The AVANCE Randomized Controlled Trial Outcomes Study - PowerPoint Presentation

The AVANCE Randomized Controlled Trial Outcomes Study GSE, Feb. 6, 2019Milagros Nores, Ph.D.mnores@nieer.org

Acknowledgments Heising-Simons Foundation (Grant #2014-29). Avance, Inc. also provided funding as part of a grant from the W.K. Kellogg Foundation.The two centers and communities included in this evaluation.

Background 2-gen: serving at-risk children and parents (Chase-Lansdale & Brooks-Gunn, 2014). HV among the most studiedAvellar and Supplee (2013) reviewed 12 HV models: singled out NFP, Healthy Families America (HFA) and Early Head Start-HV; effects on health coverage & use, birth outcomes, mother’s adopting BF, some child dev. Indicators & maltreatment Peacock, Konrad et al. (2013): 21 studies using paraprofessionals; 6/13 no effects. Effects on less abuse, maltreatment, on pregnancy, and child expressive language Issel , Forrestal et al. (2011): 28 studies of prenatal HV. 41% evidence of + effects on birth weight, 21% on gestational age & 17% on use of prenatal care Nievar , Van Egeren & Pollard (2010) HV for at risk families. Effects only on maternal behavior & those w/ high intensity Others: little evidence of HV evidence, except for NFP (Brooks-Gunn & Markman , 2005; Howard & Brooks-Gunn, 2009; Wagner & Clayton, 1999) Grindal et al.’s (2016) review: suggestive evidence programs w/parenting ed focused on parenting skills and w/practice opportunities had greater effects in children. Those w/1+ HV a month  significantly larger cognitive effects

This paper What is the impact of the AVANCE program on participants’ parenting practices, child stimulation, knowledge about child development, attitudes and beliefs about parenting, social supports and difficulties, welfare resources and family functioning? What is the impact of the AVANCE program on children’s cognitive, linguistic and social development, and their overall health?(Short term impact) This trial was part of a larger study on the cultural sensitivity of the AVANCE program.

Contribution Increased high-quality studies on interventions for infants and toddlers are fundamental to the field even in the United States, which has an abundance of literature on preschool, but has lacked a strong foundation for the earlier years (Camilli, et al., 2010; Bowne, et al., 2017; Grindal, et al., 2016) Scarcity in the literature on 2-gen center-based interventions for children under the age of 3, contrasts poorly in relation to what is known for home-visitation interventions (Chase-Lansdale & Brooks-Gunn, 2014; Nievar , Van Egeren & Pollard, 2010; Peacock, et al., 2013) This study is built on a previous study that showed that AVANCE was adaptable to communities beyond the Hispanic community it has predominantly served in TX and CA (Nores et al., 2013), albeit some fidelity issues existed

Design Randomized control trial 2 communities: Newark: lowest performers in NJ; serves mostly minority and low-income families; 52% African American & 36% Hispanic, and 79% of F&RL (U.S. Census, 2010; Newark Public Schools, 2016). Site is a community-based provider that also provided Head Start and Early Head start. Brooklyn: a unique combination of African American (35%), Caribbean American (16%), and Hispanic (20%). Site provides early childhood and parenting education programs since 2005. Lottery based on oversubscription Slots were randomized for 42 dyads/triads in Newark and 37 dyads/triads in Brooklyn Baseline in the fall of 2012; post test late started spring-summer 2013 ~8/9 months of treatment (interrupted for budgetary constraints and finished then in the fall 2013) >90% retention

Timeline

Consort Flow Chart Assessed for Eligibility (n=155) Lost to follow-up (n=14) Allocated to intervention (n=87) Received allocated intervention (n=73) Did not receive allocated intervention (refused) (n=14) Lost to follow-up (n=12) Control (n=68) Did not receive intervention (n=48) Received intervention (n=20), enrolled in relation to random-ordered waiting list Allocation of Parents   Follow-Up (n=129)   Randomized (n=155) Control Treatment Retention rate 94.00% 94.10%

Intervention 9-month Parent-Child Education Program that bring parents to a “center” with their children & delivers 11 modules on children and parenting.Program: weekly 3-hr parenting classes Sept-May (Play & Toy Curriculum, Parenting Education Curriculum, & Community Resource Awareness) early childhood education for the children in a parallel space home visits transportation to & from program services, advocacy and support

Measures: Parents & Households Supportive Environment: HOME (Caldwell and Bradley, 1984) & material supports for children (Books in the home).Responsive Teaching and Feeding, Stimulation : (a) NCAST PCI Teaching and Feeding Scales (Barnard, 1994), (b) questions on parent-child interactions and (c) and questions on breastfeeding practices. Parent Knowledge, Perceptions and Attitudes about Child development : to what degree parents believe ( i ) achievements of children 0-5 are crucial for their performance in primary, (ii) period 0-5 is as equally important as adolescence, (iii) children develop naturally without effort from parents, and (iv) even when somewhat delayed, all children always develop the same skills. Also questions about importance that children play on their own, play actively with parents, interact with other adults other than parents, play with other children, attend preschool or home-based care, have adults talk to them frequently, have toys available, and have stories or books available. Plus questions on feelings about parenting, extracted from the FFCWS (Mothers’ One-Year Follow-Up Survey). Social Supports and Difficulties : (a) NCAST Community Life Skills (CLS; LeCuyer , 2003), (b) NCAST Difficult Circumstances (DLCS; Barnard, et al., 1994), (c) use of public benefits (e.g. use of WIC or food stamps) and (d) parents’ relationship quality. Maternal depression: PHQ-9 (Patient Health Questionnaire; Kroenke, Spitzer & Williams, 2001).

Measures: Children Overall Development: Ages and Stages Questionnaire (ASQ) (Squires et al., 2001).Adaptive Behavior: Vineland Adaptive Behavior Scales (Sparrow, Balla , & Cicchetti , 1989). Language, Literacy and Motor Development: The Bayley Scales of Infant Development (BSID), 3rd Edition (Bayley, 2006). Socio-Emotional Development: The Ages and Stages Questionnaire: Socio Emotional Questionnaire (ASQ: SE) (Squires et al., 2002).

Estimation Method ITT Effect (not shown): TOT Effect (crossover between treatment and control):  

Compliance Variables Lottery Losers-Not enrolled Lottery Winners-Enrolled P-value Newark 22(59%) 41(77%) 0.070 Brooklyn 32(84%) 32(82%) 0.804 Mother Education equal or above secondary 43(77%) 53(84%) 0.316 Mother Education less than secondary 11(58%) 20(69%) 0.447 Low Income (Poverty, income category 0-20k) 27(75%) 45(82%) 0.440 Non-poverty 27(69%) 28(76%) 0.536 Child Female27(75%)44(79%)0.694 Child Male27(69%) 29(81%) 0.266 Total 54(72%) 73(79%) 0.271

Sample Baseline Characteristics N Control Treatment P-value N Mean SD N Mean SD Parents                 Mother secondary complete and above 155 68 0.75 0.44 87 0.69 0.47 0.412 Low Income (income 0-20k)155680.53 0.50 87 0.61 0.49 0.322 Guardians other than parents 155 68 0.06 0.24 87 0.02 0.15 0.254 Mother Pregnant 155 68 0.01 0.12 87 0.06 0.23 0.173 Maternal marital status (single)  155 68 0.57 0.50 87 0.47 0.50 0.209 Family Size 155 68 4.40 1.29 87 4.26 1.38 0.504 Mother’s age in months 155 68 369.58 93.40 87 370.88 85.34 0.928 Mother raw PPVT scores 155 68 129.63 51.46 87 110.26 59.72 0.035 Children                 Child's gender (male) 184 84 0.54 0.50 100 0.39 0.49 0.048 Child's age in months 184 84 19.35 12.07 100 18.31 11.39 0.550

Results on Parents/Household

Results on Children

Summary Mothers in the program were much more likely to solely breastfeedParents in the program understood the importance of their involvement in children’s developmentParents marginally more likely to understand the importance of children interacting with other adults, children playing with other children, talking to children frequently, having stories or books available and having toys available*No ss effects on parent-child interactions or in feelings about parenting No ss effects on home environment For children, ss one dimension of child development, parent reported gross motor development

Discussion Findings suggest intervention increased parent efficacy among some measures although not consistentlyIncrease in breastfeeding for mothers is significant  Review of 17 breastfeeding studies found BF supports improved childhood & adolescence cognitive performance ( Horta , Mola & Victora , 2015) & Economic benefits of breastfeeding build on the health benefits of breastfeeding (Weimer, 2001; Bartick & Reinhold, 2010) Parent self-efficacy increased across many measures and effects sizes were large but significant only for the availability of toys We assessed a young AVANCE program on 2 sites on it’s 2 nd year of operating the program First year qualitative study of the program showed some fidelity weaknesses Results in a mature site, such as those that have been operating the program for decades, may look very different Future research should establish whether the effect of the full intervention, with high fidelity & in mature sites surpass those here, and if they do so, whether these persist through the preschool years