Programs that Work
Healthy Families New York (HFNY)
Program Info
Healthy and Safe Children
Indicators
Children not experiencing physical, psychological or emotional abuse
Babies born weighing more than 5.5 pounds and improving outcomes for low birth weight babies
Topic Areas
Age of Child
Early Childhood
Type of Setting
Home Visiting
Type of Service
Family Support
Parent Education
Type of Outcome Improved
Child Abuse and Neglect
Physical Health
Evidence Level (What does this mean?)
Proven
TopProgram Overview
Based on the national Healthy Families America (HFA) model, Healthy Families New York (HFNY) is a community-based prevention program that seeks to improve the health and well-being of children at risk for abuse and neglect by providing intensive home visitation services. The target population consists of expectant parents and parents with an infant less than three months of age who are considered to be at high risk for child abuse and neglect. Specially trained paraprofessionals are assigned to the participating families to deliver home visitation services until the child reaches five or is enrolled in Head Start or kindergarten. Home visitors provide families with support, education, and referrals to community services aimed at addressing the following goals: (1) to promote positive parenting skills and parent-child interaction; (2) to prevent child abuse and neglect; (3) to ensure optimal prenatal care and child health and development; and (4) to increase parents’ self-sufficiency. HFNY began operation in 1995 as an initiative of the New York State Office of Children and Family Services (OCFS) in collaboration with the New York State Department of Health, Prevent Child Abuse New York and the Center for Human Services Research at the University at Albany. HFNY is operating in 39 sites throughout New York State. In 2008, the state budgeted $23.2 million for the HFNY program.
Program Participants
Through community health and social service agencies and hospitals, the HFNY program screens expectant parents and parents with an infant less than three months of age for risk factors that are predictive of child abuse and neglect, including, but not limited to: single parenthood, teen pregnancy, poverty, poor education, unstable housing, substance abuse, and mental health problems. Parents who screen positive are referred to the HFNY program, which conducts an assessment interview to determine their eligibility, using the Family Stress Checklist, a tool that measures their risk of abusing or neglecting their children. Parents who score above a pre-determined cut-off on the Family Stress Checklist are offered the opportunity to receive home visitation services.
Evaluation Methods
The researchers evaluated the HFNY program in a sample of 1,173 at-risk women who were pregnant or who had an infant less than three months old (DuMont et al., 2008).
Families were selected for the evaluation based on the same criteria used to determine eligibility for HFNY. Women who were pregnant or who had an infant less than three months old in New York's Erie, Rensselaer, and Ulster Counties were screened and assessed for risk of child abuse and neglect. A total of 1,297 women met the eligibility criteria for the program and agreed to participate in the study. Among those women, 1,173 (90 percent) completed an intake interview and became study participants. The sample is comparable to the population of families enrolled in HFNY programs across the state on a range of measures such as demographics, employment, prior child abuse reports, substance use, and depression. Just over half of the participants were first-time mothers. Nine percent of the sample had substantiated child-abuse or child-neglect reports prior to intake, and 20 percent had been physically abused in the previous year by a partner or spouse. About two out of every five participants also scored above the clinically relevant cut point on a depression scale.
A total of 579 women were randomly assigned to the treatment group (i.e., the HFNY group) and 594 were randomly assigned to the control group. Nearly two-thirds of the women were pregnant at the time they were assigned to the treatment or control group. The control group was given information and referrals to other appropriate services available in the community. Baseline statistics on the measures mentioned above showed no significant differences between the HFNY group and the control group, one indication that the random assignment was successful.
Outcomes were compared after the first two years of participation in the program and adjusted for demographic and risk-related covariates. Of the 1,173 participants, 1,060 (90 percent of the sample) completed the Year 1 follow-up interview and 992 (85 percent of the sample) completed the Year 2 follow-up interview. To maintain data quality, interviewers were independent of the HFNY program and were not informed of a participant's group assignment. Attrition analyses showed no significant differences between the HFNY group and the control group at the time of Year 1 and Year 2 interviews. However, HFNY and control group members who remained in the study (regardless of whether they continued to participate in the HFNY program) were more likely than those who dropped out of the study to be first-time mothers, but less likely to have been randomly assigned at a gestational age of 30 weeks or less. In addition, at Year 1, rates of attrition from the study were slightly lower for non-Latina White women than for Latina women and non-Latina African-American women. However, by Year 2 these differences had disappeared. No other significant differences were found between those who continued in the study and those lost to attrition.
DuMont et al. (2008) conducted analysis on the baseline sample and the Year 1 and Year 2 follow-up samples. This article examined the outcomes of the entire sample and also two subgroups: a "prevention subgroup" (i.e., first-time mothers under age 19 who were randomly assigned at a gestational age of 30 weeks or less, about 15 percent of the sample) and a "psychologically vulnerable subgroup" (i.e., women with a low sense of mastery and high levels of depressive symptoms at baseline, about 10 percent of the sample). Both subgroups included women in the HFNY group and the control group.
The study reported retention rates for the home visiting program consistent with those for other HFA programs. Specifically, at baseline, about 90 percent of the women who were assigned to the intervention group enrolled in the HFNY program, and only 50 percent and one-third of the HFNY participants remained in the program by Year 1 and Year 2, respectively. However, to the extent possible, those who dropped out of the HFNY program were retained in the intervention group of the study.
Most recently, Lee and colleagues (2009) reported on HFNY's ability to impact low birth weight. The researchers obtained birth certificate data from the New York State Department of Health for mothers who were randomly assigned prenatally and provided informed consent. The match was performed using the names and dates of birth of the child and the mother, and was successful for 99% of the cases searched. Analyses were conducted on mothers who had a single birth and were randomized at a gestational age of 30 weeks or less in order to allow enough time prior to the target child's birth for participants to benefit from home visiting services.
Key Evaluation Findings
The study has reported overall positive program effects in terms of childbirth outcomes (Lee et al., 2009) and parenting practices (DuMont et al., 2008). Compared to their counterparts in the control group, HFNY mothers were less likely to deliver low birth weight babies, and reported engaging in less neglect, severe physical abuse, minor physical aggression, and psychological aggression against their children.
According to standard practice in the public health field, Lee and colleagues (2009) considered babies born weighing less than 2500 grams to be low birth weight. Among women who were randomized at a gestational age of 30 weeks or less, HFNY group mothers were only about half as likely as control group mothers to deliver low-birth-weight babies (5.1 percent versus 9.8 percent). Rates were measured while controlling for other factors including race/ethnicity, program site, welfare receipt, age, and smoking during pregnancy. The program was particularly effective in reducing low birth weight among African-American and Latina mothers, groups that persistently experience high levels of poor birth outcomes. For example, African-American mothers who were assigned to the HFNY group were 70 percent less likely than African-American mothers in the control group to deliver low birth weight babies (3.1% vs. 10.2%). In addition, the earlier in their pregnancies that women were offered HFNY, the greater the impact of the program on low birth weight. Among women who entered the study at a gestational age of 16 weeks or less, the rate of low birth weight experienced by the HFNY group was one-quarter as high as the rate for the control group (3.6% versus 14.1%).
With regard to parenting practices, the study used two measures for evaluation: child-abuse and child-neglect reports substantiated (or confirmed) by Child Protective Services (CPS), and parents' self-reported behaviors measured by the revised Conflict Tactics Scale (CTS).
The following is a summary of major findings based on the CTS measures:
- For self-reported neglect, at Year 1, the HFNY group had a marginally lower prevalence rate than the control group (5.5 percent versus 8.3 percent), and at Year 2, a marginally lower frequency (0.22 versus 0.46).
- Compared to the mothers in the control group, HFNY mothers reported engaging in fewer incidents of very serious physical abuse, minor physical aggression, psychological aggression, and harsh parenting at Year 1. The prevalence of these self-reported behaviors did not differ.
- At Year 2, the only significant difference between the two groups was for acts of serious abuse: HFNY mothers reported one-fourth as many acts of serious physical abuse as their counterparts in the control group.
- For the prevention subgroup, at Year 2, HFNY mothers (51 percent) were less likely to report having committed minor physical aggression against their children in the past year than did their counterparts in the control group (70 percent). HFNY mothers (41 percent) were also less likely to self-report having engaged in harsh parenting behaviors in the past week than did the control group (62 percent) at Year 2.
- No significant differences were found in the prevention subgroup analysis for the frequency of self-reported child abuse and neglect behaviors.
- For the psychologically vulnerable subgroup, at Year 2, HFNY mothers were approximately one-fourth as likely to report having engaged in serious abuse and neglect as their counterparts in the control group (5 percent versus 19 percent). Among psychologically vulnerable mothers, the average number of self-reported incidents of serious abuse and neglect at Year 2 was lower for the HFNY group (0.02) than it was for the control group (0.62), and the frequency of psychological aggression at Year 1 was significantly lower for the HFNY group (1.95) than it was for the control group (8.57).
Probable Implementers
Public health and social welfare services.
Funding
Healthy Families New York is funded through the state budget, and the allocation for the program was $23.2 million in 2007. The cost per family averages between $3,000 and $4,000 per year, with slightly higher costs in New York City.
Implementation Detail
Program Design
HFNY is a variant of the HFA home visiting model, and this variant is shown to have significant and positive impacts. HFNY participants may receive home visiting services until the child reaches the age of five or is enrolled in Head Start or kindergarten. Families are served at different service levels that correspond to different frequencies of home visits based on families' needs. Home visits are scheduled one or more times per week during pregnancy (Level 1), and families usually remain on Level 1 until the child is at least six months old. As families progress through the service levels, home visits occur on a diminishing schedule, from biweekly (Level 2), to monthly (Level 3), and then quarterly (Level 4). The content of home visits is individualized and culturally appropriate to address the unique needs of each family.
HFNY is managed by OCFS, which contracts with public and community-based agencies to provide home visitation services. Funded programs are required to follow HFA and HFNY standards and participate in the HFA credentialing process.
Curriculum
All new home visitors attend a one-week core training program provided by approved in-state Healthy Families America trainers. They receive training on parent-child interaction, child development, strength-based service delivery, and on a range of topics such as domestic violence, substance abuse issues, abuse and neglect, and well-baby care. HFNY supervisors receive an additional four days of training on their role in promoting quality services. New home visitors are mentored by experienced home visitors. Supervisors meet with each home visitor for at least 1.5 hours every week and observe one home visit per quarter.
Staffing
The program selects paraprofessionals from the community being served to be home visitors. Personal attributes such as warmth, the ability to establish trusting relationships, the ability to work effectively with children and families, and nonjudgmental attitudes are the primary selection criteria. Although postsecondary education is not a requirement, many home visitors (43 percent) have attended college, and about a third (34 percent) are college graduates.
Issues to Consider
The HFNY program received a "proven" rating. The study utilized random assignment with a fairly large sample size of 1,173 women. Parents who were randomly assigned to the HFNY program were kept in the analysis, regardless of whether or not they actually received any home visiting services. To maintain data quality, interviewers were independent of the HFNY program and were not informed of a participant's group assignment. The study found significant and positive program effects on a range of outcomes including child abuse and child neglect and childbirth outcomes. Note, however, that some of the program effects found in Year 1 did not persist into Year 2.
DuMont et al. (2008) reported a 10 percent attrition rate at Year 1 and a 15 percent attrition rate at Year 2; 2 percent of the study sample completed the Year 2 but not the Year 1 interview. Attrition analysis showed no significant difference between the HFNY group and the control group at the time of Year 1 and Year 2 interviews. However, parents who remained in the study were found to be more likely to be first-time mothers and less likely to have been randomly assigned at a gestational age of 30 weeks or less than parents lost to attrition.
Dozens of evaluations of HFA have been conducted, but most lacked a comparison group or used quasi-experimental designs, and most failed to find significant positive effects. Possible reasons for the evaluations not finding significant effects could be the relatively small sample sizes and a low base rate for child abuse and neglect reports. The three studies summarized here are the only ones of an HFA model that has met the Promising Practices Network (PPN) evidence criteria, including such factors as study design, effect size, and statistical significance.
HFNY is very similar to many other HFA programs in that it satisfies all the critical elements required by the HFA model, including participation eligibility, service content, home visitor selection and training, and service monitoring and supervision. HFNY differs from other programs only in some program details that are allowed under the HFA structure.
Previous studies have shown larger program effects from the Nurse Family Partnership (NFP) home visiting model (see PPN description at http://www.promisingpractices.net/program.asp?programid=16) than the HFA model. One hypothesis forwarded to explain the difference focuses on the training of the provider of the home visitation services—the NFP model uses nurse home visitors while the HFA model employs paraprofessional home visitors. However, DuMont et al. (2008) found more pronounced program effects among the first-time mothers under age 19 than among the entire sample, and this subgroup of first-time young mothers resembled the type of participants typically served by NFP programs. Therefore, the HFNY evaluation team proposed that the characteristics of recipients might be a key factor in explaining the differences in the program effects between the NFP and HFA model. In fact, consistent with these findings from the HFNY subgroup analysis, the NFP data have shown that higher-risk mothers also benefit more from NFP services (see the discussion in Karoly et al., 2001). Further studies that examine this hypothesis would be valuable.
The second author of the DuMont et al. article (2008) and the Lee et al. article (2009), Susan Mitchell-Herzfeld, is a member of the PPN Board of Advisors.
Example Sites
Erie, Rensselaer, and Ulster Counties in New York State
Contact Information
Bernadette Johnson
Program Coordinator
Healthy Families New York
New York State Office of Children and Family Services
52 Washington Street, 334N
Rensselaer, NY 12144
phone: (518) 402-6770
fax: (518) 402-6824
email: bernadette.johnson@ocfs.state.ny.us
Available Resources
Healthy Families New York Web site:
http://www.healthyfamiliesnewyork.org/
New York State Office of Children and Family Services Web site:
http://www.ocfs.state.ny.us
Center for Human Services Research, University at Albany Web site:
http://www.albany.edu/chsr/reports.htm
Bibliography
DuMont, K., Mitchell-Herzfeld, S., Greene, R., Lee, E., Lowenfels, A., Rodriguez, M., & Dorabawila, V. (2008). Healthy Families New York (HFNY) randomized trial: Effects on early child abuse and neglect.
Child Abuse & Neglect,
32, 295-315. As of February 2009: http://dx.doi.org/10.1016/j.chiabu.2007.07.007
Karoly, Lynn A., M. Rebecca Kilburn, James H. Bigelow, Jonathan P. Caulkins, and Jill S. Cannon,
Assessing Costs and Benefits of Early Childhood Intervention Programs: Overview and Applications to the Starting Early, Starting Smart Program,
Santa Monica, Calif.: RAND Corporation, 2001. As of January 2008: http://www.rand.org/pubs/monograph_reports/MR1336/
Lee, E., Mitchell-Herzfeld, S., Lowenfels, A., Greene, R., Dorabawila, V., & DuMont, K. (2009). Reducing low birth weight through home visitation: A randomized controlled trial.
American Journal of Preventive Medicine,
36(2), 154-160. As of February 2009: http://www.ajpm-online.net/article/S0749-3797(08)00845-3/abstract
Mitchell-Herzfeld, Susan, Charles Izzo, Rose Greene, Eunju Lee, and Ann Lowenfels,
Evaluation of Healthy Families New York (HFNY): First Year Program Impacts,
Rensselaer, N.Y.: New York State Office of Children and Family Services, Bureau of Evaluation and Research; Albany, N.Y.: Center for Human Services Research, University at Albany, February 2005. As of February 2009:
http://www.ocfs.state.ny.us/main/prevention/assets/HFNY_FirstYearProgramImpacts.pdf
Last Reviewed
February 2009
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