Evaluation of Services · January 25, 2010 . ii TABLE OF CONTENTS EXECUTIVE SUMMARY ... IBCLC...

Evaluation of Services Fiscal Year 2008/09

Prepared for:

First 5 Sacramento Commission

2750 Gateway Oaks Drive, Suite 330

Sacramento, CA 95833

Prepared by:

Walter R. McDonald & Associates, Inc.

2720 Gateway Oaks Drive, Suite 250


Evaluation of ServicesFiscal Year 2008/09

Prepared for:

First 5 Sacramento Commission2750 Gateway Oaks Drive, Suite 330


Prepared by:

Walter R. McDonald & Associates, Inc.2720 Gateway Oaks Drive, Suite 250


January 25, 2010

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TABLE OF CONTENTSEXECUTIVE SUMMARY ............................................................................................................ 1

CHAPTER 1: OVERVIEW............................................................................................................ 5

Evaluating First 5 Sacramento Services ..................................................................................... 7

Methodological and Statistical Details ....................................................................................... 8

CHAPTER 2: NUMBER AND CHARACTERISTICS OF CLIENTS ....................................... 10

Race/Ethnicity........................................................................................................................... 10

Language................................................................................................................................... 11

Family Structure ....................................................................................................................... 12

Education .................................................................................................................................. 13

Employment.............................................................................................................................. 13

Where First 5 Sacramento Families Live ................................................................................. 14

CHAPTER 3: HEALTH ACCESS RESULT AREA..................................................................... 16

CHAPTER 4: NUTRITION RESULT AREA .............................................................................. 22

Childhood Obesity Prevention.................................................................................................. 23

Tot Lots..................................................................................................................................... 25

Enhanced-Community Lactation Assistance Project................................................................ 25

Baby Friendly Trainings ........................................................................................................... 30

CHAPTER 5: EFFECTIVE PARENTING RESULT AREA........................................................ 33

CHAPTER 6: SCHOOL READINESS RESULT AREA.............................................................. 44

CHAPTER 7: DENTAL RESULT AREA .................................................................................... 59

CHAPTER 8: COMMUNITY BUILDING RESULT AREA........................................................ 62

CHAPTER 9: EARLY CARE RESULT AREA ............................................................................ 67

CHAPTER 10: CROSS-CUTTING INDICATORS .................................................................... 75

CONCLUSION............................................................................................................................. 85

APPENDICESAPPENDIX A: RESULT AREA AND CROSS-CUTTING INDICATORS .............................. 88

APPENDIX B: METHODOLOGY.............................................................................................. 92

APPENDIX C: MEASURES........................................................................................................ 98

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LIST OF TABLESTable 1.1: First 5 Sacramento Commission Priorities, Results, and Result Areas, Funding Cycle 2007/08 to 2009/10..................................................................................................6

Table 2.1: Race/Ethnicity of First 5 Sacramento Clients, Fiscal Year 2008/09 ........................... 10

Table 2.2: Primary Language of First 5 Sacramento Clients, Fiscal Year 2008/09 ..................... 11

Table 2.3: Language Spoken to Children of First 5 Sacramento Clients, Fiscal Year 2008/09 ....12

Table 3.1: Screenings Provided at Bright Futures Fairs, Fiscal Year 2008/09............................. 16

Table 3.2: Percent of Children Enrolled in Health Insurance at 3, 8, and 13 Months, Fiscal Year 2008/09 .......................................................................................................................18

Table 4.1: Providers of Childhood Obesity Prevention Services, Fiscal Year 2008/09 ............... 23

Table 4.2: Childhood Obesity Prevention Services, Fiscal Year 2008/09.................................... 24

Table 4.3: Enhanced-Community Lactation Support Services, Fiscal Year 2008/09 .................. 26

Table 4.4: Relationship between Lactation Support Services and Breastfeeding, Fiscal Year 2008/09 .......................................................................................................................28

Table 5.1: Effective Parenting Services, Fiscal Year 2008/09 ..................................................... 34

Table 6.1: Providers of School Readiness Services, Fiscal Year 2008/09.................................... 46

Table 6.2: School Readiness Services, Fiscal Year 2008/09 ........................................................ 47

Table 6.3: Children from School Readiness Meeting Developmental Milestones, Fiscal Year 2008/09 .......................................................................................................................56

Table 6.4: PBM Teachers’ Responses to Education Questions, Fiscal Year 2008/09 ................. 57

Table 6.5: Percent of Teachers by Level on the Child Development Matrix (n = 33), Fiscal Year 2008/09 .......................................................................................................................58

Table 6.6: Percent of PBM Teachers by Type of Learning Center in the Classroom, Fiscal Year 2008/09 .......................................................................................................................58

Table 8.1: Neighborhood Connectedness by Community Event Participation by Fiscal Year .....64

Table 8.2: Parents with High Neighborhood Cohesion by Community Event Participation by Fiscal Year...........................................................................................................65

Table 8.3: Parents with High Efficacy by Community Event Participation by Fiscal Year......... 66

Table 9.1: CARES Tracks and Stipends Provided, Fiscal Year 2008/09 ..................................... 67

Table 9.2: Number of Licensed and Accredited Child Care Facilities and Spaces for Children Ages 0 to 5 Years by Type and School District Catchment Area, Fiscal Year 2008/09 .......................................................................................................................69

Table B.1: Completion by Result Area of Baseline and One-Year Follow-Up Samples ............. 96

Table B.2: Outcome of Baseline versus One-Year Follow-Up Parent Interviews ....................... 97

Table C.1: Available Data for Calculating BMI, Fiscal Year 2008/09 ...................................... 100

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LIST OF FIGURESFigure 1.1: Proportion of First 5 Sacramento Program Expenditures for $14 Million by Result Area, Fiscal Year 2008/09 ...............................................................................................7

Figure 2.1: Structure of First 5 Sacramento Families, Fiscal Year 2008/09................................. 12

Figure 2.2: Highest Level of Education among First 5 Sacramento Families, Fiscal Year 2008/09 .......................................................................................................................13

Figure 2.3: Occupational Status of First 5 Sacramento Families, Fiscal Year 2008/09 ............... 14

Figure 2.4: Number of Families Receiving Services by County Regions, Fiscal Year 2008/09 ..........................................................................................................................................15

Figure 3.1: Percent of Two-Year-Olds with Complete Immunizations, Fiscal Year 2008/09 ..........................................................................................................................................19

Figure 3.2: Percent of Five-Year-Olds with Complete Immunizations, Fiscal Year 2008/09 ..........................................................................................................................................19

Figure 3.3: Children Who Have Seen a Dentist by Age One, Fiscal Year 2008/09..................... 21

Figure 4.1: Six-Month Exclusive Breastfeeding among Nutrition Clients Compared with California and National Rates, Fiscal Year 2008/09 .............................................................29

Figure 4.2: Children Exclusively Breastfed 12 Months after Delivery by Result Area and Survey Time Point, Fiscal Year 2008/09 ................................................................................30

Figure 4.3: Number of Errors on Breastfeeding Knowledge Quiz, Baby Friendly Trainings, Fiscal Year 2008/09......................................................................................................31

Figure 4.4: Overall Support for Breast versus Formula Feeding, Baby Friendly Trainings, Fiscal Year 2008/09......................................................................................................32

Figure 5.1: Parent’s Risk Score by Result Area, Fiscal Year 2008/09 ......................................... 37

Figure 5.2: Relationship between Parenting Education Services and Parents’ Knowledge of Infant Development, Fiscal Year 2008/09.................................................................................39

Figure 5.3: Relationship between Case Management Services and Parents’ Knowledge of Infant Development, Fiscal Year 2008/09.................................................................................39

Figure 5.4: Relationship between Father Engagement Services and Decreased Stress, Fiscal Year 2008/09 .......................................................................................................................40

Figure 5.5: Parents Who Never or Rarely Spank Their Children by Result Area, Fiscal Year 2008/09..................................................................................................................................42

Figure 6.1: Percent of Children with Hearing Screenings by Fiscal Year.................................... 51

Figure 6.2: Percent of Children with Vision Screenings by Fiscal Year ...................................... 51

Figure 6.3: Comparisons of Percent of Children Regularly Attending Pre-Kindergarten Schools, Fiscal Year 2008/09 ........................................................................................................52

Figure 7.1: Sacramento County Fluoridation Overview Map ...................................................... 60

Figure 9.1: Total Number of Child Care Spaces, Fiscal Year 2008/09 ........................................ 70

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Figure 9.2: Change in PBM Environmental Rating Scales, Fiscal Year 2008/09 ........................ 72

Figure 9.3: Progress in Obtaining Licensure among Family, Friends, and Neighbor Child Care Providers, by Fiscal Years...........................................................................................73

Figure 10.1: Changes in the Percent of Children with Health Insurance, Fiscal Years 2007/08 and 2008/09......................................................................................................................76

Figure 10.2: Two and Five-Year-Olds with Complete Immunizations, Fiscal Year 2008/09 ..........................................................................................................................................77

Figure 10.3: Children Exclusively Breastfed for 12 Months, Fiscal Year 2008/09 ..................... 79

Figure 10.4: Percent of Community Resources Received through the Assistance of First 5 Sacramento Service Providers, Fiscal Year 2008/09..........................................................82

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DEFINITIONS

Cross-cutting IndicatorsThe 10 indicators applicable to services available from providers funded through the Health Access, Nutrition, Effective Parenting, & School Readiness Result Areas.

Baseline The first Parent Interview conducted with randomly sampled families from Persimmony.

Community Building Result Area: Community groups are funded to develop and implement CBI events.

Community Building Initiative

Community events designed to increase social capital and connections within neighborhoods.

Control/Third VariablesVariables such as race/ethnicity, language, and education that were included in the statistical analyses to reduce the chance that outcomes are due to client characteristics rather than services.

Dental Result Area: Water companies funded to fluoridate water.

“Direct” ServicesServices provided directly to clients by providers through the Health Access, Nutrition, Effective Parenting, and School Readiness Result Areas.

Early CareResult Area: Providers are funded to improve child care by increasing the number of licensed and accredited child care spaces, for example.

Effective ParentingResult Area: Providers are funded to improve family functioning and address families in crisis.

Family Intake FormForm used to collect demographics and contact information such as telephone number from clients.

One-Year Follow-UpThe second Parent Interview conducted with randomly sampled families from Persimmony approximately one year after baseline.

Health AccessResult Area: Providers are funded to assist families with obtaining comprehensive health insurance for children.

“Indirect” ServicesServices provided indirectly to clients by funded providers through the Community Building, Dental, & Early Care Result Areas.

Longitudinal Survey A survey conducted with the same group of individuals more than once.

NutritionResult Area: Providers are funded to support the initiation and continuation of breastfeeding and address childhood obesity.

Other Result AreasFindings from Result Areas are combined to compare with findings from the Result Area of interest.

Parent Interview The longitudinal survey of parents randomly sampled from Persimmony.

PersimmonyThe web-based data system that providers use to enter client-specific information such as demographics and services received.

Result AreasSimilar services offered by one or more providers to address a particular area the First 5 Sacramento Commission has established as a priority, for example School Readiness.

School ReadinessResult Area: Providers are funded to prepare families for the transition into kindergarten.

Statistical SignificanceFindings, such as differences between groups or correlations between services and outcomes, are likely due to services rather than chance. Criterion of statistical significance was set at P ≤ 0.05.

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ACRONYMS

BMI Body Mass Index

CARES Comprehensive Approaches to Raising Educational Standards

CBI Community Building Initiative

CDC Centers for Disease Control and Prevention

CRP WIC Community Resource Project, Women, Infants and Children

DHHS WICSacramento County Department of Health and Human Services, Women, Infants and Children

DRDP-R Desired Results Developmental Profile – Revised Edition

DTBY Dare to Be You

ECERS-R Early Childhood Environment Rating Scale – Revised Edition

ERS Environment Rating Scale

FCCERS-R Family Child Care Environment Rating Scale – Revised Edition

FFN Family, Friends, and Neighbors

FSCSacramento County Department of Health and Human Services, Family Support Collaborative

HEC Health Education Council

IBCLC International Board Certified Lactation Consultant

ITERS-R Infant Toddler Environmental Rating Scale – Revised Edition

KIDI Knowledge of Infant Development Inventory

LCA Lactation Consultant Assistants

MPAP Making Parenting a Pleasure

NAEYC National Association for the Education of Young Children

NAFCC National Association for Family Child Care

NECRS Neighborhood Environment for Children Rating Scale

NIS National Immunization Survey

PBM Sacramento County Office of Education, Preschool Bridging Model

PC Peer Counselors

PC/LCA Peer Counselors or Lactation Consultant Assistants

PIPE Partners in Parenting Education

POP Elk Grove Unified School District, Power of Parenting

PSI Parenting Stress Index

QCCC Quality Child Care Collaborative

SCHIP State Children’s Health Insurance Program

SCS Social Cohesion Scale

SETA Sacramento Employment and Training Agency

SMEFC Strengthening Multi-Ethnic Families and Communities

UCDMC University of California Davis Medical Center

WIC Women, Infants and Children program

WRMA Walter R. McDonald & Associates, Inc.

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EXECUTIVE SUMMARY

First 5 Sacramento programs and services to benefit children ages 0 to 5 years and their families are supported by the County’s share of the 50-cent tax on all tobacco products sold in California,as approved by voters in 1998 under the California Children and Families Act (Proposition 10).

During fiscal year 2008/09, the First 5 Sacramento Commission used a portion of these funds to distribute 23,179 “Kits for New Parents” and support “2-1-1 Sacramento,” a 24-hour telephone referral service that connects families with employment, training, housing, financial, health care, and other valuable services. Through “Bright Futures,” First 5 Sacramento also supported 449dental, 135 vision, 110 hearing, and 72 developmental screenings of children at no cost to parents.

The majority of Sacramento’s Proposition 10 funds are awarded to organizations that demonstrate in competitive proposals the capacity to provide those services given priority through a comprehensive strategic planning process. For the current three-year funding cycle, the following services are provided under seven “Result Areas”:

First 5 Sacramento Result Area

Partial List of Services

Health Access

Families receive assistance with applying for comprehensive health insurance for young children, and ongoing follow-up to verify enrollment and receipt of medical, dental, and vision services. Insurance premiums for children ages 0 to 5 years who are not eligible for Medi-Cal, Healthy Families, or other health insurance programs are also covered through Health Access.

NutritionExpecting and new mothers receive breastfeeding support services. Nutritionservices also include interventions for parents and children to address childhood obesity.

Effective Parenting

Education and crisis intervention services for parents; a home visitation program for expecting or new mothers; temporary child care for parents in crisis; and parenting classes and father engagement events, are available under this Result Area.

School ReadinessPre-kindergarten aged children, their parents, and school staff receive early care and education services to better prepare children and their parents for kindergarten entry.

DentalWater companies are funded to provide fluoridated water within Sacramento County to decrease the prevalence of dental caries.

Community Building

Small grants are available to support community events and activities designed to build social capital and strengthen relationships among families and community members with young children to empower parents, foster support networks, and develop healthier and safer neighborhoods.

Early CareChild care providers receive information and referrals, technical assistance and training, and professional consultation towards improving child care.

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Services funded through the first four Result Areas are provided directly to clients. That is, provider staff have one-on-one contact with children and adults, which facilitates recordingdemographic and service information on them. During fiscal year 2008/09, or year two of the current three-year funding cycle, 14,878 children and 11,396 adults received a total of 190,710 services through the Health Access, Nutrition, Effective Parenting, and School Readiness Result Areas.

The evaluation of First 5 Sacramento services was guided by specific indicators developed by the First 5 Sacramento Commission. These indicators, or bench markers for determining program effectiveness, were established prior to the start of the current funding cycle. The methodology to address most Result Area indicators was the Parent Interview, a longitudinal survey of parents from randomly-selected families. Now in the second year of the current three-year evaluation, we have findings from baseline and one-year follow-up Parent Interview responses. Thus, the evaluation findings presented in this report include changes in outcomes over the one-year period, as well as specific First 5 Sacramento services in relation to improvements in preventative care, healthy behaviors, and educational opportunities. In addition, local evaluation findings are put into perspective by comparing them with the results from published research studies at the state and national levels. Below are selected findings from the Parent Interview,preceded by brief descriptions of the related First 5 Sacramento services.

KEY FINDINGS

Health Access: The Health Access service provider, Cover the Kids, maintains a relationship with the families they help apply for insurance for the purpose of making sure that children get insured and eventually receive medical care; all service providers emphasize the importance of medical care and refer families for needed services, including immunizations and dental care.

Result Area Findings

Among Health Access families:

* Immunization rates significantly increased to levels above the national and state averages.

* The percent of children seeing a dentist by 12 months of age increased from 3% to 13%.

* Up-to-date well-child visits among children receiving services from Health Access exceeded the national average (89% versus 85%).

Nutrition: Lactation support services through the Nutrition Result Area provide expecting and new mothers with information, encouragement, and tools to initiate breastfeeding and continue to provide infants with breast milk; exclusive breastfeeding is a behavior promoted by all First 5 Sacramento service providers.

Result Area Finding

* Six- and 12-month breastfeeding rates among mothers receiving lactation support services were higher than those reported nationally and for California.

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Effective Parenting: Over one-fifth of First 5 Sacramento funds during 2008/09 supported a variety of services to help parents and caregivers practice appropriate parenting skills.

Result Area Finding

* Over time, parents receiving Effective Parenting services demonstrated improved parenting skills.

Effective Parenting: Services within this Result Area include multi-session parenting classes and case management services to provide parents with the information, referrals, and skills they need to become more knowledgeable and effective parents.


Significant correlations were found between knowledge of infant development and

* Number of parenting classes attended; and

* Number of case management services provided.

Effective Parenting: Events target fathers and are designed to increase their level of engagement in their children’s lives and become active participants in educating their children.

Result Area Finding

* Father engagement services were associated with a significant decrease in parental stress.

School Readiness: A central focus of School Readiness services is to provide access to quality early care and education programs.

Result Area Finding

* The proportion of First 5 Sacramento children attending preschool surpassed the level for children within Sacramento County.

Community Building: Grants are available for community groups to support activities and events to build connections within communities, make neighborhoods safer for children, and empower parents to improve their lives. A total of 360 Community Building Initiative events were reported during the year.


* Attendees of CBI events reported higher levels of community connectedness (more people in their neighborhood that they know by name and more people who visit each other’s homes).

* First 5 Sacramento clients were also more likely than those attending non-CBI or no community event at all to report higher levels of neighborhood cohesion, which includes trust in one’s neighbors.

* Higher levels of efficacy, or the perceived degree of control over life circumstances, were reported by those who attended a CBI event.

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The findings reported above are based on interview data from families receiving services within the specified Result Area. The evaluation of First 5 Sacramento services also includes examining 10 indicators across all families from the Health Access, Nutrition, Effective Parenting, andSchool Readiness Result Areas. The rationale behind the 10 “Cross-Cutting” indicators is that there are common messages communicated by all service providers that could affect more general health-related behaviors and improve family circumstances. In addition, the referral network established among providers leads some families to receive services other than those they were initially enrolled, thereby producing a number of eventual benefits from connecting with a First 5 Sacramento service provider. Cross-Cutting indicator findings include:

* The rate for uninsured children across all First 5 Sacramento families decreased from 14% to 6% from service enrollment to follow-up, and remained at 6% when parents were contacted and interviewed one year later.

* Twelve-month breastfeeding rates significantly increased over time among mothers receiving any type of First 5 Sacramento service.

Successes of First 5 Sacramento services to date certainly include connecting families to health insurance programs for children, ensuring that families maintain health insurance coverage, and the eventual increases in routine and recommended services, such as immunizations and dental care by 12 months of age. In addition, breastfeeding rates among First 5 Sacramento mothers are higher than state and national averages, and lactation services and supports are prompting more mothers to continue to breastfeed for longer periods of time. The direct correlations between specific Effective Parenting services and outcomes are also impressive. However, one area in apparent need of improvement are those services designed to influence family functioning and parenting skills.

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CHAPTER 1OVERVIEW

First 5 Sacramento services are designed to improve the health and education of children ages 0 to 5 years and their families, and are supported by a 50-cent tax on all tobacco products sold in California. A wide-range of services are potentially available to address the First 5 Sacramento Commission’s mission of “supporting the healthy development of children prenatal to age five, the empowerment of families, and the strengthening of communities.” To narrow the types ofservices to eventually receive financial support, priorities and goals are established before every funding cycle through a number of activities and with input from numerous voices in the community.

Before the current three-year (fiscal years 2007/08 to 2009/10) funding cycle, the comprehensive strategic planning process included a series of public meetings with members of the First 5 Sacramento Commission, input from members of First 5 Sacramento’s Advisory Committee, and findings from an assessment of unmet needs by interviewing over 400 Sacramento County parents.

The result of these efforts was the report “First 5 Sacramento Commission 2006 Strategic Plan Update.”1 The opinions and recommendations of providers of services targeting young children and their families, as well as key stakeholders and members of the public, were also used to develop the priorities outlined in this document.

The “Strategic Hierarchy” of the 2006 Strategic Plan explicated and logically connected the identified priorities to overall goals, and then to specific results. Table 1.1 lists the resultant three Priorities and corresponding 10 Results identified for funding for services during the current funding cycle. Services to children ages 0 to 5 years and their families began on July 1, 2007 within a total of seven “Result Areas” – the brief titles given to the program areas intended to address the related Results. The seven Result Areas are Health Access, Nutrition, Effective Parenting, School Readiness, Community Building, Dental, and Early Care.

1 Available at: www.first5sacramento.net

First 5 Sacramento CommissionFoundational Statements, 2006

Vision: Sacramento will have strong and inclusive communities, safe and healthy families, and valued children who can realize their potential and enjoy productive and fulfilling lives.

Mission: The First 5 Sacramento Commission is committed to supporting the healthy development of children prenatal to age five, the empowerment of families, and the strengthening of communities.

Core Components: Services and supports for children prenatal to age five and their families shall be affordable and accessible; culturally competent; community-driven; and responsive to special needs.

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Table 1.1: First 5 Sacramento Commission Priorities, Results, and Result Areas, Funding Cycle 2007/08 to 2009/10

Priority Result Result Area

Health

Increase comprehensive health insurance coverage Health Access

Increase use of medical/dental homes Health Access

Improve nutrition Nutrition

Decrease dental disease Dental

Early Care & Education

Increase use of effective parenting Effective Parenting

Increase caregivers’ use of developmentally appropriate practices School Readiness

Increase schools’ readiness for kindergarten School Readiness

Increase participation in quality early care and education Early Care

Empowered Families

Increase family participation in community activities Community Building

Increase family and community self-advocacy to make change Community Building

Health Access services include assisting parents with enrolling their children in health insurance programs, and then keeping in contact with families to verify insurance coverage is maintainedand services are utilized. This Result Area also supports insurance premiums for children who are not eligible for Medi-Cal, Healthy Families, or other health insurance programs. In addition, the “Bright Futures” program sponsored by First 5 Sacramento offers families no-cost dental, hearing, vision, and developmental screenings for children. First 5 Sacramento’s participation in community events provides a captive audience for publicizing services to help parents enroll children in health insurance programs.

Nutrition includes one-on-one lactation support services for expecting and new mothers and interventions directed at families to address childhood obesity. Breastfeeding is also promoted by “Baby Friendly” trainings to nurses and other hospital staff involved in the direct care of new mothers. Increased physical activity is addressed by “Tot Lots” playgrounds.

Effective Parenting services are designed to increase the use of positive parenting practices through formal classes and home visits, and to assist families in crisis.

School Readiness services for children, parents, and teachers better prepare children for kindergarten, by providing quality preschool, infant/toddler play groups, workshops for parents, health and development screenings, and summer transition activities for children with little or no prior preschool experience.

Community Building provides support for community-driven projects or events that foster and strengthen relationships among families and community members with young children to empower parents, create support networks, and develop healthier and safer neighborhoods for children.

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As we will see later in this report, from any of these five Result Areas were used toprograms.

The remaining Results Areas are within Sacramento County and the latthroughout the County.

During this second year of the current funding cycle, the First 5 Sacramento Commission expended $14,054,000 million for program expenses in support of all seven Result Areas. Figure 1.1 shows the proportion of program expenditures for each Result Area.

Figure 1.1: Proportion of First 5 Sacramento Program Result Area, Fiscal Year 2008/09

The First 5 Sacramento Commission also provided $962,000year 2008/09. These included Sacramento County; the annual “young children ages 0 to 5 years provided at nohour telephone referral service that connects families with employment, training, housing, financial, health care, and other needed services

Evaluating First 5 Sacramento Services

The First 5 Sacramento Commissiospecific “indicators,” or statements that defined how

School Readiness, 36.8%

Community Building, 4.3%

Dental, 4.8%

ter in this report, data from a random sample of families who received services these five Result Areas were used to assess outcomes from First 5 Sacramento

The remaining Results Areas are Dental and Early Care, the former supports water fluoridation the latter facilitates programs to improve the quality of

During this second year of the current funding cycle, the First 5 Sacramento Commission expended $14,054,000 million for program expenses in support of all seven Result Areas. Figure

of program expenditures for each Result Area.

Figure 1.1: Proportion of First 5 Sacramento Program Expenditures for $14 Million by Result Area, Fiscal Year 2008/09

ommission also provided $962,000 for selected projects during fiscal These included “Kits for New Parents” distributed to parents

“Children’s Celebration,” an educational event young children ages 0 to 5 years provided at no-charge to parents; and “2-1-1 Sacramento,” a 24hour telephone referral service that connects families with employment, training, housing, financial, health care, and other needed services.

Evaluating First 5 Sacramento Services

The First 5 Sacramento Commission’s strategic planning process also included developing specific “indicators,” or statements that defined how progress towards a desired Result would be

Health Access, 8.2%

Nutrition, 12.0%

Effective Parenting, 28.0%

School Readiness, 36.8%

Dental, 4.8%

Early Care, 5.9%

from a random sample of families who received services First 5 Sacramento

water fluoridation e quality of child care

During this second year of the current funding cycle, the First 5 Sacramento Commission expended $14,054,000 million for program expenses in support of all seven Result Areas. Figure

Expenditures for $14 Million by

jects during fiscal distributed to parents throughout educational event for families with

1 Sacramento,” a 24-hour telephone referral service that connects families with employment, training, housing,

n’s strategic planning process also included developing progress towards a desired Result would be

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monitored. Each Result Area has a set of indicators that were established prior to the implementation of services. In fact, service providers were required to describe in their proposals for funding how they would address the indicators pertinent to the Result Area for which they requested funds. The First 5 Sacramento Evaluation Committee, which includes members of the First 5 Sacramento Commission, was instrumental in developing the current 32 Result Area indicators.

Most indicators apply to a specific Result Area. However, the core health-related messages and strategies communicated and implemented by all First 5 Sacramento providers justify examining related outcomes among all families receiving one-on-one services. In total, 10 “Cross-Cutting” indicators were approved by the Evaluation Committee as applicable to the population of children and parents receiving direct services through the Health Access, Nutrition, Effective Parenting, or School Readiness Result Areas. As an example, breastfeeding is the centerpiece of lactation support services funded through Nutrition, and indicators within this Result Area address longer-term breastfeeding behaviors. Yet, the advantages of breastfeeding are recognized and promoted by service providers from Health Access, Effective Parenting, and School Readiness. Thus, breastfeeding duration rates are also assessed at the cross-cutting level. Please refer to Appendix A of this report for a list of the Result Area and Cross-Cutting indicators.

The outcomes presented in this report to address most Result Areas and all Cross-Cutting indicators came from the longitudinal survey of parents titled the “Parent Interview.” Families were sampled at random for the Parent Interview from a web-based data system referred to as Persimmony – short for the name of the software provider, Persimmony International, Inc. Data are entered into Persimmony by First 5 Sacramento service providers, and include demographics and service information about the parent and their children ages 0 to 5 years. Persimmony data are used to describe in Chapter 2 of this report the population of First 5 Sacramento clients and the services they received. However, these data are only from families recruited through the direct service Result Areas – Health Access, Nutrition, Effective Parenting, and School Readiness. Chapter 2 does not include information on the children who benefited from the services provided through the Dental and Early Care Results Areas; the 23,179 families who received Kits for New Parents, the 10,636 attendees of Bright Futures events, or the 6,277attendees of the 2008 Children’s Celebration. The nature of these services does not allow for obtaining consent from clients or collecting from them the demographic details that are presented in Chapter 2.

In the remainder of this fiscal year 2008/09 report are the findings for the Result Area (Chapters 3 through 9) and Cross-Cutting (Chapter 10) indicators. Last year’s 2007/08 report presented the initial or “baseline” information for the indicators; this year’s report examines changes over time. This second of three evaluation reports for the current funding cycle also examines types and levels of First 5 Sacramento services in association with outcomes.

Methodological and Statistical Details

Readers interested in the complete methodology to evaluate First 5 Sacramento services, including sampling, recruiting, and response rates for the baseline and one-year follow-up Parent

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Interview, should refer to Appendix B. The questions that parents were asked on the Parent Interview to assess the Result Area and Cross-Cutting indicators appear in Appendix C.

The most advanced statistical techniques were used to analyze Parent Interview data when appropriate. These models examined changes over time – from baseline to one-year follow-up –within the Result Area of interest, and within “Other Result Areas.” For example, changes over time in the percent of children seeing a dentist by age 1 year was examined for families from Health Access, and for families from the Other Result Areas (Nutrition, Effective Parenting, andSchool Readiness).

These linear mixed model analyses included parents’ race/ethnicity and primary language as control variables. A “family education” variable was developed based on the highest education of the father or mother, and was also included in the statistical models. One or more of these “third variables” was found to be significant in the majority of our statistical findings. This is important to note because it shows that client characteristics such as race/ethnicity, language, and education play an influential role in affecting breastfeeding, parenting styles, and the other behaviors of interest to the First 5 Sacramento Commission. Furthermore, this underscores the importance of including these variables in the analyses. Otherwise, observed changes over time could be due to client characteristics rather than First 5 Sacramento services.

For most analyses our database of 871 Parent Interview responses provided more than sufficient data to support the linear mixed model analyses. However, some indicators pertain to a very specific subpopulation of clients (e.g., only children aged 2 years with health insurance), and for these cases simple comparisons were made between the baseline and follow-up interview findings. Finally, when appropriate we compare outcomes with comparable published data for children or parents from other populations at the local, state, and national levels.

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CHAPTER 2NUMBER AND CHARACTERISTICS OF CLIENTS

During fiscal year 2008/09 the First 5 Sacramento Commission funded services to a diverse population. A total of 12,834 families, speaking over 13 different languages, received services funded through the four direct-service Result Areas. A family was considered to have received a service if a parent or child had a record of at least one service during the fiscal year, whether the family consented to participate in the evaluation in 2007/08 or 2008/09. Children were considered clients if they or their parent(s) received services. For adults, only those who received services were identified as clients; a larger number of parents signed the consent form, were entered into Persimmony, but never received services. Overall, 26,274 individuals (14,878 children and 11,396 parents) were First 5 Sacramento clients during 2008/09. The number of families (12,834) exceeds the number of parents (11,396) because some services were provided only to children. Additionally, the number of children (14,878) exceeds the number of parents because some parents had more than one child. About half (49.4%) of all 26,274 clients received services through the Nutrition Result Area. The remaining clients received services provided through Effective Parenting (28.1%), School Readiness (20.1%), and Health Access (2.4%).

Race/Ethnicity

The same proportion (45.7%) of children and parents identified as Hispanic/Latino (Table 2.1); 15.4% of children and 17.6% of parents were White, non-Hispanic, and 12.7% of children and 13.3% of parents were African American. A greater proportion of children (9.4%) were identified as Multiracial than were parents (6.4%).

Table 2.1: Race/Ethnicity of First 5 Sacramento Clients, Fiscal Year 2008/09

Children, %(n = 14,878)

Parents, %(n = 11,396)

Hispanic/Latino 45.7 45.7

White, non-Hispanic 15.4 17.6

African American 12.7 13.3

Russian/Ukrainian 4.2 4.4

Other Slavic 0.2 0.2

Hmong 2.7 2.1

Chinese 0.9 0.9

Filipino 0.9 1.1

Vietnamese 0.9 0.9

Asian Indian 1.0 1.2

Other Asian 1.9 2.1

Native Hawaiian 0.1 0.1

11

Children, %(n = 14,878)

Parents, %(n = 11,396)

Other Pacific Islander 1.1 1.2

Alaska Native/American Indian 0.6 0.8

Other Single Race 1.8 1.1

Multiracial 9.4 6.4

Latino and White 1.0 1.4

African American and White 1.1 0.7

Other Multiracial/Not Defined 7.3 4.3

Information Not Provided 0.5 0.9 Source of Data: Persimmony

Language

Just over half of parents receiving First 5 Sacramento services identified English as their and their children’s primary language (Table 2.2). Spanish was the primary language spoken by over one-third of children and adults.

Table 2.2: Primary Language of First 5 Sacramento Clients, Fiscal Year 2008/09

Children, %(n = 14,878)

Parents, %(n = 11,396)

English 53.2 53.5

Spanish 35.0 34.7

Hmong 2.2 1.6

Russian 3.3 3.3

Ukrainian 0.7 0.7

Vietnamese 0.7 0.7

Lao 0.1 0.1

Mien 0.1 0.1

Tagalog 0.2 0.4

Hindi 0.4 0.4

Korean <0.1 0.1

Chinese-Cantonese 0.5 0.5

Chinese-Mandarin 0.1 0.1

Other Language 2.1 2.1

Information Not Provided 1.4 1.7 Source of Data: Persimmony

The previous table shows that the primary language spoken by roughly 47% of clients was not English. We also asked parents to tell us the languages they use when speaking to their children at home. The purpose of this question was to further examine the Fipopulation, specifically as it relates to the need for bilingual service provider staff challenges that clients likely face, including children when beginning preschool or kindergarten. As Table 2.3 shows, 40.3% of familie

Table 2.3: Language Spoken to Children of

English Only

Multiple Languages, Including English

Single or Multiple Languages, Not Including Source of Data: Parent Interview

Family Structure

Single-parent households are more likely to face financial and parenting challenges. For fiscal year 2008/09, we found that oneservices came from single-parent householdsparent (Figure 2.1). The majorityhouseholds. About one percent of households hneither mother nor father as parent.

Figure 2.1: Structure

24.7%

1.1%

Source of Data: Parent Interview

The previous table shows that the primary language spoken by roughly 47% of clients was not English. We also asked parents to tell us the languages they use when speaking to their children at home. The purpose of this question was to further examine the First 5 Sacramento client population, specifically as it relates to the need for bilingual service provider staff

likely face, including children when beginning preschool or kindergarten. 2.3 shows, 40.3% of families did not speak English at home to their children.

to Children of First 5 Sacramento Clients, Fiscal Year 2008/09

%

36.4

Multiple Languages, Including English 23.2

Single or Multiple Languages, Not Including English 40.3ource of Data: Parent Interview

parent households are more likely to face financial and parenting challenges. For fiscal year 2008/09, we found that one-fourth (25.8%) of families receiving First 5 Sacramento

parent households; 24.7% of households included only the mothermajority (73.0%) of First 5 Sacramento families had

s. About one percent of households had a father only, and about one percentneither mother nor father as parent.

of First 5 Sacramento Families, Fiscal Year 2008/09

73.0%

1.1% 1.1%

Both Parents in Household

Mother Only

Father Only

Neither Parent


12

The previous table shows that the primary language spoken by roughly 47% of clients was not English. We also asked parents to tell us the languages they use when speaking to their children

rst 5 Sacramento client population, specifically as it relates to the need for bilingual service provider staff and the

likely face, including children when beginning preschool or kindergarten. not speak English at home to their children.

Fiscal Year 2008/09

parent households are more likely to face financial and parenting challenges. For fiscal receiving First 5 Sacramento

only the mother as (73.0%) of First 5 Sacramento families had two-parent

, and about one percent included


Both Parents in

Mother Only

Neither Parent

13

Education

Education for both parents was measured forfamily level based on the highest level of education of either parent. Education levels are related to income and other socioeconomic variables relevant at the family level. One fourth of families had less than a high school education; 8.4% of families’ level of education was at or below 8grade (Figure 2.2). However, 15.1% of families had a parent with a college degree.

Figure 2.2: Highest Level of Education

Employment

Employment was also examined at the family level using the same methodology we used for family education. Most households (56.5%) hadFigure 2.3, 22.1% of families wereone parent seeking employment.and looking for work (data not in figure

24.2%

15.1%


Education for both parents was measured for the evaluation, and subsequently converted to the family level based on the highest level of education of either parent. Education levels are related to income and other socioeconomic variables relevant at the family level. One fourth of families

than a high school education; 8.4% of families’ level of education was at or below 8grade (Figure 2.2). However, 15.1% of families had a parent with a college degree.

Figure 2.2: Highest Level of Education among First 5 Sacramento Families,Fiscal Year 2008/09

Employment was also examined at the family level using the same methodology we used for family education. Most households (56.5%) had at least one parent working full

of families were unemployed. Among these families, 45.4% employment. Thus, one-in-10 First 5 Sacramento families were unemployed

(data not in figure; calculated from 45.4% of 22.1%).

8.4%

18.2%

34.2%

<= 8th Grade

Some High School

High School

Some College

>= College Degree


the evaluation, and subsequently converted to the family level based on the highest level of education of either parent. Education levels are related to income and other socioeconomic variables relevant at the family level. One fourth of families

than a high school education; 8.4% of families’ level of education was at or below 8th

grade (Figure 2.2). However, 15.1% of families had a parent with a college degree.

mong First 5 Sacramento Families,

Employment was also examined at the family level using the same methodology we used for at least one parent working full-time. As seen in

, 45.4% included at least 10 First 5 Sacramento families were unemployed

Some High School

>= College Degree

Figure 2.3: Occupational Status

Where First 5 Sacramento Families Live

The zip codes provided by parents oSacramento County where First 5 Sacramento families reside. As seen in Figure 2.4,were provided to families throughout the County,the South Sacramento region (1,483 families lived in zip code 95823).

56.5%

Full-time


Figure 2.3: Occupational Status of First 5 Sacramento Families, Fiscal Year 2008/09

Where First 5 Sacramento Families Live

zip codes provided by parents on the Family Intake Form were used to identify areas within Sacramento County where First 5 Sacramento families reside. As seen in Figure 2.4,

provided to families throughout the County, with the highest concentration of families from (1,483 families lived in zip code 95823).

20.3% 22.1%

Part-time Not Working


14


n the Family Intake Form were used to identify areas within Sacramento County where First 5 Sacramento families reside. As seen in Figure 2.4, services

tion of families from

15

Figure 2.4: Number of Families Receiving Services by County Regions, Fiscal Year 2008/09

16

CHAPTER 3HEALTH ACCESS RESULT AREA

The Health Access Result Area addresses the First 5 Sacramento Commission’s commitment to provide comprehensive health services for children ages 0 to 5 years. During 2008/09, the First 5 Sacramento Commission expended $1,146,000 to support: initial and follow-up assistance with applying for health insurance by Cover the Kids; insurance coverage for dental, vision, mental health, and medical care through Healthy Kids Healthy Future; and Bright Futures community fairs that include no-cost dental, hearing, vision, and developmental screenings.

Bright Futures services were provided at five community events during the year attracting 10,636children and adults. A total of 449 dental, 135 vision, 110 hearing, and 72 developmentalscreenings were offered at no-cost to families for children ages 0 to 5 years at these events (Table 3.1).

Table 3.1: Screenings Provided at Bright Futures Fairs,Fiscal Year 2008/09

Dental 449

Vision 135

Hearing 110

Developmental 72 Source of Data: First 5 Sacramento staff

The four indicators for the Health Access Result Area apply to the services provided by Cover the Kids and Healthy Kids Healthy Future. Each of these programs is described below and thefour indicators are introduced.

Staff from Cover the Kids assist families with applying for comprehensive (medical, dental, and vision) insurance for children. Cover the Kids conducts outreach and distributes information at Bright Futures events, preschools, child care centers, and community-based organizations. Cover the Kids also sponsors enrollment events, such as “Healthy Kids Day,” develops relationships with business owners to generate referrals, and publicizes its services through grassroots advertising campaigns in multiple languages. Finally, all First 5 Sacramento service providers are required to screen families for children’s health insurance coverage and refer those in need to Cover the Kids. As a result of these efforts, Cover the Kids provided comprehensive health insurance application assistance to 477 families in 2008/09. This represents application assistance services for 611 children this fiscal year, a decrease from 793 children served last year.

Cover the Kids’ services extend well beyond helping families to apply for comprehensive health insurance. During the application assistance process, multi-lingual staff emphasize in face-to-face settings the importance of preventative care and utilization of medical, dental, and vision services. These messages are then reinforced via telephone contact with families at 3, 8, and 13

17

months post-application assistance. During these contacts enrollment and utilization of services are verified, and additional assistance is provided as necessary. The outcome of these phone calls was recorded by Cover the Kids staff, and analyzed by the evaluation team to address the First 5 Sacramento Commission indicator:

Percent of children continuously enrolled in health insurance at 3, 8, and 13 months.

Through Healthy Kids Healthy Future, the First 5 Sacramento Commission covers Healthy Kids insurance premiums for children ages 0 to 5 years. Healthy Kids Healthy Future administers theHealthy Kids insurance program in Colusa, El Dorado, Placer, Sacramento, and Yuba Counties. Healthy Kids children are from low-income families not eligible for Medi-Cal (eligibility rate of 100% or less of the Federal Poverty Level) or Healthy Families (eligibility rate of 101% to 200% Federal Poverty Level). Healthy Kids insurance premiums are covered by the First 5 Sacramento Commission for children ages 0 to 5 years in Sacramento County only.

The remaining three indicators of the Health Access Result Area are designed to directly assess whether the messages emphasizing the importance of comprehensive health care and providing families with insurance to cover these services translate into utilization of services in the areas of immunizations, well-child visits, and dental care:

Percent of children with complete immunizations at ages 2 and 5 years for children enrolled in health plans;

Percent of children who have received all age appropriate well-child visits; and Percent of children who have seen a dentist by one year of age.

In the next section we review the importance of, as well as the findings for, the four Health Access indicators.

PERCENT OF CHILDREN CONTINUOUSLY ENROLLED IN HEALTH INSURANCE AT 3, 8,AND 13 MONTHS

Children who do not have continuous health insurance are less likely than those with health insurance to receive regular and preventive health care.2 When children have access to regular health care, they are more likely to be healthy, succeed in school, and less likely to rely on emergency rooms for regular health care.3 Children who do not have health insurance often forgo needed care, impacting their development and quality of life.4 2 Stevens, G.D., Seid, M., & Halfon, N. (2006). Enrolling vulnerable, uninsured but eligible children in public health insurance: association with health status and primary care access. Pediatrics, 177(4), e751-e759.3 Sacramento County Children’s Report Card. (2006). Retrieved at http://www.communitycouncil.org/level-3/2006_ReportCard10-04-06.pdf. 4 Seid, M., Varni, J. W., Cummings, L., & Schonlau, M. (2006). The impact of realized access to care on health-related quality of life: a two-year prospective cohort study of children in the California State Children’s Health Insurance Program. Pediatrics, 149(3), 354-361.

18

The majority of Health Access families reported that they were enrolled in a health insurance program when contacted 3, 8, and 13 months from receiving application assistance from Cover the Kids (Table 3.2).

Table 3.2: Percent of Children Enrolled in Health Insurance at 3, 8, and 13 Months, Fiscal Year 2008/09

Follow-Up “Retention” Survey %

Two-Three Month 85.2

Eight Month 93.4

13 Month 88.9 Source of Data: Persimmony

These percents were calculated for follow-up contacts by Cover the Kids staff during 2008/09, and include families receiving application assistance during the previous fiscal year. Of the 477 families served by Cover the Kids during 2008/09, we estimate that 446 families have or will have health insurance for their children ages 0 to 5 years by at least eight months post-application assistance.

PERCENT OF CHILDREN WITH COMPLETE IMMUNIZATIONS AT AGES 2 AND 5 YEARS

FOR CHILDREN ENROLLED IN HEALTH PLANS

Immunizations are important for young children because vaccines are 90% to 100% effective at preventing many childhood diseases that are dangerous and potentially lethal to children.5 Immunizations are most effective when given early in life as the diseases they prevent are more likely to occur at a young age.5 Children with all required immunizations are less likely to suffer serious illness, resulting in higher school attendance and better physical health.5 Immunizations are also an important public health practice to prevent outbreaks of diseases that can result in long-term and severe developmental disabilities, sensory impairments, or death.5

First 5 Sacramento parents were asked during the Parent Interview, “In your opinion, has [child’s name] received all of the recommended shots for (his/her) age?” Responses to this question were analyzed for 2 (24 to 35 months) and 5 (60 to 71 months) year olds whose parents stated their children were covered by some form of health insurance.

Responses from the baseline Parent Interview found immunization rates relatively high among First 5 Sacramento families. Yet, at one-year follow-up, there was an increase in these rates from 85.7% to 92.9% among 2 year olds (Figure 3.1), and from 94.1% to 100% among 5 year olds (Figure 3.2).

5 Center for Disease Control and Prevention. (2007). Parents’ Guide to Childhood Immunizations (pp. 31-34). [Brochure]. United States Government Printing Office: National Center for Immunization and Respiratory Disease.

19

Figure 3.1: Percent of Two-Year

Figure 3.2: Percent of Five-Year

National and state levels immunization findings areSurvey (NIS) for children 19 to 35 months. The fullychildren at this age was 85.0%. Including those with noBoth rates are still higher than the national rate of 78.2% and the state rate of 80.6% (for the 4:3:1:3:3 series). The Centers for Disease Control and Prevention (these findings within California by regions. For Northern California (which represents thecomparison group) only 70.8% of children were

6 Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/stats-surv/nis/data/tables_2008.htm

85.7%

80.0%

84.0%

88.0%

92.0%

96.0%

Baseline

80.0%

85.0%

90.0%

95.0%

100.0%

Baseline

Year-Olds with Complete Immunizations, Fiscal Year 2008/09

Year-Olds with Complete Immunizations, Fiscal Year 2008/09

National and state levels immunization findings are available from the National Immunization for children 19 to 35 months. The fully-immunized rate among First 5 Sacramento

as 85.0%. Including those with no health insurance drops the rate to 84.1%. gher than the national rate of 78.2% and the state rate of 80.6% (for the Centers for Disease Control and Prevention (CDC) further breaks down

these findings within California by regions. For Northern California (which represents thecomparison group) only 70.8% of children were fully immunized in 2008.6 Immunization data

Centers for Disease Control and Prevention. Statistics and Surveillance: 2008 Data Tables. Retrieved from surv/nis/data/tables_2008.htm.

85.7%

92.9%

Baseline Follow-up

94.1%

100.0%

Baseline Follow-up

Olds with Complete Immunizations, Fiscal Year 2008/09

Olds with Complete Immunizations, Fiscal Year 2008/09

available from the National Immunization immunized rate among First 5 Sacramento

health insurance drops the rate to 84.1%. gher than the national rate of 78.2% and the state rate of 80.6% (for the

further breaks down these findings within California by regions. For Northern California (which represents the best

Immunization data

. Retrieved from

20

from the NIS are more reliable than data collected through our Parent Interview because they come from children’s vaccination providers rather than from parent report. We have no way of knowing to what extent self-reported biases inflated the rates reported by parents; however, we can conclude with confidence from the findings presented in Figures 3.1 and 3.2 that immunization rates increased among First 5 Sacramento families enrolled in Health Accessservices.

PERCENT OF CHILDREN WHO HAVE RECEIVED ALL AGE APPROPRIATE WELL-CHILD

VISITS

Well-child visits are an important practice to ensuring a child’s health. During well-child visits,doctors assess the general health, growth, and development of children. Early identification and treatment of any delays or disabilities can lessen the future impact of the condition on the child and family. Well-child visits are also a time when physicians can promote health behaviors conducive to healthy development, and make sure that the child is up-to-date on immunizations.

Parents were asked whether their child was seen by a “medical doctor or other health professional for a check-up, or other routine care” during the previous year. Answers to this question and each child’s age were compared with the American Academy of Pediatrics’ well-child visits schedule to determine the percent of children with age-appropriate well-child visits.No significant change in the rate of well-child visits was observed over time, but a higher percent of First 5 Sacramento children (92.6%) had all age appropriate well-child visits compared with the national average for children under six (85.0%).7

PERCENT OF CHILDREN WHO HAVE SEEN A DENTIST BY ONE YEAR OF AGE

Poor oral health has been linked to problems with eating, speaking, and sleeping.8 In addition, school performance and social relationships can be affected by dental problems.8 The American Academy of Pediatric Dentistry recommends that all children have an established dental home by their first birthday.9

Unmet dental needs among one-year-old children was determined by the question, “How old in months or years was [child’s name] when (he/she) first visited a dentist?”

7 National Health Interview Survey. (2004). Well-Child Visits. Retrieved from http://www.childtrendsdatabank.org.8 Centers for Disease Control and Prevention. (2004). Children’s Oral Health. Retrieved from http://www.cdc.gov/OralHealth/publications/factsheets/sgr2000_fs3.htm. 9 Hale, K. J. (2008). Preventive oral health intervention for pediatricians. Pediatrics, 122(6), 1387-1394.

21

The increase in the percent of children dentist by their first birthday is quite dramatic. At the baseline Parent Interview, only 3.2% of children had seen a dentist by age 1 year; by the oneparents to have visited a dentist (Figure 3.3). Dental care by age 1 year remained fairly constant over time among children from the Other Result Areas, from 5.0% to 6.2%.

Figure 3.3: Children Who Have Seen a Dentist by Age One, Fiscal Year 2008/09

The period of time from application assistance for comprehensive health insurance by Cover the Kids’ staff, to receipt of dental care, can be lengthy. Families must followinsurance, receive the necessary documents verifying coverage, and then schedule and maintain an appointment with a dental provider. Given the time involved in this processthat our initial finding for children seeinfor the Other Result Areas), but quadrupled within a year’s time. Parents may also not initially absorb messages about the value of early dental care during the Cover the Kids’ application assistance appointments, especially when they may be more focused on the importance of wellchild visits along with immunizations, but these messages may eventually be realized during follow-up telephone contacts by Cover the Kids staff.

0.0%

Follow-up

Baseline

Follow-up

Baseline

Hea

lth A

cces

sO

ther

Res

ult

Are

as

children receiving services through Cover the Kidsdentist by their first birthday is quite dramatic. At the baseline Parent Interview, only 3.2% of

een a dentist by age 1 year; by the one-year follow-up 13.2% were reported by parents to have visited a dentist (Figure 3.3). Dental care by age 1 year remained fairly constant

en from the Other Result Areas, from 5.0% to 6.2%.

re 3.3: Children Who Have Seen a Dentist by Age One, Fiscal Year 2008/09

The period of time from application assistance for comprehensive health insurance by Cover the Kids’ staff, to receipt of dental care, can be lengthy. Families must follow-up on oinsurance, receive the necessary documents verifying coverage, and then schedule and maintain an appointment with a dental provider. Given the time involved in this process

for children seeing a dentist before age 1 year was low (and below the rate for the Other Result Areas), but quadrupled within a year’s time. Parents may also not initially absorb messages about the value of early dental care during the Cover the Kids’ application

nts, especially when they may be more focused on the importance of wellchild visits along with immunizations, but these messages may eventually be realized during

up telephone contacts by Cover the Kids staff.

13.2%

3.2%

6.2%

5.0%

4.0% 8.0% 12.0%

receiving services through Cover the Kids who had seen a dentist by their first birthday is quite dramatic. At the baseline Parent Interview, only 3.2% of

up 13.2% were reported by parents to have visited a dentist (Figure 3.3). Dental care by age 1 year remained fairly constant

re 3.3: Children Who Have Seen a Dentist by Age One, Fiscal Year 2008/09

The period of time from application assistance for comprehensive health insurance by Cover the up on obtaining the

insurance, receive the necessary documents verifying coverage, and then schedule and maintain an appointment with a dental provider. Given the time involved in this process, it makes sense

low (and below the rate for the Other Result Areas), but quadrupled within a year’s time. Parents may also not initially absorb messages about the value of early dental care during the Cover the Kids’ application

nts, especially when they may be more focused on the importance of well-child visits along with immunizations, but these messages may eventually be realized during

13.2%

16.0%

22

CHAPTER 4NUTRITION RESULT AREA

Childhood obesity is addressed by the First 5 Sacramento Commission through a number of programs with services directed at adults, children, and newborns. Interventions are funded to improve eating habits and increase physical activity among parents and their children. “Tot Lots” provide environments where children can be physically active. Research has shown that children who are breastfed are less likely to become overweight or obese.10 First 5 Sacramento-funded breastfeeding services are provided directly to mothers through the Enhanced-Community Lactation Assistance Project, and indirectly to mothers through Baby Friendly trainings of labor and delivery nurses and other hospital staff having contact with new mothers. Research has linked Baby Friendly hospital policies with increased breastfeeding initiation and duration rates.11 In addition to reducing the risk of childhood obesity, breastfeeding support services have the potential to protect infants from bacterial and viral infections by the antibodies present in breast milk.12 Moreover, lower rates of certain breast and ovarian cancers have been found among women who breastfeed.10 Thus, breastfeeding benefits both the child and the mother.

During fiscal year 2008/09, these four Nutrition efforts (Childhood Obesity Prevention, Tot Lots, Enhanced-Community Lactation Assistance Project, and Baby Friendly trainings) received a total of $1,681,000 from the First 5 Sacramento Commission. In this chapter we present the findings from the four projects, including those directly related to the three Nutrition indicators:

Percent of children with Body Mass Index that is between the 5th and 95th percentile for their age;

Percent of women who are exclusively breastfeeding at 6 months after delivery; and Percent of women who are exclusively breastfeeding at 1 year after delivery.

10 Owen, C. G., Martin, R. M., Whincup, P. H., Smith, G. D., & Cook, D. G. (2005). Effect of infant feeding on the risk of obesity across the life course: a quantitative review of published evidence. Pediatrics, 115(5), 1367-1377.11 Merewood, A., Mehta, S. D., Chamberlain, L. B., Philipp, B. L., & Bauchner, H. (2005). Breastfeeding rates in US Baby-Friendly hospitals: results of a national survey. Pediatrics, 116(3), 628-634.12 National Women’s Health Information Center. (2009). Benefits of Breastfeeding. Retrieved from http://www.womenshealth.gov/breastfeeding/benefits/.

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Childhood Obesity Prevention

Four providers funded by the First 5 Sacramento Commission offered varied services to prevent or address childhood obesity (Table 4.1). Each provider included information or hands-on opportunities related to both nutrition and physical activity in the services directed at children and adults.

Table 4.1: Providers of Childhood Obesity Prevention Services, Fiscal Year 2008/09

Community School Solutions of California, Inc.

Instruction on how to cook healthful meals is provided through cooking classes. Physical activity is encouraged through exercise classes for families, and the distribution of pedometers to parents. Services include a community store that sells healthy foods.

Continuing Development Incorporated

Family-centered workshops instructing parents in becoming teachers of nutrition to their children. Preschool workshops are conducted on topics such as healthy eating, active living, and appropriate feeding dynamics. Parents and children participate in hands-on nutritional activities and learn how to extend these practices to their daily lives.

Health Education Council

Educates teachers and parents in healthy living. Provides Head Start teachers with nutrition and physical activity integration training, and implements farm stands at Head Start sites. Nutrition workshops and monthly nutrition newsletters are also provided to parents and children.

Los Rios Community College District

Educates parents and children on reading food labels, healthful food choices, and physical activity. A curriculum for parent classes addresses children’s nutritional needs, health risks and physical activity, and meal planning.

During the year, staff from all four obesity prevention programs recorded each service they provided into Persimmony, the web-based data collection system. Our analyses of these data are presented in Table 4.2, which lists and describes the 10 types of services, the percent of familieswho received each service, and the distribution of the 8,371 services across the 10 service categories. In Table 4.2, and in the other service tables appearing in this report, there can be quite a discrepancy between the number of services provided and the percent of families receiving the service. This is due in part to how each service is measured and if the service is a one-time orongoing service. As noted in Table 4.2, the number of Exercise Classes recorded intoPersimmony was 1,137. Each exercise class, in this example, represents one unit of service. This relatively large number of services were provided to only 8.8% of families, or 65 families overall, because each family participated in over 17 Exercise Classes, on average.

Approximately one-third of Nutrition families participated in the Nutrition Activities and Parent Education instructional opportunities. One-fourth of families had children who engaged in Physical Activities. Moreover, healthy foods were available to families from the vegetables children grew in Gardening Education services and through Community Store Access, which areneighborhood stores that sell fresh produce.

24

Table 4.2: Childhood Obesity Prevention Services, Fiscal Year 2008/09

Source of Data: Persimmony

Service Name Description of Service

Families Receiving Service, %(n = 736)

Services Provided

(n = 8,371)

Nutrition ActivitiesEducational activities for children to teach them about the various food groups, comprising a healthy diet, and why they are important.

34.5 3,018

Parent Education

Parent education on child obesity and children’s nutritional and physical activity needs. Topics include “how to read food labels,” “healthy fast food choices,” and the various food groups.

33.0 270

Physical ActivitiesActivities for children designed to increase heart rate and teach that physical activity can be fun and good for you.

25.0 1,321

Nutrition Workshops

Workshops for parents on nutrition topics such as “how to shop on a budget,” “how to prepare fruits and vegetables,” and dietary guidelines. Some workshops also include interactive activities and handouts.

21.7 510

Gardening EducationEducation for children on how to build and care for a vegetable garden. Children grow and eat their own vegetables from the garden.

10.6 149

Community Store Access

A community store providing families with access to fresh, reasonably priced produce.

10.5 1,246

Exercise ClassesExercise classes for parents only, and exercise classes designed for children, provided to children and parents together.

8.8 1,137

Nutrition InformationNewsletters for families including facts on a particular fruit or vegetable and recipes.

8.8 195

Cooking ClassesCooking classes for parents supporting what is learned in nutrition workshops.

6.3 231

Pedometers Pedometers provided to parents. 2.4 24

25

PERCENT OF CHILDREN WITH BODY MASS INDEX THAT IS BETWEEN THE 5THAND 95TH

PERCENTILE FOR THEIR AGE

This indicator for Childhood Obesity Prevention services required providers to measure children’s height and weight at the beginning of services and then every six months thereafter. To standardize these assessment procedures, all four providers received a Body Mass Index (BMI) “kit” with materials and instructions on the proper procedures for collecting these data. Children’s height, weight, gender, and age from Persimmony were used to calculate BMI scores following CDC guidelines.13 To address the First 5 Sacramento Commission indicator, we identified the number of children with BMI scores falling at or outside the 5th and 95th percentile, and calculated the quotient with the total number of children with services and/or having parents who received services.

Initial and six-month follow-up BMI data were available for 242 children for the fiscal year. At baseline, 19.0% of children had unhealthy BMI levels. Six months later, BMI values beyond the 5th and 95th percentile were found for 21.1% of the cohort of children. To examine potential reductions in BMI scores for overweight children, we compared the proportion of children at or exceeding the 95th percentile only, but again found no significant differences between the two points in time.

Tot Lots

During this fiscal year four districts in Sacramento County completed building “Tot Lots” to provide children with environments where they can be physically active. Tot Lots were completed at Morse Park of the Cosumnes Community Services District; Patriots Park of theCarmichael Recreation and Park District; Downtown Rio Linda Community Center Park of the Rio Linda Elverta Park District; and at Freedom Park of the North Highlands Recreation and Park District. Tot Lot construction is expected to continue into fiscal year 2009/10 with the following entities: Cosumnes Community Services District; Carmichael Recreation and Park District; Cordova Recreation and Park District; City of Folsom, Park and Recreation Department; Fulton-El Camino Recreation and Park District; Rio Linda Elverta Recreation and Park District; City of Sacramento, Department of Parks and Recreation; Southgate Recreation and Park District; and Sunrise Recreation and Park District.

Enhanced-Community Lactation Assistance Project

Enhanced-Community Lactation Assistance Project services were provided at four sites of the Sacramento County Department of Health and Human Services Women, Infants and Children Program (DHHS WIC); five Community Resource Project WIC (CRP WIC) sites; and the

13 Centers for Disease Control and Prevention. (2009). About BMI for Children and Teens. Retrieved from http://www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html.

26

University of California Davis Medical Center (UCDMC). Services are provided to mothers on a drop-in or call-in basis at DHHS WIC and CRP WIC, and to mothers delivering at UCDMC.

These 10 sites provided 23,978 services to 5,818 mothers during the year (Table 4.3); representing a 24.8% increase in services over last year. One-on-one, face-to-face breastfeeding support services were provided by Peer Counselors (PC) or Lactation Consultant Assistants (LCA) during Clinic Support services, and by International Board Certified Lactation Consultants (IBCLC) during Lactation Consultations. Lactation Consultations are provided when a problem needing greater expertise is identified by a PC/LCA, such as an infection like mastitis, or when the mother is still experiencing a problem after implementing the suggestions provided through Clinic Support services.

Mothers also received support over the phone. Calls were initiated by PC/LCA and IBCLC staff to 19.1% and 6.4% of mothers, respectively. However the majority of phone contact support services occurred because mothers called provider staff for advice related to a problem with breastfeeding; 64.8% of mothers placed at least one Breastfeeding Help Line Call. Lactation support providers had great success in recruiting mothers to participate in support groups; 2,606 mothers, or 41.7% of all mothers receiving any service, attended a Breastfeeding Support Group. The remainder of lactation support services include Breast Pump Loans and Back to Work Education for mothers returning to work or school.

Table 4.3: Enhanced-Community Lactation Support Services, Fiscal Year 2008/09


Families (Mothers) Receiving Service, %(n = 5,818)

Services Provided

(n = 23,978)

Breastfeeding Help Line Call

Mothers call to receive immediate verbal assistance with breastfeeding problems.

64.8 8,123

Clinic Support

One-on-one support by the Peer Counselor (PC) or Lactation Consultant Assistant (LCA) on topics such as how to reduce pain. PC/LCAs also provide encouragement to continue breastfeeding, and assess baby’s latch and weight.

53.1 4,638

Lactation Consultations

One-on-one consultations with mother/baby and an International Board Certified Lactation Consultant (IBCLC) primarily to intervene and provide guidance with more serious problems such as the baby being tongue-tied, infections like mastitis, or the baby losing/not gaining weight. General encouragement to continue breastfeeding and an assessment of the baby’s growth and latch are also provided, and when necessary, referrals to the pediatrician.

44.8 4,329

27


Families (Mothers) Receiving Service, %(n = 5,818)

Services Provided

(n = 23,978)

Breastfeeding SupportGroup

Forum to share challenges (e.g., engorgement, pain, exhaustion, or lack of family support), receive encouragement to continue breastfeeding from other mothers, and receive education from trained professionals on topics such as introducing solid foods.

41.7 2,986

PC/LCA Phone Contacts

PC/LCA contact mothers within 72 hours of discharge from a hospital as well as between 72 hours and 1 year post-discharge to addressbasic needs, concerns, and questions (e.g., how to properly store breast milk) through information and referrals.

19.1 1,573

Breast Pump LoansBreast pumps and related information fornursing mothers going back to work or school.

13.5 853

Referrals forLactation Support

Referrals for additional lactation support forpregnant mothers or mothers with newborns.

6.7 488

IBCLC Phone Contacts

IBCLC contact mothers within 72 hours of discharge from a hospital as well as between 72 hours and 1 year post-discharge to addressmore serious needs, concerns, and questionsabout breastfeeding through information and referrals.

6.4 470

Referrals for Health Insurance

Referrals for health insurance. 2.8 187

Home Visits

In-home lactation support provided for mothers whom are unable to leave the home, for example, due to c-section, premature birth, or twins.

2.4 198

Back to Work Education

Education for mothers on ways to continue to provide breast milk to infants after returning to work or school.

2.2 130

Referrals for Women with Limited Access to WIC

Referrals/recruitment of women in need of lactation support but not aware of lactation support services available in the community.

0.1 3

Source Data: Persimmony

The Enhanced-Community Lactation Assistance Project encourages mothers to initiate breastfeeding after delivery and exclusively breastfeed during the child’s first year. Six-month“exclusive” breastfeeding is defined as receiving only breast milk. Twelve-month “exclusive” breastfeeding represents a diet of breast milk or solid foods, but no formula until the child’s first birthday. Breastfeeding rates were measured on the Parent Interview using questions developed by the CDC.

28

Over 3,000 Sacramento County mothers received Clinic Support services (see Table 4.3), and the number of services provided was directly related to a greater probability of exclusively breastfeeding to six and 12 months (Table 4.4). Ongoing support through the Breastfeeding Helpline and IBCLC Phone Contacts were also related to breastfeeding for 12 months. The criterion commonly used to determine statistical significance in social science research is a probability (“P”) value at or below 0.05 (or 5%). As seen in Table 4.4, the P-values for these analyses, which included race/ethnicity, language, and education as control variables, were well below the traditional 0.05 level.

Table 4.4: Relationship between Lactation Support Services and Breastfeeding, Fiscal Year 2008/09

Six-MonthP-value

12-MonthP-value

Clinic Support 0.01 <0.01

Breastfeeding Helpline NS <0.01

IBCLC Phone Contact NS 0.01NS = Not SignificantSource of Data: Parent Interview & Persimmony

PERCENT OF WOMEN WHO ARE EXCLUSIVELY BREASTFEEDING AT 6 MONTHS AFTER

DELIVERY

Exclusive six-month breastfeeding rates did not significantly differ from baseline to follow-up (25.6% versus 26.1%). However, levels of breastfeeding among Nutrition mothers exceeded the most recent rates published for California and the United States from the National Immunization Survey14 (Figure 4.1).

14 Centers for Disease and Control and Prevention. Retrieved from http://www.cdc.gov/breastfeeding/data/NIS_data/2006/state.htm.

29

Figure 4.1: Six-Month Exclusive Breastfeeding among California and National Rates, Fiscal Year 2008/09

PERCENT OF WOMEN WHO

Twelve-month breastfeeding rates also did not significantly increase from baseline to followamong Nutrition clients (Figure 4.2). However, these rates were significantly greater among Nutrition mothers compared with mothers from the Other Result Areas (followversus baseline of 13.4%). It is interesting to note that 12from the Other Result Areas increased from 13.4% to 19.0% over the year’s timestate average (see Figure 4.1). Breastfeeding is a health behavior that is promoted by all First 5 Sacramento service providers, and the level of exposure to these messages for clients from Other Result Areas may have taken longer to influenc

26.1%

0.0%

10.0%

20.0%

30.0%

40.0%

Nutrition Clients

Month Exclusive Breastfeeding among Nutrition Clients Compared withCalifornia and National Rates, Fiscal Year 2008/09

ERCENT OF WOMEN WHO ARE EXCLUSIVELY BREASTFEEDING AT 1 YEAR AFTER

DELIVERY

month breastfeeding rates also did not significantly increase from baseline to followclients (Figure 4.2). However, these rates were significantly greater among

mothers compared with mothers from the Other Result Areas (followversus baseline of 13.4%). It is interesting to note that 12-month breastfeeding rates for clients from the Other Result Areas increased from 13.4% to 19.0% over the year’s timestate average (see Figure 4.1). Breastfeeding is a health behavior that is promoted by all First 5 Sacramento service providers, and the level of exposure to these messages for clients from Other Result Areas may have taken longer to influence longer-term breastfeeding behaviors.

26.1%

18.6%

13.6%

Nutrition Clients California National

Clients Compared with

YEAR AFTER

month breastfeeding rates also did not significantly increase from baseline to follow-up clients (Figure 4.2). However, these rates were significantly greater among

mothers compared with mothers from the Other Result Areas (follow-up of 23.1% month breastfeeding rates for clients

from the Other Result Areas increased from 13.4% to 19.0% over the year’s time to match the state average (see Figure 4.1). Breastfeeding is a health behavior that is promoted by all First 5 Sacramento service providers, and the level of exposure to these messages for clients from Other

term breastfeeding behaviors.

Figure 4.2: Children Exclusively Breastfed 12 Months afSurvey Time Point, Fiscal Year 2008/09

The rates presented in Figure 4.2 are based on WIC’s definition of “exclusive” breastfeeding, which excludes those who introduced formula into a child’s diet before her first birthday. California and national 12-month breastfeeding rates are based on a dieregardless of any type of supplementary nutrition. As such, we rebreastfeeding rates to match those published from the National Immunization Survey and again found that a greater percentage of mothers receiv(33.9%) versus those from California (31.1%) and nationally (22.7%).

Baby Friendly Trainings

A total of 345 hospital staff attended 11 Baby Friendly trainings sponsored by the First 5 Sacramento Commission from April 2007 to August 2008. Staff from the following hospitals participated in these trainings: Mercy General Hospital, Mercy San Juan Medical Center, Sutter Memorial Hospital, UC Davis Children’s Hospital, and The Birth Center

Questionnaires were selected and administered by the trainers at the beginning of the first session, and at the end of the second session two weeks later. The first instrument, a breastfeeding quiz, consisted of 28 true/false statements. As seen in Figure 4.3, the average number of errors made by Baby Friendly participants decreased by the end of the second training session.

0.0%

Follow-up

Baseline

Follow-up

Baseline

Nut

ritio

nO

ther

Res

ult

Are

as

Figure 4.2: Children Exclusively Breastfed 12 Months after Delivery by Result Area and Survey Time Point, Fiscal Year 2008/09

The rates presented in Figure 4.2 are based on WIC’s definition of “exclusive” breastfeeding, which excludes those who introduced formula into a child’s diet before her first birthday.

month breastfeeding rates are based on a diet that includes breast milk regardless of any type of supplementary nutrition. As such, we re-calculated 12breastfeeding rates to match those published from the National Immunization Survey and again found that a greater percentage of mothers receiving Nutrition services breastfed for one year (33.9%) versus those from California (31.1%) and nationally (22.7%).

A total of 345 hospital staff attended 11 Baby Friendly trainings sponsored by the First 5 rom April 2007 to August 2008. Staff from the following hospitals

participated in these trainings: Mercy General Hospital, Mercy San Juan Medical Center, Sutter Memorial Hospital, UC Davis Children’s Hospital, and The Birth Center.

ected and administered by the trainers at the beginning of the first session, and at the end of the second session two weeks later. The first instrument, a breastfeeding quiz, consisted of 28 true/false statements. As seen in Figure 4.3, the average

of errors made by Baby Friendly participants decreased by the end of the second training

23.1%

22.5%

19.0%

13.4%

7.0% 14.0% 21.0%

30

ter Delivery by Result Area and

The rates presented in Figure 4.2 are based on WIC’s definition of “exclusive” breastfeeding, which excludes those who introduced formula into a child’s diet before her first birthday.

t that includes breast milk calculated 12-month

breastfeeding rates to match those published from the National Immunization Survey and again services breastfed for one year

A total of 345 hospital staff attended 11 Baby Friendly trainings sponsored by the First 5 rom April 2007 to August 2008. Staff from the following hospitals

participated in these trainings: Mercy General Hospital, Mercy San Juan Medical Center, Sutter

ected and administered by the trainers at the beginning of the first session, and at the end of the second session two weeks later. The first instrument, a breastfeeding quiz, consisted of 28 true/false statements. As seen in Figure 4.3, the average

of errors made by Baby Friendly participants decreased by the end of the second training

23.1%

22.5%

28.0%

31

Figure 4.3: Number of Errors on Breastfeeding Knowledge

Participants were also asked to indicate their level of agreement point scale, from Strongly Agree to Strongly Disagree. Factor analyses of the responses revealed three distinct types of breastfeeding attitudes with acceptable reliability (Cronbach’s al0.60): Overall Support for Breast Versus Formula Feedingsuch as “Formula feeding is as good as breastfeeding” and “In industrialized nations like the US, it really doesn’t matter if a baby is formula or breastfedInvolvement (5 items including “If a mother is undecided, I would try to encourage her to start breastfeeding” and “If a mother was unsure of herself, I would make a special effort to ensure she got early skin to skin care”)items including “It is the labor and delivery nurses’ role to assist the mother to breastfeed” and “It is the postpartum nurses’ role to assist the mother to breastfeed”). Each of these dimensof breastfeeding attitudes was converted to a theoretical scale from 0 to 100, and scores were compared from the initial to the twoOverall Support for Breast Versus Formula Feedingpoints (Figure 4.4).

5.7

0.0

2.0

4.0

6.0

8.0

Initial Class

Figure 4.3: Number of Errors on Breastfeeding Knowledge Quiz, Baby Friendly Trainings, Fiscal Year 2008/09

to indicate their level of agreement to each of 19 statements , from Strongly Agree to Strongly Disagree. Factor analyses of the responses revealed

three distinct types of breastfeeding attitudes with acceptable reliability (Cronbach’s alOverall Support for Breast Versus Formula Feeding (4 items subsequently reverse coded,

such as “Formula feeding is as good as breastfeeding” and “In industrialized nations like the US, it really doesn’t matter if a baby is formula or breastfed”); Personal Responsibility and

(5 items including “If a mother is undecided, I would try to encourage her to start breastfeeding” and “If a mother was unsure of herself, I would make a special effort to ensure she got early skin to skin care”); and Hospital Staff Responsibility to Support Breastfeedingitems including “It is the labor and delivery nurses’ role to assist the mother to breastfeed” and “It is the postpartum nurses’ role to assist the mother to breastfeed”). Each of these dimensof breastfeeding attitudes was converted to a theoretical scale from 0 to 100, and scores were compared from the initial to the two-week follow-up class. These comparisons found scores for Overall Support for Breast Versus Formula Feeding to significantly increase over the two time

5.7

4.0

Initial Class Follow-up Class

Quiz, Baby Friendly Trainings,

to each of 19 statements on a 5-, from Strongly Agree to Strongly Disagree. Factor analyses of the responses revealed

three distinct types of breastfeeding attitudes with acceptable reliability (Cronbach’s alpha > (4 items subsequently reverse coded,

such as “Formula feeding is as good as breastfeeding” and “In industrialized nations like the US, Personal Responsibility and

(5 items including “If a mother is undecided, I would try to encourage her to start breastfeeding” and “If a mother was unsure of herself, I would make a special effort to ensure

y to Support Breastfeeding (3 items including “It is the labor and delivery nurses’ role to assist the mother to breastfeed” and “It is the postpartum nurses’ role to assist the mother to breastfeed”). Each of these dimensions of breastfeeding attitudes was converted to a theoretical scale from 0 to 100, and scores were

up class. These comparisons found scores for ntly increase over the two time

Figure 4.4: Overall Support for Breast versus Formula Feeding, Baby Friendly Trainings,

Finally, First 5 Sacramento Commission Friendly certification of The Birth CenterDecember 2009, only 86 hospital and birth cFriendly status, which requires outlined by the Baby Friendly Hospital Initiative.

81.3%

0.0%

25.0%

50.0%

75.0%

100.0%

Initial Class

Figure 4.4: Overall Support for Breast versus Formula Feeding, Baby Friendly Trainings,Fiscal Year 2008/09

First 5 Sacramento Commission support was instrumental in the subsequent Baby The Birth Center in Fair Oaks and Kaiser Permanente South

December 2009, only 86 hospital and birth centers in the United States had received the Baby which requires adoption of the “Ten Steps to Successful Breastfeeding,

outlined by the Baby Friendly Hospital Initiative.

81.3%85.4%

Initial Class Follow-up Class

32

Figure 4.4: Overall Support for Breast versus Formula Feeding, Baby Friendly Trainings,

instrumental in the subsequent Baby Kaiser Permanente South. As of

received the Baby ful Breastfeeding,” as

33

CHAPTER 5EFFECTIVE PARENTING RESULT AREA

Effective Parenting services funded by the First 5 Sacramento Commission support the principle that families function well through strong, caring relationships that recognize the parent as the primary nurturer, educator, and advocate for their young child. Improved family functioning can also encompass family communication and the use of positive approaches to discipline. Effective Parenting includes a variety of services to assist parents in increasing self-sufficiency, increasing the use of appropriate parenting practices, and strengthening relationships within the community and family. During 2008/09, a total of $3,939,000 was expended for Effective Parenting services including crisis intervention, emergency child care, peer support, life skills and advocacy training, home visits, and parenting education. The evaluation of these services included collecting data to address the following six indicators:

Improved family functioning; Percent of parents who report connectedness to their communities; Percent of parents with decreased stress; Percent of parents who improve knowledge of developmental stages in children; Percent of parents who practice developmentally appropriate parenting skills; and Percent of parents who interact with their children in a supportive and positive manner.

The Sacramento County Department of Health and Human Services, Family Support Collaborative (FSC), is one of four programs that offer Effective Parenting services. The FSC provides education and support services primarily on a drop-in basis at eight Family Resource Centers. An assessment is conducted upon intake to determine the appropriate services for the family. For families who have greater needs than what can be supported through one to three services, a Crisis Intervention Specialist and the family work together to develop a Family Support Plan to prioritize and address the crises the family is experiencing. As seen in Table 5.1, 23.4% of Effective Parenting families received Family Support Plans. Families receiving services through the FSC have access to additional supports such as life skills and advocacy training, through the Enhanced Core Services (received by 48.2% of Effective Parentingfamilies). Relatively few (15.6%) families received Post-Assessment of Services because either the initial assessment was not completed or because families declined to be assessed more than once. A key component of FSC Effective Parenting services includes providing Parenting Education through the use of three curricula, some of which also address cultural differences in parenting: Make Parenting a Pleasure, Dare to Be You, and Strengthening Multi-Ethnic Families and Communities.

The Elk Grove Unified School District, Power of Parenting (POP) program focuses on teaching effective parenting skills, promoting family literacy, and engaging fathers in the lives of their children. Father Engagement Events are a core service of the POP program, seeking to increase the involvement of fathers in the lives of their children. Likewise, Child Literacy Parent Events are only offered through the POP program. Father Engagement Events and Child Literacy Events were provided to 13.1% and 9.1% of families, respectively. The POP program also utilizes the “Project PLAY” model to provide children and families with Playgroups to encourage parent-

34

child play, increase child self-concept, foster greater independence, improve family and community relationships, and increase the social experiences of participants – 3.1% of Effective Parenting families participated in Playgroups.

The Sacramento County Department of Health and Human Services, Nurse Family Partnership is a high-intensity, home visitation program conducted by registered nurses who visit first time expecting and new mothers until the child is 2 years old. During home visits, the nurse discusses personal and environmental health, maternal role, mother-infant bonding, and refers families to resources in the community. Parenting Education is provided through the Partners in Parenting Education (PIPE) curriculum and is specifically designed to keep the parent focused on the child’s needs and emotional communication by providing educational support material and parent activities. A core component of this program is the Developmental Assessments conducted by the nurses to help parents understand their child’s development – 0.3% of all Effective Parenting families received this service.

The Sacramento Children’s Home, Crisis Nursery program provides a safe haven for children in need of immediate care when parents are in crisis and have no other supports. The overall goal of the program is to prevent families from entering child protective services and/or having their children put in foster care. The primary service provided by the Crisis Nursery, Respite Care, is the provision of short-term (day or overnight) temporary care for children. Table 5.1 shows this was provided to 6.2% of Effective Parenting families, giving parents in crisis a break from caring for their children. Daytime Respite Care is sometimes referred to as “emergency child care,” which parents may access when they have a legal or doctor appointment, or job interview. The Crisis Nursery also provides Transportation (provided to 3.0% of Effective Parenting families) to ensure that clients can access services such as Respite Care or can get to a medical appointment, for example. Services also include parenting education and connecting parents with other support services within the County.

Overall, Effective Parenting providers recorded 75,311 services during fiscal year 2008/09, or 44,836 more services than fiscal year 2007/08.

Table 5.1: Effective Parenting Services, Fiscal Year 2008/09


Families Receiving Service, %(n = 3,218)

Services Provided

(n = 75,311)

Enhanced Core Services

Support services for parents including life skills and advocacy training, alcohol and drug counseling, peer support, job interview support, resource, and referrals.

48.2 17,845

Assessments for Services

Assessments of families to determine the appropriate effective parenting or crisis intervention services.

40.3 1,314

Referrals for Parent Education

Referrals for parenting education. 38.3 3,692

35



Services Provided

(n = 75,311)

Home Visits

Home visits to teach parents positive parenting practices, life skills, child development, developmentally appropriate/stimulating play, and how to bond with their child.

35.1 24,393

Parenting Education

Classes for parents to learn positive parenting practices utilizing the following curricula: Make Parenting a Pleasure (MPAP), Dare to Be You (DTBY), and Strengthening Multi-Ethnic Families and Communities (SMEFC). Some classes also address cultural differences in parenting.

33.9 8,902

Referrals for Respite Care

Referrals for parents in need of respite care due to parental stress or emergencies.

29.0 2,178

Family Support Plans

Support plans developed by a Crisis Intervention Specialist with the family to identify the crises the family needs support with and ensure child safety.

23.4 995

Referrals for Crisis Services

Referrals for families in crisis needing intervention services.

23.0 1,630

Referrals for InfolineReferrals for families in need of information and service referral available in multiple languages.

23.1 1,109

Referrals for Lactation Support

Referrals provided to pregnant mothers or mothers of newborns in need of lactation support.

19.6 870


Referrals for health insurance. 19.1 870

Post-Assessments of Services

Assessments conducted at the completion of, or mid-way through, services to determine the effectiveness of services provided.

15.6 607

Father Engagement Events

Activities bringing fathers to schools, to increase the engagement of fathers in the lives of their children.

13.1 1,018

Child Literacy Parent Events

Literacy events for parents and children to increase parental engagement and teach the importance of reading to or “sharing a book” with children.

9.1 446

Case Management

Case Manager or Crisis Intervention Specialist establishes a relationship with families to assess strengths and needs, and connect families with needed support services.

8.9 1,434

36



Services Provided

(n = 75,311)

Respite Care

Short-term (day or overnight) temporary care for children, giving parents in crisis a break from caring for their children, or emergency child care when they have a legal or doctor appointment, or job interview. Provides a safe place for children while reducing parental depression and increasing parental self-confidence.

6.2 3,993

Playgroups

Regular playgroups for parents and children which teach developmentally appropriate/stimulating play and the importance of child play.

3.1 644

TransportationTransportation to ensure that clients can access services, such as respite care, or get to a medical appointment.

3.0 1,798

Enrollment Assistance / Referrals

Enrollment assistance for families needing services offered at Family Resource Centers.

1.9 62

Developmental Assessments

Developmental assessments for children to provide feedback to parents on the development of their child and determine if intervention services are needed.

0.3 60


IMPROVED FAMILY FUNCTIONING

Family functioning was defined based on family social capital, that is, the resources that families have available for greater self-sufficiency, which positively influence children’s development. A composite measure for family social capital was developed using 12 items from the Parent Interview that indicate availability of resources, or the presence of risk factors. Questions covered occupational status, parent education, parent language, parent age, family structure, recent immigration, and parent involvement in training courses or other education. A higherscore on the composite suggests that the family has reduced social capital and hence is at greater risk of poor family functioning. A lower score indicates that families have sufficient levels of family social capital. The theoretical range of the risk score is 0 to 100; the actual range for Effective Parenting families was 0 to 88.9.

In the 2007/08 report of First 5 Sacramento we hypothesized that the increased level of risk reported for those enrolled in Effective Parenting would decrease over time to levels similar to those found for parents from the Other Result Areas (i.e., Health Access, Nutrition, and School Readiness combined). By one-year follow-up, risk scores among parents participating in

37

Effective Parenting services decreasefrom the Other Result Areas (Figure 5.1). significant. Whether risk scores continue to decline to levels significantly lower than those found at baseline will be determine by our two

Figure 5.1: Parent’s Risk Score by Result Area, Fiscal Year 2008/09

PERCENT OF PARENTS WH

One’s approach to parenting is shaped by many factors such as ethnic heritage, cultural practices, socio-economic status, and family or community resources.communities can increase their sense of security and the number of sas well as strengthen their support networks. Moreover, parents’ community connections often connect them with information sourcesbenefits. These resources are protectors against pThis indicator reflects the importance of community in

How connected individuals are to their community is related to the number of people they know and can possibly look to for information, advice, and support. Thus, First 5 Sacramento parents were asked to tell us the number of people in their neighborhood wnumber of people who visit each other’s home, and the number of relatives and friends who live in their neighborhood.

15 Kotchick, B.A. & Forehand, R. (2002). Putting parenting in perspective: a discussion of the contextual factors that shape parenting practices. Journal of Child and Family Studies, 11

35.0

Follow-up

Baseline

Follow-up

Baseline

Eff

ectiv

e P

aren

ting

Oth

er R

esul

t A

reas

services decreased (from 51.8 to 49.4) to percents comparable for parents ther Result Areas (Figure 5.1). However, these differences are not statistically

significant. Whether risk scores continue to decline to levels significantly lower than those found ne by our two-year follow-up Parent Interview conducted in 2010


ERCENT OF PARENTS WHO REPORT CONNECTEDNESS TO THEIR COMMUNIT

One’s approach to parenting is shaped by many factors such as ethnic heritage, cultural practices, economic status, and family or community resources.15 Parents’ connections to their

increase their sense of security and the number of support resources they have as well as strengthen their support networks. Moreover, parents’ community connections often

information sources and safety net resources, among other potential These resources are protectors against prolonged effects from economic disadvantage.

This indicator reflects the importance of community in Effective Parenting.

How connected individuals are to their community is related to the number of people they know and can possibly look to for information, advice, and support. Thus, First 5 Sacramento parents were asked to tell us the number of people in their neighborhood who they know by name, the number of people who visit each other’s home, and the number of relatives and friends who live

otchick, B.A. & Forehand, R. (2002). Putting parenting in perspective: a discussion of the contextual factors that Journal of Child and Family Studies, 11(3), 255-269.

49.4

49.6

50.3

40.0 45.0 50.0

4) to percents comparable for parents However, these differences are not statistically

significant. Whether risk scores continue to decline to levels significantly lower than those found conducted in 2010.


SS TO THEIR COMMUNITIES

One’s approach to parenting is shaped by many factors such as ethnic heritage, cultural practices, Parents’ connections to their

upport resources they have as well as strengthen their support networks. Moreover, parents’ community connections often

mong other potential rolonged effects from economic disadvantage.15

How connected individuals are to their community is related to the number of people they know and can possibly look to for information, advice, and support. Thus, First 5 Sacramento parents

ho they know by name, the number of people who visit each other’s home, and the number of relatives and friends who live

otchick, B.A. & Forehand, R. (2002). Putting parenting in perspective: a discussion of the contextual factors that

51.8

50.3

55.0

38

No significant relationships were found between levels of services, or changes from baseline to follow-up, for measures of community connectedness. Parents from Effective Parenting reported a statistically similar number of friends over time and in comparison to parents from the Other Result Areas.

PERCENT OF PARENTS WHO IMPROVE KNOWLEDGE OF DEVELOPMENTAL STAGES IN

CHILDREN

Research has shown that parent beliefs or knowledge of child development impact parental child-rearing practices.16,17,18 That is, parents who understand the stages of young children’s growth are better equipped to provide the appropriate level of guidance, structure, discipline, and play for their child’s needs. Such knowledge is a core component of Effective Parenting.

Knowledge of child development was measured by 11 statements from the Knowledge of Infant Development Inventory (KIDI) Scale. Examples of KIDI items on the Parent Interview are “All infants need the same amount of sleep” and “A baby usually says its first real word by six months of age.” Parents were asked to indicate which of these statements are correct, or whether they believed that incorrect statements applied to younger or older children. The theoretical range of KIDI scores is 0 to 100, actual scores from Effective Parenting families were 9.1 to 90.9.

Our analyses revealed positive associations between KIDI scores and levels of Parenting Education and Case Management services. As seen in Figure 5.2, each session of Parenting Education (unit of services) was related to an increase in knowledge of infant development. Similarly, each unit of Case Management was statistically related to an increase in KIDI scores (Figure 5.3).

Parenting Education services are offered at all four Effective Parenting contractors. Family Support Collaborative and the Crisis Nursery programs both provide First 5 Sacramento Commission-funded Case Management services.

16 Stevens, J.H. (1984). Child development knowledge and parenting skills. Family Relations, 33(2), 237-244.17 Miller, S.A. (1988). Parents’ beliefs about children’s cognitive development. Child Development, 59(2), 259-285.18 Damast, A.M., Tamis-LeMonda, C.S., & Bornstein, M.H. (1996). Mother-child play: sequential interactions and the relation between maternal beliefs and behaviors. Child Development, 67, 1752-1766.

39

Figure 5.2: Relationship between ParenInfant Development, Fiscal Year 2008/09

Figure 5.3: Relationship between Case Management SerInfant Development, Fiscal Year 2008/09

The significant findings reported above are for These high-intensity services were provided to 41.5% of from baseline to follow-up were not observed combined. Thus, the influence of scores was likely diluted in the analyseemphasizing messages related to

9.1

29.5

50.0

70.4

90.9A

ctua

l Ran

ge o

f K

IDI

scor

es

9.1

29.5

50.0

70.4

90.9

Act

ual R

ange

of

KID

I sc

ores

etween Parenting Education Services and ParentsInfant Development, Fiscal Year 2008/09

etween Case Management Services and Parents’Infant Development, Fiscal Year 2008/09

The significant findings reported above are for certain types of Effective Parentingintensity services were provided to 41.5% of Effective Parenting families.

up were not observed when all Effective Parentingof Parenting Education and Case Management services

in the analyses that included all services, including those not messages related to children’s development stages.

26.3

35.7

0 24Unit of Service

20.8

45.4

0 59Unit of Service

s’ Knowledge of

’ Knowledge of

Effective Parenting services. families. Changes

Effective Parenting services were services on KIDI

including those not

PERCENT OF PARENTS WI

Parents can lower their stress by drawing upon resources in the community, such as intervention, parenting classes, counseling, other parents. When parents decrease thecare of their children. First 5 Sacramentodesigned to strengthen families’ resiliency and to address

Agreement with statements such as, ““There are quite a few things thatof stress. These items came from a welland belong to a subset of items on this scale that assess “Parental Distress.” PSI scores range from 1 to 5, and higher scores equate to

As we saw for KIDI scores among significantly change over time, but a strong empirical correlation was found between parent stress and Effective Parentingthrough the POP program, including Pizza for Papa, Read to Me Daddy, Dad’s Career Day, and Dad and Me at School events, were significantly correlated with lower level(Figure 5.4).

Figure 5.4: Relationship between Father

This outcome is based on services that target the father, although the responses on which the stress index was calculated came from mothers 94.0% of the timerespondents were mothers). This suggests that Father Engagement services influence fathers’ attitudes and behaviors to such an extent that mother’s stress is significantly reducesuch as “I feel trapped by my responsibilities as a parent” on the PSI, it is not surprising that an

3.0

1.0

2.0

3.0

4.0

5.0

0 1

ERCENT OF PARENTS WITH DECREASED STRESS

Parents can lower their stress by drawing upon resources in the community, such as parenting classes, counseling, respite care, as well as opportunities to connect with

decrease their perceived level of stress, they are better able to take First 5 Sacramento Commission-funded family support services

designed to strengthen families’ resiliency and to address sources of stress for parents.

Agreement with statements such as, “I feel trapped by my responsibilities as a parentThere are quite a few things that bother me about my life” was used to determine parents’ levels

of stress. These items came from a well-known scale, called the Parenting Stress Index (PSI), and belong to a subset of items on this scale that assess “Parental Distress.” PSI scores range

om 1 to 5, and higher scores equate to lower levels of stress.

As we saw for KIDI scores among Effective Parenting clients, levels of stress were not found to significantly change over time, but a strong empirical correlation was found between parent

services. Specifically, Father Engagement services available through the POP program, including Pizza for Papa, Read to Me Daddy, Dad’s Career Day, and Dad and Me at School events, were significantly correlated with lower levels of parent stress

etween Father Engagement Services and Decreased Fiscal Year 2008/09

This outcome is based on services that target the father, although the responses on which the calculated came from mothers 94.0% of the time (i.e., 94% of Parent Interview

. This suggests that Father Engagement services influence fathers’ attitudes and behaviors to such an extent that mother’s stress is significantly reducesuch as “I feel trapped by my responsibilities as a parent” on the PSI, it is not surprising that an

3.6

2 3 4 5 6 7

Units of Service

40

Parents can lower their stress by drawing upon resources in the community, such as crisis opportunities to connect with

stress, they are better able to take funded family support services are

sources of stress for parents.

I feel trapped by my responsibilities as a parent” and ” was used to determine parents’ levels

known scale, called the Parenting Stress Index (PSI), and belong to a subset of items on this scale that assess “Parental Distress.” PSI scores range

clients, levels of stress were not found to significantly change over time, but a strong empirical correlation was found between parent

services. Specifically, Father Engagement services available through the POP program, including Pizza for Papa, Read to Me Daddy, Dad’s Career Day, and

s of parent stress

Engagement Services and Decreased Stress,

This outcome is based on services that target the father, although the responses on which the (i.e., 94% of Parent Interview

. This suggests that Father Engagement services influence fathers’ attitudes and behaviors to such an extent that mother’s stress is significantly reduced. With items such as “I feel trapped by my responsibilities as a parent” on the PSI, it is not surprising that an

41

increase in father engagement or involvement would decrease mother’s stress as she may not feel as alone or “trapped” by her parenting responsibilities.

PERCENT OF PARENTS WHO PRACTICE DEVELOPMENTALLY APPROPRIATE

PARENTING SKILLS

When parents make use of parenting skills appropriate to their child’s developmental stage, they foster further development in their child.19 Gaining knowledge and understanding of appropriate parenting strategies can also increase feelings of greater competence and satisfaction with being a parent.20 This indicator directly addresses the use of developmentally appropriate skills that are at the core of effective parenting.

The American Academy of Pediatrics discourages parents from using spanking as a form of discipline21,22 and a 2009 study of over 2,500 children from low-income families found negative outcomes over time in relation to spanking.23 Among Effective Parenting parents, only 8.0% stated that they “sometimes” or “often” spanked or smacked their children in the last six months. This is lower than the average of 26% reported from the National Survey of Early Childhood Health.24

The percent of parents who claimed that they “never” or “rarely” spank their children increased, but not significantly, from 88.3% at baseline to 92.7% at one-year follow-up, surpassing the percents found for parents from the Other Result Areas (Figure 5.5). For parents receiving First 5 Sacramento services in Other Result Areas, levels of spanking remained unchanged over time.These findings suggest that levels of never/rarely spanking may, over time, significantly increase, which will be examined with data from the two-year follow-up Parent Interview.

19 Damast, A.M., Tamis-LeMonda, C.S., & Bornstein, M.H. (1996). Mother-child play: sequential interactions and the relation between maternal beliefs and behaviors. Child Development, 67, 1752-1766.20 Reiner Hess, C., Teti, D.M., & Hussey-Gardner, B. (2004). Self-efficacy and parenting of high-risk infants: the moderating role of parent knowledge of infant development. Journal of Applied Developmental Psychology, 25(4), 423-437.21 American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. (1998). Guidance for effective discipline. Pediatrics, 101(4), 723-728.22 American Academy of Pediatrics. (2009). What is the best way to discipline my child? Retrieved from http://www.aap.org/publiced/BR_Discipline.htm.23 Berlin, L. J., Ispa, J. M., Fine, M. A., Malone, P.S., Brooks-Gunn, J., Brady-Smith, C., Ayoub, C., & Bai, Y. (2009). Correlates and consequences of spanking and verbal punishment for low-income white, African American, and Mexican American toddlers. Child Development, 80(5), 1403-1420.24 Regalado, M., Sareen, H., Inkelas, M., Wissow, L. S., & Halfon, N. (2004). Parents' discipline of young children: results from the National Survey of Early Childhood Health. Pediatrics, 113(6), 1952-1958.

Figure 5.5: Parents Who Never or Rarely Spank Their Children

The Parent Interview also included questions for developing composite scores for Nurturance (affection and positive feedback)(encouragement of independencepunishment) parenting styles. Baseline versus followparticipants did not find significance for these measures. race/ethnicity and primary language were significant predictors of can conclude that ethnic heritage and culture play a more dominant rthan are influenced by Effective Parenting

PERCENT OF PARENTS WHO INTERACT WITH THEI

Young children grow and change rapidly, learning from the esurrounding them. They depend on their parents to nurture their development, care for their health and safety, and prepare them for new experiences.parenting approaches, parents can provide the children need in order to thrive.

The extent to which First 5 Sacramento children live in a pmeasured with a total of 16 questionshow often someone in the family reads to the child. In addition, an “Activities with Child” score was calculated by asking parents of children three years or older how often they conducted each of 15 activities with their child. These acti

86.0%

Follow-up

Baseline

Follow-up

Baseline

Eff

ectiv

e P

aren

ting

Oth

er R

esul

t A

reas

Figure 5.5: Parents Who Never or Rarely Spank Their Children by Result AreaFiscal Year 2008/09

The Parent Interview also included questions for developing composite scores for Nurturance positive feedback), Warmth (consistency in parenting practices)

(encouragement of independence), and Authoritarian (discipline by verbal or physical parenting styles. Baseline versus follow-up analyses among Effective Parenting

ignificance for these measures. These analyses did find that race/ethnicity and primary language were significant predictors of parenting stylescan conclude that ethnic heritage and culture play a more dominant role in parents’

Effective Parenting services, at least in the short term.

O INTERACT WITH THEIR CHILDREN IN A SUPP

POSITIVE MANNER

Young children grow and change rapidly, learning from the environmentThey depend on their parents to nurture their development, care for their

pare them for new experiences. By using supportive and positive parenting approaches, parents can provide the stimulating and beneficial interactions their

First 5 Sacramento children live in a positive and supportive questions. First, parents of children one year or older were asked

how often someone in the family reads to the child. In addition, an “Activities with Child” score was calculated by asking parents of children three years or older how often they conducted each of 15 activities with their child. These activities included, “Played any game or sport together

92.7%

88.3%

90.1%

90.0%

88.0% 90.0% 92.0%

42

y Result Area,

The Parent Interview also included questions for developing composite scores for Nurturance (consistency in parenting practices), Authoritative

discipline by verbal or physical Effective Parenting

These analyses did find that parenting styles, and thus we

in parents’ behaviors

R CHILDREN IN A SUPPORTIVE AND

nvironments and people They depend on their parents to nurture their development, care for their

By using supportive and positive and beneficial interactions their

ositive and supportive household was older were asked

how often someone in the family reads to the child. In addition, an “Activities with Child” score was calculated by asking parents of children three years or older how often they conducted each

Played any game or sport together,”

92.7%

94.0%

43

“Helped (him/her) learn letters, words, or numbers,” and “Talked with [child’s name] about (his/her) family history or stories about the family”.

Parents’ reported number of activities shared with their children did not significantly change over time. In addition, none of the Effective Parenting services was found to be related to parents’ reported activities.

44

CHAPTER 6SCHOOL READINESS RESULT AREA

School Readiness is intended to better prepare children for kindergarten, and services are directed at parents as well as pre-kindergarten aged children. This Result Area represents the Commission’s largest investment ($5,177,000 in fiscal year 2008/09) and is supported by state-match funds.

School Readiness services changed substantially between the last two fiscal years: Beginning on July 1, 2008, a revamped “Cycle 2” program was implemented with a core set of services offered among all school districts. Cycle 2 programs were also required to provide more services geared towards families with children ages 3 years and younger. Cycle 2 programs differ enough from Cycle 1 School Readiness that the First 5 Sacramento Commission approved a separate methodology and instruments from those discussed in this report to evaluate the new services.25

This change in services poses a challenge for interpreting changes in outcomes over time. For example, for the indicator, “Percent of children participating in school-linked transitional practices,” the types of services classified as “transitional” changed from 2007/08 to 2008/09. The implications for this change as related to interpreting the findings for this indicator are discussed later in this chapter.

Data from the Parent Interview were used to assess four School Readiness indicators:

Percent of children who have received a comprehensive health and developmental screening in the past year;

Percent of children ages 3-5 who regularly attend a nursery school, preschool, pre-Kindergarten, or Head Start program by the time of Kindergarten entry;

Percent of children with special needs who participated in early childhood care and education programs; and

Percent of participants reporting satisfaction with the content, quality, and family centeredness of services.

Some families participating in the 2008 and 2009 Parent Interviews received both Cycle 1 and Cycle 2 School Readiness services. Thus, any observed changes from baseline to one-year follow-up, as presented in the previous chapters of this report, could be due to different types of School Readiness services rather than longer-term outcomes from the outdated Cycle 1 services. A more valid analytic approach to evaluate School Readiness services, and one more applicable to the current array of services, is to examine changes over time by survey periods (2008 versus 2009). This methodology was selected for the findings presented in the following section.

25 Findings in the report, “Evaluation of School Readiness Services, Fiscal Year 2008/2009,” available at http://www.first5sacramento.net/Newsroom/reports, include a reduction in parent stress and increases in activities with children over the school year. Children of families receiving School Readiness services also were more likely to perform better in academic tests and were judged by their teachers to demonstrate less problematic behaviors.

45

The following First 5 Sacramento Commission indicators were based on school staffs’ assessments of different groups of children from the 2007/08 and 2008/09 school years to specifically address children’s readiness for kindergarten:

Percent of children meeting developmental milestones; and Percent of children assessed to be ready for Kindergarten at the completion of a school

readiness program.

The six school districts listed in Table 6.1 provided services directly to children and parentsduring fiscal year 2008/09. Data from the clients from these six school districts were used to address the seven indicators listed above. The School Readiness services of the Sacramento County Office of Education, Preschool Bridging Model program focused on working directly with teachers and providers in child care centers and family homes. The last School Readinessindicator is related specifically to the Preschool Bridging Model:

Degree to which planning/pilot service delivery model or systemic intervention is implemented.

Planning and piloting activities occurred during 2007/08. In the current report we discuss the progress that the Preschool Bridging Model has made since last fiscal year.

46

Table 6.1: Providers of School Readiness Services, Fiscal Year 2008/09

Elk Grove Unified School District

Offers family literacy events and activities for children and parents to help prepare families for the transition to kindergarten. Parenting education is provided through workshops and group meetings with parents. Early identification and intervention for children suspected of special needs is also provided.

Folsom Cordova Unified School District

Provides education on parenting and child developmentthrough classes and group meetings with parents. The importance of literacy and parent-child play is promoted through activities involving parents and children. Families are prepared for the transition into kindergarten through year-round activities.

Robla Elementary School District

Provides preschool for children and literacy promotion through a home-reading program, including workshops for parents. Identification of and intervention for suspected special needs is provided for children. Hmong children and their families receive literacy and language support. Groups are offered to foster parent-child play. Materials and activities are provided to prepare families for the transition to kindergarten.

Sacramento City Unified School District

Trained staff provides early childhood education, health and developmental screenings, parenting support services, and early literacy services to encourage reading and book sharing at families’ homes. An early literacy program is provided through classrooms on an on-going basis to encourage parents reading to or “sharing a book” with children. Children and families are assisted in the transition to kindergarten through activities throughout the year.

San Juan Unified School District

Parenting programs are offered to help parents learn to manage children’s emotional responses. Family literacy is promoted through reading activities involving parents and children. Staff visiting parents in their home link families to needed services and information.Throughout the year families are prepared for the transition to kindergarten through various activities. English as Second Language classes are available for parents.

Twin Rivers Unified School District

Provides preschool to children. Educates parents on parenting and child development, and teaches parent-child play. Visits are offered to families in their home to link them to needed services and support family literacy. Provides transition materials and activities throughout the year for families in preparation for kindergarten entry.

Sacramento County Office of Education

Through the Preschool Bridging Model, preschool and child care staff are provided with instructional materials and one-on-one assistance, for quality improvement of the classroom. Professional development opportunities are offered for site staff to extend their education and child care/preschool development. Vision and hearing screenings are also provided for children.

School Readiness services included educational opportunities for the family through workshops, courses with structured curricula, and facilitated discussions. These types of services included Literacy Programs (received by 40.6% of School Readiness families), Parent Discussions and

47

Engagement (13.1% of families), and Parenting Instructional Workshops (8.9% of families; Table 6.2). Educational services also include Preschool for children ineligible for other preschool programs in the County (received by 9.4% of School Readiness families), and Summer Camps (15.8% of families) which expose children with little or no preschool experience to a structured environment where they can learn how to properly interact with other children in a classroom-like setting. Transition Activities focus on smoothing the transition into kindergarten by familiarizing the family with classroom/school and/or teacher/principal, and discussing the expectations that will be placed on children and parents. These services are complimented with Transition Materials, which provides children and parents with the tools and information they need for kindergarten success. Transition Activities were provided to 30.9% of families receiving School Readiness services, and Transition Materials were given to 16.7% of families. Finally, as seen in the table below, a variety of health screenings are provided to children under the School Readiness Result Area.

Table 6.2: School Readiness Services, Fiscal Year 2008/09



Services Provided

(n = 83,050)

Literacy Programs

Literacy programs include family night events to discuss family literacy and the importance of reading at home; parents and children to read and talk together; library time for parents and their children; English as Second Language (ESL) workshops for parents to affect family literacy; and/or supplement to preschool for Hmong speaking children/parents. Another program is curriculum based including two components: workshops for parents discussing the importance of literacy and take-home book bags for children to read with their parents.

40.6 23,679

Transition Activities

Activities include visits to kindergarten for children; workshops to familiarize children with the classroom, teacher, and kindergarten activities; school registrations and orientations for parents on school readiness and expectations for kindergarten; parent exposure to the kindergarten classroom, and the school district/system; and/or parent-teacher meetings and opportunities to meet the principal.

30.9 1,495

48



Services Provided

(n = 83,050)

Health Screenings

Comprehensive health screenings for children addressing: vision, oral health, and immunizations. Some individual hearing, vision, and/or immunization screenings for children. Oral health screenings include dental varnishes, and all screenings result in referrals for follow-up when needed.

26.8 999

Transition Materials

Backpacks with school readinessinformation, supplies, and activities; and/or kits with information on child development, parenting, nutrition, dental care, and community resources for families with children transitioning into kindergarten.

16.7 498

Speech/Language & Development Screenings

Speech/language or developmental screenings or behavioral and developmental assessments including diagnosis for children.

16.3 525

Summer Camps

Pre-kindergarten camps offered for 4-6 weeks over the summer, provide children exposure to a classroom setting andkindergarten concepts such as numeracy, literacy, and social interaction; intended for children with little or no preschool experience.

15.8 4,962

Speech/Language & Development Interventions

Intervention services include speech/language consults; direct support to parents for developmental and/or speech/language needs of their child; developmental play therapy for the child; and/or follow-up linkage to special needs services.

13.3 850

Parent Discussions & Engagement

Topical discussions with groups of parents and facilitator including: child development, behavior, attachment, parenting, ‘male involvement,’ mental/emotional health, kindergarten readiness, importance of family literacy, “parents as their child’s best first teacher,” and activities to support cognitive development. Parent engagement in governance groups such as advisory committees or school site councils to participate in school-based decision making.

13.1 1,159

Playgroups

Playgroups for children and their parents that teach and encourage developmentally appropriate parent-child interactions; some provide age-specific Learning Toolkits with tools and materials for parents and child.

12.3 8,434

49



Services Provided

(n = 83,050)

Health Information

Information for parents on mental health, oral health, and/or immunizations, and some referrals for children’s mental or oral health follow-up.

10.0 349

Preschool

Preschool for children ineligible for other preschool programs due to family income. Services include social, emotional, physical, language development, and learning activities.

9.4 37,135

Parenting Instructional Workshops

Workshops for parents utilizing curriculum to increase dialogue and positive interaction between parent and child, and/or learn how to manage children’s emotional responses.

8.9 1,023

Home Visits

Education on positive parenting practices, child development, and/or the importance of family literacy; a needs assessment to provide case management and connect families with additional services, such as for special needs children; and/or supplying literacy materials/kits.

5.3 1,570

Oral Health ServicesOral health screenings and/or cleanings and varnishes for children.

5.3 216


Referrals for health insurance, or receipt ofhealth insurance information.

3.7 144

Referrals for Lactation Support

Through home visitation, referrals for lactation support to pregnant mothers or mothers with newborns.

0.4 12


PERCENT OF CHILDREN PARTICIPATING IN SCHOOL-LINKED TRANSITIONAL

PRACTICES

School-linked transitional practices are intended to help smooth the transition from pre-kindergarten to kindergarten. In Cycle 1, school-linked transitional practices consisted of Summer Camps, whereas in Cycle 2 (2008/09) transitional practices were comprised of Transition Activities and Summer Camps. While Summer Camps provide exposure to a structured school setting for children with little to no prior experience, Transition Activities focus on preparing families for the expectations and experiences that will come with entering kindergarten.

50

The number of transitional practices recorded in Persimmony for 2008/09 more than doubled compared with 2007/08: 6,457 versus 3,185, respectively. The inclusion of key Transition Activities in Cycle 2, and subsequently a greater number of services provided, translated into a higher percentage of families with children ages 4 or 5 years participating in school-linked transitional practices this fiscal year (62.2% versus 28.5% in 2007/08).

PERCENT OF CHILDREN WHO HAVE RECEIVED A COMPREHENSIVE HEALTH AND

DEVELOPMENTAL SCREENING IN THE PAST YEAR

Early and comprehensive health and developmental screenings are important services as physical health and motor development are critical to a child’s success and readiness to learn in school. The earlier problems are identified, the more likely they are to be addressed and have less impact on the child’s overall development. Additionally, parents of children suspected to have special needs can obtain the support and services needed to help them cope with and provide for their child’s specific needs.

A series of questions from the Parent Interview were used to address this indicator by asking parents whether their children had received a hearing or vision test (i.e., health screenings), or been “screened for development or behavior problems” during the past year. The development screening test was defined as a “brief, simple procedure usually done by a professional or medical doctor to identify possible developmental delays or disabilities.”

The percent of children receiving health screenings increased significantly from 2007/08 to 2008/09. During the most recent fiscal year, 73.9% of School Readiness children were tested for hearing difficulties (Figure 6.1) and 70.4% were tested for vision problems (Figure 6.2). One-fifth (19.7%) of children had a developmental screening, which represents a slight but notstatistically significant drop from 25.8% calculated from the 2008 Parent Interview. Overall, the percent of children reported by their parents to have all three screenings also remained statistically similar from 2008 (16.5%) to 2009 (14.8%). However, when we examine the sheer number of children receiving all three screenings, we find that 64 additional children were screened in 2008/09 versus 2007/08.

51

Figure 6.1: Percent of Children with Hearing

Figure 6.2: Percent of Children with Vision Screenings by Fiscal Year

PERCENT OF CHILDREN AGES

PRESCHOOL, PRE-KINDERGARTEN

There is a strong and growing evidence base showing that highsignificantly narrows the achievement gap and allows

0.0%

20.0%

40.0%

60.0%

80.0%

2007/08

0.0%

20.0%

40.0%

60.0%

80.0%

2007/08

Figure 6.1: Percent of Children with Hearing Screenings by Fiscal Year


GES 3-5 WHO REGULARLY ATTEND A NURSERY SCHOOL

KINDERGARTEN, OR HEAD START PROGRAM BY THE

KINDERGARTEN ENTRY

There is a strong and growing evidence base showing that high-quality preachievement gap and allows children to start school on more equitable

59.9%

73.9%

2007/08 2008/09

53.7%

70.4%

2007/08 2008/09

Screenings by Fiscal Year


A NURSERY SCHOOL,TART PROGRAM BY THE TIME OF

quality pre-kindergarten children to start school on more equitable

footing.26 Longitudinal studies also indicate that children who enter kindergarten at a disadvantage are likely to remain so, whereas participation in higheducation programs can close the gap in achievement and sustain gains into the third grabeyond.27

The Parent Interview included the question, “Is [cpreschool, pre-kindergarten or Head Start program on a School Readiness children were reported by parents year’s Parent Interview found regular school attendance to be 72.4% among children.

We can compare these percentages with those reported from the California Health Interview Survey dataset, as well as findings from the 2000 CensusRegular preschool or nursery school attendance among than the national average of 49.3%significantly higher than the 35.6

Figure 6.3: Comparisons of Percent of Children Regul

26 Zill, N., Sorongon, A., Kim, K., Clark, C., & Woolverton, M. (2006). Children's Outcomes and Program Quality in Head Starthttp://www.acf.hhs.gov/programs/opre/hs/faces/reports/research_2003/research_2003_title.html27 Burchinal, M.R. & Cryer, D. (2003). Diversity, child care quality, and developmental outcomResearch Quarterly, 18, 401-426.28 National and state data retrieved from http://29 2007 California County Data Book for Sacramento County. Retrieved from www.childrennow.org.

75.0%

0.0%

20.0%

40.0%

60.0%

80.0%

School Readiness 08/09

Longitudinal studies also indicate that children who enter kindergarten at a disadvantage are likely to remain so, whereas participation in high-quality early care and

close the gap in achievement and sustain gains into the third gra

ew included the question, “Is [child’s name] now attending a nursery school, kindergarten or Head Start program on a regular basis?” In 2008/09, 75.0% of

were reported by parents to attend school on a regular basisyear’s Parent Interview found regular school attendance to be 72.4% among School Readiness

ages with those reported for Sacramento County, which is derived Health Interview Survey dataset, as well as findings from the 2000 Census

Regular preschool or nursery school attendance among School Readiness children is much higher than the national average of 49.3%, which is higher than the state average of

35.6% reported for Sacramento County children29 (Figure 6.3).

Figure 6.3: Comparisons of Percent of Children Regularly Attending Pre-Schools, Fiscal Year 2008/09

Zill, N., Sorongon, A., Kim, K., Clark, C., & Woolverton, M. (2006). FACES 2003 Research BriefChildren's Outcomes and Program Quality in Head Start. Retrieved from http://www.acf.hhs.gov/programs/opre/hs/faces/reports/research_2003/research_2003_title.html

Burchinal, M.R. & Cryer, D. (2003). Diversity, child care quality, and developmental outcomes.

National and state data retrieved from http://www.pewtrusts.org. 2007 California County Data Book for Sacramento County. Retrieved from www.childrennow.org.

35.6%

45.8%49.3%

Sacramento County California National

52

Longitudinal studies also indicate that children who enter kindergarten at a quality early care and

close the gap in achievement and sustain gains into the third grade and

attending a nursery school, ?” In 2008/09, 75.0% of

school on a regular basis. Last School Readiness

County, which is derived Health Interview Survey dataset, as well as findings from the 2000 Census.

children is much higher than the state average of 45.8%28 and

(Figure 6.3).

-Kindergarten

FACES 2003 Research Brief

es. Early Childhood

2007 California County Data Book for Sacramento County. Retrieved from www.childrennow.org.

49.3%

National

53

These findings are not surprising given a core strategy of School Readiness is to expose children to school before kindergarten. Overall, 45.9% of First 5 Sacramento children were found to be regularly-attending nursery school or preschool, which is much higher than those reported for the County as a whole.

PERCENT OF CHILDREN WITH SPECIAL NEEDS WHO PARTICIPATED IN EARLY

CHILDHOOD CARE AND EDUCATION PROGRAMS

Attending a quality early childhood care and education program is particularly important for children with special needs, who already face challenges when entering kindergarten. Longitudinal studies suggest that children who enter kindergarten at a disadvantage are likely to remain so, whereas participation in high-quality early childhood care and education programs can close the gap in achievement and sustain gains into the third grade and beyond.30 For children with special needs, participation in preschool is important in determining their future inclusion in regular schools.

Children with special needs were defined according to responses on the Parent Interview to the question: “Has a doctor, other health or education professional, or someone from the First 5contractor ever told you that your child has special needs or disabilities, for example, physical, emotional, language, hearing, learning difficulty, or other special needs?” If the parent answered yes to this question, he/she was then asked whether the child is currently attending a “nursery school, preschool, pre-kindergarten or Head Start program.”

In response to the first question, 6.9% of children were said by parents in 2009 to have a special need based on the report of a professional. More children in the School Readiness Result Area were found to have a special need than from the Other Result Areas (11.3% versus 5.6%). This higher percentage may be due to the greater proportion of children screened through School Readiness programs, indicating that School Readiness serves an important function: assessing children for special needs and reporting the results to parents, with a focus on early identification and intervention.

The majority of children with special needs attended early childhood care and education programs in both 2007/08 (80.0%) and 2008/09 (77.8%).

The primary goal of School Readiness is early identification and early intervention because it is more effective and less costly. With the focus of the School Readiness programs on early identification and intervention, the participation rate in early childhood care and education programs suggests that many of these children may receive interventions earlier, and be fully integrated into the kindergarten classroom. Thus, it appears that School Readiness programs are providing an important service for children at risk of having special needs.

30 Burchinal, M.R. & Cryer, D. (2003). Diversity, child care quality, and developmental outcomes. Early Childhood Research Quarterly, 18, 401-426.

54

PERCENT OF PARTICIPANTS REPORTING SATISFACTION WITH THE CONTENT,QUALITY, AND FAMILY CENTEREDNESS OF SERVICES

Parents’ satisfaction with the school programs where the child “spends most of (his/her) time” were obtained from First 5 Sacramento parents in seven areas, including “Helping [child’s name] to grow and develop,” “Supporting and respecting your family’s culture and background,” and “Preparing [child’s name] to enter kindergarten.” These items were combined to represent one satisfaction score, with a theoretical range from 0 to 100.

In general, client reports of satisfaction tend to be relatively high; this was also found to be the case for School Readiness services. Over half (57.5%) of parents had a score of 100, which meant they expressed complete satisfaction with all seven items. There was a slight change in average satisfaction scores from 2007/08 to 2008/09 – 93.9 to 95.7, although this increase was not statistically significant.

PERCENT OF CHILDREN ASSESSED TO BE READY FOR KINDERGARTEN AT THE

COMPLETION OF A SCHOOL READINESS PROGRAM

Assessment for school readiness is important because children with knowledge and skills far behind those of their classmates enter school at a disadvantage. Studies show that children who enter kindergarten at a disadvantage remain so throughout adulthood.31 Children who are not successful in school manifest frustration through inappropriate behavior and are also more likely to drop out of school.32

Children’s readiness for kindergarten was recorded on the “Summer Camp & Preschool Teacher Services/Assessment Form” with the question, “If this child has been assessed for his/her readiness for kindergarten, what was the result?” Response options were: “Ready,” “Not Ready,” “Not Sure,” and “N/A – Not Assessed.” Teachers were asked to complete the form at the end of the program, or as the child exited.

For 2008/09, 85.1% of 4 and 5 year old children were considered to be ready for kindergarten. This represents a seven-point decrease in children’s school readiness compared with 2007/08.Our investigation for the reason behind this decline began with examining the data by district, where we found that only 45.2% of children from Twin Rivers Unified School District were determined to be ready for kindergarten. The School Readiness Coordinator from Twin Rivers

31 Phillips, M., Brooks-Gunn, J., Duncan, G., Klebanov, K., & Crane, J. (1998). Family background, parenting practices and the Black-White test score gap. In C. Jencks & M. Phillips (Eds.), The Black-White test score gap (pp. 103–145). Washington, DC: Brookings Institution Press.32 Finn, J. (1989). Withdrawing from school. Review of Educational Research, 59, 117-142.

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stated that the July 2008 merger of the North Sacramento, Del Paso Heights, Rio Linda Union, and Grant Joint Union High school districts into Twin Rivers resulted in a hiring freeze for full-time preschool teachers and required that new job descriptions be approved by the teachers’ union and Board of Trustees. These factors resulted in three of the four preschool positions being staffed by substitutes throughout the year. Ultimately, preschoolers did not receive the same level of education as they would have if the district were able to hire teachers with the qualifications necessary for early childhood education. Although the district made professional development available for these teachers, they found it challenging to get the substitute teachers to participate. In addition, one of the larger school districts – Elk Grove Unified School District -- contributed data for nearly 200 children last year but was not contracted to provide Preschool or Summer Camp services under the current contract; therefore, the overall number of children for which we have data also decreased.

PERCENT OF CHILDREN MEETING DEVELOPMENTAL MILESTONES

The National Education Goals Panel defines children’s readiness for school based on a number of key developmental domains including cognitive, physical, and social-emotional development as well as language skills and children’s approaches to learning. By meeting typical milestones for growth in each of these areas, children can arrive in kindergarten with the skills needed to be successful.

The Desired Results Developmental Profile Revised Edition (DRDP-R) was administered by trained staff working with children attending School Readiness programs in two of the six school districts. Scores for meeting developmental milestones are based on staff rating the child in each developmental domain at the top two levels of the four-level scales for each item within each domain.33 The percentages in Table 6.3 are based on combining all items within a core developmental area, and showing the percentage of children who were rated at the highest two levels on the DRDP-R: “building” or “integrating.”

33 In the DRDP-R PS (preschool) version, the four developmental levels are Exploring, Developing, Building, and Integrating. There are two additional ratings for each item – “emerging” and “unable to rate” – but these are considered optional and do not contribute to the scores (California Department of Education, Desired Results Developmental Profile-Revised User’s Guide, March 2008).

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Table 6.3: Children from School Readiness Meeting Developmental Milestones,Fiscal Year 2008/09

n %

Personally and Socially Competent (15 items) 43/218 19.7

Effective Learners (18 items) 33/218 15.1

Showing Physical and Motor Competence (3 items) 127/218 58.3

Safe and Healthy (3 items) 84/218 38.5 Source of Data: Persimmony

Note: Data are from only two school districts, Twin Rivers and Robla School Districts.

The percents for all four domains decreased over those reported in last year’s report. This is not surprising given that Twin Rivers was one of the two school districts providing DRDP-R data for this table. As noted above, the merger of four districts into Twin Rivers resulted in staffing challenges for preschool positions.

DEGREE TO WHICH PLANNING/PILOT SERVICE DELIVERY MODEL OR SYSTEMIC

INTERVENTION IS IMPLEMENTED

The objectives of the Sacramento County Office of Education, Preschool Bridging Model program are to promote workforce development and program improvement in private child care settings, promote collaboration between the public and private sectors, link child care to resources available in the public sector, and to help early care educators better understand the important role they have in promoting school readiness. During fiscal year 2007/08, PBM was piloted with preschool teachers and an instructional coach from the Elk Grove Unified School District to provide preschool services and connections to 15 child care facilities serving children ages 3 to 5 years.

During fiscal year 2008/09, the Preschool Bridging Model was expanded to include all six school districts. Preschool Bridging Model Family Advocates and Early Childhood Education Specialists assisted 102 private child care centers and family child care homes in enhancing the quality of care for children attending these facilities. Services included site development, instructional support, workforce and professional development for site staff, and health screenings for children. From late April through May 2009, all 102 sites had teachers/providers participate in the Teacher/Provider Survey, a questionnaire regarding their teaching practices and beliefs, classroom quality, and education. The following is a review of teachers’ reports on the quality of care and education provided by facilities served by Preschool Bridging Model.

The majority of the teachers and providers receiving services were in family child care homes (49.0%), child care centers (24.0%), and preschools (19.0%). Few teachers/providers reported teaching in pre-kindergarten classrooms (7.0%) or playgroups (1.0%). Seventy-seven percent of teachers spoke English only; 21% reported being fluent in two languages, and 2% in three

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languages. Of those teachers speaking two languages, the majority (56.5%) spoke English and Spanish (12.7% of all teachers). When asked what languages teachers use with children, the majority used only English (70.6%), and 25.5% used two languages, with the most frequent second language being Spanish (23.5% of all teachers). Teachers/providers reported teaching on average 13.6 years, and 8.2 years teaching in their current position. The average job satisfaction score was 4.6 out of 5 possible.

One objective of the Preschool Bridging Model program is to promote workforce development and program improvement in private child care settings. Most (91.2%) teachers/providers had heard of the professional development incentive program Comprehensive Approaches to Raising Educational Standards (CARES), with over one-fourth of providers participating in CARES (Table 6.4). Almost half (46.1%) of teachers/providers reported being currently active in teaching related training. The 2009/10 fiscal year will provide pre- and post measures of teacher/provider professional development to examine changes through the Preschool Bridging Model program.

Table 6.4: PBM Teachers’ Responses to Education Questions, Fiscal Year 2008/09

%

ECE Degree, BA or Higher 9.8

CDA Credential 10.8

Currently Enrolled in Teaching Related Training 46.1

Member of a Professional Association 23.5

Heard of CARES 91.2

Participant of CARES 27.5 Source of Data: Teacher/Provider Survey

Teachers were asked if they had a Child Development Permit in which 32.4% responded “yes” (Table 6.5). Over half (54.6%) of teachers with a Child Development Permit were at the Master Teacher level or higher. One-fifth (20.6%) of teachers/providers had at least a Bachelor’s degree or higher.

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Table 6.5: Percent of Teachers by Level on the Child Development Matrix (n = 33),Fiscal Year 2008/09

%

Assistant 6.1

Associate Teacher 15.2

Teacher 24.2

Master Teacher 6.1

Site Supervisor 33.3

Program Director 15.2 Source of Data: Teacher/Provider Survey

The average PBM environment score was 7.0 out of nine, indicating, on average, facilities had at least 7 out of the nine activity centers (Table 6.6). Five or more activity centers is an indicator of high-quality.

Table 6.6: Percent of PBM Teachers by Type of Learning Center in the Classroom,Fiscal Year 2008/09

%

Reading area with books 100.0

Dramatic play area or corner 94.1

Writing center or area 93.1

Art area 93.1

Private area for one or two children to be alone 89.2

Math area with manipulatives 84.3

Science or nature area with manipulatives 84.3

Computer area 35.3

Listening center 29.4 Source of Data: Teacher/Provider Survey

Teachers were asked to rate statements regarding child initiated learning practices. Teachers indicated how strongly they agreed or disagreed to statements including: “Children in classrooms should learn through active explorations” and “Children should dictate stories to the teacher.” The average teacher score was 4.3 out of 5, indicating high belief in child initiated learning.

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CHAPTER 7DENTAL RESULT AREA

For the 2007/10 funding cycle, First 5 Sacramento allocated $14 million to increase fluoridation in Sacramento County and reduce the prevalence of dental caries among children ages 0 to 5 years. The related indicators for the Dental Result Area are:

Percent of children who have fluoridated water; and Percent of children with dental caries at Kindergarten entry.

The goal is to have 76% of children ages 0 to 5 years live within a fluoridated district by 2010. Water districts with the greatest concentration of children ages 0 to 5 years are targeted with funding for capital improvements to expand fluoridation services. These districts include: Rio Linda, Zone 41 (County of Sacramento), Sacramento Suburban (North), California American (Security Park), and Del Paso Manor.

PERCENT OF CHILDREN WHO HAVE FLUORIDATED WATER

Untreated dental caries (i.e., tooth decay) can be very painful and can interfere with diet, nutrition, and sleep. When the fluoride concentration in drinking water reaches recommended levels (0.7-1.2 parts per million), the incidence of dental caries can be reduced. At the end of fiscal year 2007/08, there were 182,084 service connections providing fluoridated water to an estimated 45%, or 614,185 Sacramento County residents. By the end of the 2007/10 funding cycle, 76% of children ages 0 to 5 years will live within a fluoridated water district.

During fiscal year 2008/09, grantees funded to conduct fluoridation services conducted preliminary planning and engineering design work for the expansion of fluoridation services. The southeast area of the county is the focus for the expansion of fluoridation services. The following map produced by First 5 Sacramento shows the areas of the county currently receiving fluoridated water, as well as the expansion zones that will be fluoridated by 2010.

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Figure 7.1: Sacramento County Fluoridation Overview Map

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PERCENT OF CHILDREN WITH DENTAL CARIES AT KINDERGARTEN ENTRY

Dental caries is one of the most common diseases to affect children in the United States, and arethe most common health problem among California’s children, particularly children from low income and racial minority families.34 Poor dental health can contribute to other health problems, poor self-image, poor concentration, and difficulties in school.

Smile Keepers conducts dental screenings at Sacramento County preschools, and its services include sending home with each child a “Report of Screening” along with a list of dental resources for parents to access. Smile Keepers was not funded by the First 5 SacramentoCommission during this fiscal year, but the program offers the best available data to assess the dental health of Sacramento’s children.

Smile Keepers conducted 975 dental screenings during fiscal year 2008/09, or 655 more screenings than last year. The prevalence of dental caries increased slightly, from 48.8% to 51.2%. In addition, the oral health of 8.4% of children screened this year, versus 8.0% of children screened last year, was classified as “urgent care needed”.

34 Dental Health Foundation. (2006). “Mommy it hurts to chew” The California Smile Survey: An oral health assessment of California’s kindergarten and 3rd grade children. Retrieved from: http://www.dentalhealthfoundation.org/images/lib_PDF/dhf_2006_report.pdf

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CHAPTER 8COMMUNITY BUILDING RESULT AREA

Community groups are invited to apply for small grants through First 5 Sacramento to plan and implement events or activities with the aim of building connections (social capital) between families with children ages 0 to 5 years. The connections built through Community Building Initiative (CBI) funded projects have the potential to make neighborhoods healthier and safer for children and empower parents to improve their lives, based on the support they receive from others and the knowledge they obtain about community resources. Applications for CBI funding are carefully screened by the First 5 Sacramento Advisory Committee and staff to ensure that they meet the objectives of the program. A total of 360 CBI events met these criteria and were reported during fiscal year 2008/09. The investment in the Community Building Result Area was $598,000, representing 4.3% of funds expended during the year.

During the fiscal year, a master list of CBI events was developed as Grantee Monthly Progress Reports were submitted to First 5 Sacramento staff. Missing data for those variables crucial to linking community events reported on the Parent Interview to actual CBI events (i.e., location, date, and name) were noted and follow-up with grantees to obtain these data was conducted as necessary.

Parents randomly selected for participation in the Parent Interview were asked a series of questions about attendance at any community events during the previous six months. Responses were compared with a master list of CBI events to categorize parents into three groups: “Did Not Attend a Community Event,” “Attended a Community Event, Not CBI,” or “Likely or Definitely Attended a CBI Event.” Comparisons were then made across these three groups on the related measures for each indicator associated with the Community Building Result Area:

Percent of parents who report connectedness to their communities; Percent of parents who report a sense of investment and trust in their neighborhood; Percent of parents who report an increased utilization of formal and informal

neighborhood resources; and Percent of parents with increased efficacy.

Changes from baseline to one-year follow-up were not examined for Community Buildingoutcomes. Rather, the analyses were conducted with responses from the 2009 sample independently to examine the consistency of findings between the two survey periods.

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PERCENT OF PARENTS WHO REPORT CONNECTEDNESS TO THEIR COMMUNITIES

A feeling of connectedness with one’s community can have a variety of health, social, and economic benefits.35 These benefits may include a reduction in violence and crime rates, positive health outcomes such as lower rates of infant mortality and teen pregnancy, and improved achievement in elementary school.36,37,38,39 Greater connectedness allows parents to access formal and informal networks for support and information in times of need and to thereby moderate the effects of stressful life events and other disadvantages, such as limited education or language/cultural barriers.

First 5 Sacramento parents were asked to tell us the number of people in their neighborhood who they know by name, the number of people who visit each other’s home, and the number of relatives and friends who live in their neighborhood, to determine how connected they are to their community.

As seen in Table 8.1, linear relationships were found across the board between event attendance and the three measures of neighborhood connectedness. These relationships strongly support the premise that bringing neighbors together for community events leads to lasting relationships. Furthermore, the findings strongly suggest that CBI events have a greater impact on community connectedness than other types of community events that may not be organized with the specific focus and intent that First 5 Sacramento requires of CBI events.

35 Altschuler, A., Somkin, C.P., & Adler, N.E. (2004). Local services and amenities, neighborhood social capital, and health. Social Science & Medicine, 59, 1219-1229. 36 Sampson, R.J., Raudenbush, S.W., & Earls, F. (1997). Neighborhoods and violent crimes: a multilevel study of collective efficacy. Science, 277, 918-924.37 Crosby, R.A. & Holtgrave, D.R. (2006). The protective value of social capital against teen pregnancy: a state-level analysis. Journal of Adolescent Health, 38, 556-559.38 Cagney, K.A. & Browning, C.R. (2004). Exploring neighborhood-level variation in asthma and other respiratory diseases: the contribution of neighborhood social context. Journal of General Internal Medicine, 19, 229-236. 39 Parcel, T.L. & Dufur, M.J. (2001). Capital at home and at school: effects on student achievement. Social Forces, 79, 881-911.

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Table 8.1: Neighborhood Connectedness by Community Event Participation by Fiscal Year

Average Number of People in

Neighborhood Known by

Name

Average Number of

People Who Visit in Each

Other's Homes

Average Number of Friends/

Relatives Who Live in Your

Neighborhood

2007/08

Did Not Attend a Community Event 4.2 2.1 2.1

Attended Community Event, Not CBI 6.7 2.3 2.6

Likely or Definitely Attended a CBI Event 7.7 5.5 2.8

2008/09

Did Not Attend a Community Event 4.9 1.9 1.6

Attended Community Event, Not CBI 6.2 2.5 2.2

Likely or Definitely Attended a CBI Event 6.9 3.8 2.7Source of Data: Parent Interview

PERCENT OF PARENTS WHO REPORT A SENSE OF INVESTMENT AND TRUST IN THEIR

NEIGHBORHOOD

Neighborhoods where parents report a lack of investment and trust in the environment have been associated with a variety of child outcomes in those neighborhoods such as infant mortality and low birth weight, juvenile delinquency, high school dropout, and child abuse and neglect.40

Parents who believe that their neighborhood is unsafe may limit their child's independent play outside, which can decrease the child's opportunities for spontaneous play and exploration and possibly limit the child’s relationships with peers. Finally, neighborhoods that are rated unsafe generally have fewer resources to support families and children’s development compared with those that are rated as safe.

Connectedness to the community, or involvement with one’s neighborhood, is a complex concept. This evaluation used nine items drawn from two well-known measures: the Neighborhood Environment for Children Rating Scale (NECRS) and the Social Cohesion Scale (SCS). These items, such as “I live in a close-knit neighborhood” and “People in my neighborhood can be trusted,” were combined into one score to determine levels of “Neighborhood Cohesion.”

40 Leventhal, T. & Brooks-Gunn, J. (2000). The neighborhoods they live in: the effects of neighborhood residence on child and adolescent outcomes. Psychological Bulletin, 126(2), 307-337.

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The correspondence between the 2007/08 and 2008/09 Parent Interview findings for the percent of parents with high neighborhood cohesion is striking (Table 8.2). Attending any community event increased the proportion of parents who reported high neighborhood cohesion over not attending an event, with the highest levels of cohesion found for CBI attendees.

Table 8.2: Parents with High Neighborhood Cohesion by Community Event Participation by Fiscal Year

% With HighNeighborhood

Cohesion

2007/08

Did Not Attend a Community Event 50.3

Attended Community Event, Not CBI 56.5

Likely or Definitely Attended a CBI Event 75.0

2008/09



Likely or Definitely Attended a CBI Event 75.8 Source of Data: Parent Interview

The findings presented in Tables 8.1 and 8.2 can be interpreted as follows: CBI events are associated with parents connecting with others in their communities in ways that might not otherwise be available. Parents who are more connected to their community have a greater sense of investment and trust in their neighbors.

PERCENT OF PARENTS WHO REPORT AN INCREASED UTILIZATION OF FORMAL AND

INFORMAL NEIGHBORHOOD RESOURCES

The degree to which parents make use of their neighborhood resources tends to lessen parental feelings of isolation and can counteract the negative effects of stress in parents’ lives. Such resources may include babysitting groups, mothers’ clubs, community centers, neighborhood watch groups, family resource centers, and the like. Parents and their children can benefit from the use of resources in their communities.

Parents were asked if someone in their household was receiving formal or informal communityresources, which included training to improve reading and writing skills, English as a Second Language classes, and job training.

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For 2009 data, parents who did not attend a community event reported the fewest number of community resources; CBI attendees reported the highest number of resources utilized, on average. However, the differences across groups were not found to be statistically significant.

PERCENT OF PARENTS WITH INCREASED EFFICACY

Parenting efficacy is the degree to which parents feel they can be in control of their lives, rather than feeling helpless and unable to change what is happening to them, and is related to parents’ sense of self-esteem. With sufficient levels of efficacy, parents can positively impact their children’s behavior and development through positive parenting practices and nurturance, and by reaching out to access personal social networks as well as formal and informal resources to assist them when needed.

Efficacy, or the perceived degree of control over life circumstances, was measured by asking parents to express their agreement with seven statements, such as “I have little control over the things that happen to me,” and “I often feel helpless in dealing with the problems of life.”

Significant associations were found between CBI attendance and high personal efficacy (Table 8.3). Significant findings were also found between CBI attendance and average efficacy scores. It is these findings that offer the best empirical case for the contention that CBI has the potential to make one more autonomous and thus less reliant on social or other types of publicly-funded services.

Table 8.3: Parents with High Efficacy by Community Event Participation by Fiscal Year

% With High Efficacy

2007/08



Likely or Definitely Attended a CBI Event 76.5

2008/09



Likely or Definitely Attended a CBI Event 72.7 Source of Data: Parent Interview

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CHAPTER 9EARLY CARE RESULT AREA

The aim of Early Care is to improve child care throughout Sacramento County. The First 5 Sacramento Commission expended $834,000 in 2008/09 on the Quality Child Care Collaborative (QCCC), through a contract with Child Action, Inc. The QCCC is a partnership of community agencies, governmental and educational institutions, and private businesses that work together to help family child care homes and child care centers throughout Sacramento County provide quality care. During the year, 1,860 providers received QCCC services. Key activities of the QCCC included information and referrals, technical assistance and training, and professional consultation. Child Action, Inc. also administered the local CARES (Comprehensive Approaches to Raising Educational Standards) program, a First 5 California-matched program intended to promote child care workforce development. Workforce development activities include providing stipends of varying amounts to child care providers participating in continuing education (Table9.1). Educational activities included, but were not limited to, early childhood education courses and classes towards an Associate or Bachelor degree.

Presented below are the evaluation findings for the First 5 Sacramento Commission indicators related to the Early Care Result Area:

Percent of providers moving up on the professional development matrix; Percent of licensed and accredited family child care spaces per 100 children in school

district catchment areas & percent of licensed and accredited centers per 100 children in school district catchment areas;

Percent of children with special needs who participate in early childhood care and education programs;

Percent of child care providers who increase their Environmental Rating Scales; and Percent of family, friends, and neighbors who make progress or obtain licensure.

Table 9.1: CARES Tracks and Stipends Provided, Fiscal Year 2008/09

Track Stipend Track Goals

Track 1Resource Kit at

$150 valueComplete 15 hours of training

Track 2A $500 Complete 4 units of college coursework in ECE

Track 2B $500 Complete 25-54 hours of training

Track 3 $1,500 Complete 6 units of college coursework towards an AA or a permit

Track 4 $3,000Complete 6 units of college coursework toward a BA or MA In Early Education

Track 5A $750 Complete 21 hours of professional development

Track 5B $750 (first year) Complete assessments of CARES classrooms

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PERCENT OF PROVIDERS MOVING UP ON THE PROFESSIONAL DEVELOPMENT MATRIX

Researchers have found that teachers’ education is associated with the quality of care for children and the degree to which child care environments provide stimulation and learning opportunities for children.41 While there is some disagreement on whether a Bachelor level of qualification is necessary, it is clear that staff with training in early childhood education tend to provide higher quality care.

By advancing up the professional development matrix, providers are improving the quality of care available for children. Advancement entails obtaining the next level of permit on the Child Development Permit Matrix.42 The Child Development Permit Matrix has six levels: Assistant, Associate Teacher, Teacher, Master Teacher, Site Supervisor, and Program Director. Advancing to the next level requires a certain combination of early childhood education and general education coursework.

In fiscal year 2008/09, 343 individuals applied for CARES stipends, and 183 stipends were awarded. The average amount of a CARES stipend was $1,230. Of the 183 CARES recipients, 115 were eligible for advancement on the Professional Matrix; 68 were ineligible because they were Track 1 and 2 participants working on their basic permitting requirements. Of the 115 eligible for advancement only eight recipients (7.0%) advanced. An important consideration is the time required of providers to complete the required coursework to move up the matrix. The percentage of providers moving up the professional development matrix this year is lower than in fiscal year 2007/08 when 15.2% advanced.

PERCENT OF LICENSED AND ACCREDITED FAMILY CHILD CARE SPACES PER 100CHILDREN IN SCHOOL DISTRICT CATCHMENT AREAS & PERCENT OF LICENSED AND

ACCREDITED CENTERS PER 100 CHILDREN IN SCHOOL DISTRICT CATCHMENT AREAS

Children’s cognitive, emotional, and physical development is impacted by their child care and preschool environments. Since many children spend a significant amount of time in these settings, the availability of quality early child care is important. Quality early care and education can promote positive relationships and behaviors, and help prepare children for later school success. The minimum standard for adequate care is licensure, while accreditation typically indicates higher quality child care environments. Accreditation can be issued through the

41 Whitebook, M., Howes, C., & Phillips, D. (1990). Who Cares? Child Care Teachers and the Quality of Care in America. Final Report: National Child Care Staffing Study. Oakland, CA: Child Care Employee Project.42 Child Development Training Consortium. (2009). Child Development Permit Matrix. Retrieved from http://www.childdevelopment.org/cs/cdtc/print/htdocs/services_permit.htm

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National Association for the Education of Young Children (NAEYC) for center-based or National Association for Family Child Care (NAFCC) for family-based facilities.

By the end of fiscal year 2008/09, there were three licensed and accredited family-based child care facilities with the capability of serving up to 36 children. Twenty-four center-based child care facilities, serving 2,126 children, were licensed and accredited (Table 9.2).

Accreditation, especially if done by the NAEYC or NAFCC, is a time-consuming and potentially expensive process. These factors may contribute to the number of facilities that were licensed and accredited this year.

Only one facility was newly-licensed and accredited this year (a family-based center in the Elk Grove district), while two center-based facilities did not renew their accreditation; which must be renewed every five years or three years for family-based facilities. Although there was a decrease of one facility this fiscal year, because accredited facilities can be expanded with additional spaces and/or additional staff, the number of spaces accredited in Sacramento County grew by 46.0% from fiscal year 2007/08. As seen in Figure 9.1, 655 spaces were added at center-based and 15 at family-based facilities. The increase in licensed and accredited spaces still only accounts for 4.5% of the total child care spaces in Sacramento County.

Table 9.2: Number of Licensed and Accredited Child Care Facilities and Spaces forChildren Ages 0 to 5 Years by Type and School District Catchment Area,

Fiscal Year 2008/09

Family-based Center-based

Center Unified School District 0 2

Twin Rivers Unified School District 0 1

San Juan Unified School District 0 4

Folsom Cordova Unified School District 1 3

Sacramento City Unified School District 0 2

Elk Grove Unified School District 2 11

Natomas Unified School District 0 1

Total number of licensed and accredited child care facilities 3 24

Total number of licensed and accredited child care spaces 36 2,126

Percentage of total child care spaces* <1% 4.5%

*Based on 47,548 total child care spaces Source of Data: Child Action, Inc. staff on November 3, 2009

Figure 9.1: Total Number of Child Care Spaces, Fiscal Year 2008/09

PERCENT OF CHILDREN W

CHILDHOOD CARE AND E

Early childhood care and education programs are important for children with order to optimize their development and interactoften do not receive services through an early care environment at all or until they are older, and when they are in child care it is often f

Child Action, Inc. provides “enhanced referrals” to families of children with special needs. Families of children with special needs include those with a physical disability, developmental or learning delay, chronic health condition, or severe emotional issue.

Child Action, Inc. was less successful in fiscal year 2008/09 than the previous year children with special needs in child care. They linked special needs to child care, as opposed to 63.6% in fiscal year 2007/08. Child Action, Inc. staff explained that 13 families are continuing their childwithout determining the result of their child care search, and 10 families gave up their search. Of the 10 families that gave up their search, six decided to provide care themselves and four cited the cost of care as a barrier.

0

Center-based Accredited

0

Family-based Accredited

: Total Number of Child Care Spaces, Fiscal Year 2008/09

ERCENT OF CHILDREN WITH SPECIAL NEEDS WHO PARTICIPATE IN EAR

CHILDHOOD CARE AND EDUCATION PROGRAMS

Early childhood care and education programs are important for children with order to optimize their development and interaction with their peers. Children with special needs often do not receive services through an early care environment at all or until they are older, and when they are in child care it is often for fewer hours than children without special needs.

Child Action, Inc. provides “enhanced referrals” to families of children with special needs. Families of children with special needs include those with a physical disability, developmental or learning delay, chronic health condition, or severe emotional issue.

Child Action, Inc. was less successful in fiscal year 2008/09 than the previous year children with special needs in child care. They linked 41.2% of children identified as having special needs to child care, as opposed to 63.6% in fiscal year 2007/08. Child Action, Inc. staff explained that 13 families are continuing their child care search, 11 families’ cases were closed without determining the result of their child care search, and 10 families gave up their search. Of the 10 families that gave up their search, six decided to provide care themselves and four cited

1471 655

600 1200 1800 2400

21 15

10 20 30 40

2007/08

2008/09

70

: Total Number of Child Care Spaces, Fiscal Year 2008/09

O PARTICIPATE IN EARLY

Early childhood care and education programs are important for children with special needs in with their peers. Children with special needs

often do not receive services through an early care environment at all or until they are older, and or fewer hours than children without special needs.

Child Action, Inc. provides “enhanced referrals” to families of children with special needs. Families of children with special needs include those with a physical disability, developmental or

Child Action, Inc. was less successful in fiscal year 2008/09 than the previous year in placing of children identified as having

special needs to child care, as opposed to 63.6% in fiscal year 2007/08. Child Action, Inc. staff care search, 11 families’ cases were closed

without determining the result of their child care search, and 10 families gave up their search. Of the 10 families that gave up their search, six decided to provide care themselves and four cited

2400

2007/08

2008/09

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PERCENT OF CHILD CARE PROVIDERS WHO INCREASE THEIR ENVIRONMENTAL

RATING SCALES

Early childhood care environments often use Environmental Rating Scales to measure program’slanguage and reasoning learning activities for children, and interaction and social development. Environmental Rating Scales may also assess issues related to staff training, health and safety of the facility, and its space and furnishings. Based on the scores received on these assessments, providers can identify specific areas for improving their facility and the overall quality of their program. High quality early childhood care has been shown to contribute to increased school readiness among children.43

To assess changes in child care program quality associated with participation in the Preschool Bridging Model program, formal pre-assessments were conducted at 101 Preschool Bridging Model sites and post-assessments were conducted for 102 Preschool Bridging Model sites using two Environment Rating Scales (ERS): the Early Childhood Environment Rating Scale-Revised Edition (ECERS-R)44 for center-based providers, and the Family Child Care Environment Rating Scale-Revised Edition (FCCERS-R)45 for family child care homes. The average time between the ERS pre- and post-test was 175 days.

Overall, the 46 center-based programs improved from an average of 4.3 at the initial assessment to 5.3 (out of a maximum of 7) at the follow-up. The 56 family child care homes also improved more than a point from 4.1 to 5.2 on a 7-point scale (Figure 9.2). The scores suggest that the early care settings have attained a level of quality close to the “good” rating on both scales (a score of 5). The increase in the ERS scores of Preschool Bridging Model sites indicates that both center-based providers and family child care homes improved their quality during fiscal year 2008/09. It should be noted, however, that the scales cannot be compared, so a score of 4 on the FCCERS-R may not equate the same as a score of 4 on the ECERS-R.

43 Dearing, E., McCartney, K., & Taylor, B. (2009). Does higher quality early child care promote low-income children's math and reading achievement in middle childhood? Child Development, 80(5), 1329-1349.44 Harms, T., Clifford, R. & Cryer, D. (2005). Early Childhood Environment Rating Scale-Revised Edition (ECERS-R). New York: Teachers College Press.45 Harms, T., Cryer, D. & Clifford, R. (2007). Family Child Care Environment Rating Scale-Revised Edition(FCCERS-R). New York: Teachers College Press.

Figure 9.2: Change in PBM Environmental Rating Scales, Fiscal Year 2008/09

Average pre- and post score for Center Source of Data: Preschool Bridging Model

Child Action, Inc. staff and CARES advisors assessments for sites associated with participants of the CARES stireported from a total of 85 sites. Fortygiven at 26 sites, and 13 sites completed the ITERSScale-Revised Edition).46 The average ECERSFCCERS-R scores ranged from 2.86 to 6.19 and the average of the 26 sites was 4.36. The average ITERS score was 4.38, and scores ranged from 2.68 to 5.64.

The average ERS scores reported by both PBM and Child Actscores from national studies, particularly those of Head Start, and are higher than those reported historically for center-based child care using the ECERSthe FCCERS-R since it changed from a prior scale).

46 Harms, T., Reid, D., Cryer, D. & Clifford, R. (2006). (ITERS-R). New York: Teachers College Press.47 Zill, N., Resnick, G., Kim, K., O’Donnell, K., Sorongon, A., McKey, R. H., PaiR., & D’Elio, M. A. (2003). Head Start FACES 2000: A WholeFourth Progress Report. Washington, DC: Administration for Children and Families, U.S. Department of Health and Human Services.

4.3

4.1

3.5

4

4.5

5

5.5

Center-Based Providers

: Change in PBM Environmental Rating Scales, Fiscal Year 2008/09

and post score for Center-Based Providers (ECERS-R, n=56) and Family Child Care Homes (FCCERSata: Preschool Bridging Model staff on June 23, 2009

Child Action, Inc. staff and CARES advisors in Track 5 of the stipend program completed assessments for sites associated with participants of the CARES stipend program. Scores were reported from a total of 85 sites. Forty-six sites administered the ECERS-R, the FCCERS

sites completed the ITERS-R (Infant Toddler Environmental Rating average ECERS-R score was 4.71, with a range of 1.86 to 7.

R scores ranged from 2.86 to 6.19 and the average of the 26 sites was 4.36. The average ITERS score was 4.38, and scores ranged from 2.68 to 5.64.

The average ERS scores reported by both PBM and Child Action, Inc. are well in line with the scores from national studies, particularly those of Head Start, and are higher than those reported

based child care using the ECERS-R (historical data are not available for hanged from a prior scale).47

D., Cryer, D. & Clifford, R. (2006). Infant/Toddler Environment Rating Scale. New York: Teachers College Press.

Zill, N., Resnick, G., Kim, K., O’Donnell, K., Sorongon, A., McKey, R. H., Pai-Samant, S., Clark, C., O’Brien, Head Start FACES 2000: A Whole-Child Perspective on Program Performance,

. Washington, DC: Administration for Children and Families, U.S. Department of Health

5.35.2

Based Providers Family Child Care Homes

72

: Change in PBM Environmental Rating Scales, Fiscal Year 2008/09

R, n=56) and Family Child Care Homes (FCCERS-R, n=46)

in Track 5 of the stipend program completed ERS pend program. Scores were

R, the FCCERS-R was (Infant Toddler Environmental Rating

score was 4.71, with a range of 1.86 to 7. R scores ranged from 2.86 to 6.19 and the average of the 26 sites was 4.36. The

ion, Inc. are well in line with the scores from national studies, particularly those of Head Start, and are higher than those reported

R (historical data are not available for

ddler Environment Rating Scale-Revised Edition

Samant, S., Clark, C., O’Brien, Child Perspective on Program Performance,

. Washington, DC: Administration for Children and Families, U.S. Department of Health

73

PERCENT OF FAMILY, FRIENDS

Sacramento County has a number of famicare for children 0 to 5. Child Action, Inc. administers Sacramento County’s CARES which is intended to promote workforce development among child care providershelping FFN work toward obtaining licensure for their home child care facility. child care tends to be higher in quality than nonproviders who are licensed may be more likely to offer semore stimulation and learning opportunities for children.

In fiscal year 2008/09 there were 21 FFNthese (57.1%) obtained licensure and the remaining 42.9% made progress toward licensure. significant that in one year, all of those who participated in the pprogress towards licensure (Figure 9.3). A significantly higher number of family, friends and neighbors obtained licensure than in so.

Figure 9.3: Progress in Obtaining Licensure among FamiCare Providers, by Fiscal Years

40.0%

0.0%0.0%

15.0%

30.0%

45.0%

60.0%

No Progress Made

FRIENDS, AND NEIGHBORS WHO MAKE PROGRESS OR OBTAI

LICENSURE

Sacramento County has a number of family, friends, and neighbors (FFN) who provide child Child Action, Inc. administers Sacramento County’s CARES

which is intended to promote workforce development among child care providerswork toward obtaining licensure for their home child care facility.

o be higher in quality than non-licensed family child care, and fproviders who are licensed may be more likely to offer sensitive and responsive care more stimulation and learning opportunities for children.

year 2008/09 there were 21 FFN participating in the CARES program, and over half of these (57.1%) obtained licensure and the remaining 42.9% made progress toward licensure.

of those who participated in the program either obtained or maprogress towards licensure (Figure 9.3). A significantly higher number of family, friends and neighbors obtained licensure than in fiscal year 2007/08 when only one of the 10 participants did

aining Licensure among Family, Friends, and Neighbor Child Care Providers, by Fiscal Years

50.0%

10.0%

42.9%

57.1%

Made Progress towards Licensure Acquisition

Licensure Acquisition

KE PROGRESS OR OBTAIN

) who provide child Child Action, Inc. administers Sacramento County’s CARES program

which is intended to promote workforce development among child care providers. This includes work toward obtaining licensure for their home child care facility. Licensed family

licensed family child care, and family child care nsitive and responsive care as well as

participating in the CARES program, and over half of these (57.1%) obtained licensure and the remaining 42.9% made progress toward licensure. It is

rogram either obtained or made progress towards licensure (Figure 9.3). A significantly higher number of family, friends and

fiscal year 2007/08 when only one of the 10 participants did

ly, Friends, and Neighbor Child

Licensure Acquisition

2007/08

2008/09

74

In summary, fewer child care providers were able to advance on the professional development matrix this year, apparently as a result of the economic downturn. Results from a Child Action, Inc. survey suggests that the primary reason stipend recipients did not return to the program was because of termination or layoff. Furthermore, a study released by the California Child Care Resource and Referral Network, as reported in the Sacramento Bee (Jan. 25, 2010), found that Sacramento County lost more than 4,300 child care slots, or approximately 8% of the total slots available from 2006 to 2008. The study indicated that job losses and foreclosures were the causes of this decline. However, Child Action, Inc. found that child care slots for children ages 0 to 5 years only decreased by 2.5%, or from 48,790 in 2008 to 47,548 in 2009. In addition, the number of highest quality slots – those that are licensed and accredited - for children ages 0 to 5 years grew by 46%. Thus, the economic downturn has impacted child care in Sacramento County, but not as much for children ages 0 to 5 years due to the support of the First 5 Sacramento Commission.

75

CHAPTER 10CROSS-CUTTING INDICATORS

In the previous chapters we examined the findings for the First 5 Sacramento Commission indicators applicable to each of the seven Result Areas. This chapter examines 10 outcomes for First 5 Sacramento families regardless of the Result Area from which they were recruited or the types and levels of services received. These 10 “Cross-Cutting” indicators were examined with Parent Interview responses from a representative sample of families from the Health Access, Nutrition, Effective Parenting, and School Readiness Result Areas.

PERCENT OF CHILDREN ENROLLED IN HEALTH INSURANCE

Children who do not have health insurance often forgo both preventive and acute care, leading to more serious medical conditions that adversely affect growth and development.48 Despite the availability of the federally-funded SCHIP program, many families without health insurance do not enroll their children. For these reasons, it is important for all providers serving uninsured children ages 0 to 5 years old to encourage families to get assistance with enrollment in health insurance.

Children’s health insurance was measured at three points in time: On the Family Intake Form when families at a First 5 Sacramento provider consented to take part in the evaluation, and later during baseline and follow-up Parent Interviews conducted in spring 2008 and 2009.

Family Intake Form data were examined for 12,834 families consenting to participate in the evaluation of First 5 Sacramento services during fiscal years 2007/08 and 2008/09. Two year’s worth of data show that 15% of children ages 0 to 5 years come to First 5 Sacramento services without health insurance. Family Intake Form versus baseline Parent Interview responses show that First 5 Sacramento services are related to an increase in insurance coverage, from a rate of roughly 85% to 93.9% (Figure 10.1). When interviewed a year later, the rate of health insurance among children remained stable at 93.6%. Through recruitment by, or referral to, the Health Access provider Cover the Kids, all First 5 Sacramento children are obtaining and maintaining health insurance coverage, and at a rate higher than the national averages (89.2% for children under 3 years and 89.9% for children 3 to 5 years).49

48 Seid, M., Varni, J. W., Cummings, L., & Schonlau, M. (2006). The impact of realized access to care on health-related quality of life: a two-year prospective cohort study of children in the California State Children’s Health Insurance Program. Pediatrics, 149(3), 354-361.49 U.S. Census Bureau. (2008). Current Population Survey. Retrieved from www.census.gov.

Figure 10.1: Changes in the Percent of

PERCENT OF CHILDREN WITH COMPLETE IMMUNIZ

Immunizations are an important public health practice to prevent outbreaks of diseases that are now virtually unknown in the United States disabilities, sensory impairments, or death.readiness for school is that they have completed all of their immunizations. funded by First 5 Sacramento there are opportunities to inform parents of the timeline for and importance of immunizations.

The immunization status of First 5 Sacramento children was based on parent responses to the question, “In your opinion, has [child’s name] received all of the recommended shots for (his/her) age?”

Parent responses based on children 2 and 5 years of age weComplete immunizations were found for 96.8% of 2 and 5 year olds; an increasebaseline (Figure 10.2). Advanced analyses (i.e., linear mixed models) that controlled for race/ethnicity, language, and family education found that immunization rates significantly increased over time.

50 Center for Disease Control and Prevention. (2007). [Brochure]. United States Government Printing Office: National Center for

85.9%

60.0%

70.0%

80.0%

90.0%

100.0%

Family Intake Form 07/08

Figure 10.1: Changes in the Percent of Children with Health Insurance, Fiscal Years 2007/08 and 2008/09

ITH COMPLETE IMMUNIZATIONS AT AGE TWO AN

FIVE

Immunizations are an important public health practice to prevent outbreaks of diseases that are United States and can result in long-term severe developmental

disabilities, sensory impairments, or death.50 Further, an important component of a child’s is that they have completed all of their immunizations. Throughout activities

funded by First 5 Sacramento there are opportunities to inform parents of the timeline for and

The immunization status of First 5 Sacramento children was based on parent responses to the r opinion, has [child’s name] received all of the recommended shots for

Parent responses based on children 2 and 5 years of age were combined for this indicator. Complete immunizations were found for 96.8% of 2 and 5 year olds; an increasebaseline (Figure 10.2). Advanced analyses (i.e., linear mixed models) that controlled for race/ethnicity, language, and family education found that immunization rates significantly

Center for Disease Control and Prevention. (2007). Parents’ Guide to Childhood Immunizations[Brochure]. United States Government Printing Office: National Center for Immunization and Respiratory Disease.

83.9%

93.9% 93.6%

Family Intake Form 08/09

Baseline Parent Interview

FollowInterview

76

Health Insurance, Fiscal Years

ATIONS AT AGE TWO AND AGE

Immunizations are an important public health practice to prevent outbreaks of diseases that are term severe developmental

Further, an important component of a child’s Throughout activities

funded by First 5 Sacramento there are opportunities to inform parents of the timeline for and

The immunization status of First 5 Sacramento children was based on parent responses to the r opinion, has [child’s name] received all of the recommended shots for

re combined for this indicator. Complete immunizations were found for 96.8% of 2 and 5 year olds; an increase from 92.8% at baseline (Figure 10.2). Advanced analyses (i.e., linear mixed models) that controlled for race/ethnicity, language, and family education found that immunization rates significantly

Parents’ Guide to Childhood Immunizations (pp. 31-34). Immunization and Respiratory Disease.

93.6%

Follow-up Parent Interview

77

Figure 10.2: Two and Five-Year

PERCENT OF CHILDREN WHO HAVE RECEIVED ALL

Well-child visits are an opportunity for physicians to monitor the child’s health and development to ensure the child is within normal ranges and to screen for potential problems.physical development within normal ranges are related to the child’s ability to learn and socialize with peers, and ultimately to the child’s school readiness. Many First 5 have an opportunity to encourage adherence to the the American Academy of Pediatrics

Children’s age in months and reported recent history of receiving routine checkcompared with the American Academy of Pediatrics wellextent of age appropriate well-child visits among the First 5 Sacramento population.

Our initial analyses found that the proportion of children adhering to the wellsignificantly decreased over time, from 92.8% to 87.9% at onehowever are still above the national average of 85.0%.

The incongruence between this outcome and the increase in immunization rates from baseline to follow-up for children 2 and 5 years led us to believe that age may play an important role in parents’ compliance with the well

51 Medline Plus, National Institutes of Health. (2009). http://www.nlm.nih.gov/medlineplus/ency/article/001928.htm52 National Health Interview Survey, 2004. Retrieved from http://

80.0%

85.0%

90.0%

95.0%

100.0%

Baseline

Year-Olds with Complete Immunizations, Fiscal Y

HO HAVE RECEIVED ALL AGE APPROPRIATE

VISITS

visits are an opportunity for physicians to monitor the child’s health and development s within normal ranges and to screen for potential problems.

physical development within normal ranges are related to the child’s ability to learn and socialize with peers, and ultimately to the child’s school readiness. Many First 5 Sacramentohave an opportunity to encourage adherence to the well-child visits schedule recommended by

of Pediatrics.

Children’s age in months and reported recent history of receiving routine checkAcademy of Pediatrics well-child visits schedule to determine the child visits among the First 5 Sacramento population.

Our initial analyses found that the proportion of children adhering to the well-child visit schedule over time, from 92.8% to 87.9% at one-year follow

however are still above the national average of 85.0%.52

The incongruence between this outcome and the increase in immunization rates from baseline to dren 2 and 5 years led us to believe that age may play an important role in

parents’ compliance with the well-child schedule. In a recent study of factors related to

Medline Plus, National Institutes of Health. (2009). Well-child Visits. Retrieved from http://www.nlm.nih.gov/medlineplus/ency/article/001928.htm.

National Health Interview Survey, 2004. Retrieved from http://www.childtrendsdatabank.org.

92.8%

96.8%

Baseline Follow-up

Fiscal Year 2008/09

AGE APPROPRIATE WELL-CHILD

visits are an opportunity for physicians to monitor the child’s health and development s within normal ranges and to screen for potential problems.51 Health and

physical development within normal ranges are related to the child’s ability to learn and socialize Sacramento providers

recommended by

Children’s age in months and reported recent history of receiving routine check-ups were child visits schedule to determine the

child visits among the First 5 Sacramento population.

child visit schedule year follow-up. Both years

The incongruence between this outcome and the increase in immunization rates from baseline to dren 2 and 5 years led us to believe that age may play an important role in

child schedule. In a recent study of factors related to

.

78

noncompliance with well-child visits, “immunizations” was identified by parents of children age 0 to 24 months as the most important reason for getting well-child care.53 We reviewed the American Academy of Pediatrics and the American Academy of Family Physicians immunization schedule and noted that there is a gap for recommended immunizations between a child’s age of 16 and 23 months. If immunizations were perceived as one of the primary and possibly sole reason for taking a child to the doctor among First 5 Sacramento parents, then child’s age would be associated with adherence to the well-child schedule. Subsequent statistical analyses found this to be the case. Among families with children 16 to 23 months, 69.0% versus 92.4% for all other families were compliant with the well-child schedule. Moreover, when selecting only families with children outside of the 16- to 23-month age range, the rates for well-child visits were identical, 92.4% at baseline and one-year follow-up. Yet these findings do not explain why parents would initially, but then later not comply with the well-child schedule. Possibly the importance of immunizations conveyed by First 5 Sacramento service providers, and then reinforced by the primary care physician and other sources, make it such that parents conclude during initial medical appointments that the only reason for well-child visits is to get a child immunized. Once parents become familiar with the immunization schedule, or are simply told by the physician when the child is next due for shots, they decide to forgo their next medical visit until that time.

PERCENT OF WOMEN WITH CHILDREN UNDER THREE WHO WERE EXCLUSIVELY

BREASTFEEDING AT 6 MONTHS AND ONE YEAR AFTER DELIVERY

Children who are breastfed during their first year of life experience a variety of nutritional, health, immunological, developmental, and psychological benefits.54 Breastfeeding also supports bonding between infant and mother, and children who are breastfed are less likely to be overweight or obese later in life.55 There are differing opinions regarding the appropriateness of exclusive breastfeeding at one year of age, but there is agreement that breastfeeding should be exclusive at least through the first six months, and thereafter in combination with the introduction of solid foods (complementary breastfeeding). The health, nutritional, and effective parenting benefits of breastfeeding make it an important focus of First 5 Sacramento activities.

Exclusive breastfeeding for infants 6 months and younger is defined as providing only breast milk to infants. Twelve-month breastfeeding rates are based on children receiving breast milk and appropriate solid foods, but no formula until 12 months of age.

Six-month exclusive breastfeeding rates remained unchanged over time, and were 27.6% for the one-year follow-up Parent Interview. The rates for First 5 Sacramento mothers who continue to 53 Jhanjee, I., Saxeena, D., Arora, J., & Gjerdingen, D. K. (2004). Parent’s health and demographic characteristics predict noncompliance with well-child visits. Journal of the American Board of Family Practice, 17(5), 324-331. 54 National Women’s Health Information Center. (2009). Benefits of Breastfeeding. Retrieved from http://www.womenshealth.gov/breastfeeding/benefits/.55 Owen, C. G., Martin, R. M., Whincup, P. H., Smith, G. D., & Cook, D. G. (2005). Effect of infant feeding on the risk of obesity across the life course: a quantitative review of published evidence. Pediatrics, 115(5), 1367-1377.

79

provide only breast milk to children for six months are well above th(18.6%) and national (13.6%) levels.

The proportion of mothers who breastfed to 12 months grew significantly from the baselinfollow-up interview (Figure 10.3).

Figure 10.3: Children Exclusively Breastfed for 12 Months, F

The baseline rate excluded children under 12 months of age. Thus, the overall increase by oneyear follow-up is due to the inclusion of age by the follow-up interview

PERCENT OF CHILDREN WHO

Children who have not seen a dentist experience a variety of problems associated with poor oral health.57 These problems – ranging from eating and speaking difficulties to poor physical growth, cognitive, linguistic, and social development Sacramento service providers.

First 5 Sacramento parents were asked, “Has [child’s nafor dental care in the past year?”

56 Centers for Disease Control and Prevention. Retrieved from www.cdc.gov/breastfeeding/data/NIS_data/2006/state.htm.57 Centers for Disease Control and Prevention. (2004). http://www.cdc.gov/OralHealth/publications/fact

14.3%

0.0%

7.5%

15.0%

22.5%

30.0%

Baseline

provide only breast milk to children for six months are well above those reported at the state (18.6%) and national (13.6%) levels. 56

The proportion of mothers who breastfed to 12 months grew significantly from the baselin(Figure 10.3).

Figure 10.3: Children Exclusively Breastfed for 12 Months, Fiscal Year 2008/09

The baseline rate excluded children under 12 months of age. Thus, the overall increase by oneup is due to the inclusion in the analyses of data from children who reached one year

interview.

CENT OF CHILDREN WHO HAVE SEEN A DENTIST IN THE PAST YEAR

Children who have not seen a dentist experience a variety of problems associated with poor oral ranging from eating and speaking difficulties to poor physical

and social development – are seen by a variety of First 5

First 5 Sacramento parents were asked, “Has [child’s name] been to a dentist or dental hygienist

Centers for Disease Control and Prevention. Retrieved from www.cdc.gov/breastfeeding/data/NIS_data/2006/state.htm.

Centers for Disease Control and Prevention. (2004). Children’s Oral Health. Retrieved from http://www.cdc.gov/OralHealth/publications/factsheets/sgr2000_fs3.htm.

14.3%

21.5%

Baseline Follow-up

ose reported at the state

The proportion of mothers who breastfed to 12 months grew significantly from the baseline to

iscal Year 2008/09

The baseline rate excluded children under 12 months of age. Thus, the overall increase by one-of data from children who reached one year

IN THE PAST YEAR

Children who have not seen a dentist experience a variety of problems associated with poor oral ranging from eating and speaking difficulties to poor physical

are seen by a variety of First 5

me] been to a dentist or dental hygienist

80

The adjusted percent of children seeing a dentist in the last year was 59.3%, and did not differ between baseline and follow-up. On average, First 5 Sacramento children fare better than children in the United States in terms of recent dental care; national data from 2004 show that 47.1% of two through four year olds in the U.S. have been to the dentist in the past year.58 Given the importance of dental care as a preventive health measure for all children over age one, many opportunities remain to bring the benefits of community dental screenings, provision of dental insurance for children, and oral health education to families in Sacramento.

PERCENT OF PARENTS WHO REPORT CONNECTEDNESS TO THEIR COMMUNITIES

Parents who feel connected to their communities have resources at their disposal that can serve to bolster the family’s social capital, thereby offsetting or moderating stressful life events or risk factors.59 Neighborhoods that foster good cohesion and connectedness provide a healthy environment for children to develop and to be ready for school. Health, social, economic, and educational outcomes tend to be higher for families who feel connected to their communities.

Responses to items measuring “Neighborhood Networks” and “Neighborhood Cohesion” were examined for all First 5 Sacramento parents.

At the cross-cutting level, or across all parents recruited from the four Result Areas having direct contact with clients, no significant correlations were detected over time for measures of neighborhood networks or cohesion. These findings replicate those reported in Chapter 5 for Effective Parenting parents only. Most First 5 Sacramento services are intended to influence outcomes other than getting families more connected to their community, such as exclusivebreastfeeding or providing parents with improved parenting skills. The secondary outcome or “added benefit” inherent in most First 5 Sacramento services of getting families more connected to their community is apparently not robust enough to be observed over time. However, as we saw in Chapter 8 for CBI events, First 5 Sacramento services do increase neighborhood relationships and perceptions when services are designed specifically to have these outcomes.

58 National Center for Health Statistics, 2004. Retrieved from http://www.cdc.gov.59 Altschuler, A., Somkin, C.P., & Adler, N.E. (2004). Local services and amenities, neighborhood social capital, and health. Social Science & Medicine, 59, 1219-1229.

81

PERCENT OF PARENTS WHO REPORT THAT THE SERVICE PROVIDER HELPED THEM

INCREASE KNOWLEDGE AND UTILIZATION OF FORMAL AND INFORMAL RESOURCES IN

THE COMMUNITY

Formal and informal resources are important components of parents’ engagement with their community. If a community has resources available to support families, outcomes for children can improve.

Parents were presented with the following list and asked whether anyone in their household was receiving the service:

Food and nutrition assistance - like Food Stamps or WIC; Income assistance--like welfare, TANF or SSI; Help with housing or utilities (running water, hot water, heat, telephone service); Prenatal care; English as a Second Language training (ESL classes); Payments for unemployment or disability (disability insurance, or workers compensation,

including pregnancy disability); Adult Education (GED, College Selection); Family Resource Centers where parents and children learn and can get connected with

services they need; Job training; Respite child care, where you can get emergency help with child care; Legal aid/ Free legal services; and Family literacy classes, for example, where you or your family learn reading or writing

skills.

For each service being utilized by First 5 Sacramento families, parents were asked whether a First 5 Sacramento service provider helped them connect to the service.

A variable was created to represent the proportion of services obtained through the help of First 5Sacramento providers from all those services received. As seen in Figure 10.4, the percent of families connecting to community services with First 5 Sacramento help increased over time.

Figure 10.4: Percent of Community Resources Received tSacramento Service Providers, Fiscal Year 2008/09

Baseline versus follow-up changes for the top three services received by clients, in terms of the percent of these services that parents reported receiving assistance service providers, were food and nutrition assistance(25.2% versus 34.0%), and help with housing or utilities (9.9% versus 11.3%).

The baseline proportion from Figure 10.4 may represent referraproviders during the assessment of families’ circumstancesservices. As parents recognize provider staff as a resource for information about andservices within the County, they may increasiwithin their family to obtain needed services. The data in Figure 10.4 represent the proportion of services obtained with First 5 Sacramento provider help in relation to all services received, and thus do not indicate that families needed more services over time looked to provider staff when services were needed.

PERCENT OF CHILDREN W

DEVELOPMENTAL SCREEN

Early identification of developmental made by comprehensive health and developmental screenings. special needs early, an individualized learning plan can be developed tspecial needs children with peers and thus full participation in preschool and kindergarten activities.

17.7%

0.0%

7.5%

15.0%

22.5%

30.0%

Baseline

f Community Resources Received through the Assistance of First 5 Sacramento Service Providers, Fiscal Year 2008/09

up changes for the top three services received by clients, in terms of the percent of these services that parents reported receiving assistance from First 5 Sacramento

ood and nutrition assistance (11.5% versus 19.3%), income assistance (25.2% versus 34.0%), and help with housing or utilities (9.9% versus 11.3%).

The baseline proportion from Figure 10.4 may represent referrals by First 5 Sacramento providers during the assessment of families’ circumstances during initial enrollment into services. As parents recognize provider staff as a resource for information about and

ounty, they may increasingly rely on provider staff to assist them or others within their family to obtain needed services. The data in Figure 10.4 represent the proportion of services obtained with First 5 Sacramento provider help in relation to all services received, and

o not indicate that families needed more services over time – families just increasingly looked to provider staff when services were needed.

ERCENT OF CHILDREN WHO HAVE RECEIVED A COMPREHENSIVE HEALTH

DEVELOPMENTAL SCREENING IN THE PAST YEAR

developmental challenges, as well as vision and hearing h and developmental screenings. By identifying children with

special needs early, an individualized learning plan can be developed to allow the integration of special needs children with peers and thus full participation in preschool and kindergarten

17.7%

21.5%

Baseline Follow-up

82

rough the Assistance of First 5

up changes for the top three services received by clients, in terms of the m First 5 Sacramento

(11.5% versus 19.3%), income assistance

ls by First 5 Sacramento during initial enrollment into

services. As parents recognize provider staff as a resource for information about and a link to ngly rely on provider staff to assist them or others

within their family to obtain needed services. The data in Figure 10.4 represent the proportion of services obtained with First 5 Sacramento provider help in relation to all services received, and

families just increasingly

OMPREHENSIVE HEALTH AND

problems, can be By identifying children with

o allow the integration of special needs children with peers and thus full participation in preschool and kindergarten

83

Parents were asked whether their children had received a hearing and vision test during the previous year. They were also asked if, during the past year, the child had been screened for development or behavior problems, described as a “brief, simple procedure usually done by a professional or medical doctor to identify possible developmental delays or disabilities.” Children whose parents reported they had hearing, vision, and development tests during the previous year were considered to have had comprehensive health and development screenings.

Advanced analyses found our three control variables (race/ethnicity, language, and family education) each related to receipt of a developmental screening, but no changes were observed over time from baseline to one-year follow-up in the percent of children receiving all three screenings. Overall, the prevalence of comprehensive screenings among First 5 Sacramento children was 19.5%.

PERCENT OF PARENTS WITH DECREASED STRESS

Parents with high levels of stress associated with their parenting role tend to use harsher discipline practices and are less nurturing and warm with their children, thereby affecting the child’s social and emotional development.60 Resources to reduce parenting stress focus on giving parents the tools necessary to deal with their feelings about being a parent, and to give them skills to become more nurturing and make them more apt to use pro-social discipline techniques.

Parental distress was measured from a widely-used scale called the Parenting Stress Index. Parents were asked about their agreement with statements such as, “I feel trapped by my responsibilities as a parent” and “There are quite a few things that bother me about my life” which were used as a measure of their levels of stress in their parenting role.

No changes in levels of stress were observed over time at the cross-cutting level. That is, PSI scores, which can range from 1.0 to 5.0, went from 3.5 to 3.6 over time.

PERCENT OF PARENTS WHO PRACTICE DEVELOPMENTALLY APPROPRIATE PARENTING

SKILLS

Parents who use an authoritative parenting style, rather than authoritarian or permissive parenting styles, tend to raise children with strong social skills and self-regulated behavior.

60 Pinderhughes, E., Dodge, K., Bates, J., Pettit, G., & Zelli, A. (2000). Discipline responses: influences of parents'socioeconomic status, ethnicity, beliefs about parenting, stress, and cognitive-emotional processes. Journal of Family Psychology, 14(3), 380-400.

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Additionally, parents who gain knowledge and understanding of appropriate parenting strategies can develop a sense of competence and satisfaction with being a parent. Making use of parenting skills appropriate to the child’s developmental stage is a way for parents to enhance their relationship with the child and strengthen their family.

To assess the percentage of parents who practice developmentally appropriate parenting skills, parents were asked the degree to which their parenting practices matched certain behaviors. Examples of these statements include, “I encourage my child to be curious, to explore, and to question things” and “I believe physical punishment to be the best way of disciplining.” The responses to these questions were used to characterize parents with high Nurturance or Warmth and Energy, and also to distinguish between Authoritative and Authoritarian parenting styles.

None of the measures was found to be statistically related to baseline versus follow-up.

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CONCLUSION

In last year’s evaluation report we presented a number of positive outcomes in relation to First 5 Sacramento services. Now with two years worth of client, service, and outcome data, this report provides further evidence to support the benefits of programs funded by the First 5 Sacramento Commission. This report documents certain changes over time in outcomes that would be expected from effective programs, and identifies which types of services are associated with improvements in preventative care, healthy behaviors, and educational opportunities. Furthermore, the wealth of data available for this report allowed for performing, for the first time, more advanced statistical analyses that controlled for important family characteristics, and thus increasing our confidence that First 5 Sacramento services are indeed responsible for the previously-reported and newly-identified findings.

Increases over time were found for dentist care by 1 year of age; breastfeeding until a child is 1 year old; and immunization rates among 2 and 5 year olds, regardless of race/ethnicity, primary language, or a family’s level of education. Rates for children with health insurance from enrollment into First 5 Sacramento services to initial and one-year follow-up also increased.

The results from published research studies were used to put many of the findings into perspective. These comparisons show that children receiving First 5 Sacramento services fare better than similar populations at the national and state levels in terms of adherence to the well-child visit schedule; exclusive breastfeeding for at least six months; and preschool attendance among pre-kindergarten-aged children.

The protocol for the evaluation of First 5 Sacramento services calls for each contractor to record and then enter into a centralized web-based system the number of services they provide to each client. The data from this time-consuming endeavor were put to use in this report for statistical models of association with outcomes that controlled for race/ethnicity, language, and education. The results of these analyses found Clinic Support, Breastfeeding Helpline, and Phone Contact with an International Board Certified Lactation Consultant (described on page 27) strongly related to continued breastfeeding behaviors; Parenting Education courses and Case Management (page 39) related to increased knowledge of infant development; and Father Engagement activities (page 40) associated with decreased stress.

Our approach to investigating the benefits of the 360 CBI (Community Building Initiative) events that were reported during the year included classifying First 5 Sacramento parents into three groups based on their responses to a series of questions about recent attendance at any event within the County. The Community Building Result Area, in which CBI events fall, is intended to connect parents to the community, foster cohesion and trust among neighbors, and provide parents with the knowledge and connections to take greater control over their family’s future. Our findings for 2008/09 CBI events mirror those we reported for 2007/08 – parents attending a CBI event, versus those not attending any community event or an event other than CBI, demonstrated the highest levels of connectedness, cohesion, and efficacy.

In the absence of a true randomized control research design, which is virtually non-existent for community-based evaluation studies due to the ethical concerns of withholding services from a

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portion of the eligible population, the statistics and methodology employed to collect and analyze the data reported here represent the best alternative – longitudinal survey data analyses in models that included important control variables. It is important to note as a limitation of our evaluation that most findings in this report came from self-reported data and thus are subject to recall error and social desirability biases. However, the findings from other studies presented in this report in comparison with First 5 Sacramento outcomes also were derived from self-report, often using the same survey items. In addition, we would expect the same levels of self-reported error to influence the baseline and follow-up Parent Interviews, thus any changes observed over time should be due to real outcomes rather than other influences.

Given these limitations, the findings presented in this report strongly suggest that First 5 Sacramento services are producing tangible benefits. Our confidence in the value of First 5 Sacramento services is also bolstered by the fact that providers have recruited the vast majority of clients for participation in the evaluation, we followed strict procedures for the random selection of families for the Parent Interview, and we obtained high retention rates for this longitudinal survey. Furthermore, the questionnaire’s items for the Parent Interview were selected from national surveys with established reliability and validity, and the majority of interviews were conducted in a face-to-face setting, as opposed to over the telephone, by staff who participated in comprehensive interview training sessions.

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APPENDIX A

RESULT AREA AND CROSS-CUTTING INDICATORS

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Result Area Indicators

Health AccessPercent of children continuously enrolled in health insurance at 3, 8, and 13 monthsPercent of children with complete immunizations at ages 2 and 5 years for children enrolled in health

plansPercent of children who have received all age appropriate well-child visitsPercent of children who have seen a dentist by one year of age

Nutrition Percent of children with Body Mass Index that is between the 5th and 95th percentile for their agePercent of women who are exclusively breastfeeding at 6 months and 1 year after delivery

Effective Parenting Improved family functioningPercent of parents who report connectedness to their communitiesPercent of parents who improve knowledge of developmental stages in childrenPercent of parents with decreased stressPercent of parents who practice developmentally appropriate parenting skillsPercent of parents who interact with their children in a supportive and positive manner

School ReadinessPercent of children participating in school-linked transitional practicesPercent of children who have received a comprehensive health and developmental screening in the

past yearPercent of children ages 3-5 who regularly attend a nursery school, preschool, pre-Kindergarten, or

Head Start program by the time of Kindergarten entryPercent of children with special needs who participated in early childhood care and education

programsPercent of participants reporting satisfaction with the content, quality, and family centeredness of services

Percent of children assessed to be ready for Kindergarten at the completion of a school readiness program

Percent of children meeting developmental milestonesDegree to which planning/pilot service delivery model or systemic intervention is implemented

DentalPercent of children who have fluoridated waterPercent of children with dental caries at Kindergarten entry

Community BuildingPercent of parents who report connectedness to their communitiesPercent of parents who report a sense of investment and trust in their neighborhoodPercent of parents who report an increased utilization of formal and informal neighborhood resourcesPercent of parents with increased efficacy

Early CarePercent of providers moving up on the professional development matrixPercent of licensed and accredited family child care spaces per 100 children in school district

catchment areas & percent of licensed and accredited centers per 100 children in school district catchment areas

Percent of children with special needs who participate in early childhood care and education programsPercent of child care providers who increase their Environmental Rating ScalesPercent of family, friends, and neighbors who make progress or obtain licensure

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Cross-Cutting Indicators

Percent of children enrolled in health insurancePercent of children with complete immunizations at age two and age fivePercent of children who have received all age appropriate well-child visitsPercent of women with children under three who were exclusively breastfeeding at 6 months and one

year after deliveryPercent of children who have seen a dentist in the past yearPercent of parents who report connectedness to their communitiesPercent of parents who report that the service provider helped them increase knowledge and utilization

of formal and informal resources in the communityPercent of children who have received a comprehensive health and developmental screening in the past

yearPercent of parents with decreased stressPercent of parents who practice developmentally appropriate parenting skills

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APPENDIX B

METHODOLOGY

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This section of the report details the methodology for the evaluation of First 5 Sacramento services during fiscal years 2007/2008 and 2008/2009, as conducted by Walter R. McDonald & Associates, Inc. (WRMA) and Harder+Company Community Research (the “evaluation team”).

Client Consent Procedures and Training

Recruitment procedures for the evaluation required service providers to present parents61 with a consent form and Family Intake Form. The consent form was reviewed and approved by the Institutional Review Board of WRMA and was also approved by the Sacramento County Counsel. Both forms were available in Hmong, Russian, Spanish, Ukrainian, and Vietnamese, with translation of the English form conducted by certified translators. In addition to the consent form, in situations where the parent was a minor, there was a separate assent form and accompanying “Grandparent” consent form. These forms were not translated. The seven consent and teen assent forms were distributed by the evaluation team to service providers in triplicate copies, allowing the parents and providers to each retain a copy of the signed form, with the original saved for eventual collection by the evaluation team. On-site training by the evaluation team in recruitment and consent procedures included requesting that providers write “Refused” on a consent form when a parent chose not to participate in the evaluation. These trainings often involved discussions with staff on strategies for effectively recruiting clients and when best to introduce the forms during the intake and service delivery procedures occurring at the site. Finally, informational fact sheets summarizing the main components and procedures of the evaluation – one for service providers and one designed for distribution to clients – were given to those staff attending the recruitment and consent trainings.

Persimmony

Data entered into Persimmony included the date of consent and information from the Family Intake Form – demographics about the parents and child(ren)’s demographics, health and dental insurance status, and special needs. Types and duration of services provided to parents and children as funded by First 5 Sacramento were also entered into Persimmony. In addition to the forms for documenting services, the evaluation team developed forms for school staff to record preschoolers’ readiness for kindergarten.

Service providers also entered into Persimmony information about their contracted services to comply with the quarterly reporting requirements of First 5 Sacramento. Evaluation team members worked closely with First 5 Sacramento staff to modify the description of services outlined in providers’ contracts to measurable objectives for the quarterly reporting requirements, and with Persimmony to modify and enhance the data entry screens to address the requirements of the evaluation overall and the needs of service providers. Finally, the evaluation team developed and distributed “Client-Level” and “Milestone and Aggregate” Data Entry Guides for service providers’ reference. These documents included step-by-step instructions for entering data with accompanying screen shots from Persimmony.

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Parents or adults with legal custody of children under six years could sign the consent form. For this report the term “parent” is used to refer to any adult with legal custody, and in very few cases includes other adults within the family who received services.

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Parent Interview

The Parent Interview is the longitudinal survey of a randomly-selected group of families, and parent responses from this interview are used to address most Result Area and all Cross-Cutting indicators. The development of the Parent Interview, including pilot testing of the survey instrument, was discussed extensively in last year’s report of the evaluation of fiscal year2007/2008 services. Below we outline some of the most pertinent features of the Parent Interview including those applicable to this year’s one-year follow-up survey.

Field Interviewers for Parent InterviewThe Parent Interview was administered by field interviewers. Bilingual field interviewers were paired with the primary language identified by parents on the Family Intake Form –Russian/Ukrainian, Spanish, and Hmong.

Prior to administering the instrument, field interviewers participated in a two-day training course. During the training, interviewers were given a number of opportunities to conduct mock interviews with evaluation team members and with each other. The second day of training ended with the interviewers pairing off with a member of the evaluation team. During this interview the evaluation team members recorded on a “Certification” form interviewers’ ability to read the instrument verbatim and follow instructions, including the various skip patterns throughout the instrument, and to probe appropriately when required. The Certification process was developed to ensure that interviewers demonstrated professional behaviors and the ability to administer the instrument in a manner that would reduce potential biases.

Training, Reference, and Tracking DocumentsPreparing for the Parent Interview included the development of the following documents that were reviewed during the field interviewer training and used during parent recruitment and interviewing:

A comprehensive question by question (QxQ) document that provided instructions or additional information for the majority of items on the questionnaire. The document presented this information on the page opposite each page of the Parent Interview for easy reference.

A checklist of items to be brought to each interview. A document outlining specific procedures for calling parents to schedule interviews. Interviewing Safety Procedures. Confidentiality Procedures. General Interview Guidelines. A shortened version of the General Interview Guidelines for quick reference. An age calculation sheet to determine the age of the child at the interview based on the

present month and the date of child’s birth as recorded on the Family Intake Form. A laminated “Interview in Progress” card to be placed on a door when interviews were

conducted at service provider sites. “Show Cards” that interviewers presented to parents at 11 specified points during the

interview. The Show Cards depicted in large text the possible response options and

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allowed the parent to visually review the range of possible answers when deciding which options best represented their circumstances.

A Disposition Sheet to record the outcome of each attempt to contact by telephone the parents sampled for the Parent Interview. The Disposition Sheet also ensured that multiple attempts were made at different days and times to contact parents and invite them to participate in the Parent Interview. The document was also used to note when phone numbers from Persimmony were incorrect, and the outcome of attempts to obtain updated information from contractors.

A Phone Screening document that included the script to be read to parents who signed the consent form once they were identified over the phone. The document was used to verify information entered in Persimmony, such as the names and ages of children; identify any additional children under six years who were not in Persimmony; and to record the date and location of the scheduled interview.

Recruitment and Data Collection MonitoringScheduling Parent Interviews occurred over the phone using the telephone numbers parents provided on the Family Intake Form. Recruitment calls included verifying information from the Family Intake Form and a request to schedule the interview at the parent’s residence or a nearby location, such as a coffee shop or library. Telephone interviews were presented as an option only when personal interviews were not feasible due to parents’ schedules or preferences. Personal interviews, while more costly than telephone interviews, were recognized as a superior method of data collection since they allow interviewers to develop a better rapport with parents and visually display the response options using the “Show Cards,” thus leading to more truthful and accurate responses. Moreover, receipt of the incentive (i.e., $20 Target gift card) could occur immediately following the interview in face-to-face settings, as opposed to having the incentive mailed to those interviewed by phone.

The recruitment protocol required at least eight attempts to reach parents by phone, although some parents were called up to 15 times. The disposition sheets used to record the day, time, and outcome of each attempted contact were carefully screened to ensure that calls were dispersed throughout the day and included at least one weekend attempt.

The following strategies were employed in an attempt to contact those who could not be located:

Service providers where these parents were recruited were contacted and asked for updated contact information;

Service providers were sent a list of names for posting on site with a request that they keep on the look-out for these parents, and if identified, to let them know that they have been selected for the Parent Interview;

Numerous searches were conducted to investigate whether there was updated information in the Persimmony database, or if the parents had been entered by more than one service provider with different contact information;

Reverse telephone directories were used to investigate the availability of new phone numbers connected with a given address.

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Through service providers’ regular contact with parents, updating client entries in Persimmony, and directly providing the evaluation team with new information, many parents with out-of-date contact information were found and interviewed.

Weekly evaluation team meetings during the data collection periods (March through June 2008 and 2009) included reviewing a number of tables of data to assess the status of recruitment and adjust tactics, both in the office and in the field. These data included the average number of hours interviewers were taking to complete one interview (which include recruitment calls, travel, and time to complete and verify paperwork); the average time per interview; the number of interviews completed overall, by Result Area and language, and face-to-face versus over the phone; and the number of parents who refused to participate. Refusals were categorized as “hard” and “soft” based on how ardent the parent was in his or her lack of interest in rejection of participating in the survey. Soft refusals were contacted towards the end of data collection in an attempt to persuade them to participate in the survey.

Field interviewers dropped off completed questionnaires to the evaluation team on a weekly basis; each questionnaire was carefully reviewed for skipped questions or other errors. When such cases were discovered, the related items were flagged and parents were contacted by phone to collect additional information or rectify discrepant responses.

Sampling and Outcome of Parent InterviewRandom samples of families within each of the four direct-service Result Areas were taken for the Parent Interview. A total of 458 families participated in the baseline Parent Interview in 2008, for a response rate of 63.2%. We used the response rate within each Result Area to project the number of completed interviews by the end of the one-year follow-up. With the objective of having at least 100 interviews per Result Area, we re-sampled 149 families in 2009 for “baseline” interviews. This objective was accomplished for three of the four Result Areas (Table B.1).

Table B.1: Completion by Result Area of Baseline and One-Year Follow-Up Samples

Baseline Follow-Up

Families Selected

Completed Interviews %

Families Selected

Completed Interviews %

Nutrition 148 116 78.4 156 126 80.8

School Readiness 179 115 64.2 145 105 72.4

Effective Parenting 174 98 56.3 132 93 70.5

Health Access 150 85 56.7 174 113 64.9

Racial Sub-Group oversample 74 44 59.5 - - -

Total 725 458 63.2 607 437 72.0

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Table B.2 displays the outcome of the baseline and one-year follow-up Parent Interviews. In 2009, we had a smaller percentage of parents who refused participation (4.1% versus 5.8%), who were unreachable (6.3% versus 12.3%), and who were not available (17.1% versus 18.7%); and our response rate was higher in 2009 compared with 2008. We also conducted a smaller proportion of interviews this year by telephone than last year.

Table B.2: Outcome of Baseline versus One-Year Follow-Up Parent Interviews

Baseline Follow-Up

n % n %

Sample (Including Refresh) 742 - 610 -

Ineligibles 17 2.3 3 0.5

Eligible Parents 725 97.7 607 99.5

Refused 42 5.8 25 4.1

Unreachable 89 12.3 38 6.3

Not Available 135 18.7 104 17.1

Completed Interviews 459 63.2 437 72.0

Phone Interviews* 123 26.8 77 17.6

*Phone Interviews are included in Completed Interviews

Retention ActivitiesOur ongoing efforts to maintain contact with parents include sending them and their children birthday cards. The cards include a note, translated into the parent’s primary language, thanking them for participating in the Parent Interview, and informing them that a $20 Target gift card will be available for participating in a future interview. The cards also request that parents contact the evaluation team if they plan to change their address or phone numbers. Cards were sent “Return Service Requested, Do Not Forward,” and returned cards indicated that a parent hadmoved and follow-up phone calls were made to identify and record the new address.

During November 2009 we sent holiday cards to families participating in the Parent Interview. English and Spanish versions of the holiday card “from the First 5 Parent Interview Team” and a refrigerator magnet were sent to families depending on the language of the prior interview. The refrigerator magnet mentioned that we will be giving parents a $20 Target gift card again if they participate in the two-year follow-up interview in 2010, and contains the contact information for our English or Spanish speaking team members with a request that parents “please let us know if you move or change your phone number.”

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APPENDIX C

MEASURES

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CHAPTER 3

Continuously enrolled in health insuranceThe retention findings presented in Table 3.2 are based on families who Cover the Kids’ staff were able to reach by phone 2-3, 8, and 13 months post application assistance. The percent of families with confirmed insurance coverage, which takes into account those families who could not be reached by phone, is reduced to 27.2%, 48.4%, and 41.5% for each of the follow-up surveys, respectively.

Immunizations at ages 2 and 5 years for children enrolled in health plansEnrollment in a health plan was determined by affirmative responses to the question, “Is [child’s name] covered by some form of health insurance?” Complete immunizations were estimated based on parents’ responses to the question, “In your opinion, has [child’s name] received all of the recommended shots for (his/her) age?” Age in months was calculated from the difference between date of interview and date of birth, and separate analyses were performed on children aged 24 to 35 months and 60 to 71 months.

Age appropriate well-child visitsAge appropriate well-child visits were determined by taking each child’s age and the number of times he or she received routine check-ups (“visits to the doctor when (he/she) is not sick, but to get (him/her) checked over, or for vaccinations”) during the past year, and comparing these data with the recommended well-child visits schedule.

Seeing a dentist by one year of ageAnalyses to assess the percent of children with a dental visit by age one year were based on the questions, “How old in months or years was [child’s name] when (he/she) first visited a dentist?”Excluded from these analyses were children under the age of one.

CHAPTER 4

Childhood obesityA total of 912 families with 1,005 children were recruited for the evaluation by the Childhood Obesity Prevention service providers. Children between 2 and 5 years of age with a service recorded in Persimmony, or if their parents had a service, were considered “eligible” for the BMI analyses. Sixty-two percent of the 705 eligible children had height and weight data entered into Persimmony shortly after enrollment. Less than full compliance is due to children from Health Education Council not also enrolled in SETA Head Start (HEC obtains their BMI data from SETA Head Start). The percents presented in Table C.1 for six-month follow-up are based on data obtained from eligible children some time during the two-month window-period (five to seven months from baseline), and the seven-months from baseline date falling within the fiscal year. Thus, these percents exclude children for which follow-up data were not due in fiscal year 2008/2009. Overall, baseline to six-month changes in BMI were calculated on 424 (705 X .343) children.

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Table C.1: Available Data for Calculating BMI, Fiscal Year 2008/09

Source of Data: Persimmony 1 Age 2 to 5 years with service received by child or parent. 2 Weight and height entered into Persimmony. 3 Had baseline BMI, and 6-month follow-up should have occurred within the FY.

BreastfeedingBreastfeeding items for the Parent Interview were developed by the Centers for Disease Control and Prevention (CDC) and have been used in national surveys such as the 2006 National Immunization Survey (NIS). The length of time that a child was breastfed was measured with the question, “How old was [child’s name] when (he/she) completely stopped breastfeeding or being fed breast milk?” Two subsequent questions were asked of the mother or father to assess the child’s age when something other than breast milk was first introduced into his or her diet to determine if the child was exclusively breastfed for 6 months:

“How old was [child’s name] when (he/she) was first fed formula?” “The next question is about the first thing that [child’s name] was given other than breast

milk or formula. Please include juice, cow’s milk, sugar water, baby food, or anything else that [child’s name] many have been given, even water. How old was [child’s name] when (he/she) was first fed anything other than breast milk or formula?”

The difference between the child’s date of birth and his or her age when first fed something other than breast milk established the number of days that each child was exclusively breastfed for six months. The difference between date of birth and date when he or she was first fed formula established 12-month exclusive breastfeeding. The denominator for both calculations included children who were never breastfed.

CHAPTER 5

Improved family functioningAn index variable was created from a number of items on the Parent Interview to assess a family’s risk of functioning as a family and in society. Specifically, a value of 1 was assigned to a family for each of the following conditions:

1. Family occupational status in the lowest quarter of the distribution of all parents participating in the Parent Interview;

2. Parents do not speak English to the children;

Number of Children 1,005

Number of “Eligible” Children1 705

Percent of Children with Baseline BMI Data2 62.0%

Percent of Children with “6-month” Follow-up BMI Data3 68.2%

Percent of Children with Baseline and Follow-up BMI Data 34.3%

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3. Parent single or neither parent in household; 4. Birth mother was 20 years or younger when oldest child was born;5. Neither parent works full-time;6. Either child has not seen at least one birth parent within 182 days;7. One or both parents did not graduate from high school;8. One or both parents do not speak English;9. One or both parents were not born in the United States; and10. One or both parents were recent immigrants to the United States.

Thus, families with a score of 10 are considered at greatest risk of dysfunction. Two items on the Parent Interview were noted to reduce risk, and therefore were subtracted from each family’s risk score. One or both parents taking a class was assigned a -0.5, and -1.0 was given to families where one or both parents was working on a degree. Family’s combined scores were multiplied by 100, for a theoretical range of the risk index of 0 to 100.

Knowledge of developmental stages in childrenParents’ knowledge of stages of children’s development was assessed by the Knowledge of Infant Development Inventory.62 The KIDI first asks parents to indicate their level of agreement with the following statements:

All infants need the same amount of sleep. A young brother or sister may start wetting the bed or thumb-sucking when a new baby

arrives in the family. A child thinks he is speaking correctly even when he says words and sentences in an

unusual or different way, like “I goed to town” or “What the dolly have?” Children learn all of their language by copying what they have heard adults say.

Next, parents who disagree with any of the following seven statements are asked whether the behavior is more applicable to a younger or an older child:

A one-year-old knows right from wrong. A baby will begin to respond to her name at 10 months. Most infants are ready to be toilet trained by one year of age. A baby of 12 months can remember toys he has watched being hidden. One-year-olds often cooperate and share when they play together. A baby is about 7 months old before she can reach for and grab things. A baby usually says its first real word by six months of age.

The standardized procedures for scoring the KIDI results is an average score for knowledge of developmental stages, ranging from 0% to 100%.

62 MacPhee, D. (1981). Manual: Knowledge of Infant Development Inventory. Unpublished manuscript, University of North Carolina.

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Parental stressThe Parenting Stress Index (Short Form)63 asks for level of agreement with the following statements:

I find myself giving up more of my life to meet my children’s needs than I ever expected. I feel trapped by my responsibilities as a parent. Since having a child, I have been unable to do new and different things. Since having a child, I feel that I am almost never able to do things that I like to do. There are quite a few things that bother me about my life. I feel alone and without friends. I don’t enjoy things as I used to.

Developmentally appropriate parenting skillsParents were presented with different methods of discipline and asked “How often you have used it in the last 6 months: never, rarely, sometimes, or often?”64 Statements from the Parenting Dimensions Inventory65 and Child Rearing Practices Report were used to determine levels of Parental Nurturance, Energy, and Authoritative versus Authoritarian parenting styles. During the Parent Interview, survey participants were presented with each statement and asked if it was “very much like them,” “somewhat like them,” or “nothing like them.” Parental Nurturance, Energy, Authoritative, and Authoritarian scores ranged from 1.0 to 3.0.

The following statements were used to determine the Parental Nurturance Score:

My child and I have warm intimate/affectionate moments together. I encourage my child to be curious, to explore, and to question things. I make sure my child knows that I appreciate what (he/she) tries to accomplish.

Higher levels of Parental Energy were established with the following items:

There are times I just don’t have the energy to make my child behave as (he/ she) should. Once I decide how to deal with a misbehavior of my child, I follow through on it. I have little or no difficulty sticking with my rules for my child even when close relatives

(including grandparents) are there.

Parental Authoritative items consisted of:

I encourage my child to be curious, to explore, and to question things. I am easygoing and relaxed with my child. I make sure my child knows that I appreciate what (he/she) tries to accomplish.

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Haskett, M.E., Ahern, L.S., Ward, C.S., & Allaire, J.C. (2006). Factor structure and validity of the Parenting Stress Index-Short Form. Journal of Clinical Child & Adolescent Psychology, 35, 302-312.64 MacPhee, D. & Rattenborg, K. (1991). Parental Discipline Methods scale. 65 Slater, M. A. & Power, T. G. (1987). Multidimensional assessment of parenting in single-parent families. In J. P. Vincent (Ed.), Advances in family intervention, assessment, and theory (pp. 197-228). Greenwich, CT: JAI Press.

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I encourage my child to be independent of me.

And Parental Authoritarian items included:

I control my child by warning (him/her) about the bad things that can happen to (him/her).

I teach my child that misbehavior or breaking the rules will always be punished one way or another.

I do not allow my child to get angry with me. I believe physical punishment to be the best way of disciplining.

Interact with children in a supportive and positive mannerThe extent to which parents interacted in a positive and supportive manner was assessed by recording the frequency of participation in certain activities with their children three years of age and older. Parents were first asked how often they engaged in the following activities during the previous week:

Played with toys or indoor games Played any game or sport together Sung to or with (him/her) songs or music Told (him/her) a story Helped (him/her) learn letters, words, or numbers Played counting games like singing songs with numbers or reading books with numbers Talked about TV, radio programs, or videos Talked about what happened in preschool, nursery school or early education program Cooked or prepared a meal together Watched a children’s movie together

Parents were then asked if they did the following activities within the past month:

Talked with [child’s name] about (his/her) family history or stories about the family Attended family functions or events such as a quinceañera, a birthday party, a wedding,

or a christening Attended an event sponsored by a community or ethnic group Taken [child’s name] to watch sports, or a game such as soccer Attended a religious activity or religious school

An “Activities with Child” score was computed with a value of 1 given to parents for every weekly activity they did “3 or more times,” and for every monthly activity. Activities with Child scores ranged from 1 to 15.

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CHAPTER 6

Regular attendance at a nursery school, preschool, pre-Kindergarten, or Head Start program Parents were asked, “Is [child’s name] now attending a nursery school, preschool, pre-kindergarten or Head Start program on a regular basis?”

Special needs children’s participation in early childhood care and education programsChildren’s special needs were determined through parent self-report, as with all items on the Parent Interview, by asking, “Has a doctor, other health or education professional, or someone from [Name of First 5 Sacramento service provider] ever told you that [child’s name] has special needs or disabilities, for example, physical, emotional, language, hearing, learning difficulty, or other special needs?”

Satisfaction with the content, quality, and family centeredness of school programsParents were asked about their levels of satisfaction (“not satisfied,” “somewhat satisfied,” or “satisfied”) with each of the areas below in the school programs where the child “spends most of (his/her) time.”

Helping [child’s name] to grow and develop Being open to your ideas and participation Supporting and respecting your family’s culture and background Identifying and helping to provide services that help your family—for example, public

assistance, transportation, or job training Maintaining a safe program—for example, secure play grounds, clean and tidy

classrooms Preparing [child’s name] to enter kindergarten Helping you become more involved in groups that are active in your community

Satisfaction scores ranged from 1 to 100.

Kindergarten readiness at the completion of a school readiness programChildren’s readiness for kindergarten was recorded on the “Summer Camp & Preschool Teacher Services/Assessment Form” with the question, “If this child has been assessed for his/her readiness for kindergarten, what was the result?” Response options were: “Ready,” “Not Ready,” “Not Sure,” and “N/A – Not Assessed.” Teachers were requested to complete the form once a quarter, or before the child left the program. Data from the only or most recent assessment were analyzed.

Children meeting developmental milestonesData to assess the developmental milestones of children in the School Readiness Result Area came from the Desired Results Developmental Profile-Revised (DRDP-R), which is scheduled to be administered at the beginning and end of the preschool program by school staff. Pre- and post- DRDP-R data were entered into Persimmony. Due to not all children with a DRDP-R having both the pre- and the post- assessment done, data from the most recent assessment or the only assessment entered into Persimmony (a proxy for the post assessment) were analyzed.

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CHAPTER 8

Community Building EventsAttendees are often not fully aware that a CBI activity or event is sponsored by First 5 Sacramento, which posed a challenge in assessing the relationship between attendance and the outcomes reflected in the related Result Area indicators. In other words, we could not expect all Parent Interview participants who attended a CBI event to know that they had attended a CBI event. To address this challenge, the evaluation team developed descriptive summaries of six types of CBI events. After each summary was read to parents they were asked if they had heard about such an event occurring in their neighborhood or community during the past six months. If they had, they were asked whether they attended the event. The six types of events are listed below.

1. Events that promote a safe neighborhood, such as crime or drug prevention events with local police, or Neighborhood Watch groups or block club meetings.

2. Events that help parents become better parents, such as parent education classes, discussion and support groups, or community resource awareness meetings for parents.

3. Events that encourage literacy and early childhood education, through such activities as neighborhood book clubs, reading programs, or library hours for children.

4. Events that are celebrations and festivals such as neighborhood celebrations, holiday festivals, cultural events, pot-luck dinners, or barbeques.

5. Events that promote children’s creativity, such as with arts and crafts, dance, or music.

6. Events that promote nutrition, health and fitness, such as community bike rides for children, health fairs, or community gardens to teach children nutrition.

A series of questions were asked of parents who indicated that they had attended one or more of these events. Field interviewers recorded when the event took place (i.e., month and/or date), the name of the event, and its location (specific address or general location). This information was subsequently compared with the master list of CBI events provided by First 5 Sacramento staff.

Evaluation staff developed a set of specific procedures for comparing and identifying potential CBI events derived from the Parent Interview with actual CBI events. These procedures resulted in each parent receiving a code of “Definitely Did Not Attend,” “Likely Did Not Attend,” “Likely Attended,” and “Definitely Attended” for each event they identified. (Some parents identified multiple events, and thus received multiple codes.) Two members of the evaluation team coded a sample of these identified events independently, compared their answers and revised the procedures until agreement was obtained for over 80% of coded events.

Ultimately, each parent was coded as “Did Not Attend a Community Event,” “Attended a Community Event, Not CBI,” or “Likely or Definitely Attended a CBI Event.” Analyses were

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conducted across these three groups on the related measures for each indicators associated with the Community Building Result Area.

Trust in NeighborhoodTrust in one’s neighborhood was assessed with items from the Social Cohesion Scale66 and the Neighborhood Environment for Children Rating Scale.67 When combined, these scales allowed for calculating Neighborhood Cohesion scores. Scores ranged from 2-10, with scores of 6.4 and above considered high cohesion.

The Social Cohesion Scale items are:

People in my neighborhood are willing to help their neighbors. I live in a close-knit neighborhood. People in my neighborhood do not share the same values as me. People in my neighborhood can be trusted. People in my neighborhood generally don’t get along with each other.

And the Neighborhood Environment for Children Rating Scale includes the following items:

My neighborhood is a good place to raise children. Neighbors should mind their own business about their neighbor’s children. I disagree with the way my neighbors discipline their children. Any adult has the right to verbally correct a neighborhood child if the parents are not

around.

Increased efficacyEfficacy was assessed on the Parent Interview with the following items from the Pearlin Mastery Scale68 and asked to respond: strongly disagree, disagree, agree, or strongly agree.

There is really no way I can solve some of the problems I have. Sometimes I feel that I am being pushed around in life. I have little control over the things that happen to me. I can do just about anything I really set my mind to do. I often feel helpless in dealing with the problems of life. What happens to me in the future depends mostly on me. There is little I can do to change many of the important things in my life.

66 Sampson, R.J., Raudenbush, S.W., & Earls, F. (1997). Neighborhoods and violent crime: a multilevel study of collective efficacy. Science, 277, 918-924.67

Coulton, C. J., Korbin, J. E., & Su, M. (1996) Measuring neighborhood context for young children in an urban area. American Journal of Community Psychology, 24, 5–32.68

Pearlin, L.I., Lieberman, M.A., Menaghan, E.G., & Mullan, J.T. (1981). The stress process. Journal of Health and Social Behavior, 22, 337-353.

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Parents were then scored 1-4 based on their responses, with scores of 3-4 considered high efficacy.

CHAPTER 10

Enrolled in health insuranceParents were asked to note on the Family Intake Form whether their children had health insurance. These data were not collected through the Health Access Result Area since those parents go to Cover the Kids specifically to obtain coverage for their uninsured children. Thus, the calculation of the baseline rate for children enrolled in health insurance included in the denominator responses of “no” on the Family Intake Form and all children recruited for the evaluation through Cover the Kids, but excluded all the cases where this question was not answered or was unavailable.

Evaluation of Services · January 25, 2010 . ii TABLE OF CONTENTS EXECUTIVE SUMMARY ... IBCLC...

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