The mission of the Early Head Start Program (EHS) is to serve low-income pregnant women and families with infants and toddlers. This expansion of Head Start to include the prenatal period offers many opportunities and challenges to programs and service providers accustomed to working only with young children and their families. Unlike most Early Head Start grantees, the Panhandle Early Head Start began as a program to serve expectant families. We are now moving from three years' experience as a federal Healthy Start home visiting demonstration project, with a mission to reduce infant mortality among a high-risk population, to becoming an Early Head Start program and a training site for home visitors. We offer readers some of the lessons learned as we implemented our Healthy Start project so others may benefit, as we have, from our experiences.

As a Healthy Start home visiting demonstration project with a strong evaluation component, Panhandle Healthy Start recruited during a 27-month period more than 500 pregnant women in a six-county area in rural North Florida. The women were randomly assigned to receive one of three types of services: a) weekly home visits from a registered nurse; b) weekly visits from a paraprofessional home visitor; or c) services already available from other community sources, ranging from no support to a moderate level of support.

Our Panhandle nurses and paraprofessional home visitors provided participants with education about the value of prenatal care, childbirth education, proper nutrition, breastfeeding, smoking cessation, family planning, parenting skills, and self-esteem. They also offered to help them overcome barriers to high school graduation or pursue other vocational preparation.

Lessons learned

Our "lessons learned" cluster around four principal themes:

1. Effective strategies for meeting the needs of expectant families;
2. Selecting, training, and supporting effective home visitors;
3. Quality improvement within a home visiting program; and
4. Affecting community systems that serve expectant families.

Serving expectant families

Serving pregnant women is different from serving families with infants and young children. Programs should use comprehensive prenatal and infancy curricula that address the varying needs of expectant families and babies.

Most early childhood programs are focused on the child. Working with expectant families requires detailed knowledge of maternal health, prenatal care, warning signs of problems in pregnancy, childbirth education, labor and delivery, lactation, postpartum depression, family planning, and community resources that are available to assist families with all of the above.

On the basis of our experience, we believe that comprehensive programs with multiple goals need detailed curricula. Certainly home visitors need to be flexible and respond to individual needs and interests of the women or families they visit. But, regardless of the issues or crises that arise, visitors also must focus a significant portion of each visit on critical topics. We found that our home visitors, especially paraprofessional visitors, needed and wanted highly prescriptive instructions regarding what they should be teaching, the logical sequence in which to teach it, suggested prompts for talking on the topics, and lists of other resources they might use to get their messages across.

With input from visitors, supervisors, and consultants, we developed curricula to be used sequentially during prenatal, postpartum and infancy stages to help home visitors plan and organize their visits. We created magazine-style handouts for families with pictures and easy-to-read text. The home visitors appreciated the simple format and having the handouts at their fingertips each week so they did not have to spend time collecting and organizing the appropriate handout materials. Visitors were given flexibility to re-order the sequence in which they covered curriculum topics according to the needs of specific families; however each topic had to be addressed within a reasonable time frame.

Serving pregnant women, especially those living in difficult circumstances, requires flexibility in work hours. At the same time, it is important for home visitors to work toward regularly scheduled visits with families, and for supervisors to help home visitors track and address problematic patterns of contact.

Initially, we informed project participants that home visits would take place weekly and last an hour. We instructed visitors to adhere to this prescribed schedule. Yet we soon found it necessary to modify the frequency of visits to accommodate some families' needs. When their babies were born, some new mothers wanted to modify the frequency or length of their visits, at least until they had adjusted to new responsibilities and recovered physically. We found that, after a couple of months postpartum, some women who had participated eagerly in weekly visits while pregnant became less available for visits because they were returning to school or work. The additional pressures of recent welfare reform work requirements also appeared to make scheduling more difficult. We found that the consequences of being too rigid in scheduling appointments were an increase of "no shows' for appointments and requests to drop out of the program.

Outreach to a family described as living "past the red mailbox near the store on Route 17" may be most successful during the evening or on a weekend. We encouraged staff to schedule their work in a flexible manner to accommodate families work or school schedules. However, we find it also necessary to set reasonable boundaries. When a home visitor spent 20 hours as a labor coach during childbirth, the strong bond that was establish between visitor and mother laid the foundation for excellent rapport with the family; however, this degree of involvement had its costs in overtime pay, missed appointments with other families, and interference with the home visitor's own home life.

We have learned that home visitors whose assigned families are spread over a wide geographical area need help in planning their days efficiently. Encouraging visitors to schedule the next visit with a family before concluding the current visit helps then work toward a weekly routine, although this strategy cannot entirely eliminate cancellations or the need to reschedule. Our supervisors learned to watch closely for a succession of canceled visits or "no shows" and help visitors identify and address obstacles to regular contact (Does the family not see the value of the visits? Are they getting bored with the visits?). Because of the numerous families assigned to each visitor, and the numbers of visitors overseen by one supervisor, it was difficult for a supervisor to detect patterns of missed visits. For this reason, supervisors maintained detailed records of visits accomplished by their visitors with each family. These records were collected on a monthly basis and percentages were computed for the visits that each visitor successfully accomplished that month.

Home visitors are more likely to be effective change agents when they believe established a strong and trusting relationship with the family, when they believe in what they are teaching, and when they feel comfortable discussing the topic at hand.

The role of our home visitors during pregnancy is to provide education and encouragement to help mothers have healthy babies. Before she can make a difference, the visitor must build a trusting relationship with each family she visits--especially if she is going to affect their habits or lifestyle. Building trust is the continuous, never-ending subject of visitor training, modeling, and supervisor guidance. At each of our home visitor staff meetings and training sessions, it seemed the key to every dilemma, and the answer to every question was, "It depends upon your relationship with the family." Yet even with a strong relationship, the home visitor can only present information and options; it is the family who must choose to change.

The home visitor also must believe in the message she offers before she can convince others. We learned that a home visitor's level of comfort in discussing a topic is critical. Although we provided detailed information for visitors on the topic of family planning, we later found that some visitors were not comfortable discussing this intimate topic, so we did more extensive role playing and modeling to help them be more at ease. The visitors needed practice talking about the benefits of spacing pregnancies for mother and baby. They discussed future plans for birth control throughout pregnancy, as unplanned pregnancies may occur even before the six-week postpartum visit. Consequently, project data have confirmed that the more times the home visitors talked about family planning, the longer mothers waited to have another baby.

Selecting, training, and supporting effective home visitors

Although the effectiveness of nurse home visitors in improving child and family outcomes for high-risk pregnant women has been demonstrated (Olds, Eckenrode, Henderson, Kitzman, Powers, Cole, Sidora, Morris, Petitte & Luckey 1997; Kitzman, Olds, Henderson, Hanks, Cole, Tatelbaum, McConnochie, Sidora, Luckey, Shaver, Engelhardt, James & Barnard, 1997; Olds, Kitzman, Cole, et al, 1997; Kitzman, Olds, Henderson, et al, 1997; Olds, Henderson, Kitzman & Cole, 1995; Olds & Kitzman, 1993; Olds, Henderson, Chamberlin, Tatelbaum, 1988; Henderson, Chamberlin, Tatelbaum, 1986), little research has shown that community outreach workers or paraprofessionals can be as effective in improving specific clinical outcomes.

In our Healthy Start experience, we employed home visitors with varying educational backgrounds to work with expectant families, and found that effectiveness had more to do with individual characteristics (for example, an outgoing personality, good listening skills, sensitivity to cues) than educational background as long as the program itself provided each home visitor with strong supervision and training support. Some nurses were effective; some were not. Some paraprofessionals were outstanding; others never mastered the job. We are in the process of profiling the characteristics of our home visitors to see if there are common qualities predicting effectiveness.

All home visitors who work with expectant families need training and ongoing supervision, regardless of their initial educational level.

We found that all our new home visitors needed practice in communicating effectively with expectant families. Since nurses had more knowledge of health issues than did paraprofessionals, they did not feel the need for prompts in the curriculum to help them talk with families about health care issues, but paraprofessionals welcomed the prompts. Some paraprofessionals were better able than nurses to simplify information and communicate it in a way that families who came from similar backgrounds could understand. Initially, nurses were quicker to recognize warning signs of a problem in pregnancy, but with training the paraprofessionals were able to recognize the signs and, in fact, to prevent several preterm deliveries.

In order to ensure competence, classroom training must be followed by practice in context and direct observation of the home visitor's ability to demonstrate specific skills.

Our Panhandle Healthy Start program began with five weeks of pre-service training. During this initial period and in bi-weekly sessions thereafter, we provided training on prenatal topics, infant care topics, Mediated Learning and Active Learning. When the project director observed visitors in the home, however, she was disappointed to observe that the conversations between home visitors and families lacked adequate focus on important topics. Some home visitors reported that it was difficult to get to these topics because the families were always "in crisis."

We learned that while our pre-service training had been highly motivating and essential to building core competencies, too much information had been given too fast, without adequate time for home visitors to practice and master skills before going on to new topics. We were reminded that merely covering content did not ensure competency in teaching. Despite extensive opportunities for practice and role-playing of new skills during initial training, most home visitors needed repeated guided opportunities to teach the content before they were comfortable with it. Supervisors had to follow through on training by scheduling visit observations with each of their staff in order to observe how they applied the new skill with their families, and provide further guidance as necessary. Such focused supervisory observations not only provided assistance to the visitor, but also provided feedback about the effectiveness of our training and curricula design.

Intensive supervision is critical in order to provide a quality home-visiting program staffed by paraprofessionals.

Supervision requires the ability to focus on the daily activities that accomplish the mission, solve problems, provide feedback on performance, and continually motivate performance. Supervision of home visitors, especially those who are spread over several counties and office locations, is a challenge for even the most experienced of managers. Supervision of paraprofessional home visitors requires frequent large and small group meetings, individual conferences, and review of weekly written reports to mentor appropriate behavior.

Due to the intense level of supervision that paraprofessional visitors require, supervisors should be responsible for only a small number of home visitors. We believe that supervisors should be responsible for no more than six visitors if they all work out of a central office location, or no more than four visitors if their offices and work areas are spread geographically. These small ratios are especially important when the visitors or supervisors are inexperienced in their roles.

Paraprofessionals who are new to home visiting need clear, detailed guidelines on rules, procedures, and expectations of the organization. Many paraprofessionals have little or no previous work experience in related areas. Since home visiting is conducted in a relatively independent work environment, they may have fewer opportunities to observe seasoned staff modeling "professional" work behaviors. Rules about dress, punctuality and attendance, travel documentation, and the use of beepers or cellular telephones must be made clear up front.

The supervisor should be personally familiar with each family served by her home visitor.

We found it helpful to have supervisors accompany the home visitor to meet newly referred families on the initial visit-or at least within the first month - to introduce themselves, explain their role as supervisor, and let families know to expect to see or hear from them periodically. Direct contact with the family prepares the supervisor to handle crisis situations, facilitates her oversight of visits, provides moral support and opportunity for mentoring with the visitor. The supervisor's contacts with the family also serves as a buffer against potential staff turnover.

We learned to ask our supervisors to routinely telephone each participating family and ask them about how visits were going, what they felt was helpful or not, and inquire about their visitor's reliability and punctuality. When visitors knew in advance that such inquiries were routine, they did not see this process as a sign of their supervisor's lack of trust. Supervisors' calls included a direct question, "When was your most recent visit?" Typically, they obtained enthusiastic comments which they could pass on as positive feedback to the visitor, but such aggressive solicitation of feedback in the absence of the visitor occasionally yielded negative responses which needed urgent attention. We now know that such a routine is critical to ensure that visits are occurring on schedule and families are satisfied with their visitor's efforts.

Home visitors need to be part of a strong, supportive peer group, fostered by their supervisor. Supports specifically designed to help home visitors deal with personal and job-related stress are also important.

Home visiting, especially in rural areas, can be a lonely job. The stress of interacting alone, day after day, with families facing complex problems at times deflated our home visitors' enthusiasm and ability to cope. Supervisors can alleviate these problems by establishing at least daily telephone contact with visitors in outlying areas and weekly one-on-one, face-to-face conferences, usually at the visitor's office. Performance and moral can also be boosted by offering regular opportunities to meet together to share experiences, solve problems together, participate in informal staff development, and practice new skills.

Some of our home visitors faced family and economic stresses similar to those of families they were serving, and of course these problems could affect their work. We found some visitors needed help solving the very problem that it was their job to help their families address. Some problems had practical implications. For example, we discovered one home visitor cut back on visits because she couldn't afford gas or car repairs. In that instance we helped by arranging for gas credit cards and expediting travel reimbursements, but helping staff overcome difficulties in managing time and money was a longer-term issue.

Some home visitors were experiencing marital problems or domestic abuse. In addition to providing support from supervisors and our staff mental health consultant, we encouraged home visitors to access counseling services available through our university. We can attest to the benefits of this resource and concur with the Early Head Start requirement that a mental health professional be available to help both families and staff members.

Home visitors' work with families should be supported through routine consultation with professionals from related disciplines.

The need to conduct quarterly "case reviews" to discuss the status of each visitor's work with each of her assigned families initially arose from a concern about the paraprofessional home visitor's ability to deal with families who had complex medical issues. Although nurse home visitors were more familiar with this exercise, they too found it helpful, whether the family's issues were complex or not. At these conferences, the home visitor was asked to present specific information about the mother or family's status (designed to reveal "red flags" or situations that suggested some further action), and was questioned by the project coordinator and a team of professionals (including her supervisor, the medical or nurse consultant, a nutritionist, child development consultant, and mental consultant).

We used existing community resources or project consultants to provide this kind of professional support, and varied composition of the team depending upon whether or not the mother had given birth, and other individual circumstances.

The objective of these reviews was to help the visitor and her supervisor identify issues and discuss how to address them. For example, "The 18 month old sibling isn't walking? Have you suggested that he see a developmental specialist?" Or "Sounds like the mom might be depressed. Would she like to have our mental health consultant come with you on the next visit?" Follow-up actions were noted and each tracked for follow-through. Although not always possible, it was helpful to have someone from the referral source - usually a nurse from the public health department - join the team and share their knowledge of any issues requiring attention (specific consent for information sharing was obtained at time of recruitment).

Quality improvement within a home visiting program

Evaluation activities are best understood as a part of what EHS calls "continuous improvement." Careful documentation of both frequency and content of home visits provides the information essential for ongoing supervision, quality improvement, and analysis of outcomes.

Early in the Panhandle Healthy Start project we struggled to find a balance between evaluation and direct service. For those of us who are researchers in a university setting, evaluation activities were of primary importance. On the other hand, community stakeholders wished all project monies could be spent on direct services. We learned that evaluation is more likely to be viewed as "valuable" when the community sees how it can be used for quality assurance.

Our home visitors' completion of Weekly Home Visit Report Forms offered raw data that could be used for supervision, quality improvement, and tracking of program outcomes. Records of the frequency of visits, illustrated in a graph of the low, high, and mean number of visits accomplished, gave home visitors objective feedback on how many visits they had provided compared with their peers and provided an incentive for making improvements. These records also allowed supervisors to identify patterns of missed visits. A list of topics on the forms allowed home visitors to check off topics that they had discussed with each family. Visitors and supervisors could keep track of the topics covered, and cumulative summaries allowed them to identify any gaps. Computer analysis of this information allowed us to link topical content to program outcomes. We found some correlations between the frequency with which certain topics were discussed (e.g., breastfeeding) and the desired outcome (e.g., longer duration of breastfeeding). In our Early Head Start program, home visitors are entering their weekly reports directly into the computerized database in order to facilitate more rapid feedback.

To collect evaluation data on the project which would be of value to multiple articles, we established an evaluation advisory committee for the project that included key state agency staff who were responsible for collecting vital statistics and hospital discharge data. An exchange of information between state-level policy makers and project staff provided the state with the ability to measure the reliability and validity of birth certificates and other statistical forms.

Affecting community systems that serve expectant families

Systems changes have the potential to affect the future of many more pregnant women than can be achieved by direct services alone.

In our area, as in many communities, multiple direct service providers come into contact with high-risk pregnant women. When these providers forge alliances, they have an opportunity to work collaboratively to identify complex problems, learn from each other, and improve the efficiency, coordination, and appropriateness of their services. We learned that home visitors, supervisors, project leaders, and consumer/community policy councils all have important roles to play.

Guided by their supervisors, home visitors can coordinate their services with those of other agencies to minimize overlap and maximize effective use of resources. When serving expectant families, engagement with the obstetrical community is especially important. Home visitors frequently transport pregnant women to prenatal care and other services. While there may be important clinical reasons for a home visitor to provide this concrete service to a family, in the long term visitors may help families more effectively by showing them how best to use the transportation system that is available in the community. By doing so, they facilitate families' access to multiple community resources and empower then to take control over their own lives.

When leaders of community-based programs that serve expectant families work with local and state agencies, they can improve outcomes for babies. We believe it is important for leaders of home visiting programs to meet with local and state decision-makers within the health care system to identify and pursue a common agenda. Meetings with HMO provider networks helped to resolve numerous conflicts and improved relationships between medical providers, HMO's and public health departments in the counties served by our project. State policy makers valued our detailed knowledge of quality assurance problems and asked that we advise then on ways to improve health care for pregnant women and young children statewide. For example, our input influenced state regulations restricting unscrupulous recruitment of Medicaid families into HMO's.

Summary

As Early Head Start programs begin to serve their families and children during the prenatal period, they will be challenged to adapt and build upon the program cornerstones of child development, family development, staff development, and community development to meet the unique needs of expectant families. We believe that the lessons that we learned during the Panhandle Healthy Start home visiting project will make our Panhandle Early Head Start a better program. We hope that other Early Head Start programs and other initiatives serving expectant families will benefit from our experience and, in turn, teach us the lessons they learn.

Partners for A Healthy Baby

Home Visiting Training Institute

The FSU Center for Prevention and Early Intervention Policy is providing training and mentoring for home visiting projects throughout the nation. The Institute will feature materials developed by the Panhandle project including:

• Partners for a Healthy Baby: Prenatal and Infancy
  Comprehensive curricula providing monthly guidance for home visitors including content, prompts and resources for enhancing maternal health and personal development; infant health and development; and parent/child interaction.
• Home Visiting Training Guide
  A competency-based preservice training for home visitors including content for home visiting during prenatal, postpartum and infancy; novel techniques for training such as role playing and games to demonstrate competencies; and integration of forms to link home visiting services to outcomes.
• Home Visitor Handbook
  Overview of the characteristics of effective home visiting programs and qualities of effective home visitors based on research.
• Supervision Training Materials
  Supervisory tools including home visitor position descriptions, performance standards, job performance quality rating scale, a MIS system including forms for documenting quality and quantity of visits, and a training video illustrating effective supervision techniques.

Dissemination of these materials is anticipated in December 1997. For further information contact: Florida State University Center for Prevention & Early Intervention Policy, Partners for A Healthy Baby Institute, 1339 East Lafayette Street, Tallahassee, Florida 32301 Phone: (850) 922-1300 Fax: (850) 922-1352 email: mgraham@mailer.fsu.edu

References

Kitzman, H., Olds, D.L., Henderson, C.R. Jr., et al. (1997). Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing: A randomized controlled trial. JAMA, 278, 644-652.

Olds, .D, Eckenrode, J., Henderson, C. Jr., et al. (1997). Long-term effects of home visitation on maternal life course and child abuse and neglect: A fifteen-year follow-up of a randomized trial. JAMA, 278, 637-643.

Olds, D., Henderson, C., & Tatelbaum, R. (1994). Intellectual impairment in children of women who smoke cigarettes during pregnancy. Pediatrics, 93, 221-227.

Olds, D., Kitzman, H., Cole, R., et al. (1997). Theoretical and empirical foundations of a program of home visitation for pregnant women and pa rents of young children. Journal of Community Psychology, 25, 9-25.

Olds, D.L., Henderson, C.R., Kitzman, H., & Cole, K. (1995). Effects of prenatal and infancy nurse home visitation on surveillance of child maltreatment. Pediatrics, 95, 365-372.

Olds, D. (1992) Home visitation for pregnant women and parents of young children. American Journal of Disease in Children, 146, 704-708.

Olds, D. & Kitzman, H. (1993). Review of research on home visiting for pregnant women and parents of young children. In Center for the Future of Children: The David and Lucile Packard Foundation, The Future of Children, 3, 53-92.

Olds, D., Henderson, C., & Kitzman, H. (1994). Does prenatal and infancy nurse home visitation have enduring effects on qualities of parental caregiving and child health at 25 to 50 months of life? Pediatrics, 93(1), 89-98.

Olds, D., Henderson, C., Phelps, C., Kitzman, H. & Hanks, C. (1993). Effect of prenatal and infancy nurse home visitation on government spending. Med Care, 3, 1-20.

Olds, D., Henderson, C., Tatelbaum, R., & Chamberlin, R. (1988). Improving the life- course development of socially disadvantaged mothers: A randomized trial of nurse home visitation.

Olds, D., Henderson, C., Phelps, C., Kitzman, H. & Hanks, C. (1993). Effect of prenatal and infancy nurse home visitation on government spending. Med Care, 3, 1-20.

Olds, D., Henderson, C., Tatelbaum, R., & Chamberlin, R. (1988). Improving the life- course development of socially disadvantaged mothers: A randomized trial of nurse home visitation. American Journal of Public Health, 78,1436-1445.

Olds, D., Henderson, C., Chamberlin, R., & Tatelbaum, K. (1986). Preventing child abuse and neglect: A randomized trial of nurse home visitation. Pediatrics, 78(1), 65-78.

Olds, D., Henderson, C. Tatelbaum, R, & Chamberlin, R. (1986). Improving the delivery of prenatal care and outcomes of pregnancy: A randomized trial of nurse home visitation. Pediatrics, 77, 16-28

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