Family Strengthening – A Key to Public Health
This
article was originally published in Summer 2003 issue
of
Winds of Change.
An update follows.
Every week teen parents and parents-to-be are educated and
supported in their homes by family health educators, many
of whom were themselves teen parents. There are three
male-female teams of family health educators on the Navajo
Nation and one male-female team on the White Mountain
Apache Reservation. The family health educators begin
meeting with teen parents as early as possible in the
mother’s pregnancy. Typically the female family health
educator works one-on-one with the teen mother, while her
male counterpart works one-on-one with the teen father.
However, a growing number of couples on the Navajo Nation
now meet two-on-two with their family health educator team.
Every visit includes opportunities for teens to talk about
their challenges and accomplishments. The family health
educator (FHE) also spends 35 to 40 minutes presenting
lessons related to one of the topics of the curriculum,
which is designed to help parents build healthy families.
The topics include getting ready for the baby, labor and
delivery, the basics of infant care, the building blocks of
parenting, culture and history, planning for the future,
developing good health habits, and preventing risk
behaviors, such as alcohol and drug abuse. Visits are
typically weekly. FHEs work with parents until the baby is
one-year old.
These in-home educational visits are part of a
family-strengthening program called the Family Spirit
Project. Indian people working in public health identified
the need for this project and have also been working with
their local communities in developing and carrying out this
program. Since an earlier version of the program began in
1996, more than 1000 young families have been served. To
date, the outcomes are promising.
Partnership
The Family
Spirit Project is a partnership between the Navajo Nation,
the White Mountain Apache Tribe and the Center for American
Indian Health at Johns Hopkins Bloomberg School of Public
Health in Baltimore. Novalene Goklish, White Mountain
Apache, and Lola Riggs, Navajo, are
the senior field managers for the personnel at four
sites where the program takes place: (1) Whiteriver on
the White Mountain Apache Reservation, (2) Tuba City,
(3) Fort Defiance, and (4) Gallup on the Navajo
Reservation.
Goklish has primary responsibility for training new FHEs
and for overseeing the quality of the project. Riggs
coordinates the development of the program. She works on
curriculum development and makes presentations on behalf of
the project to local groups, potential funders of the
project, and others. Riggs and Goklish are assisted by two
other Navajo site managers, Pauline Fields, who runs the
Gallup site, and Brandii McCabe, who runs the Fort Defiance
site. The senior staff also includes Baltimore-based John
Walkup, MD, principal investigator; Allison Barlow, MPH,
project manager; and Golda Ginsburg, PhD, evaluator.
Kristen Speakman, the field program coordinator, is based
in Albuquerque.
The Training of Family Health Educators
The family
health educators have received hundreds of hours of
training from the local and Hopkins-based senior staff as
well as from traditional healers and various experts who
have been brought in to talk about special topics. The
focus of the training program is to help the FHEs develop
the knowledge and skills needed for teaching and counseling
their clients.
In order to track their progress and ensure the quality of
the program, FHEs take knowledge exams, which Riggs
developed on each topic area. In addition, Goklish
periodically observes the FHEs while they are interacting
with clients. Riggs, who has also observed the FHEs in
action says: “The family health educators know the topics
well, so they are respected even though they are about the
same age as their clients.”
Gokilish facilitates weekly conference calls for the FHEs
and senior staff. These calls enable FHEs to report on
their work, get help with challenging situations, and
provide feedback regarding any additions or changes that
need to be made to the curriculum or overall program.
Teen Mothers’ Program
The Family
Spirit Program is the outgrowth of an earlier program for
teen mothers. In 1995 Native outreach
workers, who were visiting mothers in their homes as part
of a public health biomedical research project, told
Dr. Ray Reid, Navajo,
medical field director for the Center for American
Indian Health, that mothers were asking them numerous
non-medical questions about child care that were outside
their expertise. “We did a study of the mothers and
found out that many of them were teens who didn’t know
how to take care of babies,” says Reid. “Some of them
had to drop out of school. Because of the stigma
attached to being a teen mother, a lot of these women
had lost their friends. Some of their parents and
relatives disapproved of their situation. We weren’t
trained to provide the educational and emotional support
that they needed.”
A further problem was the change in cultural patterns.
Riggs explains, “In the past young mothers were taught the
skills they needed by their mother, grandmother, aunts and
others in their extended family. Now days, our mothers
work. Our grandmothers are out herding sheep. We aren’t as
close as before.”
In 1996 funding was secured for a program in which four
Native outreach workers were paired with young Navajo and
Apache women who had themselves been teen mothers. A
curriculum was developed that focused on 4 topics:
breast-feeding, nutrition, immunizations, and the
prevention of sexually transferred infections. After the
teams were trained, they identified teen mothers who wanted
their help and began educating them in their homes.
The program was successful, but the fathers also wanted
recognition and help as parents. Some of them were even
sitting in on parts of the lessons. Greg Wauneka, Navajo,
an outreach worker who at that time taught some of the
nutrition and immunization lessons, advocated for creating
a program for the fathers.
Teen
Fathers’ Program
In the spring
of 1999 Wanuneka, along with other Navajo and White
Mountain Apache male outreach workers, interviewed 137
fathers of teen-formed families. They wanted to better
understand the fathers' status and needs and what might
help these fathers stay engaged in the lives of their
children and partners. They found that the average age of
fathers at the time of the baby’s conception was 18. Most
of them (80%) were not married. The majority of them,
however, lived with their child and partner and wanted to
be involved with their family. Obstacles to parenting for
some fathers included insufficient education, unemployment,
lack of effective communication skills, and substance
abuse. Many had little awareness of existing services and
resources in the community and saw little or no link
between their situation and the community.
Asking
the Teen Mothers About the Fathers
Goklish, Riggs,
Fields, and McCabe interviewed 134 teen mothers, who were
enrolled in the home visitation program, to get their
points of view regarding the needs of fathers. The young
women ranged in age from 14-17. Their partners ranged in
age from 14 to 22 years old. The field workers found that
the older fathers, who had completed high school, tended to
be more highly involved with their families and more able
to provide for them.
Most of the women felt positive about the father of their
children. More than half said their partner’s greatest
strength was being emotionally supportive to them. However
many mothers reported that the fathers had difficulty
dealing with the stress resulting from their increased
responsibilities as fathers. Obstacles to being an
effective parent for some fathers included difficulty
controlling their anger, susceptibility to peer pressure,
and substance abuse.
Interviews and Roundtables
The senior
staff, led by Dr. John Walkup, then conducted 32 in-depth
interviews with individuals from four groups of community
stake holders: Elders, politicians, teen parents, and
parents of the teens. Then Goklish, Riggs and Wauneka
facilitated 22 round tables with small groups of the same
stakeholders, plus teens who weren’t parents and service
providers, including physicians. They conducted 5-6
sessions at each of the four sites.
According to Riggs, “We met with each group of stakeholders
separately. If we had mixed them, it would have been hard
to get information. The teen parents were more apt to talk
if they weren’t with other people. If we had mixed the
politicians with the grandmas, that wouldn’t have been
good. The parents of the teens were the hardest group. Most
of them were single parents. Some of them finally spoke
out, but it was hard for them.”
The facilitators gave the results of all of interviews to
the stakeholders who attended the roundtables. “Then,” says
Goklish, “we asked each group a series of questions,
including what we should be teaching the fathers. We also
asked the fathers what they wanted to learn.”
Adds Riggs, “We wrote out all of the responses in a booklet
that we can refer back to. The round tables took a huge
amount of work. But the community gave us good direction.”
Riggs, Wauneka, Goklish, and other staff developed a
curriculum for the men with numerous topic areas. Although
typically this kind of health education is done in groups,
the staff followed the communities’ recommendation that the
curriculum be presented in the homes, one-on-one, using a
picture flipchart.
Riggs concludes, “The men were very thankful to learn the
basic skills of being a Daddy. They learned how to bathe a
baby, how to diaper and wrap a baby and other cool skills.
These skills aren’t taught in schools.” The curriculum also
includes topics related to getting a job, supporting a
family, and dealing with anger.
Wanting
More
The teen
mothers were still being taught only four topics. Goklish,
Riggs, and other women who helped develop the men’s
curriculum decided that the mothers should get the many
other topics that were being offered to the men. Riggs
headed up the process of creating a parallel curriculum for
the women, offered from the mothers’ point of view.
“Meanwhile,” says, Riggs, “the curriculum evolved as needs
were recognized.” The Native Advisory Boards from the two
tribes annually reviewed what was now being called the
Family Spirit Project. Riggs reflects, “The leaders were
grateful that we had a fathers’ program. The older people
and the medicine men urged us to continue to develop the
cultural aspects of the curriculum.”
Cultural Education
Consequently,
with the help of Navajo and White Mountain Apache elders,
Riggs, Goklish, and their colleagues are developing
cultural lessons. For example, Riggs says, “In one lesson
we talk about the newborn baby’s clans and how each of the
clan systems came about. Knowing about your clans helps you
identify yourself as a person. It’s very prideful
information.” Family health educators can also choose to
include cultural segments that have been designed to add to
existing programs. For example, while discussing the
delivery of a baby with Navajo parents, if appropriate,
FHEs can talk with the parents about the tradition of
burying the umbilical cord. Because there are differences
in the traditions, Goklish and her colleagues are
developing separate cultural lessons for the White Mountain
Apache clients.
Some of the cultural teaching is happening naturally as
parents and elders are playing a role in the education of
the young parents. Riggs offers, “Sometimes the mothers of
the teens sit in on the sessions. It’s cool when some of
them join in on teaching cultural aspects. This sparks an
interest for the mothers of teens to also teach other
cultural aspects to their daughters and sons. We have
granddaddies who have a lot of wisdom, but there’s a
communication gap between them and young people who don’t
know how to speak Navajo very well. Sometimes after the
family health educator teaches what’s important in our
culture about being a father, the young man will go to his
grandfather and asks him to teach him more. We want to
learn our language again. We’re into our culture. When the
old people see that we’re interested, they start telling us
all kinds of things”
The
Curriculum
The curriculum
is being rigorously evaluated to ensure that it is having a
significant impact. The evaluation includes
tracking
a group of young parents who do not receive the family
strengthening home-visiting program and comparing their
outcomes with the parents who receive the full
program. The staff is
also trying to get the program certified by Johns Hopkins
University and by the Substance Abuse and Mental Health
Services Administration, which could help distribute the
curriculum through its national clearinghouse
Riggs and the rest of the senior staff at Johns Hopkins are
working to package the curriculum so it can be distributed
to other tribes. “The curriculum will include a
step-by-step guide so that other tribes can do their own
cultural piece,” says Riggs. “That guide will indicate what
we did, who we turned to and so on. There will also be
exams for the FHEs to complete, to assure the quality and
standards of the program are maintained.” If all goes well,
Riggs and Goklish will run a train-the-trainers workshop
for the current FHEs so these FHEs can help other tribes
train their people to use the curriculum.
Enhancing and Sustaining the Project
In
time the goal is for the local communities to take over the
full management of the Family Spirit Program. Johns Hopkins
staff members are working with tribal and national experts
to design a process that will ensure the continual
improvement of the program and enable the tribes to sustain
the program over time.
This
article was originally published in Summer 2003 issue
of
Winds of Change.
(The cover
artist is Tina Santiago, Coushatta.)
Update
January, 2007
Some of the staff members, including Lola Riggs have moved
on to other jobs.
Kristen Speakman: “The Family Spirit Project has completed
two rigorous evaluation trials: The first a pilot study
conducted from 1999-2001, which demonstrated significant
increases in knowledge, maternal involvement and positive
trends in decreased maternal depressive symptoms among
participating mothers; the second, a demonstration trial
conducted from 2002-2005, a preliminary analysis shows
significant increases in knowledge and child
behavior/emotional outcomes among participating mothers.
The curriculum is currently being packaged and replicated
as a service project in seven Native communities around the
country including one urban area. A grant from the National
Institutes of Drug Administration was awarded to Hopkins
Center to develop curriculum up through the babies’ second
year. This trial is expected to be completed in 2009. For
more detail on the progress of these initiatives, see
the Center for American Indian Health
website.