Healthy Families Arizona Annual Evaluation Report FY2012 July 2011 – June 2012 Prepared by: LeCroy & Milligan Associates, Inc. 2020 N. Forbes Blvd., Suite 104 Tucson, Arizona 85745 (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, Craig W. LeCroy, Ph.D., Olga Valenzuela, B.A, and data management staff, Veronica Urcadez, Eloina Cardenas, and Frankie Valenzuela. We extend appreciation to Janice Mickens, Manager, Jenna Shroyer, HFAz Statewide Program Coordinator, and Esthela Navarro, HFAz Statewide Program Coordinator, all in the Office of Prevention and Family Support, for their guidance and support. We would also like to extend our appreciation to Karen Bulkeley, former HFAz Manager. The members of the Healthy Families Arizona Steering Committee are thanked for their long term commitment, enthusiasm and leadership in Arizona (a list of members is included in the appendices). 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. (2012). Healthy Families Arizona Annual Evaluation Report 2012. Tucson, AZ: LeCroy & Milligan Associates, Inc. Healthy Families Arizona Annual Evaluation Report 2012 1 Table of Contents Table of Contents ....................................................................................................................... 2 List of Exhibits ............................................................................................................................ 3 Executive Summary ................................................................................................................... 4 Introduction ................................................................................................................................ 8 Healthy Families Arizona Statewide System ..................................................................... 8 KIDS COUNT: The Status of Children Nationally and in Arizona .............................. 10 The Prevention-Protection Continuum............................................................................. 11 In this Report ............................................................................................................................ 15 Evaluation Methodology .................................................................................................... 15 Program Updates ..................................................................................................................... 17 Maternal, Infant, Early Childhood Home Visiting Competitive Grant ....................... 17 Program Affiliation in Yuma County ............................................................................... 18 Quality Assurance and Training........................................................................................ 18 Healthy Families Arizona Evaluation ............................................................................... 18 Healthy Families Arizona Participant Characteristics........................................................ 19 Length of Time in Program and Reasons for Termination ............................................ 21 Maternal Risk Factors .......................................................................................................... 21 Infant Characteristics ........................................................................................................... 22 Race and Ethnicity ............................................................................................................... 23 Assessment of Risk Factors ................................................................................................. 24 Summary ............................................................................................................................... 25 Key Healthy Families Arizona Services ................................................................................ 26 Developmental Screens and Referrals for Children ........................................................ 26 Outcomes for Families............................................................................................................. 28 Parent outcomes ................................................................................................................... 28 Healthy Families Parenting Inventory Reveals Positive Parent Change ................. 28 Healthy Families Parent Inventory (HFPI) Subscales ................................................. 29 Total Change Score on the HFPI .................................................................................... 30 Child Abuse and Neglect .................................................................................................... 30 Child Development and Wellness ..................................................................................... 32 Immunizations.................................................................................................................. 32 Safety Practices in the Home .......................................................................................... 33 Mothers’ Health, Education, and Employment ............................................................... 34 Subsequent Pregnancies and Birth Spacing ................................................................. 34 School, Educational Enrollment, and Employment .................................................... 35 Substance Abuse Screening ................................................................................................ 37 2012 Participant Satisfaction Survey ................................................................................. 38 Conclusions and Recommendations ..................................................................................... 40 References ................................................................................................................................. 43 Appendix A. Site Level Data .................................................................................................. 47 Appendix B. Healthy Families Arizona Steering Committee Members .......................... 61 Appendix C. Parent Survey .................................................................................................... 63 Appendix D. Healthy Families Arizona Prenatal Logic Model ........................................ 64 Appendix E. Healthy Families Arizona Postnatal Logic Model ....................................... 65 Healthy Families Arizona Annual Evaluation Report 2012 2 List of Exhibits Exhibit 1. Healthy Families Arizona Program Sites as of June 2012 .................................. 9 Exhibit 2. The Prevention-Protection Continuum .............................................................. 12 Exhibit 3. Participants Included in the Evaluation for State Fiscal Year 2012 ................ 20 Exhibit 4. Most Frequent Reasons for Termination State Fiscal Year 2012 ...................... 21 Exhibit 5. Selected Risk Factors for Mothers at Intake State Fiscal Year 2012 ................. 22 Exhibit 6. Risk Factors for Infants - State Fiscal Year 2012 ................................................ 22 Exhibit 7. Mother’s Ethnicity* (N=2414) State Fiscal Year 2012 ....................................... 23 Exhibit 8. Father’s Ethnicity* (N=2196) State Fiscal Year 2012 ......................................... 23 Exhibit 9. Percentage of Parents Rated Severe on Parent Survey Items PRENATAL (N=600) ...................................................................................................................................... 24 Exhibit 10. Percentage of Parents Rated Severe on Parent Survey Items POSTNATAL (N=1874)* ......................................................................................................... 25 Exhibit 11. ASQ-3 Screening State Fiscal Year 2012 ............................................................ 26 Exhibit 12. ASQ-3 Follow-up Services State Fiscal Year 2012 ............................................ 27 Exhibit 13. Change in Subscales of the HFPI ...................................................................... 29 Exhibit 14. Overall Change in Healthy Families Parenting Inventory Outcomes .......... 30 Exhibit 15. Percent of Families Showing No Child Abuse and Neglect Incidences – 2007, 2008, 2009, 2010, 2011, 2012........................................................................................... 32 Exhibit 16. Immunization Rate of Healthy Families Arizona Children ........................... 33 Exhibit 17. Percent of all Families Implementing Safety Practices.................................... 34 Exhibit 18. Percentage of Mothers who Reported Subsequent Pregnancies State Fiscal Year 2012 ................................................................................................................................... 35 Exhibit 19. Length of Time to Subsequent Pregnancy for Those Families ....................... 35 with Subsequent Births ........................................................................................................... 35 Exhibit 20. Percent of Mothers Enrolled in School – State Fiscal Year 2012 .................... 36 Exhibit 21. Mother’s Employment Status ............................................................................. 36 Exhibit 22. Percent Screened and Assessed Positive on the CRAFFT .............................. 37 Exhibit 23. Percent Who Strongly Agreed on Satisfaction Survey Statements 2012 ...... 39 Healthy Families Arizona Annual Evaluation Report 2012 3 Executive Summary The Healthy Families Arizona program serves families with multiple stressors and risk factors that can increase the likelihood that their children may suffer from abuse or neglect. The continued effects of a weak economy in Arizona have increased the stresses on families. Arizona is currently ranked 46th in the nation in terms of child well-being according to the 2012 KIDS COUNT Data Book. 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. Families that choose to participate receive home visits and referrals from trained staff. By providing services to underresourced, stressed, and overburdened families, the Healthy Families Arizona program fits into a continuum of services provided to Arizona families. The Healthy Families Arizona Program Healthy Families Arizona is in its twenty-first year, and is modeled after and accredited with the Healthy Families America initiative under the auspices of Prevent Child Abuse America. In September, 2011, a new four year federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) grant was awarded to Arizona to allow for the expansion of Healthy Families Arizona and another evidence based home visitation program. In State Fiscal Year 2012, with combined funding from the Arizona Department of Economic Security (DES), First Things First (FTF), and the new funding from MIECHV, Healthy Families Arizona is providing services to families living in 13 of 15 counties through 36 sites. Who Does Healthy Families Arizona Serve? A total of 3,447 children had data submitted for evaluation purposed during the current study year from July 1, 2011 through June 30, 2012. The evaluation of the statewide Healthy Families Arizona system covers only children that are 24 months old or younger (n=3,211). In order to have a meaningful evaluation of the program effects only the families where the most complete information on the effectiveness is available are included. This further restricts our dataset to include only those children that has received at least four home visits (n=2,477). Approximately, one-fourth of the families enter in the prenatal period and the average length of time in the program is just under 12 months. Healthy Families Arizona Annual Evaluation Report 2012 4 Healthy Families Arizona program families have a significant number of maternal and infant risk factors at entry into the program compared to the overall state rates. The mothers enrolled into Healthy Families Arizona are more likely to be single parents, unemployed, undereducated, living in poverty, and receiving AHCCCS. The infants are also more likely to suffer from birth defects, be of low birth weight, be born preterm, and have positive alcohol or drug screens at birth than for Arizona as a whole. 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 Risk Factors for Infants Born < 37 weeks gestation Birth Defects Low Birth Weight Positive Alcohol/Drug Screen Prenatal Families 16.9% 79.3% 44.0% 78.7% 6.6% 84.7% 23.9% $7,800 Prenatal Families 11.5% 1.0 % 9.5% 0.7% Postnatal Families 11.4% 74.3% 43.8% 82.5% 4.5% 88.2% 33.2% $9,600 Postnatal Families 16.4% 1.4% 13.8% 6.7% Arizona State Rates 9.9% 44.3% 21.7% 50.3% 3.5% 53.0% 17.8% $46,789 Arizona State Rates 10.0% 0.6% 7.1% 1.1% Sources: 2010 and 2011 data from the Arizona Department of Health Services Vital Statistics records, and the U.S. Census Bureau, American Community Survey, 2010 Outcomes for Families and Children Participating in Healthy Families The Healthy Families Parenting Inventory (HFPI) revealed statistically significant improvement on all subscales at 6 months and all but social support at 12 months. This indicated that Healthy Families Arizona participants are reducing their risk factors related to child abuse and neglect. Parents in Healthy Families report significant changes in: • • • • • • • • • Increased social support Increased problem solving Increased personal care Improved mobilization of resources Increased parenting role satisfaction Improved parent/child interaction Improved home environment Improved parenting efficacy Decreased depression Healthy Families Arizona Annual Evaluation Report 2012 5 Child Development and Wellness Timely immunizations remain an important component for positive child health and development outcomes. This year, there was a large increase in the number of infants reported as receiving immunizations at each immunization period through the first year of life, but a drop in percentage that had received all immunizations by age 18 months this year compared to last year. At 2 months, 94% of children had received the appropriate immunizations compared to 70% last year. The immunization rate for the children of Healthy Families Arizona participants by 18 months was 68% compared to 74% last year, and a 76% immunization rate for 2 year-olds in the state of Arizona as a whole. Healthy Families Arizona also educates families on home safety practices. Results indicate that families who have been in the program for 12 months: 99.7% of participants are using car seats, 95.2% have poisons locked, and 90.5% have working smoke alarms. Developmental delays are screened for at regular intervals in the Healthy Families Arizona program to assure that children who need further services are referred appropriately. The statewide performance measure goal of 80% of children screened for developmental delays was exceeded this year. Child Abuse and Neglect Records of child abuse and neglect incidents (substantiated) were examined for program participants who had received services for at least six months. The statewide program performance measure goal is for 99.7% of families to have no substantiated reports to child protective services. This year the percent of families with no child abuse or neglect incidences was 97.9%, and did not meet the performance measure goal. A total of 44 Healthy Families Arizona families had a substantiated case of child abuse and/or neglect out of 2,099 families that had participated in the program for at least 6 months. Mothers’ Health, Education, and Employment In addition to the parenting outcomes noted earlier, Healthy Families Arizona 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 pregnancies at least 24 months apart has positive health benefits for the mother. This year only 2.7% of mothers with a subsequent pregnancy waited over 24 months before they got pregnant with their next child, while 60% the mothers with subsequent pregnancies waited a year or less. The number of mothers enrolled in school has continued to decrease in the last two years, with 16.4% enrolled at 1 year of program participation compared to 17.7% last year and 22.0% in 2010. The home visitors also complete screenings and provide referrals for substance abuse problems. Healthy Families Arizona Annual Evaluation Report 2012 6 Substance abuse continues to be a difficult problem for families. Approximately 45% of the participants were screened as having potential substance abuse problems during the first 2 months of the program, with 15% continuing to have problems after six months in the program. Healthy Families Arizona Annual Evaluation Report 2012 7 Introduction Healthy Families Arizona is in its twenty-first year after its establishment as a home visitation services for at-risk families initiative of the Arizona Department of Economic Security (DES) in 1991. The Healthy Families Arizona 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 the 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 has 442 affiliated program sites in 43 States, the District of Columbia, and all five US territories. In February 2011, the US Department of Health and Human Services named Healthy Families America one of only seven proven and effective home visiting models and the only model recognized as showing outcomes in all eight benchmark areas. The Healthy Families program model was also noted for leadership in the categories of “Child Development and School Readiness” and “Reductions in Child Maltreatment”. 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. Families that choose to participate receive home visits and referrals from trained staff. By providing services to underresourced, stressed, and overburdened families, the Healthy Families Arizona program fits into a continuum of services provided to Arizona families. Healthy Families Arizona Statewide System Until the economic downturn in 2009, all of Healthy Families Arizona was funded solely through the Arizona Department of Economic Security (DES). Due to the economic downturn, DES budget reductions resulted in a decrease of the number of Healthy Families Arizona sites from 58 to 26. However, also in 2009, First Things First (FTF) released emergency dollars to agencies providing home visiting services consistent with the goals of FTF. On May 22, 2012, programs began enrolling families through additional funds from the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Grants administered by the Arizona Department of Health Services. In State Fiscal Year 2012, funding for the statewide system included $6,361,649 from DES, $5,876,715 from FTF, and $117,212 from MIECHV. Healthy Families Arizona Annual Evaluation Report 2012 8 The combined funding from DES, FTF, and MIECHV allows the Healthy Families Arizona programs and sites to provide services to families living in 13 counties and 234 zip code areas around Arizona. For the 2012 state fiscal year, there were 11 programs and 36 sites (13 DES funded, 11 FTF funded, 3 MIECHV funded, and 9 receiving funding from more than one source). See Exhibit 1 for a list of sites funded in fiscal year 2012. Exhibit 1. Healthy Families Arizona Program Sites as of June 2012 Maricopa County Cochise/Santa Cruz County Central Phoenix Douglas/Sierra Vista Maryvale Nogales East Valley Sunnyslope Mesa Graham/Greenlee County Safford Mohave County West Phoenix Kingman Central Phoenix #1 Bullhead City Central Phoenix #2 Lake Havasu (in Mohave County) North Phoenix Coconino County Southeast/Northeast Maricopa Page Combination Phoenix Flagstaff #1 South Phoenix Flagstaff #2 Southeast Maricopa #7 Southeast Maricopa #8 MIECHV Phoenix Pima County Pima Team #8 Pima Team #9 Yavapai County Prescott Navajo County Winslow Tuba City Yuma Pima Team #10 Yuma #15 Pima Team #11 Yuma #70 Pima Team #27 Pinal County MIECHV Tucson MIECHV Casa Grande/Coolidge Healthy Families Arizona Annual Evaluation Report 2012 9 KIDS COUNT: The Status of Children Nationally and in Arizona Since 1990, the Annie E. Casey Foundation, a private national philanthropy, has compiled and published an annual KIDS COUNT Data Book. The purpose of KIDS COUNT is to provide national and state level data on the well-being of children living in the United States. The KIDS COUNT indicators are collected across all states at least biannually for children from birth through high school. As research on child development and well-being has expanded over the years, KIDS COUNT updated their index to include newly available state-level data and address the gains in knowledge. The newest edition, the 2012 KIDS COUNT Data Book, has expanded from a 10-indicator index to 16 indicators within four categories. The four categories are Economic Well-Being, Education, Health, and Family and Community. The 2012 KIDS COUNT Data Book states that while there is not a consensus on the best way to track child well-being, the measurements should at least acknowledge that: • Children are affected by both positive/protective factors as well as negative/risk factors; • A child is affected by their environment which includes family, peer relationships, communities, institutions, and cultural influences; • Both basic survival (mortality and heath) and quality of life (life skills and happiness) are important; • Multiple domains, such as health, education, and economic well-being influence a child’s life; • The developmental stages of childhood should be incorporated; and • Both indicators of current well-being as well as factors that affect future outcomes should be included Nationally, children’s Economic Well-Being status has gotten worse. Of note is a 22% increase in parental unemployment and a 16% increase in the number of children living in poverty since 2005. At the national level, the long-term changes in policy in education, health, and safety have led to improvements in the categories of Education and Health. Graduation rates as well as reading and math proficiency have improved. More children have health insurance due to the Children’s Health Insurance Program (CHIP) and it’s reauthorization in 2009 (CHIPRA) which provides health insurance to low-income children who do not meet the eligibility requirements for Medicaid. In addition, fewer children and teenagers are dying, and fewer teens are abusing drugs and alcohol. However, 1 in 12 children still lack health insurance and 1 in 14 teens are abusing drugs and alcohol. In the category of Family and Community, it has been mixed. There are more children living in single parent Healthy Families Arizona Annual Evaluation Report 2012 10 families and high-poverty areas, but teenage births and head of households without a high school diploma have both decreased. The National indicators are used to show trends over time in child well-being. For states, the most currently available data is collected and states are ranked within each category based on the indicators and given an overall ranking. Arizona is ranked 46 overall, as well as in the Economic Well-Being, Education, and Family and Community rankings. Arizona does better in the category of Health, coming in at rank 36. Overall, Arizona ranked worse than the national trend in 15 of the 16 indicators. The percentage of low-birthweight babies at 7.1% was the only indicator better than the national average of 8.2%. In summary, Arizona does not score well in the realm of child well-being. This indicates that children in Arizona are more at risk for poor outcomes both in childhood as well as when they transition to adults. One additional comment that KIDS COUNT made in the 2012 KIDS COUNT Data Book is that based on the years of research and data, the best predictors of success for a child include: • getting a healthy start at birth and maintaining healthy development in the early years; • being raised by two married parents; • having adequate family income; • doing well in school; • graduating high school and completing postsecondary education or training; • avoiding teen pregnancy and substance abuse; • staying out of trouble; and • becoming connected to work and opportunity. The Prevention-Protection Continuum Based on both the predictors of success for children as well as the predictors of risk for child abuse and neglect an action plan for a comprehensive child abuse and neglect prevention system in Arizona was initially set forth in 2004 with recommendations that “a family at risk for child abuse and neglect is likely to cross multiple risk and protective factors. Thus, the recommended strategy is one that encompasses all domains, and involves an intelligent wraparound service delivery concept for children and families at risk for child abuse and neglect” (Action Plan for Reform of Arizona’s Child Protection System, 2004). There is a continuing need for examination and refinement of the “continuum of services” across state agencies and Healthy Families Arizona Annual Evaluation Report 2012 11 community-based organizations to maximize the value of limited resources to serve families in need. Since its inception, Healthy Families Arizona has sought to provide a continuum of services for children and families, so that families are served appropriately as their needs increase or decrease. A continuum of services ensures that the family receives the appropriate level of service with sufficient support, coordination, consistency, and follow-up to provide the optimal chance for success. The purpose of this Prevention-Protection Continuum is to provide a better understanding of where Healthy Families Arizona fits into the overall model of prevention and protection services. The model starts by conceptualizing a prevention-protection continuum. As Exhibit 2 shows, the continuum starts at the far left, representing primary or universal prevention, and continues to the far right, with required child protection. Along this continuum families function at five different levels: families without significant difficulties (5), families with identifiable difficulties (4), families with significant risk factors present (3), families likely to neglect or abuse their children (2), and families with child protection required (1). Exhibit 2. The Prevention-Protection Continuum Families with Families with significant risk identifiable factors present difficulties Families with few difficulties 5 4 3 Prevention Provide support services to strengthen positive development and functioning Families very likely to abuse or neglect 2 Families needing child protection 1 Protection Identify and address specific risks in families to prevent maltreatment and promote wellbeing Healthy Families Arizona Annual Evaluation Report 2012 Protect against harm 12 This framework is helpful in understanding how Healthy Families Arizona addresses the needs of a wide range of families and spans much of the prevention-protection continuum. The program is considered a prevention program designed to promote wellness while also preventing maltreatment. On the wellness side, Healthy Families considers prevention more than the absence of disease or discord—it involves the promotion of protective factors that impact wellness such as support, parenting competence, and positive parent child interactions. The program also concerns itself with child maltreatment and identifies families at risk and seeks to reduce child neglect and abuse in the home. It is important to recognize that all families can benefit from the different interventions—for example, home visitation efforts to promote support and well-being benefit both families with less serious problems as well as families who are at risk for maltreatment. Giving another example, when working with families with identifiable difficulties (scale level 4), the program emphasizes providing support and identifying services to help families ease stress and function more effectively. For families with identifiable risk factors present (scale level 3), the focus will be on assessing the level of risk and the multiplicity of risk factors. Depending on the assessment, families may be referred for psychological treatment, domestic violence services, or substance abuse counseling. These families will need to be more closely monitored and supervised. For families likely to neglect or abuse (scale level 2), the risk factors are severe enough that monitoring the family’s progress, providing targeted services, and involving supervisors in ongoing decision-making is required. If families are unable to reduce their risk factors, additional services are required. For example, families with substance abuse problems would receive more intensive attention because research has shown that substance abuse is a significant risk factor associated with neglect and abuse. For families that require protection for the children (scale level 1) Child Protective Services must be brought into the picture. Although the goal of Healthy Families is to prevent abuse and limit the need for Child Protective Services, the program provides an opportunity for observation and monitoring of families that can bring safety to a child when needed. Without this “window” into the family’s life, a child needing protection might not be identified. Healthy Families Arizona Annual Evaluation Report 2012 13 It is important to note that the outcomes of most interest to program staff may vary with the different types of families described above. For example, the program can be evaluated according to outcomes related to promoting family wellness, and it can be evaluated with regard to its ability to avert abuse among families with the highest risk. It is also important to realize that families change and move up and down the continuum depending on a number of factors. Several programmatic implications emerge from the prevention-protection continuum conceptualization. Child maltreatment is more likely when numerous high risk factors are present. However, it is possible that at this high level of risk, prevention of maltreatment may rarely occur. This may be a situation where it is too little and too late to truly prevent child maltreatment. It is possible that Healthy Families works more effectively in preventing families from moving toward greater risk factors and higher levels of risk. Because these families at a lower level of risk have an even lower base rate of child maltreatment it is difficult to test this theory with research. Hopefully, this continuum captures the many different families the Healthy Families Arizona programs attempts to serve and suggests the need for an evaluation that can assess a wide range of outcomes. Healthy Families Arizona Annual Evaluation Report 2012 14 In this Report The purpose of the 2012 Healthy Families Arizona Annual Evaluation Report is to provide information on families’ outcomes, program performance measures, process and implementation information, and evaluation information that can be used to guide program improvement. This report covers the state fiscal year 2012 from July 1, 2011 to June 30, 2012. The evaluation of Healthy Families Arizona includes both process and outcome evaluation. The process evaluation includes an update of statewide implementation, describes the characteristics of families participating in the program and provides narratives from families participating in the program. The outcome evaluation examines program outcomes and looks at the program’s impact across a number of measures, with comparisons to previous years when appropriate and available. Detailed appendices provide specific site data on process and outcome variables. The description of evaluation methodology outlines the methods used for each part of the report. The 2012 annual evaluation report has been designed to provide critical information and reporting of yearly 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 cumulative performance reports for ongoing program monitoring. These reports are used during quality assurance and technical assistance site visits to review and assess progress on key program activities, including administration rates for developmental screenings and parenting skills inventories, attainment of immunization data, and substance abuse screening. Evaluation Methodology The Healthy Families Arizona 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 for families in the program? The goal of the process component of the evaluation is to describe the participants involved in the Healthy Families Arizona program and document the services they Healthy Families Arizona Annual Evaluation Report 2012 15 receive. In the process evaluation, the program “inputs” such as numbers served, participant characteristics, and services received are described. 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. The overall aim for the outcome study is to examine program effects and 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, 12 months, 18 months, and 24 months. 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 Annual Evaluation Report 2012 16 Program Updates Maternal, Infant, Early Childhood Home Visiting Competitive Grant In July 2010, the Arizona Department of Health Services was awarded $1.8 million each year with extension for five years to implement the Maternal, Infant and Early Childhood Home Visiting (MIECHV) Program. In September 2011, the Arizona Department of Health Services was awarded two additional grants: * The Federal Fiscal Year 2011 Formula Funding for $2.6 million each year with extension for five years; and * The MIECHV Competitive Grant for $9.4 million each year with extension for four years. Only ten States were awarded the Competitive Grant and only three States including Arizona received the full 9.4 million in funding. Grant Funding supports: Nurse Family Partnership and Healthy Families, along with the Promising Practice of Family Spirit with the White Mountain Apache Tribe. In addition to program expansion funds, the grant allows for the utilization of funds to begin the implementation of system building processes. Activities may include expanding and supporting regional home visiting coalitions, system wide data collection and analysis, and training and work force development opportunities for Family Support Specialists and Supervisors. Interagency agreements are in place between the Arizona Department of Economic Security, First Things First, and the Arizona Department of Health Services, the administrative agency for the MIECHV grant. These agreements relate to evaluation, training, quality assurance, technical assistance, program development, and other program related services. The Arizona Department of Economic Security acts as Central Administration for the Healthy Families Arizona Program. Quarterly meetings are conducted between the three agencies to enhance collaboration and future program guidance. The MIECHV funded programs started enrolling families on May 22, 2012. There are three full teams of Family Support Specialists in Maricopa County, Pima County, and Healthy Families Arizona Annual Evaluation Report 2012 17 Pinal County. There have also been staff increases in Graham County and in Winslow which is in Navajo County. Program Affiliation in Yuma County On September 26, 2011, the Department of Economic Security Central Administration office of the Healthy Families Arizona Program granted official affiliation to Healthy Families Yuma County, comprised of two teams, to the State system. As an affiliated program, the Yuma County Healthy Families program became an active participant in all aspects of the Healthy Families Arizona multi-site system to satisfy all of the requirements of Healthy Families America accreditation processes. Quality Assurance and Training An additional Quality Assurance (QA)/Technical Assistance (TA) specialist was hired in state fiscal year 2012, and there are now 3 full-time QA specialists who will continue facilitation of annual sites visits and oversee the continued quality improvement aspects of program implementation. The QA team reviews the standards of best practice and provides technical assistance based on the sites’ needs and issues at each site visit. The quarterly cumulative performance reports are used at each visit and data systems have been developed to provide information about home visit rates. Healthy Families Arizona Evaluation Due to the extensive requirements of the MIECHV grant, two systems are in place to handle the evaluation needs of the program. One is for the statewide Healthy Families Arizona Program as a whole, and another is for the MIECHV funded sites only. Data collection trainings have been conducted to clarify the data requirements for each system to the sites. The Department of Economic Security Central Administration collaborated with the MIECHV evaluation team to integrate the data collection requirements into the standard data collection for the MIECHV funded sites. LeCroy & Milligan Associates continues to provide the statewide evaluation instruments. These instruments were revised in June 2012 and all sites were trained on the revisions through webinars prior to their implementation on July 1, 2012. The first MIECHV data collection training took place on May 21, 2012. Additional trainings will be held as new MIECHV funded sites are approved. Healthy Families Arizona Annual Evaluation Report 2012 18 Healthy Families Arizona Participant Characteristics A total of 3,447 children had data submitted for evaluation purposed during the current study year from July 1, 2011 through June 30, 2012. A total of 1,799 were funded through the Department of Economic Security; 1,581 through First Things First; and 67 through MIECHV. The evaluation of the statewide Healthy Families Arizona system covers only children that are 24 months old or younger (n=3,211). In order to have a meaningful evaluation of the program effects only the families where the most complete information on the effectiveness is available are included. This further restricts our dataset to include only those children where we have full data showing that they have received at least four home visits (n=2,477). 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 four or more home visits) in the Healthy Families program regardless of when they entered the program. Just under a quarter (24.2%) of the families enter the program in the prenatal period (prenatal participants) and about three quarters (75.8%) of the families enter the program after the birth of the child (postnatal participants). For the July 2011 to June 2012 evaluation cohort, there were 600 prenatal and 1,877 postnatal participants. Exhibit 3 presents the total numbers of prenatal and postnatal participants actively engaged from July 2011 to June 2012. Healthy Families Arizona Annual Evaluation Report 2012 19 Exhibit 3. Participants Included in the Evaluation for State Fiscal Year 2012 County Site Prenatal Postnatal Total Cochise Douglas/ Sierra Vista 7 41 48 Coconino Flagstaff #1 32 20 52 Page 5 3 8 Tuba City 19 35 54 Flagstaff #2 9 10 19 Graham Safford 6 23 29 Maricopa Central Phoenix 17 71 88 Maryvale 19 90 109 East Valley 27 68 95 Sunnyslope 15 104 119 Mesa 22 91 113 West Phoenix 25 88 113 Central Phoenix #1 22 60 82 Central Phoenix #2 32 74 106 North Phoenix 23 59 82 Southeast/Northeast Maricopa 23 66 89 Combination Phoenix 27 61 88 South Phoenix 9 44 53 Southeast Maricopa #7 18 58 76 Southeast Maricopa #8 18 77 95 Mohave Bullhead City 22 73 95 Kingman 45 31 76 Lake Havasu City 26 47 73 Navajo Winslow 13 23 36 Pima Pima #8 22 60 82 Pima #9 20 72 92 Pima #10 17 45 62 Pima #11 12 86 98 Pima #27 8 44 52 Santa Cruz Nogales 9 32 41 Yavapai Prescott 6 81 87 Yuma Yuma #15 18 62 80 Yuma #70 7 78 85 Total 600 1877 2477 Healthy Families Arizona Annual Evaluation Report 2012 20 Length of Time in Program and Reasons for Termination In State Fiscal Year 2012, a total of 1,036 families closed. The length of time in the program for closed families was slightly higher than for last year but still not as high as in 2010. For all families (N=1,036) who closed in State Fiscal Year 2012: • The median number of days in the program was 290 days (as compared to 257 in 2011, and 305 in 2010); • The average length of time in the program was 352 days (as compared to 317 in 2011, and 385 in 2010); and • Thirty-eight percent of families were in the program one year or longer (as compared to just over 30% in 2011, and 40% in 2010). Exhibit 4 shows the most frequent reasons families left the program during this year. A breakout by site is presented in Appendix A. Exhibit 4. Most Frequent Reasons for Termination State Fiscal Year 2012 Reason Moved away Family refused further services Did not respond to outreach efforts Self-sufficiency Other Refused worker change Unable to contact Prenatal Postnatal 28.0% 14.4% 11.3% 11.7% 8.6% 7.4% 6.6% 20.9% 20.3% 18.5% 12.2% 6.0% 8.5% 5.6% Maternal Risk Factors Upon enrollment into Healthy Families Arizona, both prenatal and postnatal mothers have certain risk factors that are higher than the average rates for all mothers in the State of Arizona. There has been a decrease in the percentage of Healthy Families Arizona mothers who are teenagers compared with last year. In 2012, approximately 17% of prenatal mothers and just over 11% of postnatal mothers enrolled are teens compared to 23% and 14% respectively in 2011. Approximately three –fourths of all mothers are single parents at enrollment. Mothers enrolled in Healthy Families Arizona are twice as likely to have less than a high school education (44%) compared to all mothers in the State (22%). Four out of five of the mothers are unemployed and receiving AHCCCS at enrollment. The median income is well below the poverty level indicating that many participants are living in poverty. In relation to the state rates, these data confirm that Healthy Families Arizona participants do represent an “atHealthy Families Arizona Annual Evaluation Report 2012 21 risk” group of mothers and that the program has been successful in recruiting families with multiple risk factors associated with child abuse and neglect and poor child health and developmental outcomes. Exhibit 5 presents selected risk factors for both prenatal and postnatal mothers at intake compared with state rates. Exhibit 5. Selected Risk Factors for Mothers at Intake State Fiscal Year 2012 Prenatal Postnatal Arizona state Risk Factors of Mothers Families Families Rates Teen Births (19 years or less) 16.9% 11.4% 9.9%* Births to Single Parents 79.3% 74.3% 44.3%* Less Than High School Education 44.0% 43.8% 21.7%** Not Employed 78.7% 82.5% 50.3%*** No Health Insurance 6.6% 4.5% 3.5%* Receives AHCCCS 84.7% 88.2% 53.0%* Late or No Prenatal Care 23.9% 33.2% 17.8%* Median Yearly Income $7,800 $9,600 $46,789 *** Percent does not include “unknown.” *Source: 2011 data from the Arizona Department of Health Services Vital Statistics records. **Source: 2010 data from the Arizona Department of Health Services Vital Statistics records. ***U.S. Census Bureau, American Community Survey, 2010 Note: Percentages for the combined total for prenatal and postnatal families can be found in Appendix A. Infant Characteristics In addition to mother 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 that entered prenatally and postnatally. Exhibit 6. Risk Factors for Infants - State Fiscal Year 2012 Risk Factors for Infants Prenatal Families* Born < 37 weeks gestation Birth Defects Low Birth Weight Positive Alcohol/Drug Screen 11.5% 1.0 % 9.5% 0.7% Postnatal Families** 16.4% 1.4% 13.8% 6.7% 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. ***2010 data from the Arizona Department of Health Services Vital Statistics records. The overall risk factors for infants are similar to prior years. The percentage of postnatal Healthy Families Arizona program infants born early (less than 37 weeks gestation) is 6.4% higher than the overall state rate, suggesting that the families being Healthy Families Arizona Annual Evaluation Report 2012 22 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. Race and Ethnicity The Healthy Families Arizona program serves a culturally diverse population. In the following two exhibits, race and ethnicity is examined for all mothers and fathers based on information gathered at enrollment. More than half of mothers and fathers enrolled in the program are Hispanic. Starting with July 1, 2012, race and ethnicity (Hispanic/Non-Hispanic) will be two separate variables. Site level data is available in Appendix A. Exhibit 7. Mother’s Ethnicity* (N=2414) State Fiscal Year 2012 White/Caucasian 30.1% African American 6.0% Native American 7.5% Other/Mixed 0.8% Hispanic 54.5% Asian American 1.1% *This includes all mothers who entered the program either prenatally or postnatally. Exhibit 8. Father’s Ethnicity* (N=2196) State Fiscal Year 2012 White/Caucasian 26.8% African American 7.8% Native American 6.7% Asian American 0.9% Other/Mixed 0.7% Hispanic 57.1% *This includes all fathers who entered the program either prenatally or postnatally. Healthy Families Arizona Annual Evaluation Report 2012 23 Assessment of Risk Factors Both mothers and fathers are assessed at intake using an interview with the Parent Survey 1. 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 9 and 10. Exhibit 9. Percentage of Parents Rated Severe on Parent Survey Items PRENATAL (N=600) Parental Attachment Mom Dad Difficult Child Discipline Attitudes Expectations of Infant Violence Potential Current Life Stresses Social Support, Isolation CPS Involvement Crime, Substance Abuse, Mental Illness Parent Childhood Abuse 0 10 20 30 40 50 60 70 80 90 100 Previously known as The Family Stress Checklist, it was renamed the Parent Survey based on revisions to focus on a more strength 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 2012 24 Exhibit 10. Percentage of Parents Rated Severe on Parent Survey Items POSTNATAL (N=1874)* Parental Attachment Mom Dad Difficult Child Discipline Attitudes Expectations of Infant Violence Potential Current Life Stresses Social Support, Isolation CPS Involvement Crime, Substance Abuse, Mental Illness Parent Childhood Abuse 0 10 20 30 40 50 60 70 80 90 100 * Does not include missing data Consistent with previous years’ data, 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. A higher percentage of prenatal mothers had severe scores on history of childhood abuse (77.2%) and history of crime, substance abuse, or mental illness (46.3%) than postnatal mothers at 68.0% and 40.6% respectively. Summary The process evaluation for fiscal year 2012 suggests that the Healthy Families Arizona program is effectively reaching parents and their babies who have high risks of child maltreatment and other unhealthy outcomes. Overall, the Healthy Families Arizona program is reaching families that are impoverished, stressed, socially disadvantaged, and lacking in resources to manage the demands of parenting. In general, the prenatal families have slightly higher risks than the postnatal families. However, the risk factors of low birth weight babies and preterm birth are lower for those families participating in Healthy Families Arizona prenatally than for those that enter in the postnatal period. This suggests that these high risk families benefit from the early support that is offered in the home visitation program. Healthy Families Arizona Annual Evaluation Report 2012 25 Key Healthy Families Arizona Services The primary goals of reducing child abuse and neglect and improving child wellbeing are only attainable when families stay engaged in the program and receive the services and resources they need. One important aspect of the Healthy Families program model is linking families with needed community resources. Home visitors provide not only assistance and guidance in the home, but they also connect families with education, employment, and training resources, counseling and support services, public assistance and health care services. Developmental Screens and Referrals for Children Developmental screens 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, Third Edition (ASQ-3) to help parents assess the developmental status of their child across five areas: communication, gross motor, fine motor, problem solving, and personal-social. The Healthy Families Arizona program administers the ASQ-3 at 4, 6, 9, and 12 months in the first year of the infant’s life and then every six months until the child is three years of age and then yearly at age 4 and 5. The statewide program performance goal is to screen at least 80% of the children in the program. As Exhibit 11 shows, the number of children receiving the ASQ-3 at each interval is exceeding the program goal of 80% at all time periods. This is great improvement over last year when that goal was only exceeded at the 4-month time period. Overall, the rates of screening for this year range from 8.6% to 13.2% higher than in Fiscal Year 2011. This is a significant improvement from last year. Exhibit 11. ASQ-3 Screening State Fiscal Year 2012 Interval Percent of children ASQ-3 Screened with ASQ-3 Screening 4-month 93.5% 6-month 92.0% 9-month 91.7% 12-month 88.2% 18-month 85.2% 24-month 80.9% Healthy Families Arizona Annual Evaluation Report 2012 Percent screened as delayed 2.6% 2.1% 2.3% 1.8% 5.0% 6.6% 26 Healthy Families Arizona works to ensure that children who may have developmental delays obtain needed interventions. Program data tracks what happens after a family’s ASQ-3 is scored as follows: 1) the child is screened as having no delays, 2) the 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 2% to 7% of children (depending on their age) are initially screened as delayed in their development, up to 13% of the children who initially screen as delayed on the ASQ-3 in the early months of their life are determined to be “not delayed” upon further assessment (see Exhibit 12 below). For example, of the families at 4 months who screened as delayed on the ASQ-3 and were referred for more assessment, 3 families showed no delay, 21 families were referred to the AzEIP, 3 families were referred to an early intervention program, 36 families received developmental intervention, 6 families were referred to specialized therapy, and 11 declined further referral. The ASQ-3 screening provides a valuable service to families because it enables them to access appropriate services to meet their child’s particular needs. This practice is consistent with the American Academy of Pediatrics strategic plan to promote developmental screening and establish a medical home when needed (Tait, 2009). There is a national effort to increase early developmental screening after studies found that up to 70% of developmental problems were not identified until school entry (e.g., see Glascoe & Dworkin, 1993). The following exhibit shows the outcome of these follow-up assessments that are completed with families at the different time intervals. Exhibit 12. ASQ-3 Follow-up Services State Fiscal Year 2012 Screening Interval 4-month 6-month 9-month 12-month 18-month 24-month Continued Assessment shows “no delay” % (n) 6.4% (3) 5.4% (2) 9.5% (2) 0.0% (0) 3.2% (1) 13.6% (3) Referred to AzEIP % (n) Referred to other Early Intervention % (n) Provided Developmental Intervention % (n) Referred to Therapy % (n) Parent Declined Referral % (n) 44.7% (21) 62.2% (23) 47.6% (10) 38.9% (7) 54.8% (17) 68.2% (15) 6.4% (3) 5.4% (2) 4.8% (1) 0.0% (0) 6.5% (2) 4.5% (1) 76.6% (36) 64.9% (24) 57.1% (12) 66.7% (12) 77.4% (24) 72.7% (16) 12.8% (6) 13.5% (5) 4.8% (1) 5.6% (1) 3.2% (1) 9.1% (2) 23.4% (11) 5.4% (2) 14.3% (3) 11.1% (2) 25.8% (8) 22.7% (5) Note: Percentages do not equal 100% as multiple referrals can happen for a single child. Healthy Families Arizona Annual Evaluation Report 2012 27 Outcomes for Families The Healthy Families Arizona program focuses the outcomes evaluation on the following primary 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. Recent research from a randomized clinical trial of the Arizona Healthy Families program (LeCroy & Krysik, 2011) supports the finding that the program can produce positive change favoring the experimental group in contrast to the control group across multiple outcome domains such as violent parenting behavior, parenting attitudes and practices, parenting support, mental health and coping, and maternal outcomes. Healthy Families Parenting Inventory Reveals Positive Parent Change In order to evaluate critical goals of the Healthy Families program, the evaluation team developed the Healthy Families Parenting Inventory (HFPI) in 2004 (LeCroy, Krysik, & Milligan, 2007). This instrument was developed, in part, because of measurement difficulties identified in the literature (See LeCroy & Krysik, 2010). 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 Healthy Families Arizona Annual Evaluation Report 2012 28 similar measures. The process included focus groups with home visitors, the development of a logic model, and a review of relevant literature. In an initial validation study the pattern of inter-item and item-to-subscale correlations as well as an exploratory factor analysis and sensitivity to change analysis supported the ninefactor model of the HFPI. This work was recently published in the journal Infant Mental Health (Krysik & LeCroy, 2012). 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. The following section describes the results obtained for each subscale of the HFPI. The level of significance is reported along with the effect size. An effect size gives a sense of how large the change or improvement is from baseline to 6 months or 12 months. Effect sizes below 0.20 are considered small changes, and those between 0.20 and 0.50 are considered small to medium changes. 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=1304) and participants who also had matched instruments at the 12 month interval (n=770). Healthy Families Parent Inventory (HFPI) Subscales Exhibit 13. Change in Subscales of the HFPI Significant improvement Sub- scale from Significance baseline to 6 months Social support 0.000  Problem 0.000  solving Depression 0.000  Personal care 0.000  Mobilizing 0.000  resources Commitment 0.000  To Parent Role Parent/child 0.000  Behavior Home 0.000  Environment Parenting 0.000  Efficacy Significant improvement Effect Effect from Significance size size baseline to 12 months (0.10) 0.261 (0.04) None (0.24)  0.000 (0.27) (0.12) (0.20)   0.000 0.000 (0.21) (0.20) (0.35)  0.000 (0.43) (0.15)  0.000 (0.23) (0.27)  0.016 (0.15) (0.31)  0.000 (0.45) (0.22)  0.002 (0.20) Healthy Families Arizona Annual Evaluation Report 2012 29 From baseline to 6 months, there were statistically significant changes in all subscales. Consistent with data from last year, significant gains were lost in the area of social support at 12 months. The largest improvements( as shown by the effect sizes) at 6 months after entering the program are in the categories of mobilizing resources (0.35), home environment (0.31), parent/child behavior (0.27), problem solving (0.24), and parenting efficacy (0.22) scales. At 12 months the largest improvements are in home environment (0.45), mobilizing resources (0.43), problem solving (0.27), commitment to parenting role (0.23), and depression (0.21). This indicates that the Healthy Families programs are effective at connecting parents to resources, improving the atmosphere of the home, improving parents’ problem solving skills and increasing the parent’s self-assessment of parenting efficacy. Total Change Score on the HFPI In order to provide a more comprehensive understanding of outcomes 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. As Exhibit 14 below shows, there were significant changes from baseline to 6 months and from baseline to 12 months on the HFPI total scale. This finding supports the conclusion that program participants changed during the course of the program. Overall, approximately two-thirds of parents had positive changes on the total score from baseline to 6 months (66.4%) and from baseline to 12 months (66.6%). Exhibit 14. Overall Change in Healthy Families Parenting Inventory Outcomes Significant Significant improvement improvement SubEffect Effect Significance Significance from from scale size size baseline to 6 baseline to months 12 months Total  .000 (0.31)  .000 (0.34) Scale Child Abuse and Neglect One of the main goals of Healthy Families Arizona is to reduce the incidence of child maltreatment and abuse. In order to look at child abuse and neglect directly, data from CHILDS, the Arizona Department of Economic Security Child Protective Services data system is used to determine the rates of child abuse and neglect for Healthy Families Arizona participants. It is important to acknowledge that using Healthy Families Arizona Annual Evaluation Report 2012 30 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). In 2009 as a result of Legislation, the Substantiation pending adjudication came into process: CPS proposes to substantiate on dependency cases. An allegation of child abuse or neglect may be substantiated when: • a dependency petition is filed alleging dependency based upon an allegation of child abuse and/or neglect, and • the court finds the child dependent based on an allegation of abuse or neglect contained in the petition. CPS does not propose to substantiate pending dependency adjudication when a petition is filed based on incorrigibility, delinquency or when a parent’s inability to provide services for a child with a disability or chronic illness is solely the result of the unavailability of reasonable services. 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 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. Healthy Families Arizona Annual Evaluation Report 2012 31 In order to best represent families that have received a significant impact from the Healthy Families Arizona program, only families that have been in the program for at least six months are analyzed to determine if they have a substantiated report of child abuse or neglect. This year, 97.9% of the Healthy Families Arizona eligible families (2,055 out of 2,099) were without a substantiated report, as can be seen in Exhibit 15. The program performance goal was set at 99.7% based on the 2006-2007 data. A total of 44 cases were determined to be substantiated reports. 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). Exhibit 15. Percent of Families Showing No Child Abuse and Neglect Incidences – 2007, 2008, 2009, 2010, 2011, 2012 Group 2006-2007 (n = 3,301) 2007-2008 (n = 3,885) 2008-2009 (n = 4,247) 2009-2010 (n = 878) 2010-2011 (n = 1,874) 2011-2012 (n=2,099) All Families with at least 6 months in the program 99.7% 98.9% 98.8% 97.4% 99.98% 97.9% 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 Healthy People 2020 goal is to have at least 90% of all children immunized. Arizona has set an additional standard of 95% of all children within the state under the age of six having received at least one set of vaccinations. As of 2011, the Arizona immunization rate for 24 month olds was 64.4%, and the U.S. rate was 72.8% (www.cdc.gov). The Healthy Families Arizona program supports children obtaining all their necessary immunizations as a key step in preventing debilitating diseases. The home visitors encourage the families to follow through on completing their child’s immunizations and ask to check the family’s immunization booklet to record the dates of immunizations and assess completion. Healthy Families Arizona Annual Evaluation Report 2012 32 Exhibit 16 presents the past three years of data on immunization rates for the 2, 4, 6, and 12 month immunization periods as well as the overall complete immunizations through age 18 months for children. In 2012, there has been an increase from the drop in 2011 in immunization rates among Healthy Families Arizona participants in each time period. However, Healthy Families Arizona families still fell below both the state and national immunization rates for 2-year olds. This is potentially due to the economic factors of prior years and now, where families do not have the resources to visit the doctor regularly. However, the improved rates at the youngest ages suggest that the efforts to increase immunizations in the Healthy Families Arizona program have been successful in this past year. Exhibit 16. Immunization Rate of Healthy Families Arizona Children Immunization Period Percent Immunized 2010 Percent Immunized 2011 Percent Immunized 2012 92.9% 89.9% 74.0% 85.3% 69.7% 70.2% 68.2% 62.7% 93.8% 87.9% 75.6% 71.3% 79.8% 74.4% 67.7% 2 month 4 month 6 month 12 month Received all recommended immunization by age 18 months Immunization Rate for 2-year-olds in Arizona (2010)* 76.3% *Source: 2010 data from the CDC National Immunization Survey. Safety Practices in the Home A recent study released by the Centers for Disease Control and Prevention (MMWR 2012) states that even though injury death for children have decreased from 15.5 to 11.0 per 100,000 population from 2000 to 2009, they continue to be the leading cause of death for children over the age of 1. Unintentional injuries are also the fifth leading cause of death for newborns and infants under the age of 1. A report in 2004, Home visiting and childhood injuries, concluded that home visits can reduce the risk of accidental injuries in the home by approximately 26 percent. The Healthy Families Arizona home visitors both assess and promote safe environments for children. The home visitors provide education about safety practices and monitoring safety in the home through the completion of the safety checklist with the family. Exhibit 17 reports the use of four key safety practices across five time points for postnatal participants. Families that continue to participate in Healthy Families Arizona see increased safety practices and reach high rates. The National Highway Traffic Safety Administration in 2009 estimated the rate of child Healthy Families Arizona Annual Evaluation Report 2012 33 seat use for children under the age of 1 as 98%. The national rate for children between the ages of 1 to 3 however is estimated to be 96%. The families participating in Healthy Families Arizona maintain their high use of car seats overtime, indicating that the message of child safety in cars has been well received. The National Fire Protection Association reports that smoke detectors were present in only 72% of all reported home fires and operated in only 51% of home fires. The high rates of 85% to 91% of Healthy Families Arizona households with working smoke alarms adds to the safety of the household environment for these families. Furthermore, families obtain relatively high rates of covered outlets and poisons locked adding to the overall safety being maintained. Exhibit 17. Percent of all Families Implementing Safety Practices Outlets Covered Poisons Locked Smoke Alarms Car Seats 2-Month (n = 2187) 6-Month (n = 1796) 12-Month (n = 1168) 18-Month (n = 727) 24-Month (n = 420) 41.8% 54.5% 69.8% 74.1% 74.9% 84.7% 91.6% 95.2% 97.0% 96.7% 85.0% 88.2% 90.5% 91.2% 90.5% 99.5% 99.6% 99.7% 99.7% 99.0% Mothers’ Health, Education, and Employment The Healthy Families Arizona program also attempts to influence maternal life course outcomes. The home visitors encourage families to seek new educational opportunities, complete their high school education, obtain greater economic selfsufficiency, and obtain better paying and better quality jobs. Information is also provided to mothers regarding the positive health impacts of delaying subsequent pregnancies to at least 24 months. Subsequent Pregnancies and Birth Spacing Multiple births for some families can lead to increased stress and parenting difficulties, especially if the birth is unwanted or unplanned. 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 home visitors emphasize the benefits of delaying repeat pregnancies and promote longer birth spacing for the mothers in the program. Exhibit 18 shows that the percent of HFAz mothers who reported subsequent pregnancies has increased in 2012 to nearly 8%. Healthy Families Arizona Annual Evaluation Report 2012 34 Exhibit 18. Percentage of Mothers who Reported Subsequent Pregnancies State Fiscal Year 2012 Percent of mothers with subsequent pregnancies 2009 2010 2011 2012 9.9% 7.1% 4.9% 7.9% In addition to the increase in mothers who have subsequent pregnancies while enrolled in the Healthy Families Arizona program, there is also an unfortunate decrease in the percentage of women waiting at least two years before becoming pregnant again. Exhibit 19 below shows the length of time to subsequent pregnancy for those mothers who do have subsequent births. The low percentage of mothers that wait at least 2 years between subsequent births indicates that the message of delaying subsequent pregnancies is either not being received or embraced. Exhibit 19. Length of Time to Subsequent Pregnancy for Those Families with Subsequent Births Length of Time to Subsequent Pregnancy 2009 Percent of Mothers 2010 Percent of Mothers 2011 Percent of Mothers 2012 Percent of Mothers 1 to 12 mos. 13 to 24 mos. Over 24 mos. 49.3% 46.8% 4.0% 54.1% 42.6% 3.3% 65.1% 31.0% 3.9% 59.9% 37.4% 2.7% School, Educational Enrollment, and Employment Continued educational obtainment and increased employment 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 Exhibit 20, at each interval, 15-17% of the mothers are enrolled in school either full- or part-time, this is a decrease from 17-22% in fiscal year 2011. The extended weakened economy may be a relevant factor in the small number enrolled in the past few years. 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. Healthy Families Arizona Annual Evaluation Report 2012 35 Exhibit 20. Percent of Mothers Enrolled in School – State Fiscal Year 2012 Percent Percent Percent Percent enrolled enrolled enrolled enrolled part-time (2011 full-time (2011 part-time (2012) full-time (2012) prior report) prior report) 6 month 6.1% 10.9% 5.5% 11.0% 12 month 6.3% 11.4% 6.5% 9.9% 18 month 9.3% 12.4% 7.2% 9.6% 24 month 4.8% 12.7% 5.3% 9.3% Maternal employment shows an increasing rate over time. Just over 39% of the mothers are employed at 24 months. According to the most recent Bureau of Labor Statistics report for 2011, 55.8% of mothers with children less than 1 year of age, and 63.9% of mothers with children less than 6 years of age participate in the labor force. 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 currently available for families with low incomes. Exhibit 21. Mother’s Employment Status 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Baseline 6 months 12 months Part-time 18 months 24 months Full-time Healthy Families Arizona Annual Evaluation Report 2012 36 Substance Abuse Screening The relationship between substance abuse and the potential for child maltreatment is strong and well known (Pan, et al., 1994; Windom, 1992; Wolfe, 1998). When parents or caretakers are abusing substances, children may not be adequately cared for or supervised. While successful substance abuse treatment often requires intensive inpatient or outpatient treatment and counseling, home visitors can still play a critical role in screening for substance abuse, educating families about the effects of substance abuse on their health and the health of their children, and in making referrals for treatment services. Healthy Families Arizona uses the CRAFFT as a method of screening for substance use and abuse. The CRAFFT is a short screening tool for adults and adolescents to assess high risk drug and alcohol use disorders developed by the Center for Adolescent Substance Abuse Research (CeASAR), at the Children’s Hospital of Boston. A positive screen occurs if there are two or more “yes” answers out of six questions and indicates that further assessment and or referrals are recommended. Exhibit 22 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. Approximately 45% of families screened at intake assessed positive for a history of substance use putting them at potential risk. The decreased number of families with positive substance abuse screens drops dramatically at 6 months (15%) and continues to drop at 12 months (11%). Exhibit 22. Percent Screened and Assessed Positive on the CRAFFT Time at assessment Percent Screened Percent Assessed Positive 2 months (lifetime) 90.1% 45.3% 6 months 89.7% 14.6% 12 months 87.5% 11.2% Note: The 2 month screen asks lifetime substance use; later screens cover the past 6 months. Healthy Families Arizona Annual Evaluation Report 2012 37 2012 Participant Satisfaction Survey Data on participant satisfaction information provides valuable information for program staff and a time for reflection for participants. If participants are satisfied with the program and the work of the home visitor, they are more likely to benefit from the program. The following data summarizes the responses of participants who took the Healthy Families participant satisfaction survey in Spring 2012. The survey is distributed to all current participants in the program and returned by mail. A total of 1317 surveys were returned. The ethnic breakdown of these participants was 60% Hispanic, 24% White, 6% American Indian, 5% African American, 4% Two or More Races, 1% Asian, less than 1% Hawaiian/Pacific Islander, and less than 1% Other. Exhibit 23 below shows key highlights from participant satisfaction survey responses. The exhibit presents the items which received the highest percent of strongly agree responses from participants and the items receiving the lowest percent of strongly agree. Based on the results of the survey it appears that participants feel they have good communication with their home visitors. Fewer participants (74.4%) agree strongly that finding services was easy. For the remaining statements in the satisfaction survey, more than 80% of the respondents strongly agreed. This is similar to the 2011 survey results and indicates a strong satisfaction level with the program. Healthy Families Arizona Annual Evaluation Report 2012 38 Exhibit 23. Percent Who Strongly Agreed on Satisfaction Survey Statements 2012 Finding services was easy. 74.4% Program services were scheduled at convenient times. 83.2% The program fit my family beliefs, cultures, and values. 81.7% My family's experience with the program was very good. 84.8% The program provided the help and services my family and I needed. 84.0% I received high quality services from my home visitor. 86.4% I felt comfortable discussing my concerns and acted on them. 87.0% The program staff listened to my concerns and acted on them. 85.7% My home visitor did a good job explaining things to me. 88.9% I am satisfied with the information I received. 85.7% As a result of this program, I can support my children better. 85.0% I would recommend this program to others. 87.8% My home visitor ... assist me in accessing… services based on language and cultural needs. 83.2% The educational materials ... are respectful of my cultural beliefs and practices. 83.3% 65.0% 70.0% Healthy Families Arizona Annual Evaluation Report 2012 75.0% 80.0% 85.0% 90.0% 39 Conclusions and Recommendations The 2012 state fiscal year has been productive for Healthy Families Arizona. The combined funding from the Department of Economic Security, First Things First, and the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) grant has increased the number of families receiving services in more locations throughout the state. The Healthy Families Arizona evaluation report focuses on the following primary outcome indicators: parent outcomes, child health and wellness, and child abuse and neglect. The results from the Healthy Families Parenting Inventory, participant tracking data sheets, safety checklists, screening tools, child abuse and neglect rates, and immunization rates all suggest that the Healthy Families Arizona program continues to address and reach most of its goals. The Healthy Families Arizona program uses evidence-based methods to guide the practice of home visitation. In order to continue to see successful outcomes and to improve other outcomes, the Healthy Families Arizona program needs to rigorously investigate the program at least annually and use evidence for program improvement. Recommendations for this year are focused on ways the program can continue to emphasize quality programming, provide the most critical services to the highest risk families, and improve parent and child outcomes. • Direct additional efforts toward increasing the time between births. This continues to be a concern for the health of the mothers in the Healthy Families Arizona program. There continues to be an increase in the percentage of subsequent pregnancies that are happening within 24 months of a prior birth. Additional training for Family Support Specialists and creative strategies to educate parents on the benefits of delayed pregnancy should be undertaken. One possibility is to conduct a pilot effort in one or two sites using additional training and educational materials to determine if this increases the time between births. • Place additional emphasis on maternal educational attainment. Forty-four percent of mothers have less than a high school education at enrollment. Less than 20% of mothers are enrolled in educational programs at any specific data collection time point. Maternal educational attainment should be encouraged by the Family Support Specialists. Programs may want to find resources in their local areas to provide information and referrals to the mothers regarding educational opportunities. Healthy Families Arizona Annual Evaluation Report 2012 40 • Maintain attention to recruiting and serving families during the prenatal period. Families that are enrolled during the prenatal period continue to have better birth outcomes than those that have not received Healthy Families Arizona services prior to birth. It is suggested, that the programs consider emphasizing enrollment efforts for families in the prenatal period. These strategies may need to be customized to the local community in order to most effectively reach families in the prenatal period. • Use the Site Profiles provided to the sites at the local level. The Site Profiles include the basic demographic information of the families served by each site that were included in the Annual Evaluation Report. These are the families that were actively engaged in receiving the Healthy Families Arizona program. The data can be used by the sites to share with board members, city councils, and other key stakeholders to emphasize the good work being done by the program and the needs of the families. • Review and update the program logic models and provide training in the core elements of the program logic model to sharpen focus on key program objectives and activities. Healthy Families Arizona developed comprehensive logic models for both the prenatal program and the postnatal program, to illustrate the key goals, objectives, activities, outputs, outcomes, and evaluation methods. Although many of the critical elements remain unchanged, it would be useful to re-examine if the models are depicting the program as currently implemented. These logic models can be distributed and used by all program staff to maintain focus on key aspects of the intervention model. Training for program staff can support the use of the logic model to maintain sharp focus on fidelity to the model. • Place increased focus on assuring timely immunizations and full immunization. While there has been an increase in the number of infants completing their immunizations at each time point this year compared to last year, the percent of 18 to 24 month olds with completed series of vaccinations has dropped. While this may be partially due to the continued economic situation where families are unable to obtain immunizations easily due to clinic closures, lack of transportation, and other reasons, it remains essential to the health of the Healthy Families Arizona Annual Evaluation Report 2012 41 child that immunizations be completed. The Family Support Specialists may need to place more emphasis on the importance of immunizations and may need to make additional referrals to local immunization clinics. • Continue to develop the Healthy Families system using “evidence-based” strategies to improve outcomes. Ongoing training and quality assurance efforts for Healthy Families should focus on using strategies that are evidence-based. Further, ongoing data collection, for example with the HFPI should be used for data-based decision making by selecting interventions and curriculum activities based on information obtained from assessment instruments like the HFPI. Ongoing use of evidence-based protocols can increase the effectiveness of the program. Healthy Families Arizona Annual Evaluation Report 2012 42 References Ahrens, Marty (2011). Smoke Alarms in U.S. Home Fires, National Fire Protection Association Fire Analysis and Research, Quincy, MA. September 2011. Barth, R.P. (1991). An experimental evaluation of in-home child abuse prevention services. Child Abuse & Neglect, 15, 363-375. Barth, R. (1999). Preventing child abuse and neglect with parent training: Evidence and opportunities. The Future of Children, 19, 95–118. 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. Glascoe FP, Dworkin PH. (1993). Obstacles to effective developmental surveillance: errors in clinical reasoning. 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Site Level Data  Age of Child at Entry by Site ..................................................................................... 48  Days  Top to Program Exit by Site ..................................................................................... 49 Four Reasons for Program Exit by Site............................................................. 50  Health  Late Insurance at Intake by Site ............................................................................ 51 or No Prenatal Care or Poor Compliance at Intake by Site .......................... 52  Ethnicity of Mother by Site Prenatal ......................................................................... 53  Ethnicity of Mother by Site Postnatal ....................................................................... 54  Gestational  Low Age by Site............................................................................................... 55 Birth Weight by Site ........................................................................................... 56  Yearly Income by Site ................................................................................................. 57  Mother’s Parent Survey Score by Site....................................................................... 58  Trimester  Engaged of Enrollment into Prenatal Program by Site ........................................ 59 Prenatal Families that Exited before Baby’s Birth by Site ..................... 60 Healthy Families Arizona Annual Evaluation Report 2012 47 Site Central Phoenix Maryvale East Valley Nogales Page Pima-Team 8 Pima-Team 9 Pima-Team 10 Pima-Team 11 Douglas / Sierra Vista Tuba City Yuma #15 Lake Havasu Flagstaff #1 Sunnyslope Prescott Mesa Pima- Team 27 Safford Winslow Kingman Bullhead City West Phoenix Flagstaff #2 Central Phoenix #1 Central Phoenix #2 North Phoenix SE/NE Maricopa Combo Phoenix South Phoenix SE Maricopa #7 SE Maricopa #8 Yuma #70 Total Age of Child at Entry by Site – 2012 (Age in Days) Mean Number (Age in Days) 44.46 43.32 42.35 12.13 9.00 28.47 27.43 29.27 31.56 21.44 14.83 17.18 21.09 39.05 44.55 18.20 49.95 33.55 24.52 12.26 24.10 28.95 37.90 34.40 38.33 43.95 40.37 54.94 35.77 46.39 36.29 29.26 19.17 33.83 71 90 68 30 3 59 72 45 86 41 35 62 47 20 104 81 91 44 23 23 31 73 88 10 60 74 59 66 61 44 58 77 78 1874 Standard Deviation 21.76 25.53 25.17 19.66 5.57 22.08 21.60 22.56 25.09 38.60 31.69 16.22 24.43 34.14 30.22 16.07 24.97 20.93 36.61 29.61 29.57 32.15 25.16 26.29 24.62 33.03 23.87 106.18 24.89 25.59 46.71 22.31 17.56 34.29 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 2012 48 Days to Program Exit by Site – 2012 (For families who left the program) Site Central Phoenix Maryvale East Valley Nogales Page Pima-Team 8 Pima-Team 9 Pima-Team 10 Pima-Team 11 Douglas / Sierra Vista Tuba City Yuma #15 Lake Havasu Flagstaff #1 Sunnyslope Prescott Mesa Pima- Team 27 Safford Winslow Kingman Bullhead City West Phoenix Flagstaff #2 Central Phoenix #1 Central Phoenix #2 North Phoenix SE/NE Maricopa Combo Phoenix South Phoenix SE Maricopa #7 SE Maricopa #8 Yuma #70 Total Prenatal Standard Median Mean Number Median Deviation 261.00 777.00 570.50 282.00 671.00 214.50 596.50 289.00 323.00 337.00 568.57 503.90 282.00 671.00 322.10 631.83 439.33 277.67 317.30 342.50 237.74 135.76 222.03 274.63 409.42 435.42 78.52 7 7 10 2 2 10 6 3 3 356.00 196.00 307.00 229.00 426.00 255.00 339.00 347.50 250.00 485.00 445.60 158.78 5 216.00 376.00 339.00 345.00 161.00 721.00 281.50 627.00 382.00 248.00 439.00 206.00 693.50 305.00 250.00 226.00 226.50 209.00 292.00 288.00 274.00 234.50 292.00 386.80 308.60 372.87 426.44 232.78 645.00 264.50 545.33 362.50 294.32 480.29 307.89 694.83 423.00 278.53 293.24 301.33 253.73 344.25 298.83 304.83 284.75 363.67 351.50 208.58 260.66 217.61 187.20 186.97 142.49 292.95 168.18 254.56 280.18 205.46 129.97 286.99 144.42 232.37 177.53 189.48 133.89 136.03 128.51 144.99 246.86 5 5 15 9 9 3 8 6 0 4 22 7 9 6 7 15 21 12 15 8 6 6 4 257 Healthy Families Arizona Annual Evaluation Report 2012 Postnatal Standard Mean Number Deviation 444.41 284.43 376.69 333.58 426.00 298.35 388.00 574.25 346.45 282.70 213.10 252.58 237.73 170.80 217.15 390.44 219.30 29 37 16 12 1 20 29 8 31 378.00 405.28 211.51 18 234.00 365.00 311.00 176.50 405.00 358.50 305.00 277.00 255.00 229.00 177.00 276.00 238.00 283.00 276.50 305.00 382.00 179.00 305.00 276.00 345.00 315.00 212.50 283.00 258.73 371.67 354.30 308.50 404.51 385.67 342.84 334.29 291.43 296.77 295.69 339.31 342.08 345.33 301.00 346.38 443.69 216.14 336.00 338.41 392.84 356.00 235.46 349.25 81.22 261.56 223.36 270.62 225.41 242.00 224.29 176.71 162.94 183.63 240.69 226.44 253.74 187.77 198.74 189.74 277.76 140.00 216.16 224.60 221.46 228.52 91.63 226.29 11 12 30 8 41 36 38 28 7 13 13 35 25 6 26 26 51 35 22 37 25 31 24 779 49 Top Four Reasons for Program Exit by Site – 2012 Percent and number within site Overall (Prenatal and Postnatal Combined) #1 Moved #2 Family #3 Did Not #4 Self Away Refused Respond to Sufficiency Further Outreach Site Services Efforts Central Phoenix Maryvale East Valley Nogales Page Pima-Team 8 Pima-Team 9 Pima-Team 10 Pima-Team 11 Douglas / Sierra Vista Tuba City Yuma #15 Lake Havasu Flagstaff #1 Sunnyslope Prescott Mesa Pima- Team 27 Safford Winslow Kingman Bullhead City West Phoenix Flagstaff #2 Central Phoenix #1 Central Phoenix #2 North Phoenix SE/NE Maricopa Combo Phoenix South Phoenix SE Maricopa #7 SE Maricopa #8 Yuma #70 Total % 9.1 4.6 5.3 14.6 12.5 6.1 5.4 4.8 7.1 14.6 9.3 15.0 16.4 11.5 6.7 13.8 7.1 9.6 10.3 16.7 18.4 17.9 6.2 31.6 3.7 9.4 9.8 13.5 11.4 5.7 7.9 2.1 9.4 9.5 n 8 5 5 6 1 5 5 3 7 7 5 12 12 6 8 12 8 5 3 6 14 17 7 6 3 10 8 12 10 3 6 2 8 235 % 3.4 10.1 1.1 9.8 12.5 1.2 10.9 1.6 11.2 4.2 9.3 1.2 4.1 11.5 9.2 11.5 7.1 13.5 3.4 2.8 13.2 7.4 3.5 0.0 12.2 3.8 7.3 7.9 10.2 24.5 2.6 20.0 7.1 7.9 n 3 11 1 4 1 1 10 1 11 2 5 1 3 6 11 10 8 7 1 1 10 7 4 0 10 4 6 7 9 13 2 19 6 195 Healthy Families Arizona Annual Evaluation Report 2012 % 5.7 3.7 5.3 4.9 0.0 14.6 12.0 0.0 6.1 18.8 7.4 2.5 9.6 0.0 9.2 8.0 10.6 11.5 3.4 11.1 0.0 5.3 6.2 5.3 9.8 4.7 8.5 4.5 6.8 20.8 2.6 4.2 5.9 7.0 n 5 4 5 2 0 12 11 0 6 9 4 2 7 0 11 7 12 6 1 4 0 5 7 1 8 5 7 4 6 11 2 4 5 173 % 10.2 3.7 5.3 0.0 0.0 0.0 1.1 3.2 2.0 0.0 0.0 1.2 13.7 3.8 9.2 2.3 2.7 7.7 0.0 11.1 2.6 3.2 7.1 0.0 1.2 2.8 4.9 16.9 4.5 0.0 15.8 6.3 8.2 5.0 n 9 4 5 0 0 0 1 2 2 0 0 1 10 2 11 2 3 4 0 4 2 3 8 0 1 3 4 15 4 0 12 6 7 125 50 Health Insurance at Intake by Site – 2012 Percent and number within Site* Site Central Phoenix Maryvale East Valley Nogales Page Pima-Team 8 Pima-Team 9 Pima-Team 10 Pima-Team 11 Douglas / Sierra Vista Tuba City Yuma #15 Lake Havasu Flagstaff #1 Sunnyslope Prescott Mesa Pima- Team 27 Safford Winslow Kingman Bullhead City West Phoenix Flagstaff #2 Central Phoenix #1 Central Phoenix #2 North Phoenix SE/NE Maricopa Combo Phoenix South Phoenix SE Maricopa #7 SE Maricopa #8 Yuma #70 Total None % n 5.9 5.3 14.8 0.0 0.0 9.1 0.0 6.2 0.0 1 1 4 0 0 2 0 1 0 16.7 5.9 11.1 3.8 3.1 0.0 20.1 9.1 0.0 0.0 0.0 11.4 9.5 0.0 0.0 9.1 9.7 13.0 8.7 3.7 0.0 11.1 5.6 0.0 6.6 PRENATAL AHCCCS % n Private % n None % n 88.2 89.5 70.4 100 80.0 81.8 84.2 87.5 90.9 15 17 19 9 4 18 16 14 10 5.9 5.3 7.4 0.0 20.0 9.1 10.5 6.2 9.1 1 1 2 0 1 2 2 1 1 5.6 4.5 7.5 6.7 0.0 1.8 2.8 2.3 3.5 4 4 5 2 0 1 2 1 3 1 83.3 5 0.0 0 0.0 1 2 1 1 0 1 2 0 0 0 5 2 0 0 2 3 3 2 1 0 2 1 0 39 88.2 77.8 88.5 87.5 100 80.0 90.9 100 100 100 65.9 90.5 88.0 100 90.9 87.1 78.3 69.6 85.2 100 77.8 77.8 100 84.7 15 14 23 28 15 4 20 8 6 12 29 19 22 9 20 27 18 16 23 9 14 14 7 499 0.0 0.0 7.7 9.4 0.0 0.0 0.0 0.0 0.0 0.0 22.7 0.0 4.0 0.0 0.0 0.0 8.7 21.7 7.4 0.0 11.1 11.1 0.0 6.8 0 0 2 3 0 0 0 0 0 0 10 0 1 0 0 0 2 5 2 0 2 2 0 40 0.0 3.4 4.3 5.0 3.8 5.0 6.6 2.3 4.3 4.3 6.5 1.4 6.8 10.0 3.4 8.1 3.4 7.6 3.3 4.5 5.2 5.2 4.0 4.5 POSTNATAL AHCCCS % n Private % n 88.7 92.1 83.6 90.0 100 84.2 88.7 95.5 83.5 63 82 56 27 3 48 63 42 71 5.6 3.4 9.0 3.3 0.0 10.5 8.5 2.3 12.9 4 3 6 1 0 6 6 1 11 0 85.4 35 12.2 5 0 2 2 1 4 4 6 1 1 1 2 1 6 1 2 6 2 5 2 2 3 4 3 83 97.1 96.6 89.1 90.0 89.4 80.0 82.4 90.9 82.6 91.3 83.9 91.8 89.8 90.0 93.2 86.5 91.5 80.3 86.9 88.6 79.3 92.2 94.7 88.2 34 57 41 18 93 64 75 40 19 21 26 67 79 9 55 64 54 53 53 39 46 71 71 1639 2.9 0.0 2.2 5.0 6.7 13.8 11.0 4.5 13.0 0.0 9.7 6.8 3.4 0.0 1.7 5.4 3.4 12.1 8.2 6.8 15.5 2.6 1.3 6.7 1 0 1 1 7 11 10 2 3 0 3 5 3 0 1 4 2 8 5 3 9 2 1 125 *”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 2012 51 Late or No Prenatal Care or Poor Compliance at Intake 2012 by Site Percent and number ( ) within Site Did the mother have late or no prenatal care or poor compliance with prenatal care? PRENATAL POSTNATAL Site Yes No Unknown Yes No Unknown Central Phoenix 35.3% (6) 64.7% (1) 0.0% (0) 36.6% (26) 62.0% (44) 1.4% (1) Maryvale 31.6% (6) 68.4% (13) 0.0% (0) 40.0% (36) 60.0% (54) 0.0% (0) East Valley 14.8% (4) 85.2% (23) 0.0% (0) 45.6% (31) 54.4% (34) 0.0% (0) Nogales 22.2% (2) 77.8% (7) 0.0% (0) 31.0% (9) 62.1% (18) 6.9% (2) Page 20.0% (1) 80.0% (4) 0.0% (0) 66.7% (2) 33.3% (1) 0.0% (0) Pima-Team 8 22.7% (5) 77.3% (17) 0.0% (0) 25.4% (15) 74.6% (44) 0.0% (0) Pima-Team 9 15.0% (3) 85.0% (17) 0.0% (0) 22.2% (16) 77.8% (56) 0.0% (0) Pima-Team 10 29.4% (5) 70.6% (12) 0.0% (0) 24.4% (11) 75.6% (34) 0.0% (0) Pima-Team 11 25.0% (3) 75.0% (9) 0.0% (0) 22.1% (19) 77.9% (67) 0.0% (0) Douglas / 14.3% (1) 85.7% (6) 0.0% (0) 24.4% (10) 75.6% (34) 0.0% (0) Sierra Vista Tuba City 26.3% (5) 73.7% (14) 0.0% (0) 28.6% (10) 62.9% (22) 8.6% (3) Yuma #15 50.0% (9) 50.0% (9) 0.0% (0) 43.5% (27) 56.5% (35) 0.0% (0) Lake Havasu 11.5% (3) 76.9% (20) 11.5% (3) 19.1% (9) 66.0% (31) 14.9% (7) Flagstaff #1 16.1% (5) 83.9% (26) 0.0% (0) 10.0% (2) 85.0% (17) 5.0% (1) Sunnyslope 13.3% (2) 86.7% (13) 0.0% (0) 27.2% (28) 72.8% (75) 0.0% (0) Prescott 20.0% (1) 60.0% (3) 20.0% (1) 55.7% (44) 43.0% (34) 1.3% (1) Mesa 31.8% (7) 68.2% (15) 0.0% (0) 38.5% (35) 61.5% (56) 0.0% (0) Pima- Team 27 12.5% (1) 87.5% (7) 0.0% (0) 22.7% (10) 77.3% (34) 0.0% (0) Safford 33.3% (2) 66.7% (4) 0.0% (0) 4.3% (1) 73.9% (17) 21.7% (5) Winslow 30.8% (4) 69.2% (9) 0.0% (0) 17.4% (4) 82.6% (19) 0.0% (0) Kingman 13.3% (6) 80.0% (36) 6.7% (3) 29.0% (9) 71.0% (22) 0.0% (0) Bullhead City 40.0% (8) 55.0% (11) 5.0% (1) 42.5% (31) 54.8% (40) 2.7% (2) West Phoenix 20.0% (5) 80.0% (20) 0.0% (0) 28.4% (25) 71.6% (63) 0.0% (0) Flagstaff #2 22.2% (2) 77.8% (7) 0.0% (0) 40.0% (4) 60.0% (6) 0.0% (0) Central Phoenix #1 28.6% (6) 71.4% (15) 0.0% (0) 41.7% (25) 58.3% (35) 0.0% (0) Central Phoenix #2 21.9% (7) 78.1% (25) 0.0% (0) 34.2% (25) 63.0% (46) 2.7% (2) North Phoenix 26.1% (6) 73.9% (17) 0.0% (0) 40.7% (24) 59.3% (35) 0.0% (0) SE/NE Maricopa 21.7% (5) 78.3% (18) 0.0% (0) 25.8% (17) 74.2% (49) 0.0% (0) Combo Phoenix 18.5% (5) 81.5% (22) 0.0% (0) 42.6% (26) 57.4% (35) 0.0% (0) South Phoenix 33.3% (3) 66.7% (6) 0.0% (0) 25.0% (11) 75.0% (33) 0.0% (0) SE Maricopa #7 29.4% (5) 70.6% (12) 0.0% (0) 29.3% (17) 70.7% (41) 0.0% (0) SE Maricopa #8 35.3% (6) 64.7% (11) 0.0% (0) 41.6% (32) 57.1% (44) 1.3% (1) Yuma #70 42.9% (3) 57.1% (4) 0.0% (0) 38.5% (30) 61.5% (48) 0.0% (0) Total 23.9% 74.7% 1.3% 33.2% 65.4% 1.3% (142) (443) (8) (621) (1223) (25) Healthy Families Arizona Annual Evaluation Report 2012 52 Site Central Phoenix Maryvale East Valley Nogales Page Pima-Team 8 Pima-Team 9 Pima-Team 10 Pima-Team 11 Douglas / Sierra Vista Tuba City Yuma #15 Lake Havasu Flagstaff #1 Sunnyslope Prescott Mesa Pima- Team 27 Safford Winslow Kingman Bullhead City West Phoenix Flagstaff #2 Central Phoenix #1 Central Phoenix #2 North Phoenix SE/NE Maricopa Combo Phoenix South Phoenix SE Maricopa #7 SE Maricopa #8 Yuma #70 Total Ethnicity of Mother by Site PRENATAL – 2012 Percent and number within Site Caucasian/ White % n Hispanic % n 5.9 27.8 33.3 11.1 0.0 21.1 30.0 5.9 33.3 1 5 9 1 0 4 6 1 4 70.6 50.0 40.7 88.9 0.0 68.4 55.0 88.2 66.7 12 9 11 8 0 13 11 15 8 14.3 1 85.7 0.0 11.1 73.1 22.6 61.5 33.3 21.1 50.0 33.3 23.1 89.2 72.7 20.0 0.0 13.6 18.8 42.1 40.9 24.0 11.1 44.8 50.0 0.0 32.5 0 2 19 7 8 2 4 4 2 3 33 16 5 0 3 6 8 9 6 1 4 9 0 187 0.0 77.8 19.2 54.8 38.5 66.7 73.7 25.0 66.7 23.1 5.4 13.6 64.0 55.6 59.1 50.0 47.4 36.4 48.0 88.9 50.0 38.9 85.7 47.8 African American % n 17.6 16.7 14.8 0.0 0.0 5.3 0.0 5.9 0.0 3 3 4 0 0 1 0 1 0 6 0.0 0 14 5 17 5 4 14 2 4 3 2 3 16 5 13 16 9 8 12 8 9 7 6 275 0.0 5.6 0.0 0.0 0.0 0.0 5.3 0.0 0.0 0.0 0.0 9.1 12.0 0.0 22.7 25.0 10.5 22.7 16.0 0.0 0.0 5.6 0.0 7.7 Asian American % n 0.0 0.0 0.0 0.0 0.0 0.0 5.0 0.0 0.0 0 0 0 0 0 0 1 0 0 0 0.0 0 1 0 0 0 0 1 0 0 0 0 2 3 0 5 8 2 5 4 0 0 1 0 44 0.0 0.0 7.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.7 0.0 0.0 0.0 0.0 3.1 0.0 0.0 0.0 0.0 0.0 5.6 0.0 1.0 Healthy Families Arizona Annual Evaluation Report 2012 Native American % n Mixed/ Other % n 5.9 0.0 7.4 0.0 100 5.3 10.0 0.0 0.0 1 0 2 0 5 1 2 0 0 0.0 5.6 3.7 0.0 0.0 0.0 0.0 0.0 0.0 0 1 1 0 0 0 0 0 0 0 0.0 0 0.0 0 0 0 2 0 0 0 0 0 0 0 1 0 0 0 0 1 0 0 0 0 0 1 0 6 100 5.6 0.0 22.6 0.0 0.0 0.0 25.0 0.0 53.8 2.7 0.0 0.0 44.4 0.0 3.1 0.0 0.0 12.0 0.0 0.0 0.0 14.3 9.9 19 1 0 7 0 0 0 2 0 7 1 0 0 4 0 1 0 0 3 0 0 0 1 57 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 4.5 4.0 0.0 4.5 0.0 0.0 0.0 0.0 0.0 5.6 0.0 0.0 1.0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 1 0 0 0 0 0 1 0 0 6 53 Site Central Phoenix Maryvale East Valley Nogales Page Pima-Team 8 Pima-Team 9 Pima-Team 10 Pima-Team 11 Douglas / Sierra Vista Tuba City Yuma #15 Lake Havasu Flagstaff #1 Sunnyslope Prescott Mesa Pima- Team 27 Safford Winslow Kingman Bullhead City West Phoenix Flagstaff #2 Central Phoenix #1 Central Phoenix #2 North Phoenix SE/NE Maricopa Combo Phoenix South Phoenix SE Maricopa #7 SE Maricopa #8 Yuma #70 Total Ethnicity of Mother by Site POSTNATAL – 2012 Percent and number within Site Caucasian/ White % n Hispanic % n 28.6 11.8 18.2 0.0 0.0 15.3 29.2 6.8 32.5 20 10 12 0 0 9 21 3 27 52.9 78.8 69.7 100 0.0 81.4 68.1 75.0 48.2 37 67 46 30 0 48 49 33 40 36.6 15 53.7 0.0 3.2 63.0 20.0 38.5 71.2 28.9 35.7 52.2 17.4 76.7 74.0 15.9 10.0 24.1 11.3 38.6 42.9 28.8 4.5 39.3 23.7 15.8 29.4 0 2 29 4 40 57 26 15 12 4 23 54 14 1 14 8 22 27 17 2 22 18 12 540 0.0 96.8 30.4 60.0 49.0 22.5 54.4 50.0 47.8 8.7 16.7 19.2 69.3 30.0 65.5 62.0 47.4 46.0 54.2 84.1 50.0 68.4 80.3 56.6 African American % n 11.4 7.1 7.6 0.0 0.0 1.7 1.4 4.5 8.4 8 6 5 0 0 1 1 2 7 22 2.4 0 60 14 12 51 18 49 21 11 2 5 14 61 3 38 44 27 29 32 37 28 52 61 1041 0.0 0.0 2.2 5.0 9.6 0.0 5.6 9.5 0.0 0.0 3.3 2.7 10.2 0.0 3.4 16.9 3.5 3.2 6.8 11.4 8.9 1.3 3.9 5.4 Asian American % n 0.0 1.2 1.5 0.0 0.0 0.0 0.0 4.5 4.8 0 1 1 0 0 0 0 2 4 1 2.4 0 0 1 1 10 0 5 4 0 0 1 2 9 0 2 12 2 2 4 5 5 1 3 100 0.0 0.0 0.0 0.0 0.0 2.5 1.1 2.4 0.0 0.0 0.0 1.4 0.0 0.0 0.0 1.4 5.3 3.2 1.7 0.0 0.0 0.0 0.0 1.1 Healthy Families Arizona Annual Evaluation Report 2012 Native American % n Mixed/ Other % n 7.1 1.2 1.5 0.0 100 1.7 1.4 6.8 4.8 5 1 1 0 3 1 1 3 4 0.0 0.0 1.5 0.0 0.0 0.0 0.0 2.3 1.2 0 0 1 0 0 0 0 1 1 1 2.4 1 2.4 1 0 0 0 0 0 2 1 1 0 0 0 1 0 0 0 1 3 2 1 0 0 0 0 21 100 0.0 4.3 15.0 2.9 2.5 8.9 2.4 0.0 65.2 3.3 1.4 2.3 60.0 5.2 7.0 5.3 3.2 8.5 0.0 1.8 6.6 0.0 6.7 35 0 2 3 3 2 8 1 0 15 1 1 2 6 3 5 3 2 5 0 1 5 0 123 0.0 0.0 0.0 0.0 0.0 1.2 1.1 0.0 0.0 8.7 0.0 1.4 2.3 0.0 1.7 1.4 0.0 1.6 0.0 0.0 0.0 0.0 0.0 0.8 0 0 0 0 0 1 1 0 0 2 0 1 2 0 1 1 0 1 0 0 0 0 0 14 54 Gestational Age by Site – 2012 (Number and Percent within Site) Was the gestational age less than 37 weeks? Site Central Phoenix Maryvale East Valley Nogales Page Pima-Team 8 Pima-Team 9 Pima-Team 10 Pima-Team 11 Douglas / Sierra Vista Tuba City Yuma #15 Lake Havasu Flagstaff #1 Sunnyslope Prescott Mesa Pima- Team 27 Safford Winslow Kingman Bullhead City West Phoenix Flagstaff #2 Central Phoenix #1 Central Phoenix #2 North Phoenix SE/NE Maricopa Combo Phoenix South Phoenix SE Maricopa #7 SE Maricopa #8 Yuma #70 Total % No PRENATAL n % 60.0 90.9 90.0 100 100 89.5 90.9 84.6 87.5 6 10 18 5 5 17 10 11 7 40.0 9.1 10.0 0.0 0.0 10.5 9.1 15.4 12.5 100 2 100 100 85.7 86.4 100 75.0 90.9 42.9 80.0 100 95.5 90.9 100 87.5 100 90.5 92.9 60.0 89.5 50.0 92.3 100 80.0 88.5 13 13 18 19 10 3 10 3 4 9 21 10 20 7 9 19 13 9 17 4 12 17 4 355 Yes n POSTNATAL No Yes % n % n 4 1 2 0 0 2 1 2 1 80.3 79.5 86.6 93.3 100 89.8 87.1 88.9 83.5 57 70 58 28 3 53 61 40 71 19.7 20.5 13.4 6.7 0.0 10.2 12.9 11.1 16.5 14 18 9 2 0 6 9 5 14 0.0 0 78.9 30 21.1 8 0.0 0.0 14.3 13.6 0.0 25.0 9.1 57.1 20.0 0.0 4.5 9.1 0.0 12.5 0.0 9.5 7.1 40.0 10.5 50.0 7.7 0.0 20.0 11.5 0 0 3 3 0 1 1 4 1 0 1 1 0 1 0 2 1 6 2 4 1 0 1 46 92.6 88.3 90.9 88.9 71.3 96.2 84.4 80.5 68.2 91.3 92.0 87.5 80.5 70.0 68.3 70.3 77.6 81.8 84.7 88.4 81.0 86.7 93.5 83.6 25 53 40 16 72 77 76 33 15 21 23 56 70 7 41 52 45 54 50 38 47 65 72 1519 7.4 11.7 9.1 11.1 28.7 3.8 15.6 19.5 31.8 8.7 8.0 12.5 19.5 30.0 31.7 29.7 22.4 18.2 15.3 11.6 19.0 13.3 6.5 16.4 2 7 4 2 29 3 14 8 7 2 2 8 17 3 19 22 13 12 9 5 11 10 5 299 Healthy Families Arizona Annual Evaluation Report 2012 55 Low Birth Weight by Site – 2012 (Number and Percent within Site) Did the child have low birth weight? (less than 2500 grams, 88 ounces, or 5.5 pounds) Site Central Phoenix Maryvale East Valley Nogales Page Pima-Team 8 Pima-Team 9 Pima-Team 10 Pima-Team 11 Douglas / Sierra Vista Tuba City Yuma #15 Lake Havasu Flagstaff #1 Sunnyslope Prescott Mesa Pima- Team 27 Safford Winslow Kingman Bullhead City West Phoenix Flagstaff #2 Central Phoenix #1 Central Phoenix #2 North Phoenix SE/NE Maricopa Combo Phoenix South Phoenix SE Maricopa #7 SE Maricopa #8 Yuma #70 Total % No PRENATAL n % 75.0 100 85.0 100 100 100 100 91.7 100 9 10 17 4 5 17 12 11 8 25.0 0.0 15.0 0.0 0.0 0.0 0.0 8.3 0.0 100 2 100 100 75.0 94.7 100 100 90.0 57.1 100 100 91.3 100 93.3 77.8 100 88.9 92.3 78.6 94.7 33.3 91.7 92.9 80.0 90.5 12 14 12 18 7 3 9 4 5 7 21 10 14 7 9 16 12 11 18 2 11 13 4 334 Yes n POSTNATAL No Yes % n % n 3 0 3 0 0 0 0 1 0 80.9 82.6 86.4 89.7 100 91.2 89.9 88.6 89.4 55 71 57 26 3 52 62 39 76 19.1 17.4 13.6 10.3 0.0 8.8 10.1 11.4 10.6 13 15 9 3 0 5 7 5 9 0.0 0 80.0 32 20.0 8 0.0 0.0 25.0 5.3 0.0 0.0 10.0 42.9 0.0 0.0 8.7 0.0 6.7 22.2 0.0 11.1 7.7 21.4 5.3 66.7 8.3 7.1 20.0 9.5 0 0 4 1 0 0 1 3 0 0 2 0 1 2 0 2 1 3 1 4 1 1 1 35 93.9 95.0 86.7 89.5 73.8 93.8 86.8 83.7 71.4 91.3 93.3 90.1 85.2 80.0 78.0 74.3 81.0 80.0 85.2 90.9 89.5 90.8 97.3 86.2 31 57 39 17 76 75 79 36 15 21 28 64 75 8 46 52 47 52 52 40 51 69 71 1574 6.1 5.0 13.3 10.5 26.2 6.2 13.2 16.3 28.6 8.7 6.7 9.9 14.8 20.0 22.0 25.7 19.0 20.0 14.8 9.1 10.5 9.2 2.7 13.8 2 3 6 2 27 5 12 7 6 2 2 7 13 2 13 18 11 13 9 4 6 7 2 253 Healthy Families Arizona Annual Evaluation Report 2012 56 Yearly Income by Site – 2012 Site Central Phoenix Maryvale East Valley Nogales Page Pima-Team 8 Pima-Team 9 Pima-Team 10 Pima-Team 11 Douglas / Sierra Vista Tuba City Yuma #15 Lake Havasu Flagstaff #1 Sunnyslope Prescott Mesa Pima- Team 27 Safford Winslow Kingman Bullhead City West Phoenix Flagstaff #2 Central Phoenix #1 Central Phoenix #2 North Phoenix SE/NE Maricopa Combo Phoenix South Phoenix SE Maricopa #7 SE Maricopa #8 Yuma #70 Total PRENATAL Median Number Yearly Income $0 17 $14,400 19 $0 27 $18,000 9 $8,400 5 $3,360 22 $0 20 $0 17 $0 12 $3,600 7 $6,000 19 $6,214 18 $14,400 26 $10,800 32 $11,400 15 $0 6 $8,976 22 $3,864 8 $6,600 6 $8,340 13 $12,000 45 $6,000 22 $12,000 25 $7,560 9 $4,722 22 $ 5,940 32 $10,200 23 $7,200 23 $12,000 27 $8,088 9 $13,800 18 $1,980 18 $1,440 7 $7,800 600 Healthy Families Arizona Annual Evaluation Report 2012 POSTNATAL Median Number Yearly Income $12,000 71 $9,600 90 $10,000 68 $7,000 30 $18,000 3 $0 59 $2,640 72 $4,800 45 $955 86 $11,592 41 $5,280 35 $8,214 62 $14,400 47 $2,400 20 $8,724 104 $0 81 $12,000 91 $550 44 $10,000 23 $6,300 23 $9,600 31 $8,400 73 $9,900 88 $14,200 10 $12,000 60 $11,400 74 $12,720 59 $7,200 66 $12,000 61 $12,000 44 $8,706 58 $12,000 77 $9,600 78 $9,600 1874 57 Mother’s Parent Survey Score by Site – 2012 Site Central Phoenix Maryvale East Valley Nogales Page Pima-Team 8 Pima-Team 9 Pima-Team 10 Pima-Team 11 Douglas / Sierra Vista Tuba City Yuma #15 Lake Havasu Flagstaff #1 Sunnyslope Prescott Mesa Pima- Team 27 Safford Winslow Kingman Bullhead City West Phoenix Flagstaff #2 Central Phoenix #1 Central Phoenix #2 North Phoenix SE/NE Maricopa Combo Phoenix South Phoenix SE Maricopa #7 SE Maricopa #8 Yuma #70 Total 0 – 20 PRENATAL 25 – 40 45 – 65 70+ 0 – 20 POSTNATAL 25 – 40 45 – 65 70+ 0.0% 47.1% 47.1% 5.9% 1.4% 29.6% 62.0% 7.0% 0.0% 0.0% 11.1% 0.0% 0.0% 0.0% 0.0% 8.3% 47.4% 25.9% 55.6% 20.0% 50.0% 20.0% 52.9% 33.3% 36.8% 74.1% 33.3% 80.0% 36.4% 70.0% 47.1% 58.3% 15.8% 0.0% 0.0% 0.0% 13.6% 10.0% 0.0% 0.0% 0.0% 1.5% 6.7% 0.0% 3.4% 5.6% 13.3% 8.1% 27.8% 38.2% 93.3% 100% 71.2% 43.1% 64.4% 58.1% 62.2% 52.9% 0.0% 0.0% 22.0% 45.8% 22.2% 30.2% 10.0% 7.4% 0.0% 0.0% 3.4% 5.6% 0.0% 3.5% 0.0% 57.1% 42.9% 0.0% 9.8% 41.5% 43.9% 4.9% 21.1% 22.2% 7.7% 3.1% 0.0% 0.0% 9.1% 12.5% 0.0% 0.0% 2.2% 0.0% 0.0% 0.0% 57.9% 44.4% 69.2% 59.4% 33.3% 33.3% 22.7% 50.0% 83.3% 7.7% 20.0% 27.3% 52.0% 55.6% 21.1% 27.8% 19.2% 37.5% 60.0% 33.3% 63.6% 37.5% 16.7% 53.8% 66.7% 59.1% 44.0% 44.4% 0.0% 5.6% 3.8% 0.0% 6.7% 33.3% 4.5% 0.0% 0.0% 38.5% 11.1% 13.6% 4.0% 0.0% 5.7% 6.5% 10.6% 10.0% 1.0% 0.0% 0.0% 6.8% 13.0% 8.7% 6.5% 4.1% 0.0% 0.0% 82.9% 75.8% 57.4% 45.0% 26.0% 67.9% 25.3% 31.8% 60.9% 26.1% 19.4% 38.4% 51.1% 50.0% 11.4% 17.7% 31.9% 35.0% 49.0% 29.6% 61.5% 56.8% 26.1% 60.9% 64.5% 52.1% 44.3% 40.0% 0.0% 0.0% 0.0% 10.0% 24.0% 2.5% 13.2% 4.5% 0.0% 4.3% 9.7% 5.5% 4.5% 10.0% 0.0% 45.5% 45.5% 9.1% 0.0% 20.0% 68.3% 11.7% 0.0% 31.2% 56.2% 12.5% 0.0% 24.3% 64.9% 10.8% 0.0% 21.7% 69.6% 8.7% 1.7% 42.4% 44.1% 11.9% 4.3% 26.1% 65.2% 4.3% 0.0% 28.8% 56.1% 15.2% 3.7% 51.9% 44.4% 0.0% 1.6% 29.5% 60.7% 8.2% 0.0% 33.3% 66.7% 0.0% 0.0% 38.6% 54.5% 6.8% 0.0% 27.8% 61.1% 11.1% 0.0% 53.4% 39.7% 6.9% 0.0% 33.3% 44.4% 22.2% 0.0% 37.7% 58.4% 3.9% 0.0% 3.2% 57.1% 39.3% 42.9% 50.2% 0.0% 7.3% 11.5% 3.5% 55.1% 43.7% 30.8% 45.6% 2.6% 7.2% Healthy Families Arizona Annual Evaluation Report 2012 58 Trimester of Enrollment into Prenatal Program by Site - 2012 Site Central Phoenix Maryvale East Valley Nogales Page Pima-Team 8 Pima-Team 9 Pima-Team 10 Pima-Team 11 Douglas / Sierra Vista Tuba City Yuma #15 Lake Havasu Flagstaff #1 Sunnyslope Prescott Mesa Pima- Team 27 Safford Winslow Kingman Bullhead City West Phoenix Flagstaff #2 Central Phoenix #1 Central Phoenix #2 North Phoenix SE/NE Maricopa Combo Phoenix South Phoenix SE Maricopa #7 SE Maricopa #8 Yuma #70 Total 1st Trimester # % 0 2 0 1 1 4 2 4 3 0.0 10.5 0.0 11.1 20.0 18.2 10.0 23.5 25.0 2 2 0 1 5 1 1 1 0 0 1 19 2 0 0 2 2 4 2 2 1 2 3 0 70 2nd Trimester # % 5 7 9 5 1 6 5 4 4 29.4 36.8 33.3 55.6 20.0 27.3 25.0 23.5 33.3 28.6 2 10.5 0.0 3.8 15.6 6.7 16.7 4.5 0.0 0.0 7.7 42.2 9.1 0.0 0.0 9.1 6.2 17.4 8.7 7.4 11.1 11.1 16.7 0.0 11.7 7 8 7 9 2 2 11 2 3 4 12 7 11 4 8 14 4 4 10 2 3 2 1 185 3rd Trimester # % 0 0 0 0 0 1 1 1 1 % 0.0 0.0 0.0 0.0 0.0 4.5 5.0 5.9 8.3 Total # # Other 12 10 18 3 3 11 12 8 4 70.6 52.6 66.7 33.3 60.0 50.0 60.0 47.1 33.3 28.6 3 42.9 0 0.0 7 36.8 44.4 26.9 28.1 13.3 33.3 50.0 25.0 50.0 30.8 26.7 31.8 44.0 44.4 36.4 43.8 17.4 17.4 37.0 22.2 16.7 11.1 14.3 30.8 7 9 18 17 9 3 9 6 3 5 6 11 14 5 12 15 14 17 13 6 13 13 5 314 36.8 50.0 69.2 53.1 60.0 50.0 40.9 75.0 50.0 38.5 13.3 50.0 56.0 55.6 54.5 46.9 60.9 73.9 48.1 66.7 72.2 72.2 71.4 52.3 3 1 0 1 3 0 1 0 0 3 8 2 0 0 0 1 1 0 2 0 0 0 1 31 15.8 5.6 0.0 3.1 20.0 0.0 4.5 0.0 0.0 23.1 17.8 9.1 0.0 0.0 0.0 3.1 4.3 0.0 7.4 0.0 0.0 0.0 14.3 5.2 19 18 26 32 15 6 22 8 6 13 45 22 25 9 22 32 23 23 27 9 18 18 7 600 Healthy Families Arizona Annual Evaluation Report 2012 17 19 27 9 5 22 20 17 12 59 Engaged Prenatal Families that Exited Before Baby’s Birth By Site – 2012 # Closed Total % Closed Site before Families before birth birth Central Phoenix Maryvale East Valley Nogales Page Pima-Team 8 Pima-Team 9 Pima-Team 10 Pima-Team 11 Douglas / Sierra Vista Tuba City Yuma #15 Lake Havasu Flagstaff #1 Sunnyslope Prescott Mesa Pima- Team 27 Safford Winslow Kingman Bullhead City West Phoenix Flagstaff #2 Central Phoenix #1 Central Phoenix #2 North Phoenix SE/NE Maricopa Combo Phoenix South Phoenix SE Maricopa #7 SE Maricopa #8 Yuma #70 Total 17 19 27 9 5 22 20 17 12 7 19 18 26 32 15 6 22 8 6 13 45 22 25 9 22 32 23 23 27 9 18 18 7 600 Healthy Families Arizona Annual Evaluation Report 2012 1 0 0 0 0 1 0 0 0 0 0 1 1 1 3 0 1 0 0 0 9 0 0 0 0 1 2 0 2 0 0 0 0 23 5.9 0.0 0.0 0.0 0.0 4.5 0.0 0.0 0.0 0.0 0.0 5.6 3.8 3.1 20.0 0.0 4.5 0.0 0.0 0.0 20.0 0.0 0.0 0.0 0.0 3.1 8.7 0.0 7.4 0.0 0.0 0.0 0.0 3.8 60 Appendix B. Healthy Families Arizona Steering Committee Members Janice Mickens Jenna Shroyer Esthela Navarro Department of Economic Security, Healthy Families Arizona Central Administration Julie Rosen Parenting Arizona K Vilay Michele Katona First Things First Beth Rosenberg Children’s Action Alliance Craig LeCroy Kerry Milligan LeCroy & Milligan Associates Becky Ruffner Mary Warren Prevent Child Abuse Arizona Judy Krysik Arizona State University Marsha Porter Phoenix Crisis Nursery Ginger Ward Suzanne Schunk Southwest Human Development Joanne M. Karolzak Casa de los Ninos Ellie Jimenez Eric Schindler Child and Family Resources Mary Ellen Cunningham Laura Gestaut Department of Health Service Stacy Reinstein Department of Economic Security Healthy Families Arizona Annual Evaluation Report 2012 61 Appendix C. 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 0, 5, or 10 Interpretation/ Administration The Parent Survey comprises a 10-item rating 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) Families Arizona Program. A family is considered eligible to receive 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 prior to enrollment through an interview by a Family Assessment Worker from the Healthy 6. Anger Management Skills (e.g., Potential for violence) 9. Perception of New Infant is administered to the mother and father 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 2012 63 Appendix D. Healthy Families Arizona Prenatal Logic Model Long Term Outcom es P rogram R esources ∈ 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 Increase the family’s support network Assess family’s support systems Model relationship skills Foster connections to positive support sources Increase parents’ health behaviors Increase the family members’ problem solving skills Improve nutrition Identify signs and history of depression, abuse, mental illness, substance abuse Assess personal risk behaviors Identify major life stressors Educate and provide materials on nutrition during pregnancy, buying and choosing healthy foods, and requirements for healthy fetal development Review history of birthing Encourage medical assessment, referral and treatment if needed Encourage exercise, personal care, rest Educate on post partum depression H.F. Parenting InventoryPrenatal (HFPIP); FSS-23 Prenatal Program Objectives Improve mother’s mental health HFPIP; FSS-23 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 HFPIP; FSS23; CRAFFT Increase empathy for the unborn baby Program Activities and Strategies 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 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 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 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 HFPIP; FSS-23 Healthy Families Arizona Annual Evaluation Report 2012 HFPIP; FSS-23 HFPIP; FSS-23; father involvement scale HFPIP; FSS-23 64 HFPIP; FSS-23; Safety checklist HFPIP; FSS-23; FSS20P Appendix E. Healthy Families Arizona Postnatal Logic Model Long Term Outcom es Program Resources ∈ Reduced child abuse and neglect ∉ Increased child wellness and development ∠ Strengthened family relations ∇ Enhanced family unity  Reduced abuse of drugs and alcohol 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 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 post- partum depression Healthy Families Parenting Inventory (HFPI); FSS-23 HFPI; FSS-23 Educate on community resources Explore domestic violence, create safety plan 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 Postnatal Program Objectives Increase the family members’ problem solving skills Improve family stability Increase parental competence Program Activities and Strategies 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 Increase positive parent-child interaction 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 Refer to parenting groups and classes Encourage family activities, celebrations Coach on father involvement Improve child health and Optimize child development 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 Prevent child abuse and neglect 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 HFPI; FSS-23; CRAFFT HFPI; FSS-23 Healthy Families Arizona Annual Evaluation Report 2012 HFPI; FSS-23 HFPI; FSS-23; father involvement scale HFPI; FSS-23 65 HFPI; FSS-23; Safety checklist; ASQ HFPI; FSS-23; FSS20