Cradling Our Future Through Family Strengthening Study

American Indians (AIs) in reservation communities have the poorest health, education and
socioeconomic status of any racial or ethnic group in the U.S., placing AI youth at
increased risk for drug abuse (alcohol, marijuana, tobacco, etc.) and adverse health and
behavior outcomes. This study focuses on one of the most vulnerable groups of
reservation-based AIs—AI teen mothers and their children.

Over the past two decades a number of research-based health promotion and drug abuse
prevention programs for youth have been found to be effective. Of these, parenting
interventions have been found to be more effective than other types of interventions. Home
visiting programs for young, high-risk mothers have been designed to impact a wide range of
outcomes--parenting, child and maternal health and behavior outcomes. More than 40 studies
have been published since 1982 supporting the short and long-term efficacy of home visiting
programs delivered during pregnancy and early childhood for low-income families. Positive
outcomes have been demonstrated for improved parenting and the home environment; increased
social support for mothers and children from extended family members and improved maternal
health and behavior outcomes; increased birth spacing; improved children's health and
behavior outcomes; prevention of child abuse and neglect; and reduced drug use.

AI teen mothers and their offspring are arguably the most vulnerable and underserved
population at risk for drug abuse and adverse health and behavior outcomes in the U.S. Given
their high-risk status, pregnant AI teens are likely to benefit from a parenting-focused,
home visiting intervention. Cultural support for developing individual strengths through a
family-based model and the noted cultural relevance of employing AI paraprofessionals are
expected to enhance participants' outcomes. As nearly half of AI women begin child-bearing
in adolescence, improvement in outcomes of teen mothers and their offspring could
substantially impact the public health and welfare of AI communities.

Both nurses and paraprofessionals have been utilized in effective home visiting programs.
However, the shortage of indigenous nurses in reservation communities renders an AI
nurse-delivered, home visiting intervention unfeasible for the participating communities at
this time. Further, young AI women's discomfort with health care delivered by non-Indians
and the potential for cultural barriers with non-Indian home visitors provides an additional
rationale for AI paraprofessionals as home visitors.

Successful home visiting programs maintain a standard for frequency and dosage of visits,
employ strategies for participant retention, provide intensive training, frequent direct
supervision and intensive quality assurance measures. For this study, we will maintain the
highest standards for dosage, retention strategies, home visitor training and supervision,
and quality assurance. The core content of the curriculum is based on American Academy of
Pediatrics' comprehensive guidelines for preparing mothers to care for infants and young
children, with cultural adaptations derived through guidance from our Native Advisory Board
and an iterative process of community input.

Inclusion Criteria:

- Pregnant AI females aged 12 to 19 years old at time of conception.

- Gestational age of 28 weeks or less (in order to complete intervention prior to
delivery).

- Parent/guardian consent for youth under 18 years old.

- Reside within 1-hour transportation range (50 miles) of the local Indian Health
Service medical facility.

Exclusion Criteria:

- Current participation in other mental or behavior health research project.

- Factors that preclude full participation, identified at baseline and after caseness
review, including: unstable and severe medical, psychiatric or drug use problem;
acute suicidal or homicidal ideation requiring immediate intervention; recent, severe
stressful life event such as physical or sexual abuse, or victim of a violent crime
that requires specific and high intensity intervention or out of home placement; or
chronic pattern of unstable caretakers or living situation.