Journal Issue: Home Visiting: Recent Program Evaluations Volume 9 Number 1 Spring/Summer 1999
A consortium of school districts15 sponsored implementation of the PAT program in the Salinas Valley of California, beginning with a two-year pilot phase in 1990,16 continuing with the launching of the randomized trial proper in 1992, and concluding with the "graduation" of participating families in 1996, when children reached their third birthdays.17
The Salinas Valley, in north Monterey County, is a largely agricultural area with a high demand for seasonal farm labor and a predominantly Latino population. The unemployment rate in the county at the time of the demonstration was among the highest in the state—15.1% in March 1995, compared with 7.8% for the state as a whole.18
The conceptual framework for the Northern California (Salinas Valley) Parents as Teachers (or Salinas Valley PAT) Demonstration and evaluation, illustrated in Figure 1, includes the key parent and child outcomes expected from the program and reflects the underlying assumption of the program: that participation in PAT services will change parent behavior and thereby enhance children's development.
Families with children no older than six months were recruited to the demonstration by local program staff over a one-year period. Recruitment sites included the local Women, Infants, and Children (WIC) office; medical clinics; and school districts. During the pilot phase, attrition from the PAT group had been higher than attrition from the control group. Therefore, to ensure sufficient numbers of families in each group at the end of the study, SRI staff randomly assigned 497 families to the participant and control groups, with a 60% probability of assignment to the participant group (n=298) and a 40% probability of assignment to the control group (n=199).19 There were no statistically significant differences between the participant and control groups at enrollment, as shown in Table 1, or at any assessment point.19
These families reflected their community. A large majority of families had Latina mothers, many of whom spoke primarily Spanish. Many families were low income, with about one in five receiving Aid to Families with Dependent Children (AFDC) benefits and more than half covered by Medi-Cal. Nearly half of the families were headed by unmarried mothers.
The PAT group was offered monthly home visits for as long as the families chose to remain in the program, up to the children's third birthdays. Each home visit, conducted by a trained parent educator, covered a lesson from the national PAT curriculum. All of the 10 parent educators who worked in the program during the course of the demonstration project had at least some college education; six had bachelor's degrees or better. Six were Latinas who spoke both English and Spanish.
Mothers were the primary program participants, occasionally joined by other family members. The enrolled children were included in the visits so the parent educators could model appropriate ways of interacting with the children. At the close of the lessons, the parent educators often left materials that reinforced or supplemented the lessons for the parents to read and share with other family members. Parent educators also conducted periodic screenings of children's hearing, vision, and general development, and made referrals to community services—for example, for child care, health care, and family crisis interventions such as counseling or battered women's shelters.
PAT program participants received an average of 20 visits over three years. Visits were planned to last from 45 to 60 minutes, but a sample of home visits that were videotaped ranged in length from 28 to 50 minutes depending on the parent educator.20 Voluntary group meetings in English and Spanish were offered periodically by parent educators, during which parents discussed issues with and received social support from the parent educators and other parents. However, less than 15% of participant group families attended any group meeting.
Control Group Services
The evaluation team periodically sent age-appropriate toys to the control group as a method of tracking their location and encouraging participation in the assessments. If annual assessments conducted for the purpose of the evaluation revealed significant developmental delays or other problems, families were referred to appropriate services. Other than that, the only services control group families received were those that they sought on their own from existing community health and human services providers.
Assessments of (1) parent knowledge, attitudes, and behavior; (2) child development; and (3) the conduciveness of the home environment to promoting child development were conducted in families' homes at children's first, second, and third birthdays by SRI field evaluators who were hired, trained, and supervised by SRI and were unaware of the group assignments of the families they assessed. In addition, families were invited to bring their children on a voluntary basis to the Monterey County Office of Education for annual developmental assessments by child psychologists using the Bayley Scales of Infant Development (BSID).21The Teen Parents as Teachers Demonstration
The Teen PAT Demonstration was sponsored by a public-private partnership initiated in 1991.22 The conceptual model for Teen PAT is illustrated in Figure 2. Designed to test the effects of a two-generation approach to social service delivery to families and children, the program combined PAT services with comprehensive case management services for the participating teen parents to produce positive life changes for both parents and children. Both a case manager and a PAT parent educator served each family in this "combined intervention." Case management activities focused on achieving positive outcomes in the teen mothers' lives, particularly related to education and postponed repeat childbearing. (See the article by St.Pierre and Layzer in this journal issue for a discussion of another two-generation program.) Because the effectiveness of the individual interventions for teens was unknown, the demonstration also included stand-alone PAT and case management intervention groups.
Teen PAT Demonstration sites in Los Angeles, San Bernardino, San Diego, and Santa Barbara Counties were selected through a competitive bid process. Applicants were agencies with established programs of case management for teen parents and the willingness to recruit and randomly assign up to 200 teens over the course of a year to one of four experimental conditions. Agencies also were responsible for the hiring and supervision of PAT-trained parent educators. The sponsoring agencies at the sites differed (for example, three were youth-serving organizations, whereas one was a partnership between a public health department and the YWCA), as did the communities they served (for example, the largely African-American neighborhood of South Central Los Angeles and largely Latino areas in Santa Barbara).
Like the Salinas Valley PAT Demonstration, the evaluation of the Teen PAT Demonstration used a randomized experimental design.23 Teens were eligible if they were less than 19 years of age and either were pregnant or had babies who were less than six months of age. SRI randomly assigned eligible participants, recruited over a one-year period from the population of youths served by the program agencies, into four groups: (1) PAT program services alone (n=177), (2) case management services alone (n=174), (3) PAT services plus case management (the two-generation group) (n=175), and (4) an untreated control group (n=178). Table 1 illustrates that the groups were equivalent at enrollment, with the exception that mothers in the PAT-alone group were significantly more likely than control group mothers to have dropped out of high school.
As Table 1 describes, the 704 enrolled Teen PAT families were fairly diverse ethnically and sociodemographically. About half of the mothers were Latina, with the remainder being fairly evenly divided between African American and Caucasian. Mothers were between 15 and 18 years of age at enrollment, and the majority were enrolled in or had completed high school. Few mothers were married. Almost one-third of families received AFDC benefits.
The PAT and combined intervention groups were offered monthly home visits and PAT group meetings through the children's second birthdays.24 During these visits, as in Salinas Valley, trained parent educators covered lessons from the national PAT curriculum. On average, participants received 10 visits during the two-year period. Visits were planned to last about one hour, but data regarding the actual length of visits were not collected. Participant attendance at group meetings was low, averaging two meetings for PAT group members and three meetings for members of the combined intervention group over two years.
The case management and combined intervention groups were offered comprehensive case management services modeled after those provided through California's Adolescent Family Life Program, with face-to-face contacts provided as often as teens needed but at least quarterly. Case managers provided referrals or arranged for services to address issues such as psychological functioning, health status, nutrition, environmental risks, and educational and vocational goals.
In the combined intervention group, the case management contacts, which could occur at home or elsewhere, were separate from the PAT program visits. On average, participants in the case management and combined intervention groups received 10 case management contacts in two years. This means that a teen mother in the combined intervention group received an average of 20 in-person contacts from both PAT and case management staff during the course of the program. Additional telephone contacts with the teens averaged 6 for the PAT group, 8 for the case management group, and 17 for the combined intervention group.
Control Group Services
As in the Salinas Valley study, the control group received toys as an incentive to maintain contact with the program, and participated in annual developmental assessments, but otherwise received only the services that were normally available in the communities and that they sought at their own initiative. Children and parents were assessed by SRI field evaluators in their homes at or around the children's first and second birthdays.