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Implementing Family Spirit®

Meets DHHS criteria for an evidenced based model Meets DHHS criteria for an evidenced based model in tribal populations

Implementation Experiences

Last Updated

May 2016


Summary of Sources

Information in this section is based on studies included in the HomVEE review. For Family Spirit, we reviewed four randomized controlled trial (RCT) studies. (Please see the study database for a list of the studies.)

Three of the RCTs examined the same sample of participants. As a result of this overlap, we refer to these as only one study throughout the rest of this section.


Characteristics of Model Participants

Family Spirit serves young Native American mothers from the time they are pregnant until the child’s third birthday. One study enrolled 86 mothers into the Family Spirit intervention and the other enrolled 159 mothers. All participants across both studies were Native American mothers who were 18 years old, on average. In one study, 24 percent of participants spoke only their native language in the home.

Nearly all of the women in both studies were unmarried (94 and 96 percent, respectively). In one study, 41 percent of the mothers had completed high school, a general equivalency diploma, or some college and 13 percent were currently employed. In the other study, 40 percent of the mothers were in school, 27 percent had completed high school or a general equivalency diploma, and 8 percent of the mothers were employed. Almost half (48 percent) of the women had lived in two or more homes within the past year, 7 percent did not have electricity in their home, and 9 percent did not have indoor plumbing (one study).

Some of the women had one or more children (23 and 9 percent, respectively), and according to one of the studies, 19 percent of the pregnancies were planned. Most mothers (67 and 77 percent, respectively) lived with their parents or the baby’s father’s parents. Most fathers (73 percent) were also living with the mothers, and 12 percent of women lived with their baby’s father apart from their own parents (one study). In addition, during pregnancy, 18 percent of mothers used alcohol, 23 percent used cigarettes, 14 percent used marijuana, and 37 percent of the women exhibited depressive symptoms (one study).

Participation in the Family Spirit program was voluntary (both studies).


Location and Setting

The intervention was implemented in four rural, southwestern tribal communities: the Navajo Reservation in New Mexico (one study) the White Mountain Apache Reservation in Arizona (both studies), the San Carlos Apache Reservation in Arizona, and the Tuba City and Fort Defiance communities on the Navajo Reservation in Arizona (one study).

Neither study included information on the type of implementing agencies.


Staffing and Supervision

Family Spirit was implemented by Native American paraprofessional home visitors, also called family health educators, from the participants’ communities (both studies). Home visitors in one study were bilingual speakers of their native language and English, had at least a high school degree, and had experience delivering health or human service programs. Neither study described the backgrounds of the supervisors.

Home visitors participated in more than 80 hours of pre-service training and had to pass written and oral tests on the curriculum (both studies). The studies did not provide information about training for supervisors.

Supervisors observed home visits quarterly (both studies) and reviewed audio-recordings of 20 percent of visits (one study). The supervisors assessed the home visitors’ professionalism, the quality of the relationship between the home visitor and the family, and the home visitors’ adherence to the curriculum (one study). Supervision also entailed reviews of session summary forms, which home visitors completed following each visit with information on the lessons completed, successes, and challenges (both studies).

Neither study included information on home visitors’ caseloads or the ratio of supervisors to home visitors.


Model Components

In the earlier study, the program consisted of 25 one-hour home visits starting at about 28 weeks gestation until six months postpartum. In the later study, the program consisted of 43 one-hour home visits. Visits were weekly throughout the participant’s pregnancy, biweekly after the child’s birth until the child reached four months of age, monthly from 4 to 12 months, and bimonthly from 12 to 36 months of age. The curriculum covered parenting skills, infant development, and maternal psychosocial development. Home visitors used illustrated charts to deliver the Family Spirit curriculum (both studies).

The studies did not include information on assessments administered as part of the intervention or whether the program materials were available in languages other than English.


Model Adaptations or Enhancements

Neither study identified model adaptations or enhancements.



In the earlier study, which reported that the program was offered until six months postpartum, 80 percent of participants completed the expected number of home visits. The later study, in which the program was offered until the child was 36 months, reported that 74 percent of participants completed at least half of the expected lessons by 12 months postpartum, 70 percent completed at least half of the expected lessons by 24 months, and 67 percent participated in half or more of the 43 lessons by the child’s third birthday. Visits lasted, on average, 52 minutes. The studies did not discuss how often visits occurred in practice.


Fidelity Measurement

Supervisors assessed adherence to the curriculum through quarterly home visit observations (both studies). One study also reported that all lessons were audio-recorded and supervisors reviewed a random 20 percent of the lessons. Supervisors also assessed fidelity through session summary forms, which home visitors completed following each visit with information on the lessons completed.



Neither study provided information about the costs associated with implementing the Family Spirit model.


Lessons Learned

The studies did not report any lessons learned about implementing Family Spirit.