•  

Intervention Summary

Back to Results Start New Search

Family Spirit

Family Spirit is a culturally tailored home-visiting intervention for American Indian teenage mothers--who generally experience high rates of substance use, school dropout, and residential instability--from pregnancy through 36 months postpartum. The intervention is designed to increase parenting competence (e.g., parenting knowledge and self-efficacy), reduce maternal psychosocial and behavioral risks that could interfere with effective parenting (e.g., drug and alcohol use, depression, externalizing problems), and promote healthy infant and toddler emotional and social adjustment (i.e., internalizing and externalizing behaviors). It also aims to prepare toddlers for early school success, promote parents' coping and life skills, and link families to appropriate community services.

Family Spirit is based on Patterson's social interaction learning model, which suggests that a parent's stressful life circumstances (e.g., unstable housing, poverty, weak family support, mental health and substance abuse issues) trigger a high level of coercive parenting associated with early childhood behavior problems that predict poor outcomes in middle and later childhood. The intervention consists of 63 structured lessons delivered one on one by Health Educators in participants' homes, starting at about 28 weeks of gestation and continuing to 36 months postpartum. The lessons, designed to correspond to the changing developmental needs of the mother and child during this period, address topics such as prenatal care, infant care, child development, family planning, and healthy living. Each home visit lasts about an hour and includes a warm-up conversation, lesson content, question-and-answer period, and review of summary handouts. Health Educators, trained American Indian paraprofessionals, deliver the lessons using illustrated table-top flipcharts. The bond formed between the Health Educator and mother is intended to facilitate the mother's progress toward goals.

The 63 lessons can be delivered in 52 home visits, which occur weekly through 3 months postpartum and gradually become less frequent thereafter. The studies reviewed for this summary used earlier versions of the intervention that included fewer visits and fewer lessons, and in two of the studies, all planned visits were conducted within 6 months postpartum.

Descriptive Information

Areas of Interest Mental health promotion
Substance abuse prevention
Outcomes Review Date: November 2013
1: Parenting knowledge
2: Mothers' perception of infant and toddler behavior
3: Parenting self-efficacy
4: Mothers' depressive symptoms
5: Mothers' substance use
Outcome Categories Alcohol
Drugs
Family/relationships
Mental health
Social functioning
Ages 0-5 (Early childhood)
13-17 (Adolescent)
18-25 (Young adult)
Genders Female
Races/Ethnicities American Indian or Alaska Native
Settings Outpatient
Home
Other community settings
Geographic Locations Rural and/or frontier
Tribal
Implementation History Johns Hopkins Center for American Indian Health, in partnership with several southwestern tribes, began development of Family Spirit in 1995. The curriculum was subsequently adapted into a modular format for use by the Indian Health Service (IHS) Early Head Start home-visiting program and the Seattle Indian Health Board. The first institutional replication of Family Spirit occurred in 2005-2009 through a Johns Hopkins partnership with the Chinle Service Unit Public Health Nursing Program. Approximately 3,000 families have received the intervention in 6 States: Arizona, California, Michigan, Minnesota, New Mexico, and Washington.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations No population- or culture-specific adaptations of the intervention were identified by the developer.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories Indicated

Quality of Research
Review Date: November 2013

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Barlow, A., Varipatis-Baker, E., Speakman, K., Ginsburg, G., Friberg, I., Goklish, N., et al. (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.  Pub Med icon

Study 2

Novins, D. K. (2009). Participatory research brings knowledge and hope to American Indian communities [Editorial]. Journal of the American Academy of Child and Adolescent Psychiatry, 48(6), 585-586.

Walkup, J. T., Barlow, A., Mullany B. C., Pan, W., Goklish N., Hasting, R., et al. (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.  Pub Med icon

Study 3

Barlow, A., Mullany, B., Neault, N., Compton, S., Carter, A., Hastings, R., et al. (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.  Pub Med icon

Barlow, A., Mullany, B., Neault, N., Goklish, N., Billy, T., Hastings, R., et al. (2014). Paraprofessional delivered, home-visiting intervention for American Indian teen mothers and children: Three-year outcomes from a randomized controlled trial. Manuscript submitted for publication.

Supplementary Materials

Campis, L. K., Lyman, R. D., & Prentice-Dunn, S. (1986). The Parental Locus of Control Scale: Development and validation. Journal of Clinical Child Psychology, 15(3), 260-267.

Carter, A. S., Briggs-Gowan, M. J., Jones, S. M., & Little, T. D. (2003). The Infant-Toddler Social and Emotional Assessment (ITSEA): Factor structure, reliability, and validity. Journal of Abnormal Child Psychology, 31(5), 495-514.  Pub Med icon

Lovejoy, M. C., Verda, M. R., & Hays, C. E. (1997). Convergent and discriminant validity of measures of parenting efficacy and control. Journal of Clinical Child Psychology, 26(4), 366-376.  Pub Med icon

Mullany, B., Barlow, A., Neault, N., Billy, T., Jones, T., Tortice, I., et al. (2012). The Family Spirit trial for American Indian teen mothers and their children: CBPR rationale, design, methods, and baseline characteristics. Prevention Science, 13(5), 504-518.  Pub Med icon

Novins, D. K., & Mitchell, C. M. (1998). Factors associated with marijuana use among American Indian adolescents. Addiction, 93(11), 1693-1702.  Pub Med icon

Substance Abuse and Mental Health Services Administration. (2002). Johns Hopkins Mothers Project graduation follow up cover sheet, Johns Hopkins Family Spirit Project visitation form, Family Spirit Program treatment satisfaction questionnaire, and quality assurance form. Rockville, MD: U.S. Department of Health and Human Services.

Versions of the Parenting Knowledge Test used in reviewed studies

Outcomes

Outcome 1: Parenting knowledge
Description of Measures Parenting knowledge was measured using a 51-, 76-, and 30-item Parenting Knowledge Test developed by the investigators. The test, which used multiple-choice and true/false items, assessed parenting and child care knowledge in the domains of general health and parenting, pregnancy health, childbirth, breastfeeding, newborn health and safety, infant care, child health and development, and nutrition. Sample items included "All of the following are signs of pregnancy except" (with the response options of "dark yellow urine," "light or absent period," "tiredness," and "nausea"), "It is normal for a baby to lose some weight after birth" (with the response options of "true" and "false"), and "Which of the following is the largest component of breastmilk?" (with the response options of "sugars," "proteins," "water," and "vitamins and minerals"). Scores ranged from 0% to 100%, with higher scores indicating more parenting knowledge.
Key Findings In a randomized clinical trial (RCT), American Indian teenagers (ages 12 to 19 at conception) in their third trimester of pregnancy were recruited from prenatal and school-based clinics in four Indian Health Service catchment areas (three Navajo and one White Mountain Apache communities) in New Mexico and Arizona and assigned to receive one of two home-visiting interventions delivered by Native paraprofessionals through 6 months postpartum: Family Spirit (41 lessons in 25 visits) or a breastfeeding/nutrition education program (20 lessons in 23 visits). Parenting knowledge was assessed at baseline (at about 28 weeks of gestation) and at 2 and 6 months postpartum. Findings included the following:

  • Intervention group mothers had higher Parenting Knowledge Test scores than comparison group mothers at 2 months (p < .001) and 6 months (p = .002) postpartum, after adjustment for baseline test score.
In a 3-year RCT, American Indian youths and young adults (ages 12 to 22 at conception) in their third trimester of pregnancy were recruited from prenatal and school-based clinics in four Indian Health Service catchment areas (three Navajo and one White Mountain Apache communities) in New Mexico and Arizona and assigned to receive one of two home-visiting interventions delivered by Native paraprofessionals through 6 months postpartum: Family Spirit (25 lessons in 25 visits) or a breastfeeding/nutrition education program (23 lessons in 23 visits). Parenting knowledge was assessed at baseline (at about 28 weeks of gestation) and at 2, 6, and 12 months postpartum. Findings included the following:

  • Intervention group mothers had higher Parenting Knowledge Test scores than comparison group mothers at 6 months (p < .01) and 12 months (p < .01) postpartum, after adjustment for mothers' age, parity, and educational status; gestational age; whether the mother resided with her partner; whether the mother's partner was also enrolled in Family Spirit; and study site.
In a 5-year RCT, American Indian teenagers (ages 12 to 19 at conception) in their third trimester of pregnancy were recruited from Indian Health Service, prenatal, and school-based clinics and by word of mouth in four participating communities: the White Mountain Apache and San Carlos Apache Reservations in eastern Arizona and the Tuba City and Fort Defiance communities on the Navajo Reservation in northern Arizona. The teenagers were assigned to receive one of two interventions through 36 months postpartum: optimized standard care plus Family Spirit (43 lessons in 43 visits) or optimized standard care alone. Optimized standard care consisted of transportation to recommended prenatal and well-baby clinic visits, pamphlets about child care and community resources, and referrals to local services. Cumulative parenting knowledge was assessed at baseline (at 28-32 weeks of gestation) and at 12, 24, and 36 months postpartum. Findings included the following:

  • Intervention group mothers had higher Parenting Knowledge Test scores than control group mothers across all postpartum assessments (p < .001), after adjustment for mothers' baseline test score, Center for Epidemiological Studies Depression Scale (CES-D) score, lifetime use of cigarettes, use of alcohol or any illegal drug during index pregnancy, and age. This group difference was associated with a small effect size (Cohen's d = 0.42).
Studies Measuring Outcome Study 1, Study 2, Study 3
Study Designs Experimental
Quality of Research Rating 2.7 (0.0-4.0 scale)
Outcome 2: Mothers' perception of infant and toddler behavior
Description of Measures Mothers' perception of infant and toddler behavior was measured using the Infant Toddler Social and Emotional Assessment (ITSEA), a 126-item parent-report instrument assessing children ages 12 to 36 months across 4 behavioral domains, each with subscales: Externalizing (with Activity/Impulsivity, Aggression/Defiance, and Peer Aggression subscales), Internalizing (with Depression/Withdrawal, General Anxiety, Separation Distress, and Inhibition to Novelty subscales), Dysregulation (with Sleep, Negative Emotionality, Eating, and Sensory Sensitivity subscales), and Competence (with Compliance, Attention, Imitation/Play, Mastery Motivation, Empathy, and Pro-Social Peer Relations subscales). Parents rate their children on each behavior using a 3-point scale ranging from 0 (not true/rarely) to 2 (very true/often). Mean scores for each ITSEA domain and subscale were calculated, with higher scores on the Externalizing, Internalizing, and Dysregulation domains and subscales representing greater problem behavior. For one study, the proportion of infants whose scores were of clinical concern or "at risk" (defined as less than or equal to the 10th percentile) were calculated.
Key Findings In a 3-year RCT, American Indian youths and young adults (ages 12 to 22 at conception) in their third trimester of pregnancy were recruited from prenatal and school-based clinics in four Indian Health Service catchment areas (three Navajo and one White Mountain Apache communities) in New Mexico and Arizona and assigned to receive one of two home-visiting interventions delivered by Native paraprofessionals through 6 months postpartum: Family Spirit (25 lessons in 25 visits) or a breastfeeding/nutrition education program (23 lessons in 23 visits). Each infant was assessed at 12 months postpartum. Findings included the following:

  • At 12 months postpartum, relative to infants of comparison group mothers, infants of intervention group mothers had lower scores on the ITSEA Externalizing behavior domain (p < .05), the activity/impulsivity (p < .01) and peer aggression (p < .01) subscales of the ITSEA Externalizing behavior domain, and the separation distress subscale (p < .05) of the ITSEA Internalizing behavior domain, after adjustment for mother's age, parity, and educational status; gestational age; whether the mother resided with her partner; whether the mother's partner was also enrolled in Family Spirit; and study site.
In a 5-year RCT, American Indian teenagers (ages 12 to 19 at conception) in their third trimester of pregnancy were recruited from Indian Health Service, prenatal, and school-based clinics and by word of mouth in four participating communities: the White Mountain Apache and San Carlos Apache Reservations in eastern Arizona and the Tuba City and Fort Defiance communities on the Navajo Reservation in northern Arizona. The teenagers were assigned to receive one of two interventions through 36 months postpartum: optimized standard care plus Family Spirit (43 lessons in 43 visits) or optimized standard care alone. Optimized standard care consisted of transportation to recommended prenatal and well-baby clinic visits, pamphlets about child care and community resources, and referrals to local services. Each child was assessed at 12, 18, 24, 30, and 36 months postpartum. Findings included the following:

  • At 12 months postpartum, infants of intervention group mothers had lower scores on the ITSEA Externalizing behavior domain (p = .03) than infants of control group mothers, after adjustment for study site, use of alcohol during index pregnancy, lifetime use of cigarettes, and baseline CES-D score. A very small effect size was associated with this group difference (Cohen's d = 0.19).
  • Among infants whose mothers reported lifetime substance use at baseline (88.5%), those of intervention group mothers had lower scores than those of control group mothers on the ITSEA Externalizing behavior domain (p = .004) and its activity/impulsivity subscale (p = .04) and lower scores on the ITSEA Dysregulation behavior domain (p = .01) and its negative emotionality subscale (p = .05) at 12 months postpartum, after adjustment for study site, use of alcohol during index pregnancy, lifetime use of cigarettes, and baseline CES-D score. The group differences on the ITSEA Externalizing and Dysregulation behavior domains were associated with small effect sizes (Cohen's d = 0.26 and 0.21, respectively).
  • Among infants of mothers who reported lifetime substance use at baseline, a smaller percentage of infants of intervention group mothers than infants of control group mothers scored in the clinically "at risk" range in the Externalizing (p = .05) and Internalizing (p = .04) behavior domains at 12 months postpartum, after adjustment for study site, use of alcohol during index pregnancy, lifetime use of cigarettes, and baseline CES-D score. These group differences were associated with small effect sizes (odds ratios = 2.15 and 1.91, respectively).
  • From 12 to 36 months postpartum, toddlers of intervention group mothers had lower scores than toddlers of control group mothers on the ITSEA Externalizing (p = .005), Internalizing (p = .004), and Dysregulation (p < .001) behavior domains, after adjustment for toddlers' gender and age at the assessment point and mothers' baseline CES-D score, lifetime use of cigarettes, use of alcohol or any illegal drug during index pregnancy, and age.
Studies Measuring Outcome Study 2, Study 3
Study Designs Experimental
Quality of Research Rating 3.3 (0.0-4.0 scale)
Outcome 3: Parenting self-efficacy
Description of Measures Parenting self-efficacy was measured using the Parental Efficacy, Parental Control of Child's Behavior, and Child Control of Parent's Life subscales (a total of 27 items) from the Parenting Locus of Control (PLOC) Scale. The full self-report instrument contains 47 items from these 3 and an additional 2 subscales: Parental Responsibility and Parental Belief in Fate/Chance. Items are rated on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Sample items include "What I do has little effect on my child's behavior" (Parental Efficacy subscale), "I always feel in control when it comes to my child" (Parental Control of Child's Behavior subscale), and "My life is chiefly controlled by my child" (Child Control of Parents' Life subscale). Scores on the Parental Efficacy subscale range from 10 to 50, and scores on the composite of the three subscales combined range from 27 to 135, with lower scores reflecting higher parenting self-efficacy.
Key Findings In a 5-year RCT, American Indian teenagers (ages 12 to 19 at conception) in their third trimester of pregnancy were recruited from Indian Health Service, prenatal, and school-based clinics and by word of mouth in four participating communities: the White Mountain Apache and San Carlos Apache Reservations in eastern Arizona and the Tuba City and Fort Defiance communities on the Navajo Reservation in northern Arizona. The teenagers were assigned to receive one of two interventions through 36 months postpartum: optimized standard care plus Family Spirit (43 lessons in 43 visits) or optimized standard care alone. Optimized standard care consisted of transportation to recommended prenatal and well-baby clinic visits, pamphlets about child care and community resources, and referrals to local services. Parenting self-efficacy was measured at 2, 6, 12, 18, 24, 30, and 36 months postpartum. Findings included the following:

  • At 12 months postpartum, intervention group mothers had lower scores on the Parental Efficacy subscale of the PLOC than control group mothers (p = .01), after adjustment for study site, use of alcohol during index pregnancy, lifetime use of cigarettes, and baseline CES-D score. A small effect size was associated with this group difference (Cohen's d = 0.23).
  • Across all postpartum assessments, intervention group mothers had lower composite scores across the three PLOC subscales used in the study than control group mothers (p = .011), after adjustment for mothers' baseline CES-D score, lifetime use of cigarettes, use of alcohol or any illegal drug during pregnancy, and age. A very small effect size was associated with this group difference (Cohen's d = 0.17).
Studies Measuring Outcome Study 3
Study Designs Experimental
Quality of Research Rating 3.3 (0.0-4.0 scale)
Outcome 4: Mothers' depressive symptoms
Description of Measures Mothers' depressive symptoms were measured using the Center for Epidemiological Studies Depression Scale (CES-D), a 20-item self-report instrument that measures the respondent's frequency and severity of depressive symptoms (e.g., feeling lonely, having a poor appetite, having restless sleep) across the prior week on a 4-point scale ranging from 0 (rarely or none of the time [less than 1 day]) to 3 (all of the time [5-7 days]). Scores range from 0 to 60, with higher scores indicating greater frequency and severity of depressive symptoms in the past week.
Key Findings In a 5-year RCT, American Indian teenagers (ages 12 to 19 at conception) in their third trimester of pregnancy were recruited from Indian Health Service, prenatal, and school-based clinics and by word of mouth in four participating communities: the White Mountain Apache and San Carlos Apache Reservations in eastern Arizona and the Tuba City and Fort Defiance communities on the Navajo Reservation in northern Arizona. The teenagers were assigned to receive one of two interventions through 36 months postpartum: optimized standard care plus Family Spirit (43 lessons in 43 visits) or optimized standard care alone. Optimized standard care consisted of transportation to recommended prenatal and well-baby clinic visits, pamphlets about child care and community resources, and referrals to local services. Measures of depressive symptoms were averaged across two time points (i.e., at <32 weeks and about 36 weeks of gestation) to generate an estimate of depressive symptoms during pregnancy as a baseline measure. Depressive symptoms were also measured at 2, 6, 12, 18, 24, 30, and 36 months postpartum. Findings included the following:

  • From 2 to 36 months postpartum, intervention group mothers had lower CES-D scores than control group mothers (p = .010), after adjustment for mothers' baseline CES-D score, lifetime use of cigarettes, use of alcohol or any illegal drug during index pregnancy, and age.
Studies Measuring Outcome Study 3
Study Designs Experimental
Quality of Research Rating 3.4 (0.0-4.0 scale)
Outcome 5: Mothers' substance use
Description of Measures Mothers' lifetime and past-month substance use was measured using a subset of items from the Alcohol and Drugs sections of the Voices of Indian Teens (VOIT) survey. Five items measured alcohol use (the quantity and frequency of alcohol use and age of first use), and another 13 items measured illicit drug use (the quantity and frequency of illicit drug use; types of illicit drugs used, including marijuana, crack/cocaine, inhalants, methamphetamine, barbiturates, and other drugs; and age of first use). The percentage rates of past-month alcohol, marijuana, and any illegal drug use were calculated.
Key Findings In a 5-year RCT, American Indian teenagers (ages 12 to 19 at conception) in their third trimester of pregnancy were recruited from Indian Health Service, prenatal, and school-based clinics and by word of mouth in four participating communities: the White Mountain Apache and San Carlos Apache Reservations in eastern Arizona and the Tuba City and Fort Defiance communities on the Navajo Reservation in northern Arizona. The teenagers were assigned to receive one of two interventions through 36 months postpartum: optimized standard care plus Family Spirit (43 lessons in 43 visits) or optimized standard care alone. Optimized standard care consisted of transportation to recommended prenatal and well-baby clinic visits, pamphlets about child care and community resources, and referrals to local services. Substance use was measured at baseline (at 28-32 weeks of gestation) and at 2, 6, 12, 18, 24, 30, and 36 months postpartum. Findings included the following:

  • From 2 to 36 months postpartum, the rates of past-month use of marijuana (p = .007) and any illegal drug (p = .010) were approximately 1.5 times higher for control group mothers than intervention group mothers, after adjustment for mothers' baseline use of marijuana and any illegal drug, baseline CES-D score, lifetime use of cigarettes, use of alcohol or any illegal drug during index pregnancy, and age. These group differences were associated with small effect sizes (odds ratios = 1.54 for marijuana and 1.49 for any illegal drug).
Studies Measuring Outcome Study 3
Study Designs Experimental
Quality of Research Rating 3.4 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 13-17 (Adolescent)
18-25 (Young adult)
100% Female 100% American Indian or Alaska Native
Study 2 0-5 (Early childhood)
13-17 (Adolescent)
18-25 (Young adult)
100% Female 100% American Indian or Alaska Native
Study 3 0-5 (Early childhood)
13-17 (Adolescent)
18-25 (Young adult)
100% Female 100% American Indian or Alaska Native

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Parenting knowledge 1.8 2.5 2.7 3.0 3.3 3.3 2.7
2: Mothers' perception of infant and toddler behavior 3.5 3.4 2.8 3.2 3.3 3.5 3.3
3: Parenting self-efficacy 3.3 3.3 3.0 3.5 3.5 3.5 3.3
4: Mothers' depressive symptoms 3.4 3.4 3.0 3.5 3.5 3.5 3.4
5: Mothers' substance use 3.5 3.5 3.0 3.5 3.5 3.5 3.4

Study Strengths

The ITSEA, PLOC, and CES-D are known, standardized instruments in the field with established psychometric properties. The reliability and validity of the items used to measure substance use were strengthened by the fact that they were taken from the VOIT survey, a culturally tailored instrument used to collect substance use and other data from American Indian high school teenagers over the 5-year Voices of Indian Teens (VOICES) project. In all three studies, intervention fidelity was very focused on cultural factors. Efforts to maximize fidelity in all studies included indepth training and ongoing supervision of the American Indian paraprofessional Health Educators, who had to demonstrate mastery of the curriculum, and quarterly observations of home visits by supervisors who rated sessions on protocol adherence, professionalism, and rapport building. In one study, all intervention sessions were audiotaped, and 20% of sessions were randomly selected to be reviewed for protocol adherence, with corrective action taken when indicated. Two of the studies statistically controlled for attrition and used sophisticated data modeling to account for missing data. All three studies used an intent-to-treat analysis. With regard to potential confounding variables, all three studies used randomization. In one study, independent data collectors carried out several key outcome assessments, were blind to condition assignment, and used audio computer-assisted self-interview technology to collect some of the self-report data. Two of the three studies used prospective power analyses; included baseline group differences in demographic, socioeconomic, and outcome measures as covariates in the data analysis; and used sophisticated multivariate, generalized linear mixed models and logistic regression modeling of the datasets. One study corrected the alpha rejection level for multiple statistical contrasts to reduce the experimentwise error rate.

Study Weaknesses

Created by the investigators, the Parenting Knowledge Test was modified across all three studies; although it has internal consistency and face validity, the psychometric properties of the instrument have not been formally evaluated. Use of the PLOC was limited to three of the instrument's five domains. The reliability of the ITSEA was restricted to parent report without independent third-party confirmation of toddler behavior, and the validity of the ITSEA for an American Indian population is unknown. Two studies had high attrition rates through 6 months postpartum in the intervention but not comparison/control group. In one study, a 32% dropout rate in the intervention group occurred prior to any follow-up; compared with dropouts in the control group, the dropouts in the intervention group were more likely to live with their parents and be enrolled in school and were recruited earlier in their pregnancies, which may have biased the findings. In the other study, the dropout rate in the intervention group was 42% at 6 months postpartum, with only 46% of the intervention group sample completing the 12-month postpartum assessment. The high attrition rate in the intervention group was not adequately addressed. In two of the studies, the Health Educators who delivered the intervention also collected assessment data, so a Hawthorne effect associated with social desirability (or pleasing the Health Educators) cannot be ruled out. One study had a small sample size coupled with a high attrition rate that limited statistical modeling of the dataset.

Readiness for Dissemination
Review Date: November 2013

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Johns Hopkins Center for American Indian Health. (n.d.). Family Spirit [Box with curriculum components and CD-ROM]. Baltimore, MD: Johns Hopkins Bloomberg School of Public Health.

Marketing and Program Information Materials [Folder]:

  • Family Spirit Brochure
  • Family Spirit Conceptual Model
  • Family Spirit Cost Sheet
  • Family Spirit Curriculum Package
  • Family Spirit Evaluation Overview
  • Family Spirit Frequently Asked Questions
  • Family Spirit Module Lessons: Pregnancy Through 3 Years
  • Family Spirit Pre-Training Replication Site Requirements
  • Family Spirit Program Overview
  • Family Spirit Quarterly Check-In Questions
  • Family Spirit Research Findings
  • Family Spirit Sample Lesson
  • Family Spirit Sequential Lesson Schedule
  • Family Spirit Supervisor Training Program
  • Family Spirit Training and Participant Certificates
  • FS Connect Membership

Other materials:

  • Family Spirit Evaluation Binder [With CD-ROM]
  • Family Spirit Flipchart Binder
  • Family Spirit Health Educator's Messenger Bag
  • Family Spirit Independent Knowledge Assessment Binder
  • Family Spirit Training Binder
  • Family Spirit Training Logistics Forms Binder

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
4.0 4.0 4.0 4.0

Dissemination Strengths

The curriculum is user friendly, easy to follow, and engaging and it allows for flexibility. Each lesson includes an overview for Health Educators to review prior to a home visit that covers the objectives of each lesson and materials needed. A Reference Manual supports implementation by providing additional information about the lessons. Organizing materials for home visits is made easier with the messenger bag, flip chart, and laminated materials. Training materials are comprehensive and engaging and highlight key content for trainers to reinforce with trainees. During the training, prospective Health Educators are rigorously evaluated on their comprehension of program materials and capacity to administer the program. Several quality assurance tools are available during training and implementation to rate Health Educators in areas such as delivery of lesson content, responses to questions, referrals, relationships, adherence, competence, and flexibility. Maternal depression and child development screening instruments are also included.

Dissemination Weaknesses

No weaknesses were noted by reviewers.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
1-week, on- or off-site training on curriculum content and implementation (includes the curriculum set consisting of the Implementation Guide, lessons, Health Educator Lesson Plans, Reference Manual, sample Participant Workbook, evaluation materials, and participant certificates) $3,000 per person for up to 30 participants, plus travel expenses Yes
Additional participant workbooks $100 each No
Tailored training development and implementation affiliation fee (includes access to all training resources; 3-year membership to the Web-based FS Connect; and consultation and technical assistance before training to establish needs and after training to support program implementation, sustainability, and data collection) $9,600 per program, plus travel expenses Yes
Supervisor training (includes ongoing technical assistance and training and 1-year certification for trainees to train new staff) $4,800 per trainer per year, plus travel expenses No
Consultation and technical assistance Varies depending on site needs No

Additional Information

Volume discounts are available when purchasing participant workbooks.

Contact Information

To learn more about implementation, contact:
Kristen Speakman, M.A., M.P.H.
(505) 797-3305
kspeakma@jhsph.edu

Nicole Neault, M.P.H.
(505) 797-3305
nneault@jhsph.edu

To learn more about research, contact:
Nicole Neault, M.P.H.
(505) 797-3305
nneault@jhsph.edu

Allison Barlow, M.A., M.P.H., Ph.D.
(410) 614-2072
abarlow@jhsph.edu

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

Web Site(s):