Family Strengthening – A Key to Public Health


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.


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 2010

Some of the staff members, including Lola Riggs have moved on to other jobs.

The Family Spirit Project successfully demonstrated the effectiveness of paraprofessional home visitors as well as positive maternal and child development as early as infancy.

Over this next decade, the staff and colleagues plan to
Continue to build curricular models to address emerging needs in young families
Develop an online training program for Native paraprofessional home visitors
Replicate the Family Spirit Project with tribes nationwide and indigenous communities around the world.

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.

See the scientific article about the project -
Home-visiting intervention to improve child care among American Indian adolescent mothers.