Implementing Healthy Families America (HFA)^®

Information in this section is based on studies included in the HomVEE review. For HFA, we reviewed 64 manuscripts, including 28 impact manuscripts describing randomized controlled trials or quasi-experimental designs and 36 implementation manuscripts. (Please see Studies for Implementation Experiences for a list of the manuscripts and to link to the characteristics of the samples examined in the impact studies.)

In the sections below, we consider all manuscripts about a particular sample to be a single study. For example, eight manuscripts were based on the same group of participants in Hawaii Healthy Start and are cited as one study. There are 40 distinct studies across the 64 manuscripts.

 

Program participants primarily were mothers (21 studies). Five studies reported some level of father involvement; of those, two reported that about 40 percent of families had a father who was involved in HFA activities.

The average age of mothers varied across studies, ranging from about 18 to 27 (23 studies). The participants in many studies were teenage mothers (17 studies). Six of the studies reviewed reported on the age of the children in the program. In one study, the average age of a child at program entry was 28 days. In two of these studies, children were younger than 3 to 6 months at the time of enrollment. Another three studies found that at enrollment, 46 to 65 percent of parents were pregnant.

Programs served racially and ethnically diverse families (31 studies).* The percentage of participants who identified as White ranged from 10 to 100 (25 studies); 1 to 100 percent identified as Black (22 studies); and 9 to 87 percent identified as Latinx/Hispanic (22 studies). Two to 41 percent of participants identified as Asian, Pacific Islander, or Filipino (seven studies); 1 to 23 percent identified as American Indian, Native Hawaiian, or Alaska Native (seven studies); and 1 to 28 percent identified as another or multiple races (14 studies).

Programs served participants with a range of socioeconomic characteristics (27 studies). Thirteen to 59 percent of program participants were employed (11 studies). Seventeen to 77 percent of program participants received or were eligible for public assistance, such as Medicaid or cash assistance (eight studies); and 57 to 63 percent had household incomes below the federal poverty level (two studies).

The education level of participants varied across studies (19 studies). In some studies, 21 to 69 percent of program participants were high school graduates or had obtained a high school equivalency degree (12 studies). Other studies reported that 36 to 72 percent of program participants had less than a high school education (16 studies).

Seven to 26 percent of participants were married (five studies) and 69 to 94 percent were single or unmarried (nine studies). One study reported that 65 percent of participants had a partner. Another study reported that 30 percent of participants were either married or living with a partner. Eight to 100 percent were first-time mothers (13 studies).

Thirteen to 100 percent of participants had previous involvement with the child welfare system (three studies).

*The count of studies for each racial and ethnic category comprises studies that included sample members from the racial or ethnic category. If the study did not include sample members from a particular category, the study is not included in the count.

Programs were located in 16 states covering every census region of the United States. Two studies examined many program sites from around the nation, including one that examined more than 100 HFA programs and one that examined 278 programs. Programs were implemented in urban, rural/small-town, and suburban settings.

A variety of agencies implemented HFA, including:

• Community agencies focused on families, child welfare, or human services;
• Hospitals; and
• State, county, and local health, child welfare, and human service departments.

Key staff included paraprofessional home visitors, sometimes called family support workers (27 studies), and family assessment workers who assessed program participants (six studies). In some programs, the home visitors were nurses (three studies). Other staff included child development specialists (three studies); parent educators (two studies); administrative or clinical supervisors (12 studies); and other administrative positions including executive directors, program directors, program managers, program coordinators, and team leaders (nine studies).

One study reported that there was no minimum education requirements for home visitors. However, all staff had at least a high school diploma or equivalent. A few studies reported that the minimum educational qualification required of the home visitors was a high school diploma (eight studies). Thirty to 90 percent of home visitors had some college (eight studies), and 33 to 100 percent had a bachelor’s degree or higher (nine studies). Home visitors had background experience in social work, substance use disorder treatment, child development, mental health, family studies, nursing, or related fields or relevant experience working with at-risk families and individuals (11 studies). Two studies reported that home visitors were from the communities being served. One of these studies reported that home visitors were familiar with the resources and challenges within the community. In another study, most of the home visitors were the same ethnicity as the parents they served. Home visitors had four years of home visiting experience (four studies) and three years’ tenure with the HFA program (one study).

The recommended minimum educational qualification for supervisors was a master’s degree plus three years of relevant experience or a bachelor’s degree with five years of relevant experience (four studies). One study stated that all of the supervisors had a master’s degree. A survey of 278 HFA programs found that 40 percent of supervisors had graduate degrees, 50 percent were college graduates, 9 percent had an associate’s degree, and 1 percent had only a high school diploma. The same study noted that supervisors typically had eight years of home visiting experience and four years’ tenure with HFA programs. Supervisors had background experience in social work, family counseling, psychology, human development, sociology, public health, or related fields (four studies).

The amount of pre-service training staff received varied across studies. Some studies reported that home visitors received 10 to 180 hours of pre-service training (five studies). Other studies reported that the amount of pre-service training staff received ranged from one to five weeks (six studies). Training topics included:

• HFA goals, services, and operating procedures (five studies);
• Community resources (five studies);
• Child abuse and neglect identification and reporting (five studies);
• Child growth, health, and development (three studies);
• Domestic violence prevention (three studies);
• Program assessments (three studies);
• Parent-child interaction (two studies);
• Crisis intervention and problem solving (two studies);
• Communication skills (two studies);
• Substance use disorders (two studies);
• Cultural competence or sensitivity (two studies);
• Confidentiality (two studies);
• Goal setting for families (one study);
• Building trusting relationships (one study);
• Drug-exposed infants (one study);
• Strategies for supporting positive outcomes (one study); and
• Strength-based service delivery (one study).

The amount of pre-service training supervisors received also varied across studies. Some studies reported that supervisors received 40 to 100 hours of pre-service training (two studies). Other studies reported that supervisors received pre-service training ranging from three days to one week (two studies). Supervisors received pre-service training on similar topics covered in the home visitor training but also received training on promoting quality services (two studies), supervisory role and techniques (one study), and family dynamics (one study).

Ongoing training for home visitors included training on specific topics (five studies) and conferences and institutes (two studies). Home visitors participated in 4 to 10 trainings per year (three studies). Ongoing training topics included:

• Parental risk factors and domestic violence (four studies);
• Substance use disorders (four studies);
• Child abuse and neglect (three studies);
• Child care (two studies);
• Child health and development (two studies); and
• Curriculum (two studies).

One study on father engagement reported that home visitors received some training on working with fathers. Trainings were provided by the local HFA program, the HFA National Office, or the curriculum developer. About 30 percent of home visitors did not receive any father-specific training. Of those who participated in father-specific trainings, 61 percent received training from the local HFA program, 36 percent from the HFA National Office, and 37 percent from the curriculum developer. Approximately 28 percent of home visitors received one training session, 28 percent received two training sessions, and 17 percent received three training sessions.

Supervisors also received in-service training (five studies), including conferences (one study) and half-week trainings several times a year (one study). Supervisors received ongoing training on parental risk factors and domestic violence (two studies), child health and development (one study), substance use disorders (one study), and child care (one study). One study reported that a program had difficulty finding supervisors with the desired qualifications, so the program had to provide additional supervisor in-service training to address gaps in supervisor qualifications.

Ten studies mentioned that formal supervision typically occurred weekly. Of these 10 studies, six reported that weekly supervision lasted for 1.5 to 2 hours. One study reported that home visitors received 3.5 hours of individual supervision and 2 hours of group supervision per month. Another study stated that home visitors received reflective supervision every other week. One study reported that supervision and quality assurance checks occur regularly but did not specify the frequency at which these meetings occur. During the meetings, home visitors reviewed their cases and discussed issues participants faced (seven studies). In addition to individual and group supervision, supervisors observed home visitors in the field (three studies). One study detailed that supervisors used the participant data system to monitor fidelity and determine whether parent and child milestones were met.

Home visitors had caseloads of 15 to 25 families (four studies). Home visitors who worked with families facing greater obstacles and challenges tended to have fewer cases (one study).

Although HFA’s core component was home visiting, other services were also provided (22 studies). Several studies described the content of the home visiting component (27 studies). Postnatal visits focused on (1) improving the parent-child relationship through instruction, reinforcement, and modeling of parent-child activities (20 studies); (2) improving parents’ understanding of child development and age-appropriate behaviors (15 studies); (3) promoting child health and development by supporting healthy behaviors, proper nutrition, or facilitating linkages to and encouraging appropriate use of well-child visits, immunizations, and community resources (18 studies); and (4) enhancing parental self-sufficiency by reinforcing strengths; building problem-solving skills; strengthening family support networks; helping parents address issues such as substance use, mental illness, and domestic violence; supporting family functioning; or making referrals to community services as needed (11 studies). The HFA model allows programs to offer services and activities that correspond to the specific needs of their communities and families (15 studies).

HFA requires that families be enrolled prenatally or within three months of birth. Services are intended to continue until at least the child’s third birthday, and preferably until the child’s fifth birthday. The intensity of services varied across studies (27 studies). Most studies reported that home visits should occur weekly (24 studies). Others described the recommended frequency as a progression from weekly to quarterly, or other decrease in frequency, as families become more self-sufficient (15 studies). Two studies stated that home visits should occur every other week during the prenatal period. In one of these studies, it was recommended that home visits increase to weekly after the baby is born, and ultimately decrease in frequency as the family’s functioning improves. Home visits were intended to last at least 60 minutes (six studies).

In addition to home visits, programs provided participants parent support group meetings, workshops, celebrations, trainings, and outings. Participants were also referred to education, health, economic, employment, and family support services in their community (15 studies). In one study that discussed referral activity, most referrals involved home visitors providing families with specific information about programs and services related to their specific needs and following up with the referred service provider to ensure the family received the service. Sometimes the home visitors only provided participants with information on available services for specific needs. Occasionally, the home visitors provided referral support such as accompanying a family to the referred service (two studies).

Programs used a variety of tools for family assessment or screening (22 studies), including:

• Kempe Family Stress Checklist (FSC) or the Parent Survey (a revised version of the FSC) (12 studies);
• Ages and Stages Questionnaire® (ASQ) (seven studies);
• Maternal Social Support Index (MSSI) (two studies);
• Adult-Adolescent Parenting Inventory (AAPI) (two studies);
• Infant/Child Monitoring Questionnaire (one study);
• Center for Epidemiologic Studies Depression Scale (CES-D) (one study);
• Nursing Child Assessment Satellite Training (NCAST) Feeding Scale and the NCAST Teaching Scales (one study);
• Key to Interactive Parenting Scales (KIPS) (one study);
• Healthy Families Parenting Inventory (HFPI) developed by Healthy Families Arizona (one study);
• CRAFFT screening tool® (one study) [CRAFFT is a mnemonic acronym of first letters of key words in the six screening questions];
• Child Abuse Potential Inventory (one study);
• Home Measurement of the Environment (one study); and
• Parenting Stress Index (one study).

Programs used curricula to guide home visits (13 studies), including:

• Parents as Teachers® curriculum (six studies);
• Partners for Healthy Babies® (four studies);
• Growing Great Kids® (two studies);
• Partners for Learning Curriculum and Activity Cards (one study);
• Helping Babies Learn: Developmental Profiles and Activities for Infants and Toddlers (one study);
• Healthy Babies...Healthy Families (one study);
• Great Beginnings® (one study);
• Model Bonding/Parent Child (one study);
• Boyz 2 Dads (one study);
• 24/7 Dads (one study);
• Inside Out (one study); and
• Life Coping Skills (one study).

Three of the studies reviewed described additional enhancements that were offered along with HFA services. These enhancements included (1) a father involvement initiative that worked with the state’s HFA programs to increase their awareness of strategies that might increase father involvement (one study); (2) the development of a father-inclusive culture, including new program strategies and staff who specialized as father support specialists to enhance fatherhood engagement and participation in HFA services (one study); and (3) an add-on designed to serve families affected by substance use and/or HIV in addition to the basic HFA model (one study).

The studies reviewed discussed lessons learned about implementation, including lessons related to recruitment and enrollment, engagement and retention, the home visitor and family relationship, referrals, staff training and supervision, home visitor satisfaction, and program management.

Recruitment and enrollment. Several studies reported on ways to improve recruitment and enrollment of families into HFA (seven studies). One study recommended partnering with health clinics and physicians to expand referral networks. Another study recommended that programs develop relationships with local social service departments because child welfare–involved families may be interested in and benefit from home visiting services. If a relationship was established, this study suggested that social service agencies might be encouraged to refer expecting or new mothers to the program. Other suggestions included focusing on families from vulnerable populations, including pregnant women, first-time mothers, low-income mothers, and child welfare–involved families (four studies). In contrast, four studies recommended broadening the focus population. One of the studies recommended that the HFA intervention be made available to all mothers in the state. Another study recommended allowing mothers to enroll after their child’s first year, when children enter the toddlerhood stage of development. The third study found that families with more than one child participated similarly to families with only one child. The findings suggest that families with more than one child should not be ineligible due to engagement concerns because they may be as likely as families with one child to successfully complete services. The fourth study noted that focusing on families with one child excludes families who could benefit from services.

Three studies focused on lessons related to the intake process. Families were screened and assessed to determine a child’s health and development status and to determine a family’s level of stress and high-risk behavior (two studies). Some families were concerned about screening questions covering sensitive topics – including history of abuse, substance use, and criminal activity – and the nature of the program (one study). To make participants more comfortable, the authors suggested that workers (1) provide a clear rationale for why the participant was selected; (2) emphasize that the program is not just for first-time, single, or low-income mothers; (3) explain the purpose of the screening questions; and (4) frame the program’s purpose within the broad goal of giving children a healthy start. One study noted that home visitors and staff members should be empowered to share the results of these assessments with families to better address psychosocial risks and challenging behavior. Another study stressed the importance of culturally competent intake workers.

Engagement and retention. Studies emphasized the importance of engaging and retaining families in order to provide needed services (15 studies). One study noted that retention was affected by factors such as participant mobility, immigrant status and deportations, incarceration, homelessness, and the poor quality of follow-up information. Another study recommended focusing more on re-engagement of families than on initial engagement. Other studies recommended the following strategies to enhance participant retention: match families to a home visitor based on shared characteristics (two studies), address scheduling difficulties between home visitors and families (two studies), consider the family’s needs when determining the appropriate level of service intensity for families rather than relying on a standard programmatic requirement (two studies), engage families in culturally competent ways (one study), and support home visitors in tailoring services to the needs of the families (one study).

Studies also recommended that home visitors have flexibility in conducting the intervention, such as when and where they meet with families (four studies). One study recommended providing home visitors with the flexibility to continue to visit families who move out of the program’s catchment area.

Two studies focusing on father engagement observed that residential fathers—those who lived in the same household as the children—were more likely to attend home visiting sessions. However, home visitor caseloads included several father types such as biological resident, biological non-resident, non-biological resident, and non-biological non-resident. Therefore, the authors suggest that model developers and programs consider training home visitors on engaging with different father types (one study). Another study used several strategies to engage fathers in the program. Strategies included hiring male workers, changing visit times to accommodate fathers, training workers to include fathers in home visiting, providing separate home visits for mothers and fathers held at the same time with two home visitors, scheduling one-on-one sessions with the father and child, and hosting a fathers’ group where home visitors provided fathers with information on parenting skills, child development, and other topics of interest.

Another study observed that no teenage mothers completed the program, which suggested that the program might not meet the unique needs of this population.

Home visitor and family relationship. Studies described lessons related to the relationship between home visitors and families (eight studies). Relationship building and strong interpersonal skills were key to establishing trust with and supporting families (six studies). Both substance use in families and program staff turnover made building relationships with families difficult (two studies). One study reported that most participants viewed their relationship with their home visitors as more like a friendship than a parenting or teaching association, and placed value on having a trusting, informal relationship. The authors suggest that the relationships are like that of a traditional extended family and facilitate implementation of the model. Families viewed home visitors more positively and as more effective when they were flexible, stayed focused on the families and their needs, and helped support positive parenting behaviors (six studies).

Referrals to community resources. Some studies found that referrals to community resources were infrequent and occasionally ineffective because the resources were insufficient to meet the needs of the family, or because families were reluctant to accept the referrals (two studies). In one study, some families reported feeling overwhelmed by the wide range of service options presented to them. Families needed to negotiate with an array of health, early childhood education, child care, and family support providers that may not all have been working to achieve the same goal. The study suggested home visitors help families negotiate these services and collaborate with these other agencies and services to coordinate their attempts to achieve family-centered goals.

Staff training and supervision. Several studies reported implementation lessons related to staff training. Two studies found that home visitors felt adequately trained to support positive parenting behaviors, but home visitors reported being unprepared to address challenges such as maternal depression and child abuse. One of these studies noted that home visitors felt that the amount of information provided during their initial training was overwhelming, and they requested that training focus on specific challenges they may encounter. Several studies reported that home visitors expressed a need for more training on the following topics (seven studies):

• Recognizing the symptoms and understanding diagnoses and medications for mental health issues, such as maternal depression and substance use (seven studies);
• Providing emotional support to families (four studies);
• Making referrals to other community agencies (four studies);
• Understanding child development (one study);
• Understanding infant mental health (one study);
• Child abuse reporting processes (one study);
• Understanding the needs of teenage parents (one study);
• Understanding and interpreting assessments (one study);
• Retaining families and engaging fathers (one study);
• Accessing community resources and programs (one study);
• Completing paperwork (one study);
• Leadership development (one study);
• Employee retention (one study);
• Creative outreach approaches (one study); and
• Understanding cultural diversity (one study).

To strengthen home visitor competence, one study noted a need for ongoing training that links the intervention’s theory with program implementation.

One study suggested that supervisors should carefully monitor home visitor caseloads and provide continual support and training on how to work with families with many risk factors and who have other psychosocial risks to help prevent home visitors from feeling overburdened by the needs of the families. Another study recommended that in addition to serving monitoring and accountability purposes, supervision should be reflective, individualized to the home visitor, flexible, and need-based. This study suggested that supervision take a more administrative and clinical approach while focusing on challenging cases rather than discussing entire caseloads. This study also suggested that supervisors make themselves available to meet at a pace and frequency that works best for a particular home visitor.

Home visitor satisfaction. One study recommended that programs have a prescribed curriculum or a set of standard curricula. This study found that when home visitors had a prescribed curriculum, they reported greater job satisfaction, may have experienced less stress, and felt more comfortable performing job tasks.*

Program management. Several studies included lessons on program start-up and operation (14 studies). Studies noted the importance of assessing the performance of staff and the effectiveness of training, and engaging in quality assurance (five studies), although another study noted that assessing implementation fidelity is challenging because of HFA’s flexibility in content and structure (one study). One study recommended establishing a career ladder for home visitors to facilitate staff retention. Employing a workforce that has characteristics similar to those of the families the program serves might also help reduce staff turnover (one study).

Studies also cautioned that (1) documentation and paperwork can become burdensome for home visitors (two studies) and (2) budget cuts can lead to increased staff turnover, which can impede relationships with families (two studies). One study recommended combining the home visitor and family assessment roles into a single position. Another study stressed the importance of clarifying expectations and increasing the transparency of systems and operations when an HFA program is implemented through a public/private partnership.

If programs chose to enroll multiparous families, program mangers recommended that they be assigned to more experienced home visitors because the families often have more complex needs (one study).

Another study found that more than one-third of home visitors were providing case management and other supportive services even though these activities are not described in the model guidelines. The home visitors noted that sometimes families’ basic needs had to be addressed before the home visitor could introduce the curriculum. The author recommended that programs acknowledge the potential need for case management services and encourage home visitors to discuss with their supervisors how to address families’ need for support services.

*HomVEE did not review the rigor of the design used in this manuscript because the analysis did not include a comparison group.