 8.0% 12 months 80.4% 5.0% Time at assessment Note: The 2 month screen asks lifetime substance use; later screens cover the past 6 months. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 37 Conclusions and Recommendations During the 2009 – 2010 program year, the Healthy Families Arizona program has adjusted to major changes due to reduced financial resources, navigated combined funding sources from DES and FTF, and prepared for re-accreditation. This year’s evaluation results highlight useful data for program accountability and help to maintain the focus of the program as it changes. While there are multiple outcomes that could be measured in home visitation programs, the Healthy Families Arizona program focuses the evaluation on the following primary outcome indicators: parent outcomes, child health and wellness, and child abuse and neglect. Results from such measures as the Healthy Families Parenting Inventory, participant tracking data, safety checklists, screening tools, child abuse and neglect rates, and participant satisfaction surveys, suggest Healthy Families Arizona continued to address and reach most of its goals. Evidence-based methods are necessary to guide the practice of home visitation. In this time of limited resources, the Healthy Families Arizona program needs to maintain efforts to rigorously investigate the program and use evidence for program improvement. Recommendations for this year are focused on ways the program can continue to emphasize quality programming, make decisions based on evidence and data, and focus providing the most critical services to the highest risk families. • Identify the families that are highest-risk and ensure they receive the services they need in a resource deficient environment. Screening and supervision are vital in this regard. Supervisors can help guide home visitors to focus on the most important needs and develop strong connections with community resources to help meet those needs. Work should continue in defining high risk families and developing protocols that match the level of risk the family is facing. • Maintain attention to recruiting and serving families during the prenatal period and during the first year of life. The highest occurrence of child abuse and neglect occurs among infants in their first year of life. With the limited resources the sites are facing, a strong focus during the first year of program enrollment could reap long-range benefits for children. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 38 • Direct additional efforts toward preventing repeat births and increasing the time between births. Progress toward this health benchmark has not gone in the desired direction, and program staff might consider increasing their efforts to educate families on these topics. In addition, training efforts for home visitors could be re-examined. • Include more emphasis on evidence-based decision-making. While compliance with outcome assessments like the HFPI has improved over time, significant improvement should be an ongoing goal. Using the HFPI results with families can help identify focus of service for the family. Training and supervision might emphasize how home visitors and supervisors can think about components of practice that can be better guided by evidence. • Continued attention to data collection and data submission should be maintained to assure the program is meeting its goals and build a body of data for credentialing, program improvement, and to contribute to the research on home visitation effectiveness. The quantity and quality of the paperwork required of program staff should be examined to determine the most useful and relevant data necessary for case management, quality assurance, compliance, and evaluation. • Continue to view and evaluate Healthy Families as part of a system of early childhood programs. Research is increasingly suggesting the importance of a systems approach to improving early childhood outcomes, one that acknowledges the complexity of issues families are facing and the need for multiple partners in addressing them. Arizona can continue to be at the forefront of this movement by maintaining this mentality and an understanding of other nationwide progress in this area. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 39 References Barth, R.P. (1991). An experimental evaluation of in-home child abuse prevention services. Child Abuse & Neglect, 15, 363-375. Daro, D. (2009). Embedding home visitation programs within a system of early childhood services. Chapin Hall Issue Brief, September 2009. Gessner, B.D. (2008). The effect of Alaska’s home visitation program for high-risk families on trends in abuse and neglect. Child Abuse & Neglect, 32, 317–333. Glassbrenner D. and Ye, J. (2007) Rear-seat belt use in 2006. Traffic Safety Facts Research Note. Report no. DOT HS-810-765. Washington, DC: National Highway Traffic Safety Administration. Gomby, D. (2005). Home Visitation in 2005: Outcomes for Children and Parents. Invest in Kids Working Paper No.7. Committee for Economic Development: Invest in Kids Working Group. July. Available at www.ced.org/projects/kids.shtm. Gray, J. A. M. (2001). The origin of evidence-based practice. In A. Edwards & G. Elwyn (Eds.), Evidence-informed client choice (pp. 19-33). New York: Oxford University Press. Haskins, R., Paxson, C., & Brooks-Gunn, J. (2009) Social Science Rising: A Tale of Evidence Shaping Policy. The Future of Children Policy Brief, October 01, 2009. Howard, K., and Brooks-Gunn, J. (2009). The role of home-visiting programs in preventing child abuse and neglect. The Future of Children, 19,119-146. Jacobs, F., Easterbrooks, M. A., Brady, A., & Mistry, J. (2005). Healthy Families Massachusetts: Final Evaluation Report. Tufts University. Kallan, J. E. (1997). Reexamination of interpregnancy intervals and subsequent birth outcomes: Evidence from U. S. linked birth/infant death records. Social Biology, 44, 205-212. Kitzman, H. J., Cole, R., Yoos, H. L., & Olds, D. L. (1997). Challenges experienced by home visitors: A qualitative study of program implementation. Journal of Community Psychology 26, 95-109. LeCroy, C.W. & Whitaker, K. (2005). Improving the quality of home visitation: An exploratory study of difficult situations. Child Abuse and Neglect, 29, 1003-1013. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 40 LeCroy & Milligan Associates. (2008) Healthy Families Arizona Annual Evaluation Report 2008. Tucson, AZ: LeCroy & Milligan Associates, Inc. Macdonald, G., et al. (2007). Home-based support for disadvantaged teenage mothers. Cochrane Database Syst Rev, 18 (3). McCurdy, K., Hurvis, S., & Clark, J. (1996). Engaging and retaining families in child abuse prevention programs. The APSAC Advisor, 9, 3–8. McDonald Culp, A., Hechtner-Galvin, T., Howell, C.S., Saathoff-Wells, T., & Marr, P. (2003). First-time mothers in home visitation services utilizing child development specialists. Infant Mental Health Journal, 25, 1-15 Mitchell-Herzfeld, Susan, Charles Izzo, Rose Greene, Eunju Lee, and Ann Lowenfels, Evaluation of Healthy Families New York (HFNY): First Year Program Impact (2005)., Rensselaer, N.Y.: New York State Office of Children and Family Services, Bureau of Evaluation and Research; Albany, N.Y.: Center for Human Services Research, University at Albany, February 2005. Olds, D. L., & Korfmacher, J. (1998). Maternal psychological characteristics as influences on home visitation contact. Journal of Community Psychology, 26,23-36. Olds, D., Robinson, J., O'Brien, R., Luckey, D.W., Pettitt, L.M., Henderson, C.R., et al. (2002). Home visiting by paraprofessionals and by nurses: A randomized controlled trial. Pediatrics, 110(3), 486-496. Olds et al. (2004a.). Olds, D., Kitzman, H., Cole, R. and others. Effects of Nurse Home-Visiting on Maternal Life Course and Child Development: Age 6 Follow-Up Results of a Randomized Trial. Pediatrics 114, 1550-1559. Olds et al. (2004b.). Olds, D., Robinson, J., Pettitt, L., and others.Effects of Home Visits by Paraprofessionals and by Nurses: Age 4 Follow-Up Results of a Randomized Trial. Pediatrics 114 (2004): 1560-1568. Pan, H. S., Neidig, P. H., & O’Leary, K. D. (1994). Predicting mild and severe husband to wife physical aggression. Journal of Consulting and Clinical Psychology, 62, 975-981. Rowland, D., DiGuiseppi, C., Roberts, I., Curtis, K., Roberts, H., Ginnelly, L., Sculpher, M., & Wade, A. (2002). Prevalence of working smoke alarms in local authority inner city housing: randomized controlled trial. BMJ, 325, pp. 998-1001. Sackett, D. L., Strauss, S. E., Richardson, W. C., Rosenberg, W., & Haynes, R. (2000). Evidence-based medicine: How to practice and teach EBM. New York: Churchill Livingstone. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 41 Taylor, D. K., & Beauchamp, C. (1988). Hospital-based primary prevention strategy in child abuse: A multi-level needs assessment. Child Abuse & Neglect, 12, 343–354. U.S. Department of Health and Human Services (2010a). Child Maltreatment: 2008. Retrieved from http://www.acf.hhs.gov/programs/cb/stats_research/ index.htm#can. U.S. Department of Health and Human Services (2010b). HHS Allocated $88 Million for Home Visiting Program to Improve the Wellbeing of Children and Families. News Release. Retrieved online at www.hhs.gov/news/press/2010pres/ 07/20100721a.htm Windom, C. S. (1992). Child abuse and alcohol use. Paper presented to the National Institute on Alcohol Abuse and Alcoholism, Washington DC. Wolfe, D. A. (1998). Prevention of child abuse and neglect. Canada health action: Building on the legacy—Determinants of health, Vol. I-Children and youth (pp. 103-131). Ste Foy, Multimondes. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 42 Appendix A: Site Level Data  Age of Child at Entry by Site .............................................................................. 44  Days to Program Exit by Site .............................................................................. 45  Top Four Reasons for Exit by Site....................................................................... 46  Health Insurance at Intake by Site ...................................................................... 47  Late or No Prenatal Care or Poor Compliance at Intake 2010 by Site ............. 48  Ethnicity of Mother by Site ................................................................................. 49  Gestational Age by Site ....................................................................................... 51  Low Birth Weight by Site .................................................................................... 52  Yearly Income by Site .......................................................................................... 53  Mother’s Parent Survey Score by Site ................................................................ 54  Trimester of Enrollment into Prenatal Program by Site ................................... 55  Engaged Prenatal Families that Exited before Baby’s Birth by Site ................. 56 Healthy Families Arizona Annual Evaluation Report 2010 FINAL 43 Age of Child at Entry by Site – 2010 (Age in Days) Site Douglas Central Phoenix Maryvale South Phoenix East Valley Nogales Page CODAC La Frontera Child and Family Resources Sierra Vista Tuba City Yuma Pascua Yaqui Lake Havasu City Flagstaff Sunnyslope Prescott Mesa Safford Winslow Kingman Bullhead City West Phoenix Williams (Kinlani) Wellspring Total Mean (Age in Days) 15.75 33.87 36.56 32.68 38.77 20.25 26.67 38.94 33.88 48.38 22.55 20.89 35.82 28.22 22.16 19.00 43.89 13.56 34.37 28.50 20.25 20.29 26.60 36.42 17.21 22.56 31.43 Number 16 46 45 47 44 12 12 35 64 16 20 9 17 9 19 25 46 34 63 14 4 7 10 48 14 27 703 Standard Deviation 9.70 21.86 21.87 22.37 23.44 14.55 22.59 28.16 27.24 35.95 21.72 21.07 26.86 33.54 22.69 21.27 23.65 10.57 24.37 31.34 7.37 6.90 20.25 25.04 24.79 28.09 24.95 Note: total does not include data for families that enrolled in the prenatal period including those that did not receive prenatal services. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 44 Days to Program Exit by Site – 2010 (For families who left the program) Site Douglas Central Phoenix Maryvale South Phoenix East Valley Nogales Page CODAC La Frontera Child and Family Resources Sierra Vista Tuba City Yuma Pascua Yaqui Lake Havasu City Flagstaff Sunnyslope Prescott Mesa Safford Winslow Kingman Bullhead City West Phoenix Williams (Kinlani) Wellspring Total Prenatal Postnatal Standard Standard Median Mean Number Median Mean Number Deviation Deviation 579.00 649.67 192.01 3 267.00 284.80 116.04 5 561.00 505.67 331.13 6 285.50 443.06 325.02 16 774.00 611.67 307.52 3 253.00 330.46 239.07 13 302.00 302.00 - 1 208.00 236.93 167.06 14 358.00 309.00 349.00 321.50 301.00 392.29 309.00 351.25 321.50 439.00 256.23 146.65 41.72 354.06 7 1 4 2 5 450.50 637.00 486.50 283.50 221.50 477.94 620.75 437.83 313.50 252.86 243.06 204.29 250.40 172.29 174.88 16 4 6 10 14 605.00 605.00 101.82 2 584.00 511.43 293.58 7 0 243.00 602.00 0 309.67 602.00 0 210.09 46.67 0 3 2 354.00 386.00 725.50 421.18 473.00 684.70 268.41 318.53 295.78 11 5 10 843.00 810.00 251.59 8 612.50 552.25 212.75 8 215.50 203.00 116.87 4 202.00 210.40 112.79 5 353.00 367.00 402.00 459.50 204.50 209.00 200.50 328.25 371.67 402.00 427.33 204.50 207.67 200.50 185.69 270.03 223.45 211.84 95.46 128.01 12.02 12 3 2 6 2 3 2 469.00 199.50 427.00 267.00 164.00 241.00 244.00 356.67 190.73 434.80 322.10 138.40 247.00 349.33 206.69 83.57 166.41 235.85 56.38 98.14 262.37 15 26 15 31 5 3 3 229.00 229.00 - 1 137.00 194.10 133.58 10 162.00 162.00 11.31 2 224.00 235.11 100.84 18 567.00 577.00 232.09 9 657.00 578.33 268.67 9 344.00 364.00 465.89 439.68 276.27 263.37 9 102 501.00 286.00 530.89 366.49 254.28 246.43 19 298 Healthy Families Arizona Annual Evaluation Report 2010 FINAL 45 Top Four Reasons for Exit by Site – 2010 Percent and number within site Site Douglas Central Phoenix Maryvale South Phoenix East Valley Nogales Page CODAC La Frontera Child and Family Resources Sierra Vista Tuba City Yuma Pascua Yaqui Lake Havasu City Flagstaff Sunnyslope Prescott Mesa Safford Winslow Kingman Bullhead City West Phoenix Williams (Kinlani) Wellspring Total Overall (Prenatal and Postnatal Combined) #1 Moved #2 Did Not #3 Family #4 Refused Away Respond to Refused Worker Outreach Further Change Efforts Services % n % n % n % n 50.0 4 12.5 1 12.5 1 0 0 31.3 5 25.0 4 18.8 3 0 0 6.7 1 40.0 6 6.7 1 20.0 3 64.3 9 7.1 1 0 0 7.1 1 31.6 6 15.8 3 10.5 2 26.3 5 0 0 50.0 1 0 0 0 0 0 0 22.2 2 44.4 4 0 0 10.0 1 40.0 4 20.0 2 10.0 1 44.4 8 16.7 3 22.2 4 0 0 0 0 20.0 1 0 0 40.0 2 50.0 33.3 50.0 20.0 33.3 26.9 10.7 35.7 53.3 83.3 50.0 20.0 9.1 50.0 18.8 14.3 30.0 3 2 3 3 2 7 3 5 16 5 1 1 1 8 3 3 99 0 16.7 33.3 60.0 16.7 19.2 10.7 35.7 16.7 16.7 0 0 0 0 0 0 .3 0 1 2 9 1 5 3 5 5 1 0 0 0 0 0 0 1 16.7 33.3 16.7 13.3 33.3 15.4 21.4 7.1 3.3 0 0 20.0 0 18.8 25.0 9.5 14.5 1 2 1 2 2 4 6 1 1 0 0 1 0 3 4 2 48 16.7 0 0 0 0 34.6 0 0 3.3 0 50.0 0 0 0 6.3 33.3 8.8 1 0 0 0 0 9 0 0 1 0 1 0 0 0 1 7 29 Healthy Families Arizona Annual Evaluation Report 2010 FINAL 46 Health Insurance at Intake by Site – 2010 Percent and number within Site* Site Douglas Central Phoenix Maryvale South Phoenix East Valley Nogales Page CODAC La Frontera Child and Family Resources Sierra Vista Tuba City Yuma Pascua Yaqui Lake Havasu City Flagstaff Sunnyslope Prescott Mesa Safford Winslow Kingman Bullhead City West Phoenix Williams (Kinlani) Wellspring Total None % n 16.7 1 PRENATAL AHCCCS % n 83.3 5 Private % n 0 0 None % n 0 0 POSTNATAL AHCCCS % n 100.0 16 Private % n 0 0 0 0 88.9 8 0 0 2.3 1 88.6 39 9.1 4 22.2 .0 15.4 0 0 0 7.1 2 0 2 0 0 0 1 77.8 100.0 84.6 100.0 85.7 80.0 92.9 7 2 11 3 6 4 13 0 0 0 0 14.3 20.0 0 0 0 0 0 1 1 0 4.5 0 4.8 0 0 2.9 5.5 2 0 2 0 0 1 3 90.9 97.9 71.4 100.0 100.0 94.1 89.1 40 46 30 11 13 32 49 4.5 2.1 23.8 0 0 2.9 3.6 2 1 10 0 0 1 2 0 0 100.0 5 0 0 0 0 100.0 15 0 0 0 22.2 0 0 0 2 0 0 50.0 77.8 100.0 93.3 1 7 3 14 50.0 0 0 6.7 1 0 0 1 5.0 0 0 0 1 0 0 0 85.0 91.7 100.0 100.0 17 11 17 8 5.0 8.3 0 0 1 1 0 0 6.7 1 80.0 12 13.3 2 5.3 1 78.9 15 15.8 3 5.6 0 0 8.3 0 0 0 0 0 1 0 0 1 0 0 0 0 0 94.4 100.0 100.0 75.0 100.0 100.0 66.7 100.0 83.3 17 3 2 9 3 6 2 1 5 0 0 0 16.7 0 0 33.3 0 0 0 0 0 2 0 0 1 0 0 5.0 6.5 0 4.9 0 0 0 0 6.3 1 3 0 3 0 0 0 0 3 95.0 84.8 93.9 88.5 100.0 100.0 100.0 90.0 87.5 19 39 31 54 13 6 9 9 42 0 8.7 6.1 6.6 0 0 0 10.0 6.3 0 4 2 4 0 0 0 1 3 5.6 1 94.4 17 0 0 0 0 88.9 8 11.1 1 0 5.9 0 12 76.9 87.1 10 176 23.1 5.9 3 12 0 3.1 0 21 91.7 90.4 22 611 8.3 6.2 2 42 *”Other” insurance percentages are not listed in this table but can be estimated by subtracting the sum of the other insurance categories from 100. Healthy Families Arizona Annual Evaluation Report 2010 FINAL 47 Late or No Prenatal Care or Poor Compliance at Intake 2010 by Site Percent and number ( ) within Site Did the mother have late or no prenatal care or poor compliance with prenatal care? Site Douglas Central Phoenix Maryvale South Phoenix East Valley Nogales Page CODAC La Frontera Child and Family Resources Sierra Vista Tuba City Yuma Pascua Yaqui Lake Havasu City Flagstaff Sunnyslope Prescott Mesa Safford Winslow Kingman Bullhead City West Phoenix Williams (Kinlani) Wellspring Total Yes 33.3% (2) 44.4% (4) 33.3% (3) .0% (0) 53.8% (7) .0% (0) 28.6% (2) 40.0% (2) 14.3% (2) PRENATAL No 66.7% (4) 55.6% (5) 66.7% (6) 100.0% (2) 46.2% (6) 100.0% (3) 71.4% (5) 60.0% (3) 78.6% (11) Unknown .0% (0) .0% (0) .0% (0) .0% (0) .0% (0) .0% (0) .0% (0) .0% (0) 7.1% (1) Yes 31.3% (5) 15.9% (7) 31.8% (14) 27.7% (13) 31.0% (13) 7.7% (1) 46.2% (6) 32.4% (11) 33.9% (19) .0% (0) 100.0% (5) .0% (0) 40.0% (6) 60.0% (9) .0% (0) 50.0% (1) 30.0% (3) 66.7% (2) 26.7% (4) 25.0% (4) 9.1% (2) .0% (0) .0% (0) 41.7% (5) 33.3% (1) 33.3% (2) .0% (0) .0% (0) .0% (0) 50.0% (1) 70.0% (7) 33.3% (1) 73.3% (11) 68.8% (11) 90.9% (20) 100.0% (3) 50.0% (1) 58.3% (7) 66.7% (2) 66.7% (4) 100.0% (3) 100.0% (1) 100.0% (6) .0% (0) .0% (0) .0% (0) .0% (0) 6.3% (1) .0% (0) .0% (0) 50.0% (1) .0% (0) .0% (0) .0% (0) .0% (0) .0% (0) .0% (0) 35.0% (7) 58.3% (7) 17.6% (3) 11.1% (1) 21.1% (4) 26.1% (6) 26.1% (12) 38.2% (13) 38.3% (23) 23.1% (3) 33.3% (2) 22.2% (2) 50.0% (5) 22.9% (11) 65.0% (13) 41.7% (5) 82.4% (14) 88.9% (8) 78.9% (15) 73.9% (17) 73.9% (34) 58.8% (20) 61.7% (37) 61.5% (8) 66.7% (4) 55.6% (5) 50.0% (5) 77.1% (37) .0% (0) .0% (0) .0% (0) .0% (0) .0% (0) .0% (0) .0% (0) 2.9% (1) .0% (0) 15.4% (2) .0% (0) 22.2% (2) .0% (0) .0% (0) 30.0% (6) 70.0% (14) .0% (0) 45.5% (5) 54.5% (6) .0% (0) 33.3% (5) 26.9% (57) 66.7% (10) 71.7% (152) .0% (0) 1.4% (3) 8.3% (2) 29.3% (201) 91.7% (22) 69.2% (474) .0% (0) 1.5% (10) Healthy Families Arizona Annual Evaluation Report 2010 FINAL POSTNATAL No Unknown 68.8% (11) .0% (0) 79.5% (35) 4.5% (2) 65.9% (29) 2.3% (1) 70.2% (33) 2.1% (1) 69.0% (29) .0% (0) 92.3% (12) .0% (0) 53.8% (7) .0% (0) 67.6% (23) .0% (0) 64.3% (36) 1.8% (1) 48 Ethnicity of Mother by Site PRENATAL – 2010 Percent and number ( ) within Site Site Douglas Central Phoenix Maryvale South Phoenix East Valley Nogales Page CODAC La Frontera Child and Family Resources Sierra Vista Tuba City Yuma Pascua Yaqui Lake Havasu City Flagstaff Sunnyslope Prescott Mesa Safford Winslow Kingman Bullhead City West Phoenix Williams (Kinlani) Wellspring Total Mixed/ Other % n 16.7 1 Caucasian/ White % n 16.7 1 Hispanic % 66.7 n 4 6 0 0 33.3 3 66.7 11.1 0 7.7 0 0 0 0 1 0 1 0 0 0 0 33.3 0 30.8 0 0 20.0 21.4 3 0 4 0 0 1 3 55.6 5 100.0 2 38.5 5 100.0 3 0 0 80.0 4 78.6 11 0 0 80.0 4 20.0 50.0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 75.0 0 0 0 16.7 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 6.7 3.3 African Asian American American % n % n 0 0 0 0 Native American % n 0 0 0 0 0 0 0 0 0 0 23.1 0 0 0 0 0 0 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 100.0 0 0 0 0 0 0 7 0 0 1 0 0 0 0 0 0 0 0 100.0 7.7 0 0 3 1 0 0 0 0 0 0 0 0 0 0 0 7.7 0 0 0 1 50.0 100.0 0 84.6 1 10 0 11 12 25.0 4 0 0 0 0 0 0 13.6 0 50.0 33.3 33.3 40.0 100.0 100.0 33.3 3 0 1 4 1 2 3 1 2 54.5 12 100.0 3 50.0 1 41.7 5 66.7 2 40.0 2 0 0 0 0 50.0 3 9.1 0 0 0 0 0 0 0 16.7 2 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 22.7 0 0 8.3 0 20.0 0 0 0 5 0 0 1 0 1 0 0 0 0 5.0 1 55.0 11 0 0 0 0 40.0 8 1 7 20.0 24.9 3 52 33.3 44.5 5 93 0 2.9 0 6 0 .5 0 1 40.0 23.9 6 50 Healthy Families Arizona Annual Evaluation Report 2010 FINAL 49 Ethnicity of Mother by Site POSTNATAL – 2010 Percent and number ( ) within Site Site Douglas Central Phoenix Maryvale South Phoenix East Valley Nogales Page CODAC La Frontera Child and Family Resources Sierra Vista Tuba City Yuma Pascua Yaqui Lake Havasu City Flagstaff Sunnyslope Prescott Mesa Safford Winslow Kingman Bullhead City West Phoenix Williams (Kinlani) Wellspring Total Mixed/ Other % n 0 0 Caucasian/ White % n 25.0 4 Hispanic African American % n 0 0 % 75.0 n 12 4.5 2 52.3 23 29.5 13 4.5 2 0 0 9.1 4 4.5 2 29.5 13 40.9 18 25.0 11 0 0 0 0 2.1 1 8.5 4 80.9 38 2.1 1 0 0 6.4 3 4.8 0 0 12.1 0 2 0 0 4 0 40.5 0 0 30.3 10.5 17 0 0 10 6 52.4 100.0 0 51.5 80.7 22 13 0 17 46 2.4 0 0 0 1.8 1 0 0 0 1 0 0 0 3.0 0 0 0 0 1 0 0 0 100.0 3.0 7.0 0 0 13 1 4 0 0 28.6 4 57.1 8 7.1 1 0 0 7.1 1 0 0 0 0 0 0 0 0 60.0 0 5.9 0 12 0 1 0 20.0 0 94.1 25.0 4 0 16 2 20.0 0 0 12.5 4 0 0 1 0 0 0 0 0 0 0 0 0 100.0 0 62.5 0 12 0 5 5.3 1 68.4 13 26.3 5 0 0 0 0 0 0 0 4.3 2.9 0 0 0 0 0 2.1 0 2 1 0 0 0 0 0 1 45.5 32.6 73.5 14.8 46.2 33.3 77.8 50.0 16.7 10 15 25 9 6 2 7 5 8 36.4 56.5 23.5 80.3 53.8 50.0 22.2 50.0 66.7 8 26 8 49 7 3 2 5 32 0 6.5 0 4.9 0 0 0 0 12.5 0 3 0 3 0 0 0 0 6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 18.2 0 0 0 0 16.7 0 0 2.1 4 0 0 0 0 1 0 0 1 0 0 9.1 1 9.1 1 0 0 0 0 81.8 9 8.3 2.6 2 18 25.0 29.4 6 201 41.7 53.4 10 365 0 5.0 0 34 0 0.1 0 1 25.0 9.4 6 64 Healthy Families Arizona Annual Evaluation Report 2010 FINAL Asian American % n 0 0 Native American % n 0 0 50 Gestational Age by Site – 2010 (Number and Percent within Site) Was the gestational age less than 37 weeks? PRENATAL No Site Douglas Central Phoenix Maryvale South Phoenix East Valley Nogales Page CODAC La Frontera Child and Family Resources Sierra Vista Tuba City Yuma Pascua Yaqui Lake Havasu City Flagstaff Sunnyslope Prescott Mesa Safford Winslow Kingman Bullhead City West Phoenix Williams (Kinlani) Wellspring Total POSTNATAL Yes No Yes % 0 n 0 % 0 n 0 % 100.0 n 2 % 0 n 0 100.0 5 0 0 67.4 29 32.6 14 88.9 100.0 100.0 100.0 100.0 0 85.7 8 1 9 1 7 0 6 11.1 0 0 0 0 0 14.3 1 0 0 0 0 0 1 61.0 87.0 70.0 100.0 83.3 75.0 85.7 25 40 28 10 10 21 42 39.0 13.0 30.0 0 16.7 25.0 14.3 16 6 12 0 2 7 7 66.7 2 33.3 1 84.6 11 15.4 2 100.0 75.0 100.0 100.0 2 3 2 2 0 25.0 0 0 0 1 0 0 72.7 80.0 87.5 100.0 8 4 14 5 27.3 20.0 12.5 0 3 1 2 0 75.0 9 25.0 3 94.4 17 5.6 1 95.0 100.0 100.0 83.3 100.0 100.0 100.0 0 100.0 19 3 2 5 1 3 2 0 4 5.0 0 0 16.7 0 0 0 0 0 1 0 0 1 0 0 0 0 0 83.3 72.1 97.0 91.4 100.0 60.0 85.7 100.0 78.3 15 31 32 53 10 3 6 1 36 16.7 27.9 3.0 8.6 0 40.0 14.3 0 21.7 3 12 1 5 0 2 1 0 10 72.2 13 27.8 5 100.0 4 0 0 100.0 89.5 10 119 0 10.5 0 14 71.4 80.8 10 467 28.6 19.2 4 111 Healthy Families Arizona Annual Evaluation Report 2010 FINAL 51 Low Birth Weight by Site – 2010 (Number and Percent within Site) Did the child have low birth weight? (less than 2500 grams, 88 ounces, or 5.5 pounds) PRENATAL No Site Douglas Central Phoenix Maryvale South Phoenix East Valley Nogales Page CODAC La Frontera Child and Family Resources Sierra Vista Tuba City Yuma Pascua Yaqui Lake Havasu City Flagstaff Sunnyslope Prescott Mesa Safford Winslow Kingman Bullhead City West Phoenix Williams (Kinlani) Wellspring Total POSTNATAL Yes No Yes % 0 n 0 % .0 n 0 % 81.3 n 13 % 18.8 n 3 87.5 7 12.5 1 72.7 32 27.3 12 87.5 7 12.5 1 71.4 30 28.6 12 100.0 1 0 0 89.4 42 10.6 5 88.9 100.0 100.0 0 88.9 8 1 7 0 8 11.1 0 0 0 11.1 1 0 0 0 1 69.0 84.6 100.0 79.4 92.9 29 11 13 27 52 31.0 15.4 0 20.6 7.1 13 2 0 7 4 66.7 2 33.3 1 92.9 13 7.1 1 100.0 100.0 100.0 2 6 3 0 0 0 0 0 0 80.0 100.0 87.5 16 12 14 20.0 .0 12.5 4 0 2 100.0 7 0 0 87.5 7 12.5 1 72.7 8 27.3 3 89.5 17 10.5 2 95.0 100.0 100.0 100.0 0 100.0 100.0 19 3 2 6 0 2 2 5.0 0 0 0 0 0 0 1 0 0 0 0 0 0 82.6 69.6 97.1 96.7 100.0 100.0 88.9 19 32 33 59 13 5 8 17.4 30.4 2.9 3.3 .0 .0 11.1 4 14 1 2 0 0 1 0 0 0 0 80.0 8 20.0 2 100.0 4 0 0 85.4 41 14.6 7 78.9 15 21.1 4 81.8 9 18.2 2 90.0 90.2 9 129 10.0 9.8 1 14 83.3 84.6 20 575 16.7 15.4 4 105 Healthy Families Arizona Annual Evaluation Report 2010 FINAL 52 Yearly Income by Site – 2010 Site Douglas Central Phoenix Maryvale South Phoenix East Valley Nogales Page CODAC La Frontera Child and Family Resources Sierra Vista Tuba City Yuma Pascua Yaqui Lake Havasu City Flagstaff Sunnyslope Prescott Mesa Safford Winslow Kingman Bullhead City West Phoenix Kinlani-Flagstaff Wellspring Total PRENATAL Median Number Yearly Income $2,160 5 $1,260 8 $14,400 8 $15,600 1 $768 10 $3,648 3 $12,000 6 $4,794 4 $7,770 12 POSTNATAL Median Number Yearly Income $12,000 11 $9,700 34 $10,404 31 $13,100 38 $12,000 31 $6,000 11 $13,200 12 $6,000 29 $10,300 40 $8,400 5 $9,000 13 $6,732 $5,520 $14,400 $7,200 $14,400 $12,000 $1,236 $27,000 $2,472 $0* $7,350 $61,000 $4,200 $7,320 $12,000 $15,600 $8,700 2 8 2 13 15 18 3 1 11 3 6 1 1 4 17 13 180 $10,878 $6,840 $10,400 $8,592 $13,780 $12,000 $12,162 $12,000 $15,600 $12,144 $12,000 $14,400 $9,600 $10,920 $12,000 $9,600 $12,000 14 8 13 6 19 21 40 9 52 9 5 8 9 38 9 24 534 *3 families reported no income Healthy Families Arizona Annual Evaluation Report 2010 FINAL 53 Mother’s Parent Survey Score by Site – 2010 Site Douglas Central Phoenix Maryvale South Phoenix East Valley Nogales Page CODAC La Frontera Child and Family Resources Sierra Vista Tuba City Yuma Pascua Yaqui Lake Havasu City Flagstaff Sunnyslope Prescott Mesa Safford Winslow Kingman Bullhead City West Phoenix Williams (Kinlani) Wellspring Total 0 – 20 PRENATAL 25 – 40 45 – 65 70+ 0 – 20 POSTNATAL 25 – 40 45 – 65 0.0% 66.7% 33.3% 0.0% 6.3% 68.8% 25.0% 0.0% 0.0% 33.3% 44.4% 22.2% 2.3% 27.3% 68.2% 2.3% 0.0% 44.4% 44.4% 11.1% 0.0% 38.6% 43.2% 18.2% 0.0% 50.0% 50.0% 0.0% 0.0% 38.3% 59.6% 2.1% 0.0% 0.0% 0.0% 0.0% 7.1% 30.8% 33.3% 28.6% 40.0% 57.1% 53.8% 66.7% 71.4% 60.0% 35.7% 15.4% 0.0% 0.0% 0.0% 0.0% 2.4% 7.7% 0.0% 8.8% 12.3% 45.2% 76.9% 53.8% 38.2% 56.1% 42.9% 15.4% 46.2% 44.1% 28.1% 9.5% 0.0% 0.0% 8.8% 3.5% 0.0% 20.0% 80.0% 0.0% 6.7% 33.3% 60.0% 0.0% 0.0% 20.0% 33.3% 0.0% 60.0% 33.3% 50.0% 20.0% 33.3% 50.0% 0.0% 0.0% 5.0% 8.3% 5.9% 45.0% 58.3% 58.8% 50.0% 33.3% 29.4% 0.0% 0.0% 5.9% 6.7% 86.7% 6.7% 0.0% 22.2% 44.4% 33.3% 0.0% 12.5% 12.5% 68.8% 6.3% 5.3% 73.7% 21.1% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 33.3% 45.5% 33.3% 100.0% 16.7% 66.7% 66.7% 33.3% 54.5% 66.7% 0.0% 83.3% 33.3% 16.7% 33.3% 0.0% 0.0% 0.0% 0.0% 0.0% 16.7% 0.0% 0.0% 0.0% 2.9% 1.6% 7.7% 0.0% 0.0% 65.2% 34.8% 67.6% 32.8% 84.6% 60.0% 44.4% 34.8% 50.0% 29.4% 60.7% 7.7% 20.0% 44.4% 0.0% 15.2% 0.0% 4.9% 0.0% 20.0% 11.1% 0.0% 0.0% 100.0% 0.0% 0.0% 50.0% 50.0% 0.0% 0.0% 33.3% 66.7% 0.0% 0.0% 50.0% 45.8% 4.2% 0.0% 75.0% 20.0% 5.0% 0.0% 54.5% 45.5% 0.0% 0.0% 3.8% 53.3% 46.7% 46.7% 45.3% 0.0% 4.2% 0.0% 3.5% 58.3% 48.0% 41.7% 43.6% 0.0% 5.0% Healthy Families Arizona Annual Evaluation Report 2010 FINAL 70+ 54 Trimester of Enrollment into Prenatal Program by Site July 2009 to June 2010 Site Douglas Central Phoenix Maryvale South Phoenix East Valley Nogales Page CODAC La Frontera Child and Family Resources Sierra Vista Tuba City Yuma Pascua Yaqui Lake Havasu City Flagstaff Sunnyslope Prescott Mesa Safford Winslow Kingman Bullhead City West Phoenix KinlaniFlagstaff Wellspring Total 1st Trimester # % 3 50.0 2nd Trimester # % 2 33.3 3rd Trimester # % 1 16.7 # 0 Other % 0 Total # 6 1 11.1 1 11.1 6 66.7 1 11.1 9 0 0 5 55.6 4 44.4 0 0 9 0 0 0 0 2 100.0 0 0 2 0 0 1 0 5 0 0 14.3 .0 35.7 4 1 4 2 1 30.8 33.3 57.1 40.0 7.1 8 2 2 3 7 61.5 66.7 28.6 60.0 50.0 1 0 0 0 1 7.7 .0 .0 .0 7.1 13 3 7 5 14 0 0 3 60.0 2 40.0 0 0 5 0 0 0 0 0 0 0 5 0 .0 50.5 0 2 5 3 100.0 50.0 100.0 0 0 0 0 0 0 2 10 3 0 0 7 46.7 7 46.7 1 6.7 15 0 0 7 43.8 7 43.8 2 12.5 16 4 0 0 3 0 1 1 18.2 0 0 25.0 0 16.7 33.3 1 1 0 1 2 1 1 4.5 33.3 .0 8.3 66.7 16.7 33.3 16 2 2 6 1 3 1 72.7 66.7 100.0 50.0 33.3 50.0 33.3 1 0 0 2 0 1 0 4.5 0 0 16.7 0 16.7 0 22 3 2 12 3 6 3 0 0 1 100.0 0 0 0 0 1 0 0 2 33.3 4 66.7 0 0 6 4 20.0 6 30.0 10 50.0 0 0 20 2 25 13.3 11.8 2 60 13.3 28.3 11 117 73.3 55.2 0 10 0 4.7 15 212 Healthy Families Arizona Annual Evaluation Report 2010 FINAL 55 Engaged Prenatal Families that Exited Before Baby’s Birth By Site – July 2009 through June 2010 Site Douglas Central Phoenix Maryvale South Phoenix East Valley Nogales Page CODAC La Frontera Child and Family Resources Sierra Vista Tuba City Yuma Pascua Yaqui Lake Havasu City Flagstaff Sunnyslope Prescott Mesa Safford Winslow Kingman Bullhead City West Phoenix Kinlani-Flagstaff Wellspring Total 6 9 9 2 13 3 7 5 14 # Closed before birth 0 0 0 0 1 0 0 0 0 5 0 0 2 10 3 15 16 22 3 2 12 3 6 3 1 6 20 15 212 0 0 0 0 1 1 0 0 0 0 1 0 0 0 0 0 4 0 0 0 0 6.3 4.5 0 0 0 0 16.7 0 0 0 0 0 1.9 Total Families Healthy Families Arizona Annual Evaluation Report 2010 FINAL % Closed before birth 0 0 0 0 7.7 0 0 0 0 56 Appendix B. Parent Survey Parent Survey* Problem Areas and Interpretation (Mother & Father) Areas (Scales) 1. Parent Childhood Experiences (e.g., Childhood history of physical abuse and deprivation) 2. Lifestyle, Behaviors and Mental Health (e.g., substance abuse, mental illness, or criminal history) Range Interpretation/ Administration The Parent Survey comprises a 10-item rating 0, 5, or 10 scale. A score of 0 represents normal, 5 represents a mild degree of the problem and a 10 represents severe for both the Mother 0, 5, or 10 and Father Parent Survey Checklist items. The Parent Survey is an assessment tool and 3. Parenting Experiences (e.g., Previous or current CPS involvement) 0, 5, or 10 4. Coping Skills and Support Systems (e.g., Selfesteem, available lifelines, possible depression) 0, 5, or 10 5. Stresses (e.g., Stresses, concerns, domestic violence) is administered to the mother and father Family Assessment Worker from the Healthy 0, 5, or 10 Families Arizona program if either parent scores 25 or higher. 0, 5, or 10 7. Expectations of Infant’s Developmental Milestones and Behaviors 0, 5, or 10 8. Plans for Discipline (e.g., infant, toddler, and child) 0, 5, or 10 10. Bonding/Attachment Issues Families Arizona Program. A family is considered eligible to receive the Healthy 6. Anger Management Skills (e.g., Potential for violence) 9. Perception of New Infant prior to enrollment through an interview by a 0, 5, or 10 0, 5, or 10 A score over 25 is considered medium risk for child abuse and neglect, and a score over 40 Total Score 0 - 100 is considered high-risk for child abuse. * Modified from the Family Stress Checklist Healthy Families Arizona Annual Evaluation Report 2010 FINAL 57 Appendix C. Healthy Families Arizona Prenatal Logic Model Long Term Outcomes Program Resources ∈ Reduced child abuse and neglect ∉ Increased child wellness and development Family Support Specialists; Family Assessment Workers; Clinical consultants; Quality Assurance/Training/Evaluation; Funding; Community based services, e.g., prenatal support & education programs, hospital programs, nutrition services, translation & transportation services, mental health, domestic violence, substance abuse services ∠ Strengthened family relations ∇ Enhanced family unity  Reduced abuse of drugs and alcohol Prenatal Program Objectives Increase the family’s support network Improve mother’s mental health Increase parents’ health behaviors Increase the family members’ problem solving skills Identify signs and history of depression, abuse, mental illness, substance abuse Assess personal risk behaviors Identify major life stressors Improve nutrition Increase empathy for the unborn baby Increase father involvement Increase safety in the home environment Increase the delivery of healthy babies, free from birth complications Explore father’s feelings, childhood experiences, expectations, hopes and fears about baby and goals for fatherhood Assess, encourage and guide family in making needed safety arrangements, e.g. crib safety, car seat, pets, SIDS, child care, feeding Connect mother to prenatal care and encourage compliance with visits Program Activities and Strategies Assess family’s support systems Model relationship skills Foster connections to positive support sources Review history of birthing Encourage medical assessment, referral and treatment if needed Encourage exercise, personal care, rest Educate on post partum depression Educate on risk behaviors, lifestyle choices, community resources, affect of drugs, medicines on fetus Explore domestic violence, form safety plan Encourage help seeking and adoption of healthy behaviors Educate on problem-solving, goal setting. Use IFSP to review progress Educate on access to community resources, how to reach out Make referrals as needed for anger and stress management Teach stress reduction Educate and provide materials on nutrition during pregnancy, buying and choosing healthy foods, and requirements for healthy fetal development Provide referrals to WIC, other resources Encourage healthy celebrations Explore and assess issues around pregnancy, relationships, hopes, fears Discuss and educate about changes in body, sexuality during pregnancy Educate about changes in intimacy, ways father can support mother Share developmental information about stages of development of fetus Encourage supportive relationships for father Encourage prebirth bonding and stimulation exercises (reading, touch, etc) Educate on father’s legal rights and responsibilities Educate on baby temperaments, how to calm baby, Shaken Baby Syndrome, medical concerns Encourage STD testing Educate on symptoms requiring medical attention Promote breastfeeding and refer to resources Refer to parenting workshops Explore cultural beliefs about discipline Outcome Evaluation Measures H.F. Parenting InventoryPrenatal (HFPIP); FSS-23 HFPIP; FSS-23 HFPIP; FSS23; CRAFFT HFPIP; FSS-23 Healthy Families Arizona Annual Evaluation Report 2010 FINAL HFPIP; FSS-23 HFPIP; FSS-23; father involvement scale HFPIP; FSS-23 58 HFPIP; FSS-23; Safety checklist HFPIP; FSS-23; FSS20P Appendix D. Healthy Families Arizona Postnatal Logic Model Long Term Outcomes Program Resources Family Support Specialists; Family Assessment Workers; Clinical consultants; Quality Assurance/Training/Evaluation; Funding; Community based services, e.g., parenting support & education programs, nutrition services, translation & transportation services, mental health, domestic violence, substance abuse services ∈ Reduced child abuse and neglect ∉ Increased child wellness and development ∠ Strengthened family relations ∇ Enhanced family unity  Reduced abuse of drugs and alcohol Postnatal Program Objectives Increase the family’s support network Improve mother’s mental health Increase parents’ health behaviors Assess family’s support systems Identify signs and history of depression, abuse, mental illness, substance abuse Assess personal risk behaviors; Educate on dangers of specific risk behaviors Address issues of grief and loss Support family in making lifestyle changes and adopting healthy behaviors Increase the family members’ problem solving skills Improve family stability Increase parental competence Increase positive parent-child interaction Improve child health and Optimize child development Prevent child abuse and neglect Program Activities and Strategies Model relationship skills Foster connections to positive support sources Educate on communication skills Encourage medical assessment, referral and treatment if needed Encourage/coa ch on exercise, personal care, rest Educate on community resources Explore domestic violence, create safety plan Educate on post- partum depression Identify major life stressors Educate on problem-solving, goal setting. Use IFSP to review progress Educate on access to community resources, how to reach out Make referrals as needed for anger and stress management Educate about effect of stress on child Assess basic living skills and needs; help family access housing, education, job, and budget management services. Coach parent to set and evaluate goals; teach basic living skills Promote use of community resources for self sufficiency Explore family planning decisions Provide empathy and support to parent in parenting role Teach child development, early brain development, temperament Address parental expectations of child Promote and teach developmentally appropriate stimulation activities Educate about rhythm and reciprocity, reading baby’s cues Promote reading, bonding during feeding Educate about importance of routines and rules Encourage family activities, celebrations Refer to parenting groups and classes Coach on father involvement Complete developmental assessments and make referrals Address medical screenings, support well child checks, immunizations, and good nutrition habits Promote play, reading; provide links to early childhood programs Assess risk of child abuse and neglect Coach and guide in choices for child care Educate about consequences of child abuse and neglect Assess and Guide family in making safety arrangements, e.g., home and car safety Outcome Evaluation Measures Healthy Families Parenting Inventory (HFPI); FSS-23 HFPI; FSS-23 HFPI; FSS-23; CRAFFT HFPI; FSS-23 Healthy Families Arizona Annual Evaluation Report 2010 FINAL HFPI; FSS-23 HFPI; FSS-23; father involvement scale HFPI; FSS-23 59 HFPI; FSS-23; Safety checklist; ASQ HFPI; FSS-23; FSS20