A parent training program for young Native American mothers that is designed to increase parenting knowledge, involvement, and stimulation of the child in the home environment, which over time helps to improve children's social, emotional, and behavioral development and the mother's well-being.
Blueprints: Promising
Family Spirit National Office
Johns Hopkins Center for Indigenous Health
PO Box 16220
Baltimore, MD 21210-9997
(505) 797-3305
Email: familyspirit@jhu.edu
Website: https://familyspiritprogram.org/
Allison Barlow (Evaluator)
Johns Hopkins Center for Indigenous Health
The Family Spirit intervention aims to provide reservation-based American Indian women with parenting lessons delivered in home visits by Native paraprofessionals. The women are also aided in realms of family planning, substance abuse prevention, and problem-solving and coping skills. Lessons are organized into six domains: (1) prenatal care, (2) infant care, (3) child development, (4) toddler care, (5) life skills, and (6) healthy living. It is recommended that the 65 lessons be taught in 54 home-visit sessions. Home visits begin by the 28th week of pregnancy and occur weekly through 3 months postpartum, thereafter tapering to bimonthly visits until the child's third birthday.
The Family Spirit intervention aims to provide reservation-based American Indian women with parenting lessons delivered in home visits by Native paraprofessionals. The women are also aided in realms of family planning, substance abuse prevention, and problem-solving and coping skills. Lessons are organized into six domains: (1) prenatal care, (2) infant care, (3) child development, (4) toddler care, (5) life skills, and (6) healthy living. It is recommended that the 65 lessons be taught in 54 home-visit sessions. Home visits begin by the 28th week of pregnancy and occur weekly through 3 months postpartum, thereafter tapering to bimonthly visits until the child's third birthday.
The curriculum is crafted to reflect local native practices but not community-specific traditions or spiritual beliefs. Tribal stakeholders emphasize that there is a broad spectrum of cultural beliefs and practices within and across tribal sites and support that the Family Spirit curriculum addresses the shared needs of all of participants. In addition, the interventionists are trained to interact in ways that respect the participants' cultural orientation and living situation. For example, some participants prefer to do the lessons in their native language, whereas others prefer English.
In the Blueprints-certified study (Barlow et al., 2013, 2015), Family Spirit consisted of 43 highly structured lessons delivered over the same time period as the current version. Updates have included 1) breaking up some of the longer lessons into two separate lessons; 2) expanding the content around substance misuse; and 3) expanding the content around infant feeding and family nutrition.
Primary Evidence Base for Certification
Study 2
Barlow et al. (2013, 2015) found that, compared to adolescent mothers in the control group, adolescent mothers in the intervention group reported significantly lower
Primary Evidence Base for Certification
Of the three studies Blueprints has reviewed, one study (Study 2) meet Blueprints evidentiary standards (specificity, evaluation quality, impact, dissemination readiness). The study was done by the developer.
Study 2
Barlow et al. (2013, 2015) randomized 322 expectant young American Indian mothers (ages 12-19 years) to one of two home-visiting interventions: the Family Spirit intervention plus optimized standard care versus just optimized standard care. Mothers were assessed with their children at baseline and 2 through 36 months postpartum using measures of parenting, parent well-being, and child development.
Study 2
Barlow, A., Mullany, B., Neault, N., Goklish, N., Billy, T., Hastings, R., . . . Walkup, J. T. (2015). Paraprofessional delivered, home-visiting intervention for American Indian teen mothers and children: Three-year outcomes from a randomized controlled trial. American Journal of Psychiatry, 172(2), 154-162. doi:10.1176/appi.ajp.2014.14030332.
Individual: Favorable attitudes towards antisocial behavior, Favorable attitudes towards drug use*
Family: Lack of prenatal care*, Mother substance use during pregnancy*, Parental attitudes favorable to antisocial behavior, Parental attitudes favorable to drug use*, Poor family management, Psychological aggression/discipline
Individual: Coping Skills, Exercise
*
Risk/Protective Factor was significantly impacted by the program
See also: Family Spirit Logic Model (PDF)
Subgroup differences in program effects by race, ethnicity, or gender (coded in binary terms as male/female) or program effects for a sample of a specific race, ethnic, or gender group.
Sample demographics including race, ethnicity, and gender for Blueprints-certified studies:
Initial Core Training for Health Educators and Supervisors is composed of four phases:
1) Pre-training Preparation (2 weeks: virtual, independent)
Trainees join two virtual cohort meetings and complete on-demand modules. This phase build familiarity with the training process, curriculum tools, home visit structure, and culturally responsive approaches while ensuring all needed supports and supplies are in place.
2) Training to Learn and Practice (1 week: live training)
Trainees gather for learning through role play, practice, and guided preparation of lesson delivery. Participants are introduced to the foundational practices of home visiting - building relationships, supporting families, and developing trust.
3) Post-training Learning Cohort (3 monthly sessions)
The cohort meets together virtually to deepen skills and reflect together. The three sessions focus on using home visiting tools, strengthening core practices, and exploring implementation considerations tailored to each community's needs.
4) Affiliate Site Support Meeting (1 session)
The training team meets with the site to offer personalized support by revisiting tools, reviewing program processes, and observing lesson delivery. After this, the Family Spirit National Office engages in quarterly check-ins with the site for ongoing implementation support.
Supervisors receive additional training, communication and ongoing support on topics such as: program start-up and implementation; adapting implementation based on culture and setting; monitoring fidelity and quality assurance; and team management within a home visiting program.
In-person trainings are offered at locations around the country at least four times each year. Virtual trainings are offered once or twice per year. Site-based trainings are available for groups with ten or more trainees.
Optional Advanced Health Educator Training:
Designed for Health Educators and Supervisors who have been certified and delivering lessons for 3-6 months, this is a weeklong training (with additional pre-training and post-training sessions) that builds upon the Family Spirit Core Curriculum training to expand capacity to support families with greater confidence, cultural responsiveness, and flexibility. The packaged training integrates three complementary components:
Source: Washington State Institute for Public Policy
All benefit-cost ratios are the most recent estimates published by The Washington State Institute for Public Policy for Blueprint programs implemented in Washington State. These ratios are based on a) meta-analysis estimates of effect size and b) monetized benefits and calculated costs for programs as delivered in the State of Washington. Caution is recommended in applying these estimates of the benefit-cost ratio to any other state or local area. They are provided as an illustration of the benefit-cost ratio found in one specific state. When feasible, local costs and monetized benefits should be used to calculate expected local benefit-cost ratios. The formula for this calculation can be found on the WSIPP website.
Health Educator: $1,900 + potential Service Fee OR Trainer Travel Costs
Supervisor: $2,800 + potential Service Fee OR Trainer Travel Costs
Observer: $75 per day
Initial training for Health Educators and Supervisors is composed of four phases:
Supervisors receive additional training, communication, and ongoing support.
Observers from Affiliate sites are welcome to sit in on any Family Spirit training; they pay a fee to cover costs of training materials, food, administrative overhead, and additional planning as required.
Trainer Travel Costs: In-person trainings occurring at the Affiliate's home site incur additional costs for trainer travel which are dependent on the training location. Site-based trainings require a minimum of 15 trainees.
Service Fee (if applicable): $425 per trainee
Applies for in-person, multiple-site or regional training; does not apply to the host site for a site-based training. The service fee enables cost-sharing across participating sites for expenses associated with in-person training logistics (e.g. trainer travel costs, material preparation, conference room reservations, equipment rental, lunch and snacks).
Family Spirit Core Curriculum: $1,200 per set. One set is required for each Health Educator, and additional sets may be purchased per Affiliate needs.
The Family Spirit Core Curriculum package includes: 65 Flip-Chart Lessons; Implementation Guide; Reference Manual (online version); Participant Workbook; Participant Certificates; Recommended Evaluation Measures. The Core Curriculum is available in a hard copy curriculum box as well as PDF files on the FS Connect portal. Pricing includes access to both formats. After the first year of affiliation, access to the FS Connect portal is dependent upon payment of affiliation renewal fees.
Single Site Affiliation Fee: $10,500
This initial start-up fee confirms an Affiliate's first year of participation in the Family Spirit Affiliate network, and includes the following resources to support program implementation:
No information is available
No information is available
Health educators who conduct home visits may be paraprofessionals from the local community. It is recommended that they be familiar with the local or tribal culture, traditions, and languages. Home educators must have at least a high school education and two years of related work experience. Nurses may also work with home visitors to conduct home visits and teach the lessons deemed most relevant to their clinical expertise.
A supervisor guides and monitors curriculum implementation. Supervisors should have a college degree or equivalent work experience, and experience in home visiting, case management, community networking, and staff supervision.
No information is available
Sites and Health Educators are required to meet a set of ongoing fidelity guidelines.
Single Site Annual Affiliation Renewal: $3,000
This fee renews an Affiliate's participation in the Family Spirit affiliate network, and includes the following resources to support program implementation:
No information is available
No information is available
Allison Barlow (Evaluator)Executive DirectorJohns Hopkins Center for Indigenous HealthPO Box 16220Baltimore, MD 21210-9997abarlow@jhu.edu
A parent training program for young Native American mothers that is designed to increase parenting knowledge, involvement, and stimulation of the child in the home environment, which over time helps to improve children's social, emotional, and behavioral development and the mother's well-being.
Young Native American mothers and their children.
Subgroup differences in program effects by race, ethnicity, or gender (coded in binary terms as male/female) or program effects for a sample of a specific race, ethnic, or gender group.
Sample demographics including race, ethnicity, and gender for Blueprints-certified studies:
Individual: Favorable attitudes towards antisocial behavior, Favorable attitudes towards drug use*
Family: Lack of prenatal care*, Mother substance use during pregnancy*, Parental attitudes favorable to antisocial behavior, Parental attitudes favorable to drug use*, Poor family management, Psychological aggression/discipline
Individual: Coping Skills, Exercise
*Risk/Protective Factor was significantly impacted by the program
The Family Spirit intervention aims to provide reservation-based American Indian women with parenting lessons delivered in home visits by Native paraprofessionals. The women are also aided in realms of family planning, substance abuse prevention, and problem-solving and coping skills. Lessons are organized into six domains: (1) prenatal care, (2) infant care, (3) child development, (4) toddler care, (5) life skills, and (6) healthy living. It is recommended that the 65 lessons be taught in 54 home-visit sessions. Home visits begin by the 28th week of pregnancy and occur weekly through 3 months postpartum, thereafter tapering to bimonthly visits until the child's third birthday.
The Family Spirit intervention aims to provide reservation-based American Indian women with parenting lessons delivered in home visits by Native paraprofessionals. The women are also aided in realms of family planning, substance abuse prevention, and problem-solving and coping skills. Lessons are organized into six domains: (1) prenatal care, (2) infant care, (3) child development, (4) toddler care, (5) life skills, and (6) healthy living. It is recommended that the 65 lessons be taught in 54 home-visit sessions. Home visits begin by the 28th week of pregnancy and occur weekly through 3 months postpartum, thereafter tapering to bimonthly visits until the child's third birthday.
The curriculum is crafted to reflect local native practices but not community-specific traditions or spiritual beliefs. Tribal stakeholders emphasize that there is a broad spectrum of cultural beliefs and practices within and across tribal sites and support that the Family Spirit curriculum addresses the shared needs of all of participants. In addition, the interventionists are trained to interact in ways that respect the participants' cultural orientation and living situation. For example, some participants prefer to do the lessons in their native language, whereas others prefer English.
In the Blueprints-certified study (Barlow et al., 2013, 2015), Family Spirit consisted of 43 highly structured lessons delivered over the same time period as the current version. Updates have included 1) breaking up some of the longer lessons into two separate lessons; 2) expanding the content around substance misuse; and 3) expanding the content around infant feeding and family nutrition.
The researchers used a theoretical model that hypothesized that parenting is the critical link between parent domains and child domains and mediates children's outcomes.
Primary Evidence Base for Certification
Of the three studies Blueprints has reviewed, one study (Study 2) meet Blueprints evidentiary standards (specificity, evaluation quality, impact, dissemination readiness). The study was done by the developer.
Study 2
Barlow et al. (2013, 2015) randomized 322 expectant young American Indian mothers (ages 12-19 years) to one of two home-visiting interventions: the Family Spirit intervention plus optimized standard care versus just optimized standard care. Mothers were assessed with their children at baseline and 2 through 36 months postpartum using measures of parenting, parent well-being, and child development.
Primary Evidence Base for Certification
Study 2
Barlow et al. (2013, 2015) found that, compared to adolescent mothers in the control group, adolescent mothers in the intervention group reported significant effects for three of four child psychosocial and behavioral outcomes, including significantly lower externalizing, internalizing, and dysregulation. Intervention groups mothers self-reported significantly lower depression, externalizing, marijuana use, and illegal drug use compared to control group mothers.
Primary Evidence Base for Certification
Study 2
Barlow et al. (2013, 2015) found that, compared to adolescent mothers in the control group, adolescent mothers in the intervention group reported significantly lower
Not examined.
Study 2 (Barlow et al., 2015) reported, at posttest, small effects sizes for parent well-being outcomes, including depression (d = .16), externalizing (d = .14), marijuana use (OR = .65) and illegal drug use (OR = .67). Effect sizes for parent-rated child behaviors were also small: externalizing, internalizing, and dysregulation scores (d values ranged from .23-.27). Additionally, small to medium effects were found for parenting self-efficacy or locus of control (d = .17) and parent knowledge (d = .42).
One study meets Blueprints standards for high quality methods with strong evidence of program impact (i.e., "certified" by Blueprints): Study 2 (Barlow et al., 2013, 2015). The sample for this study included expectant adolescent American Indian mothers.
Study 2 (Barlow et al., 2013, 2015) involved participants from four reservation communities in Arizona. Treatment included the Family Spirit program plus optimized standard care and was compared to optimized standard care alone.
Additional Studies (not certified by Blueprints)
Study 1 (Walkup et al., 2009)
Walkup, J. T., Barlow, A., Mullany, B. C., Pan, W., Goklish, N., Hasting, R., . . . Reid, R. (2009). Randomized controlled trial of a paraprofessional-delivered in-home intervention for young reservation-based American Indian mothers. Journal of the American Academy of Child and Adolescent Psychiatry, 48(6), 591-601.
Study 3 (Barlow et al., 2006)
Barlow, A., Varipatis-Baker, E., Speakman, K., Ginsburg, G., Friburg, I., Goklish, N., . . Walkup, J. (2006). Home-visiting intervention to improve child care among American Indian adolescent mothers: A randomized trial. Archives of Pediatrics and Adolescent Medicine, 160(11), 1101-1107
Blueprints: Promising
Family Spirit National Office
Johns Hopkins Center for Indigenous Health
PO Box 16220
Baltimore, MD 21210-9997
(505) 797-3305
Email: familyspirit@jhu.edu
Website: https://familyspiritprogram.org/
Walkup, J. T., Barlow, A., Mullany, B. C., Pan, W., Goklish, N., Hasting, R., . . . Reid, R. (2009). Randomized controlled trial of a paraprofessional-delivered in-home intervention for young reservation-based American Indian mothers. Journal of the American Academy of Child and Adolescent Psychiatry, 48(6), 591-601.
Barlow, A., Mullany, B., Neault, N., Compton, S., Carter, A., Hastings, R., . . . Walkup, J. T. (2013). Effect of a paraprofessional home-visiting intervention on American Indian teen mothers' and infants' behavioral risks: A randomized controlled trial. American Journal of Psychiatry, 170(1), 83-93.
Certified
Barlow, A., Mullany, B., Neault, N., Goklish, N., Billy, T., Hastings, R., . . . Walkup, J. T. (2015). Paraprofessional delivered, home-visiting intervention for American Indian teen mothers and children: Three-year outcomes from a randomized controlled trial. American Journal of Psychiatry, 172(2), 154-162. doi:10.1176/appi.ajp.2014.14030332.
Barlow, A., Varipatis-Baker, E., Speakman, K., Ginsburg, G., Friburg, I., Goklish, N., . . Walkup, J. (2006). Home-visiting intervention to improve child care among American Indian adolescent mothers: A randomized trial. Archives of Pediatrics and Adolescent Medicine, 160(11), 1101-1107
Summary
Walkup et al. (2009) randomized 167 expectant young American Indian mothers to one of two home-visiting interventions: the Family Spirit intervention versus a breast-feeding/nutrition education program. Mothers were assessed with their children at baseline and 2, 6, and 12 months postpartum using measures of parenting and child development.
Walkup et al. (2009) found that, compared to the control group, mothers in the intervention group had significantly
Design
The study was designed through a long formative development phase that engaged local and cross-tribal advisory boards and a pilot study that proved the intervention feasible and relevant to the target populations. Expectant young American Indian (AI) mothers were randomized to one of two home-visiting interventions: the Family Spirit intervention versus a breast-feeding/nutrition education program. Mothers received home-visiting lessons from 28 weeks' gestation to 6 months postpartum and were evaluated with their children at baseline and 2, 6, and 12 months postpartum. Primary outcomes included mothers' parenting knowledge and involvement. Secondary outcomes included infants' social, emotional and behavioral outcomes at age 1 year; mothers' provision of a stimulating home environment; and mothers' stress, social support, depression and substance use.
Expectant AI mothers aged 12-22 years and with 28 weeks or lesser of gestation were eligible for participation. Mothers were ineligible if they had extreme medical, legal or social problems that precluded their ability to participate in visits or assessments, for example, mothers with medical, psychiatric or substance abuse problems that required extended hospitalization or residential care off the reservation or legal problems that resulted in incarceration. Mothers were recruited from prenatal and school-based clinics in four Indian Health Service catchment areas on the Navajo and White Mountain Apache reservations in New Mexico and Arizona. Of the 181 women initially contacted, 175 (97%) were eligible and agreed to enroll. Of the 175 enrolled, 167 (95%; 92% of original 181) were randomized, with 81 participants assigned to the Family Spirit arm and 86 to the control arm. However, by the 12 month postpartum assessment, only a total of 82 women remained in the study.
Intervention and control groups were assessed at four intervals: baseline (~28 weeks' gestation), and 2, 6, and 12 months postpartum. Sociodemographic characteristics were gathered in the baseline assessment. Outcome data collected at all four assessment points included maternal self-reports on parenting knowledge, involvement, social support, depression, stress, and substance abuse. Infants' social and behavioral outcomes and quality/quantity of parent-child interactions were measured in two ways. At 6 and 12 months postpartum, evaluators administered an observational measure of the home environment. At 12 months postpartum, mothers completed a parent report questionnaire on their infant's social and emotional behavior.
Sample
The sample consisted of 167 American Indian women, primarily Navajo (65%), White Mountain Apache (18%) or from mixed tribes. Randomized participants ranged in age from 14 to 22 years with a median age of 18 years. At the time of conception, 47% (79) of the women were between 14 and 17 years of age, and 53% (88) were over the age of 18. The majority of the women (84%) had gestational ages of less than 28 weeks at the time of enrollment. Ten percent of the women had one or more children. Only 14 (8%) of the women were married at the time of the baseline survey, but 80 women (48%) had a male partner enrolled in the program. Seventy-two percent (121) of the women lived in the same household as their parents or the baby's father's parents and 68% (113) lived in the same household as their partner; these two living situations were not mutually exclusive. Slightly more than one third (39%) of the sample had completed high school, a general equivalency diploma or some college, and twenty of the women (12%) were employed.
Intervention and control participants were similar with respect to all baseline demographic characteristics and all outcome variables except intervention mothers had slightly higher baseline parenting knowledge. Baseline demographic characteristics and outcome scores did not vary across sites.
Measures
Primary Outcome Measures
Parenting Knowledge: A 76-item multiple-choice self-report test was designed by the study team to assess participants' general knowledge on pregnancy, infant care, and parenting skills.
Parenting Involvement: A 5-item self-report scored on a 4-point scale adapted from Substance Abuse and Mental Health Services Administration measures was used to assess participants' level of direct involvement in infant care and support.
Secondary Outcome Measures
Home Observation for Measurement of the Environment (HOME): A 45-item observational checklist was used to assess parent support and stimulation of the child in the home environment. Six subscales include Maternal Responsivity, Acceptance, Organization of the Home, Learning Materials, Maternal Involvement and variety (i.e. life experiences). It is intended for use at 6 and 12 months in this study. For some study participants, the HOME was completed as an interview outside of the home environment because of participant refusal to allow staff in the home or staff safety concerns.
Infant Toddler Social Emotional Assessment (ITSEA): A 126-item parent report assessed four primary domains of child behavior for ages 12-36 months including Externalizing, Internalizing, Dysregulation, and Competence. It was conducted at 12 months postpartum.
The Center for Epidemiological Studies- Depression scale: This 20-item self report scored on a 4-point scale measured participants' level of depressive symptoms.
Social Support: A 20-item self-report scored on a 5-point scale was designed to measure participants' perceived support from family, friends and community.
Parenting Stress Index: A 30-item self-report scored on a 5-point scale measuring participants' level of stress associated with parenting. As this index is only relevant after the child's birth, it was not collected at baseline.
Analysis
Multivariate generalized linear mixed models (GLMMs) were used to determine whether study outcomes were associated with intervention receipt. All analyses followed an intent-to-treat approach, irrespective of the actual amount of intervention received. Rates of attrition were compared across study group at each time point using chi-square tests.
Attrition and Fidelity: Attrition rates were significantly higher among treatment versus control group mothers at 2 months (33% vs. 17%) and 6 months (42% vs. 21%). Rates of attrition were similar for both groups at 12 months (54% vs. 48%). For the entire sample and within each study group, participants lost to follow-up at 2, 6 or 12 months were not different in baseline demographic characteristics or outcome variables from those still in the study at those time points. Treatment group mothers completed a median of 20 of 25 (70%) expected home visits; control group mothers completed a median of 21 (91%) of 23 expected home visits.
Posttest outcomes:
Primary Outcomes: Adjusting for potential confounders and multiple comparisons, treatment mothers' mean increase in parenting knowledge at 6 and 12 months was 13.5 and 13.9 points higher, respectively than mothers in the control group. Knowledge gains among treatment mothers at 2 months postpartum trended positively. No significant differences between study groups were seen for maternal involvement at any time point.
Secondary Outcomes: Family Spirit mothers reported their infants' behavioral development as significantly better on several dimensions measured by the ITSEA including lower activity and impulsivity, lower peer aggression, lower overall externalizing behaviors, and less separation distress. No significant between group differences were seen in HOME scores, maternal social support, depressive symptoms, substance abuse, or parenting stress at any time.
Subsequent analyses explored if age or educational status modified intervention outcomes. Older treatment group mothers experienced significant increases in parenting knowledge at all three time points and significantly less parenting stress at 2 months postpartum. In addition, older treatment mothers had significantly fewer depressive symptoms at 6 months postpartum. Similarly, among more educated mothers regardless of age, treatment mothers reported significantly fewer depressive symptoms and less parenting stress at 2 months postpartum.
Barlow et al. (2013) examined outcomes through the 12-month follow-up, while Barlow et al. (2015) examined outcomes through the 36-month follow-up.
Summary
Barlow et al. (2013, 2015) randomized 322 expectant young American Indian mothers (ages 12-19 years) to one of two home-visiting interventions: the Family Spirit intervention plus optimized standard care versus just optimized standard care. Mothers were assessed with their children at baseline and 2 through 36 months postpartum using measures of parenting, parent well-being, and child development.
Barlow et al. (2013, 2015) found that, compared to adolescent mothers in the control group, adolescent mothers in the intervention group reported significantly lower
Evaluation Methodology
Design:
Recruitment: Eligible participants were pregnant and under 32 weeks gestation, ages 12-19 at conception, American Indian (self-identified), and residing in one of four participating reservation communities in Arizona. They were recruited from Indian Health Service clinics, Women, Infants, and Children nutrition programs, and schools and by word of mouth. The four communities were rural and isolated, with populations ranging from 15,000 to 25,000. A total of 322 participants joined during the study period of May 2006 to September 2011. A subsample of 285 women included those with any lifetime substance use at baseline.
Assignment: Random assignment to the intervention condition (N = 159) or control condition (N = 163) was stratified by site, age (12-15 years versus 16-19 years), and history of previous live births (0 versus 1+). The control condition received optimized standard care, which consisted of transportation to recommended prenatal and well-baby clinic visits, provision of pamphlets on childcare and community resources, and referrals to local services when needed. The intervention condition received optimized standard care plus the program.
Assessments/Attrition: Outcome data were collected at eight time points: baseline and 2, 6, 12, 18, 24, 30, and 36 months after the birth of the child. None of the assessments provided a long-term follow-up for the program, which lasted 36 months postpartum. At 12 months, 6% of the 322 participants had dropped out, but 16% did not complete the parenting assessments, and 21% did not complete the child assessments. Over the full study period, 25 (8%) of the participants had withdrawn. Wave-specific assessment rates ranged from 92% at 6 months to 83% at 36 months.
Sample:
Participants were predominantly having their first birth (76.7%) and unmarried (96.6%), and their mean age was 18.1 years.
Measures:
Independent evaluators who were blind to condition collected the observational and structured interview data. The parent ratings of the child were not independent, as parents helped deliver the parenting component of the program. However, home observations and self-reports of the teenage parents were independent.
Four measures of parenting outcomes included parenting knowledge; parenting self- efficacy or locus of control; observed maternal acceptance, involvement, and responsivity; and observed home safety attitudes and practices. Reliabilities were generally low, ranging from .57 to .74 (Barlow et al., 2013, supplement). At 24 and 36 months, a measure of parent stress was added (alpha = .94).
Ten measures of mothers' psychosocial and behavioral status in Barlow et al. (2013) came from self-reports and in-person interviews. The measures included depression, internalizing problems, externalizing problems, total problems, mental health, substance abuse, alcohol use, marijuana use, illegal drug use, and alcohol or illegal drug use (alphas ranged from .69-.88). For the full study period (Barlow et al., 2015), measures of mental health, substance abuse, and any alcohol or illegal drug use were not reported.
Four separate measures of child psychosocial and behavioral functioning were obtained from parent ratings. The scales came from the Infant Toddler Social Emotional Assessment, with reliabilities ranging from .63-.81. The measures included externalizing, internalizing, dysregulation, and competence, but each was treated as both a number score and as a dichotomy indicating at clinical risk.
Analysis:
Barlow et al. (2013) examined the program effects separately at the 2, 6, and 12 months using analysis of covariance and logistic regression. The models included site (as a fixed effect) and three covariates to control for nonequivalence: mother's depression score, mother ever smoked cigarettes, and mother used alcohol during pregnancy. The models used multiple imputation with relevant baseline demographic characteristics, total scores on outcomes at each assessment point, and indicator variables for study site and treatment condition.
Barlow et al. (2015) examined program effects for all seven follow-up assessments using repeated-measures analyses of covariance. Covariates included baseline outcomes when available, the mother's age, the sex and age of the child at the time of assessment (for child outcomes), and three variables to control for nonequivalence (maternal depressive symptoms during pregnancy, lifetime cigarette use, and alcohol or illegal drug use during pregnancy). The covariance structure specified for the repeated-measures analysis was banded Toeplitz. Missing data were addressed through the application of restricted maximum likelihood estimation.
Missing Data Method. Barlow et al. (2013) used multiple imputation with relevant baseline demographic characteristics, total scores on outcomes at each assessment point, and indicator variables for study site and treatment condition. Barlow et al. (2015) adjusted for missing data with full information restricted maximum likelihood estimation.
Intent-to-Treat: The intent-to-treat analyses used all cases, either through multiple imputation or maximum likelihood estimation.
Outcomes
Implementation Fidelity:
Educators were quizzed on interventional materials and needed to score at least 80% to be cleared to deliver the intervention. In addition, study coordinators reviewed educators' session summaries and reviewed audio recordings of 20% of sessions (randomly selected). Finally, study coordinators conducted in-person quarterly ratings of home visits to ensure protocol adherence.
Within the intervention group, 13 (8%) received no Family Spirit lessons, 74.2% completed more than 50% of the Family Spirit lessons by 12 months postpartum, and 69.8% and 66.7% did so at 24 and 36 months postpartum, respectively. Intervention lessons were completed as planned for 85% of the visits. The average time for lesson visits was 52 minutes.
Baseline Equivalence:
Of 28 baseline measures in Table 1 (Barlow et al., 2013), none differed significantly across conditions at p < .05, and three differed significantly at p < .10. Mothers in the intervention group had higher depression scores, rates of lifetime cigarette use, and rates of alcohol use during pregnancy than mothers in the control group. None of the 11 outcome measures available at baseline (Tables 2 and 6) differed significantly.
Differential Attrition:
At 12 months (Barlow et al., 2013), attrition rates were similar across the intervention group (7%) and control group (5%). The overall attrition rate combined with the difference in condition attrition rates meets the WWC cautious standard for low attrition bias. No other details or tests were presented, but the use of multiple imputation minimizes concerns about attrition bias
Over the full study period in Barlow et al. (2015), there is some evidence of differential attrition. The CONSORT diagram shows attrition rates by condition at each time point. For the two-month and six-month follow-ups, the overall attrition rate combined with the difference in condition attrition rates meets both cautious and optimistic WWC standards. For the 12-,18-, 24-, 30-, and 36-month follow-ups, the attrition rates meet the optimistic standard but not the cautious standard. For example, at 36 months, 22% for the intervention group and 13% for the control group did not complete the assessment. With an overall attrition rate of 18%, the difference of 9% in condition attrition rates meets only the optimist standard. In addition, analyses of differential attrition showed significant effects for two variables. Women in the intervention group who reported no substance use during pregnancy were more likely to drop out, and participants in the control group who reported never using cigarettes were more likely to remain in the study. However, the use of maximum likelihood estimation minimizes the risks of attrition bias and may overcome the modest problems in this study.
Posttest:
Barlow et al. (2013) 2-12 Months, Interim Results:
For seven parenting outcomes (Table 2), three showed significant condition differences. The intervention parents scored better than the control parents on several risk and protective factors, including parent knowledge at 12 months (d = .33), parental self-efficacy or locus of control at 12 months (d = -.23), and home safety attitudes at 12 months (d = .19). The results were similar for parents with any lifetime substance use (Table 3).
For the 27 behavioral outcome measures of parent well-being (Table 6), only one, externalizing at 12 months, was significantly lower in the intervention than the control group (d = -.20). For the subset of adolescent mothers with any lifetime substance use (Table 7), only internalizing at 12 months was significantly lower in the intervention group.
For the four child behavior outcomes (Table 4), one showed a significant condition difference for one of the two versions. The intervention group scored significantly lower on the parent-rated externalizing score (d = -.19) than the control group but not on the clinical risk classification. For the subset of adolescent mothers with any lifetime substance use (Table 5), additional significant effects emerged for parent-rated dysregulation, parent-rated clinical externalizing risk, and parent-rated clinical internalizing risk.
Barlow et al. (2015) 2-36 Months, Posttest Results:
For four parenting outcomes (Table 2), two showed significant condition differences (both risk and protective factors). The intervention parents scored better on parent knowledge (d = .42) and parent self-efficacy or locus of control (d = .17).
For the seven behavioral outcome measures of parent well-being (Table 3), four showed significant condition differences. The intervention group scored lower than the control group on depression (d = .16), externalizing (d = .14), marijuana use (OR = .65) and illegal drug use (OR = .67).
For the four child behavior outcomes (Table 4), three showed a significant condition difference. The intervention group scored significantly lower than the control group on parent-rated externalizing, internalizing, and dysregulation scores (d values ranged from .23-.27). The clinical risks versions affirmed two of the results, for clinical externalizing, and clinical internalizing (ORs ranged from .64-.67).
Long-Term:
Not examined
The program protocol included lessons taught from 28 weeks' gestation until 6 months after birth of the child.
Summary
Barlow et al. (2006) randomized 53 pregnant American Indian teens to the program intervention group or a control group that received home lessons on breastfeeding. Mothers were assessed at two months and six months after the birth of the child using measures of parenting, family relationships, and mother behavior.
Barlow et al. (2006) did not examine child outcomes. However, compared to adolescent mothers in the control group, adolescent mothers in the intervention group had significantly improved
Evaluation Methodology
Design:
Recruitment: Pregnant American Indian adolescents aged 12 to 19 years at conception and at 28 weeks' or earlier gestation were eligible, unless they had serious medical, legal, or social problems. The expectant teens were recruited from four American Indian health service catchment areas on the Navajo and White Mountain Apache reservations in New Mexico and Arizona. Recruitment of 53 participants occurred between July 2001 and February 2002.
Assignment: The 53 participants were randomly assigned to the intervention (N = 28) or control (N = 25) condition within each site. Four educators implemented the 9-month intervention program, which included 25 home visits and 41 discrete lessons. Control participants received a breastfeeding education program consisting of 23 home visits covering 20 breastfeeding lessons.
Assessments/Attrition: Assessments occurred at baseline (by 28 weeks' gestation) and two months (mid-assessment) and six months (posttest) after birth of the child. Of the 53 randomized participants, 41 (77%) completed the baseline and one other assessment and were included in the analysis.
Sample:
The sample ranged in age from 14 to 20 years, and all participants were 19 years or younger at conception. Nearly all (96%) had never married, few (23%) had completed high school, and most (68%) lived with their parents. Three-quarters (75%) were pregnant with their first child.
Measures:
None of the primary outcomes applied directly to infant or child behavior, and all but one appear to be independently measured. The three primary parent measures (all risk and protective factors) included:
The seven secondary measures came from parents and included:
Analysis:
The models adjusted for baseline scores using regression and examined results separately for the two-month interim assessment and the six-month posttest assessment.
Intent-to-Treat: The analysis sample included participants who provided baseline data and at least one follow-up evaluation, regardless of the degree of intervention received.
Outcomes
Implementation Fidelity:
The intervention group completed 82% of 41 lessons and 85% of 25 expected home visits.
Baseline Equivalence:
Table 1 shows two significant difference between conditions at baseline in about 20 tests. Gestational age at recruitment was earlier and parent self-esteem was higher in the intervention group.
Differential Attrition:
The authors stated that "those with known data were not substantially different from those with missing data in terms of baseline characteristics and outcome variables." But attrition was 32% in the intervention group and 12% in the control group. Otherwise, the authors stated that "the dropouts by study arm appeared similar in age, tribal affiliation, employment, and father involvement, as well as baseline outcome variables." However, dropouts in the intervention group tended to live with their parents, still be enrolled in school, and have been recruited at a younger gestational age.
Posttest:
The primary outcomes, all focused on parenting, showed significantly greater improvement in the intervention group than the control group for three of the six tests (knowledge at two and six months, and involvement at two months). Involvement at six months was marginally significant (p=.06) and higher for the intervention group. The tests for the secondary outcomes, all applied to the mother, showed no significant effects in 14 tests, though parental depression at six months was marginally significant (p=.08) and lower for the intervention group.
Long-Term:
Not examined.