Using Partners for A Healthy Baby to Achieve Program Outcomes

How the Partners for a Healthy Baby Curriculum Aligns with Core Elementsof Evidence-Based Home Visitation ServicesRecently, the National Home Visitation Steering Committee* (March 2009) proposed four Core Elements of EvidencebasedHome Visitation Services. The elements address program outcomes, program models and standards, programrecipients, and program providers. The Partners for a Healthy Baby curriculum is used in numerous programs that meetthe Core Elements. Positive outcomes achieved by evidence-based programs using the Partners curriculum are cited below.Core Element 1: Demonstrate ongoing positive outcomes that enhance child health and development by improvingprenatal health; pregnancy outcomes; child health; physical, cognitive, language and social emotional development;school readiness; academic success; positive parenting practices; parent involvement; reductions in child abuse, neglectand injury; birth intervals between pregnancies; family stability; economic self sufficiency; and maternal employment.Positive Birth Outcomes• The risk of delivering a low birth weight (LBW) baby was significantly lower for the Healthy Families New York(HFNY) mothers (5.1%) than for the control group mothers (9.8%).• HFNY mothers delivered fewer small for gestational age (SGA) babies (8.8%) than control group mothers (11.6%).—Lee, E., Mitchell-Herzfeld, S., Lowenfels, A., Green, R., Dorabawila, V., & DuMont, K. (2009). Reducing low birth weight through homevisitation: A randomized controlled trial. American Journal of Preventive Medicine, 36(2), 154-160.• Teens in the Virginia Resource Mothers (VRM) program had fewer low birth weight deliveries compared to overallteen state rates (7.7% vs. 10.3% in 2006) and (8.9% vs. 10.6% in 2007).—Virginia Department of Health. (2008). Virginia Resource Mothers Program Annual Report. Richmond, VA: Author.• Mothers who participated in the Tennessee HUGS program had an average gestational age of 37.5 weeks and anaverage number of prenatal visits of 10.0 per mother.—Tennessee Department of Health, Maternal and Child Health. (2011). Tennessee Home Visiting Programs Annual Report: July 1, 2009–June 30,2010. Nashville, TN: Author. Retrieved from http://health.state.tn.us/statistics/PdfFiles/Home_Visiting_Programs_Annual_Report_2010.pdfReduction in Child Abuse• A five-year evaluation, which used a quasi experimental design, found that children in Healthy Families Florida were3.7 times less likely than the comparison group to experience child maltreatment.• There was 58% less child abuse in families who received three or more years of service or completed the programcompared to families who received less than 3 months of services or no services.• The rate of child maltreatment for HFF participants was 20% less than for families in the target service areas.—Williams, Stern & Associates (2005). Healthy Families Florida Evaluation Report: January 1, 1999–December 31, 2003. Retrieved March 26,2009 from www.healthyfamiliesfla.org/pdfs/Final_Evaluation_1999-2003.pdf• Only one substantiated incidence of child maltreatment was reported for participants in the Cabarrus Health Alliance’sIntensive Home Visiting Program for Pregnant and Parenting Teens from 2004-2009.—Stepping Stones Intensive Home Visiting Program. Quarterly Reports 2004–2009. Cabarrus Health Alliance, North Carolina.—Knight, S., & Patterson, J. (2008). “Stepping Stones” Intensive Home Visiting Program for Pregnant and Parenting Teens. Presentation to NorthCarolina Smart Start Conference, May 6, 2008.• A total of 98% (1,100 of 1,133) of the children enrolled in the Tennessee CHAD program were free of child abuseand neglect as measured by DCS reported involvement in prior 12 months.• A total of 98.8% (1,387/1404) of the children served by Tennessee Healthy Start program did not exhibit signs ofabuse or neglect.—Tennessee Department of Health, Maternal and Child Health. (2011). Tennessee Home Visiting Programs Annual Report: July 1, 2009–June 30,2010. Nashville, TN: Author. Retrieved from http://health.state.tn.us/statistics/PdfFiles/Home_Visiting_Programs_Annual_Report_2010.pdf*Children’s Defense Fund, CLASP, CWLA, Fight Crime: Invest in Kids, Home Instruction for Parents of Preschool Youngsters, National ChildAbuse Coalition, Parents as Teachers National Center, Parent-Child Home Program, Prevent Child Abuse America/Healthy Families America,and Voices for America’s Children.2 Florida State University Partners for a Healthy Baby • www.cpeip.fsu.edu • September 2011

Birth Intervals Between Pregnancies• Of mothers enrolled in Healthy Families Florida, 92% did not have a subsequent pregnancy within 2 years of thetarget child’s birth.—Williams, Stern & Associates. (2005). Healthy Families Florida Evaluation Report: January 1, 1999–December 31, 2003. Retrieved March 26,2009 from www.healthyfamiliesfla.org/pdfs/Final_Evaluation_1999-2003.pdf• The rate of repeat pregnancy for VRM teen mothers was 5.1% compared to 20% for teens statewide.—Virginia Department of Health. (2008). Virginia Resource Mothers Program Annual Report. Richmond, VA: Author.• Of the women being served by the Tennessee Healthy Start program, 93% (1,028/1,106) were not pregnant one yearafter the birth of the previous child.• Of the 1,010 mothers with at least one previous birth being served by the Tennessee HUGS program, 924 (91.5%)had a birth interval greater than 12 months.—Tennessee Department of Health, Maternal and Child Health. (2011). Tennessee Home Visiting Programs Annual Report: July 1, 2009–June 30,2010. Nashville, TN: Author. Retrieved from http://health.state.tn.us/statistics/PdfFiles/Home_Visiting_Programs_Annual_Report_2010.pdfImproved Child Health• Of the Healthy Families Florida (HFF) target children, 92% had up-to-date immunizations compared with thestatewide rate of 77%.• Of the HFF participants, 97% were linked to a medical provider.• Over 90% of HFF children were up-to-date with well-baby checks at 3 and 4 years of age.—Williams, Stern & Associates. (2005). Healthy Families Florida Evaluation Report: January 1, 1999–December 31, 2003. Retrieved March 26,2009 from www.healthyfamiliesfla.org/pdfs/Final_Evaluation_1999-2003.pdfOf the participants in the Cabarrus Health Alliance’s Intensive Home Visiting Program for Pregnant and Parenting Teens:• 100% were enrolled in a medical home within 6 weeks of entry into the program.• 100% of the children were up-to-date with their immunizations.—Knight, S., & Patterson, J. (2008). “Stepping Stones” Intensive Home Visiting Program for Pregnant and Parenting Teens. Presentation to NorthCarolina Smart Start Conference, May 6, 2008.• A total of 78% (154/198) of the children being served by Tennessee CHAD program (who turned 2 during theprogram year) were up to date on immunizations.• Of the children being served by the Tennessee Healthy Start program, 98.8% (418/440) were up to date on theirimmunizations by their 2nd birthday.• A total of 74% (650/878) of the 2-year-olds being served by the Tennessee HUGS program were up to date onimmunizations.• A total of 96% (3,549/3,690) of eligible women being served in the Tennessee HUGS program were enrolled in WIC.• A total of 80.5% (4,831/5,996) of children being served in the Tennessee HUGS program were enrolled in WIC.—Tennessee Department of Health, Maternal and Child Health. (2011). Tennessee Home Visiting Programs Annual Report: July 1, 2009–June 30,2010. Nashville, TN: Author. Retrieved from http://health.state.tn.us/statistics/PdfFiles/Home_Visiting_Programs_Annual_Report_2010.pdfPositive Parenting Practices• Mothers who completed Healthy Families Florida were significantly more likely than comparison group mothers toread to their children at early ages.—Williams, Stern & Associates. (2005). Healthy Families Florida Evaluation Report: January 1, 1999–December 31, 2003. Retrieved March 26,2009 from www.healthyfamiliesfla.org/pdfs/Final_Evaluation_1999-2003.pdfMaternal Employment• Healthy Families Florida positively affected self-sufficiency, defined as employment. At 3 years after the birth of thetarget child, Healthy Families Florida completers were 1.5 times more likely to be employed than the comparisongroup.—Williams, Stern & Associates. (2005). Healthy Families Florida Evaluation Report: January 1, 1999–December 31, 2003. Retrieved March 26,2009 from www.healthyfamiliesfla.org/pdfs/Final_Evaluation_1999-2003.pdfFlorida State University Partners for a Healthy Baby • www.cpeip.fsu.edu • September 2011 3

Improved Child DevelopmentThe Chicago Public Schools’ Cradle to Classroom program used Partners for a Healthy Baby and LearningGames toimprove developmental outcomes for children of teen mothers. Program outcomes include:• When the Ages and Stages Questionnaire (ASQ) was administered at 3 years of age, 59% of the comparison group andonly 9% of the intervention group were classified at increased risk and of special concern.• Mean scores on the ASQ for children who received the intervention were well within the normal range, whereas themean scores for the comparison children were below the cutoff points between 4 and 36 months.—York, V., Sparling, J., & Ramey, C. (2001). Cradle to Classroom Evaluation. Unpublished manuscript.Partners for a Healthy Baby includes LearningGames, the well-researched early childhood curriculum developed for theCarolina Abecedarian Project. Positive benefits for the children who received the Abecedarian intervention include:• higher IQ detected as early as 18 months of age• improved school performance in reading and math• reduced retention in grade• higher likelihood of high school graduation and college attendance• fewer teen pregnancies—Ramey, C. T., & Campbell, F. A. (1984). Preventive education for at-risk children: Cognitive consequences of the Carolina AbecedarianProject. American Journal of Mental Deficiency, 88, 515-523.—Martin, S. L., Ramey, C. T., & Ramey, S. L. (1990). The prevention of intellectual impairment in children of impoverished families: Findingsof a randomized trial of educational daycare. American Journal of Public Health, 80, 844-847.—Burchinal, M. R., Campbell, F. A., Bryant, D.M., Wasik, B. H., & Ramey, C. T. (1997). Early intervention and mediating processes incognitive performance of children of low-income African American families. Child Development, 68, 935-954.—Campbell, F. A., Ramey, C. T., Pungello, E., Sparling, J., & Miller-Johnson, S. (2002). Early childhood education: Young adult outcomesfrom the Abecedarian Project. Applied Developmental Science, 6(1), 42-57.• A total of 11,889 developmental screenings were completed on children enrolled in the Tennessee HUGS programand of these 1,740 (14%) indicated developmental delays.—Tennessee Department of Health, Maternal and Child Health. (2011). Tennessee Home Visiting Programs Annual Report: July 1, 2009–June 30,2010. Nashville, TN: Author. Retrieved from http://health.state.tn.us/statistics/PdfFiles/Home_Visiting_Programs_Annual_Report_2010.pdfCore Element 2: Conform to a clear consistent home visitation model that has been in existence for at least threeyears and is research-based; grounded in relevant empirically-based knowledge; linked to program determined outcomes;associated with a national organization or institution of higher education that has comprehensive home visitationprogram standards that ensure high quality service delivery and continuous program quality improvement; and hasdemonstrated significant positive outcomes.Core Element 3: Serves pregnant women and/or parent/s or other primary caregivers and their children under the ageof entry into kindergarten who are low income or at risk of poor outcomes.With respect to Core Elements 2 and 3, the Partners for a Healthy Baby series is unique in that, to our knowledge, itis the only comprehensive curriculum that addresses issues of child health and development within the context of themultifaceted needs of families. Developed by a multidisciplinary faculty at Florida State University and piloted at theFSU Early Head Start program, the series provides the home visitor with a planned sequence of critical topics that areessential in achieving both family and program outcomes.The Partners curricular series is used by more than 3,700 programs in a variety of research-based home visitation modelsthroughout the nation including Healthy Families, Healthy Start, and Early Head Start—the nation’s premier programfor low income infants and toddlers. These programs all have national affiliations, long histories of effectiveness, andthey serve pregnant and parenting families and their young children who are low income or at risk for poor outcomes.The Partners curriculum helps Healthy Start programs achieve better birth outcomes by addressing topics such as:prenatal care, diet and exercise, smoking cessation, healthy lifestyles, the physical and emotional changes of pregnancy,bonding and attachment, and the importance of spacing pregnancies. The Partners curriculum supports Healthy Familiesprograms efforts in child abuse prevention and family stability through its focus on positive parenting, child safety, familyrelationships, healthy birth outcomes, infant mental health, and child development. The Partners curriculum supportsEarly Head Start’s goals of family empowerment and child development through topics on economic self-sufficiency,4 Florida State University Partners for a Healthy Baby • www.cpeip.fsu.edu • September 2011

fatherhood, nutrition, parenting, and developmental skills. The Partners for a Healthy Baby series is also widely used in teenparent programs, state health departments, and other community-based home visiting programs that serve low incomeor at risk families. (See below for descriptions of programs using the Partners curriculum and their reported outcomes.)The Partners curriculum is sometimes used in conjunction with the Born to Learn curriculum in programs following theParents as Teachers model. Some agencies implementing the Nurse Family Partnership model have reported also usingthe Partners curriculum.Core Element 4: Delivered by nurses, social workers, child development specialists, or other well-trained and competentstaff, as demonstrated by education or training and the provision of ongoing and specific training and supervision in themodel of service being delivered.The Partners curriculum is designed for use by both professional home visitors—including nurses, social workers, childdevelopment specialists—and well-trained paraprofessionals in home based programs. On-going training is essential tothe effective use of the curriculum. Intensive training on the Partners curriculum series is offered in Florida for programsusing the curriculum. On-site training is also available. The Baby’s First Year Training Supplement CD-ROM is a selfguidedoverview of Baby’s First Six Months and Baby’s Months 7-12.Programs Using the Partners Curriculum: Program Description & OutcomesHealthy Families New York (HFNY) has used the Partners for a Healthy Baby curricular series since 1999. HFNY isa home visitation program for mothers at risk for developing abusive or neglectful behaviors toward their children.Goals are to promote positive parenting, prevent child abuse and/or neglect, support prenatal care and child healthand development, and improve parental self-sufficiency. A three-year evaluation of the program was conducted by theBureau of Evaluation and Research in collaboration with the University at Albany. Pregnant women and adolescentswere randomly assigned to either an intervention group receiving bi-weekly home visits (n=236) or to a control group(n=265). Home visitors encouraged healthy prenatal behavior, offered social support and provided linkage to medicaland other community services. The risk of delivering a low birth weight (LBW) baby was significantly lower for theHFNY group (5.1%) than for the control group (9.8%). HFNY mothers also delivered fewer small for gestational age(SGA) babies than control mothers (8.8% vs. 11.6%). In summary, the home visited mothers were approximately halfas likely as control mothers to deliver LBW babies. Mothers offered home visitation services earlier in their pregnanciesexperienced even greater reductions in the number of LBW deliveries, suggesting the benefit of engaging vulnerableexpectant women early in pregnancy. In addition to the study of birth outcomes, evaluators assessed maternal/childinteractions. By the child’s third year of life, HFNY mothers were more likely to use positive parenting strategies (e.g.,cognitive stimulation, attentive and responsive to affective cues) than mothers in the control group.—Lee, E., Mitchell-Herzfeld, S., Lowenfels, A., Green, R., Dorabawila, V., & DuMont, K. (2009). Reducing low birth weight through homevisitation: A randomized controlled trial. American Journal of Preventive Medicine, 36(2), 154-160.—DuMont, K., Rodriguez, M., Mitchell-Herzfeld, S., Walden, N., Kirkland, K., Greene, R., Lee, E. (2008). Effects of Healthy Families New Yorkon maternal behaviors: Observational assessments of positive and negative parenting. Rensselaer, New York: New York State Office of Children andFamily Services.Healthy Families Florida (HFF) is one of the largest home visiting programs using the evidence-based Healthy FamiliesAmerica model. Well trained paraprofessional family support workers provide home visiting services, beginning prenatallyor at the birth of a baby, to families living in geographically targeted areas who have been assessed as experiencing stressfullife situations. These visits may continue for up to five years. Goals are to prevent child abuse, promote positive parent/child relationships and healthy child development, and enhance family functioning and problem solving skills. A fiveyearindependent evaluation was conducted between 1999 and 2003, during which time 22,708 families were servedand the Partners for a Healthy Baby series was the primary curriculum. The evaluation, which used a quasi-experimentaldesign, found that HFF children were 3.7 times less likely than the comparison group to experience child maltreatmentand more likely to be up-to-date with their immunizations (92% compared to 77% statewide) and have a medical home(97%). There was 58% less child abuse in families who received 3 or more years of service or completed HFF comparedto families who received less than 3 months of services or no services. HFF mothers were 1.5 times more likely to beemployed and, when involved in the program 3 years or more, were significantly more likely to read to their child thanmothers in the comparison group. An impressive 92% of HFF mothers delayed subsequent pregnancies.—Williams, Stern & Associates. (2005). Healthy Families Florida Evaluation Report: January 1, 1999–December 31, 2003. Retrieved March 26,2009 from www.healthyfamiliesfla.org/pdfs/Final_Evaluation_1999-2003.pdfFlorida State University Partners for a Healthy Baby • www.cpeip.fsu.edu • September 2011 5

The Virginia Resource Mothers (VRM) is a statewide program that, since 1985, has targeted areas with high ratesof poverty, teen pregnancy, or poor birth outcomes. Since FY 1991, 18,463 pregnant teens have been served. Theprogram’s goals are to improve birth outcomes for pregnant teens and reduce repeat pregnancies. Community healthworkers visit moms weekly during the prenatal period through the child’s first birthday and have bee using the Partnersfor a Healthy Baby curriculum since 1999. Positive birth outcomes have been demonstrated in the program, includingreduced rates of low birth weight babies and repeat pregnancies compared to state rates. In 2006, the rate of LBWdeliveries for Virginia Resource Mother’s teens was 7.7% compared to 10.3% statewide for teens; and in 2007, it was8.9% compared to 10.6% statewide. The rate of repeat pregnancy for VRM teen mothers was 5.1% compared to 20%for teens statewide. In 2008, the majority of teens in the program (81%) were in school, enrolled in training programs,working, or all three; 2.9% were in college; 16% dropped out—which is about half of the national average of 30%.—Virginia Department of Health. (2008). Virginia Resource Mothers Program Annual Report. Richmond, VA: Author.The Stepping Stones Intensive Home Visiting Program is part of the Smart Start Initiative in North Carolina. This childabuse prevention program for adolescent and teen mothers is run by the Cabarrus Health Alliance (the local public healthdepartment) and has been using the Partners for a Healthy Baby curriculum since its inception in 1999. Three speciallytrained registered nurses each serve a case load of about 25 pregnant and parenting teens from pregnancy through thesecond year of life. The program uses the Partners curriculum to provide education about pregnancy, childbirth andearly childhood development; support individual goal setting; model appropriate parent/child interactions; and ensureearly and consistent prenatal care. The major goal of the program is to prevent child abuse and neglect. As reported inMay 2008, the Stepping Stones program has had only one substantiated case of child neglect in the nine years it has beenfunded; 100% of the participants were enrolled in a medical home within six weeks of entry to the program; 100% ofthe children were up-to-date with their immunizations; and 73% of the teens met their education/employment goals.—Stepping Stones Intensive Home Visiting Program. Quarterly Reports 2004–2009. Cabarrus Health Alliance, North Carolina.—Knight, S., & Patterson, J. (2008). “Stepping Stones” Intensive Home Visiting Program for Pregnant and Parenting Teens. Presentation to NorthCarolina Smart Start Conference, May 6, 2008.Miami Adolescent Mothers Project. The goal of this project was to improve maternal interactions and developmentaloutcomes of the children of teen mothers. Researchers at the University of Miami Miller School of Medicine investigatedthe impact of short-term, interaction-focused parenting education on maternal behaviors and child development.Selected handouts on ages and stages of development from the Partners for a Healthy Baby curriculum were used inconjunction with project-developed materials. A total of 48 teen mother/child dyads were in the intervention groupand 46 were in the comparison group. The groups met for one hour, twice a week, over a 3-month period for a total of24 sessions. When the groups were compared at post-test, mothers in the intervention group were significantly moreresponsive, less directive, and more facilitative of child language development. Children of mothers in the interventiongroup had significantly higher developmental quotient scores than children of mothers in the contrast group. Resultssupport the use of this targeted intervention with adolescent mothers to enhance nurturing behaviors and responsivenessthat facilitate the language development of their infants and toddlers.—Deutscher, B., Fewell, R. & Gross, M. (2006). Enhancing the interactions of teenage mothers and their at-risk children: Effectiveness of amaternal-focused intervention. Topics in Early Childhood Special Education, 26(4), 194-205.The Cradle to Classroom Program (CTC). The goal of this Chicago Public Schools collaboration with city andcommunity agencies and local hospitals was to improve teen parenting skills and developmental outcomes for childrenof teen mothers. Weekly home visits were provided using the Partners for a Healthy Baby curriculum and LearningGames.Results of data collected on 748 CTC mothers and children and on a comparison group of 128 children from similarChicago neighborhoods who did not receive the program indicated that at age 36 months, 59% of the comparisongroup and only 9% of the intervention group were classified at increased risk and of special concern on the Agesand Stages Questionnaire (ASQ). Mean scores on the ASQ for the children who received the intervention were wellwithin the normal range, whereas the mean scores for the comparison children were below the cutoff points between4 and 36 months. The difference between mean scores for the groups had a high statistical significance (p < .01) at allmeasurement occasions.—York, V., Sparling, J., & Ramey, C. (2001). Cradle to Classroom Evaluation. Unpublished manuscript.6 Florida State University Partners for a Healthy Baby • www.cpeip.fsu.edu • September 2011

The Tennessee Department of Health (TDH) provides home visiting services in all counties through county healthdepartments or under contract with community‐based agencies. Three of the four home visiting programs currentlyproviding services in Tennessee use the Partners for a Healthy Baby curriculum exclusively. A brief description of the threeprograms and the outcomes they achieved during the 2010 fiscal year is provided below.CHAD — Child Health & Development. The CHAD program is provided in 22 counties in NE and Eastern Tennesseeand serves teen parents under 18 years of age and other parents at risk of abuse and neglect (DCF referred), and familiesreceiving AFDC, SSI, or FPL. A total of 741 families and 1,133 children were served during the reporting period (FY2010). All children enrolled in the program were referred by public health clinics or DCS. The program aims to reducechild abuse and neglect and to promote family health. Family participation is voluntary.Goal 1: Prevent Child Abuse and Neglect• A total of 98% (1,100 of 1,133) of the children enrolled in the CHAD program were free of child abuse and neglectas measured by DCS reported involvement in prior 12 months.Goal 2: Promote Family Health as determined by having up to date immunizations.• A total of 78% (154/198) of the children being served by CHAD program (who turned 2 during the program year)were up to date on immunizations.Healthy Start. Legislatively mandated by The Tennessee Childhood Development Act of 1994 (TCA 37‐3‐703), theHealthy Start program is an evidence-based model provided in 30 counties by 8 community‐based agencies. The programaims to reduce or prevent child abuse and neglect among enrolled families and to promote and improve the health statusof family members. A total of 1,240 families with 1,404 children were served during the reporting period (FY 2010).Goal 1: Prevent Child Abuse and Neglect• A total of 98.8% (1,387/1404) of children served by Healthy Start program didn’t exhibit signs of abuse or neglect.Goal 2: Promote and Improve Health Status of Family Members• Of the children being served by the Healthy Start program, 98.8% (418/440) were up to date on their immunizationsby their 2nd birthday.• Of the women being served by the Healthy Start program, 93% (1,028/1,106) were not pregnant one year after thebirth of the previous child.HUGS — Help Us Grow Successfully. HUGS is a home visiting model that was developed by the TDH in the 1990s asa means of organizing clinic and home services emphasizing child health and well being. It is a theory‐based model and isthe only home visiting program that is offered in all counties of the state. A total of 5,996 children were served during thereporting period (FY 2010). The two primary goals of the program are to improve pregnancy outcomes and to ensureparents/caregivers are able to nurture their child’s growth and development before school entry.Goal 1: Pregnant women in the program will have a healthy pregnancy and birth.• A total of 64.9% (1,430/2,202) of pregnant women being served by the HUGS program had adequate prenatal care.• A total of 71.9% (1,583/2,202) of women being served by the HUGS program reported that they did not smokeduring pregnancy.• Of the 1,010 mothers with at least one previous birth being served by the HUGS program, 924 (91.5%) had a birthinterval greater than 12 months.• Mothers who participated in the HUGS program had an average gestational age of 37.5 weeks and an average numberof prenatal visits of 10.0 per mother.Goal 2: Parents/caregivers nurture their child’s growth and development before school entry.• A total of 74% (650/878) of the 2 year olds being served by the HUGS program were up to date on immunizations.• A total of 11,889 developmental screenings were completed on children enrolled in the HUGS program and of these1,740 (14%) indicated developmental delays.• A total of 96% (3,549/3,690) of eligible women being served in the HUGS program were enrolled in WIC.• A total of 80.5% (4,831/5,996) of children being served in the HUGS program were enrolled in WIC.—Tennessee Department of Health, Maternal and Child Health. (2011). Tennessee Home Visiting Programs Annual Report: July 1, 2009–June 30,2010. Nashville, TN: Author. Retrieved from http://health.state.tn.us/statistics/PdfFiles/Home_Visiting_Programs_Annual_Report_2010.pdfFlorida State University Partners for a Healthy Baby • www.cpeip.fsu.edu • September 2011 7