Scaling the Family Spirit Early Childhood Home-Visiting Intervention: The First Peoples Have Much to Teach Us

Introduction

Early childhood home-visiting programs have been proven an effective strategy to reduce maternal and child health problems across the lifespan, and are now funded through the federally legislated Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program.  However, many home-visiting models lack evidence for scalability in low-resource and hard-to-reach populations, such as American Indian tribes, immigrant populations, military families and the urban poor. In addition—few are focused on the behavioral and mental health disparities that are priorities for these historically disenfranchised populations.

Methods

The Family Spirit home-visiting intervention was designed through a decade long community-based participatory research process with four tribal reservation communities in the southwestern United States.  Important design features were adopted to recruit, retain and target the needs of the highest risk, hardest-to-retain American Indian teenage mothers and their children.  The paraprofessional-delivered curriculum focused on a cultural-assets vs. trauma-focused approach to promoting behavioral health outcomes for mothers and children. Three consecutive randomized trials corroborated significant impacts on maternal parenting indicators, and maternal and infant social, emotional and behavioral outcomes. The Family Spirit model developers then packaged the intervention--including 63 discrete lessons, fidelity and quality assurance devices, implementation and reference guides, and a train-the-trainers program, for scaling to other low resource, hard-to-reach communities.

Results

The Family Spirit intervention’s randomized trial results support the utility of paraprofessional-delivered home-visiting intervention to reduce intergenerational behavioral health disparities in low-income, hard-to-reach populations. Based on these data, it has been endorsed as an evidence-based model by National Registry of for Evidence Based Practices and Programs (NREPP) and the Department of Health and Human Services Home Visiting Evidence of Effectiveness (HomVEE). Since then, through a variety of mechanisms, including via State and Tribal MIECHV funding, the Indian Health Service Community Health Representatives and Public Health Nursing programs, and, most recently, non-Native county and city health departments, Family Spirit has been scaled to 39 communities across 10 states.

Conclusion

Designing Family Spirit in the context of tribal reservation communities presented important environmental and contextual challenges that led to innovations for implementing and scaling this and other home-visiting interventions in low income, hard-to-reach, culturally diverse populations who suffer intergenerational cycles of poor behavior health outcomes. The story of its development and scaling can inform scientists and policy makers alike.