official final ma thesis

Running head: CHILD CARE USE AMONG ADOLESCENT MOTHERS

Child Care Use among Adolescent Mothers Enrolled in a Massachusetts Home

Visiting Program

A thesis submitted by

LunYan Tom Hoysgaard

In partial fulfillment of the requirements for the joint degree of

Master of Arts

in

Urban and Environmental Policy and Planning

And

Child Study and Human Development

TUFTS UNIVERSITY

August 2016

Adviser: Francine Jacobs

CHILD CARE USE AMONG ADOLESCENT MOTHERS

Abstract

This thesis examines how young parents arrange child care for infants and

toddlers, using a sample of adolescent mothers participating in an evaluation of a

statewide home visiting program, Healthy Families Massachusetts (HFM). It

describes the range of child care decisions mothers make, and determines the

extent to which selected characteristics are related to these choices.

The literature suggests that child care choices and policy for these mothers

are constrained by the same factors that influence all mothers’ care choices:

quality, access, and affordability. As expected, findings from this thesis suggest

that several maternal characteristics, including education/employment and

voucher use, are associated with child care choices. While participation in home

visiting can emphasize the importance of child care and direct choices to some

degree, this association was not observed in this study; insofar as HFM does not

explicitly work to optimize child care choice, so this finding was expected.

It is recommended that home visitors inform clients about quality care and

support them in accessing care, given their role in helping young parents. Despite

the lack of association between teens’ self-reported financial resources and care

use or type of care in this study, the long wait list for vouchers and high rates of

relative care use indicate cost may be a hurdle for parents in using more group

care. This thesis is informative in guiding future work that combines the efforts

of home visiting and child care to improve the outcomes of children of adolescent

parents.

ii


Acknowledgements

This thesis would not have been possible without the support and guidance

of my adviser, Fran Jacobs. You provided much needed direction, confidence,

wisdom, and encouragement throughout this thesis and my time at Tufts. I am

incredibly grateful to have had the opportunity to learn from you and be mentored

by you. I would also like to thank my committee members, Barbara Parmenter

and Becky Fauth. Thank you for providing a critical eye and for offering your

assistance and guidance. I also appreciate the support of the entire Massachusetts

Healthy Families Evaluation team, including Maryna Raskin and Erin Bumgarner,

who served as readers during the earlier stages of writing. To my extended family

and friends, I am truly grateful for your love and support throughout my

endeavors. Finally, I would like to thank my parents, brother, and husband for

their love, support, and encouragement. Thank you for believing in me.

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Table of Contents

Abstract............................................................................................................ii

Acknowledgements.........................................................................................iii

Introduction......................................................................................................1

Chapter One: Literature Review.......................................................................5

Chapter Two: Child Care and Home Visiting in Massachusetts....................32

Chapter Three: Methods.................................................................................41

Chapter Four: Results.....................................................................................54

Chapter Five: Discussion................................................................................59

References......................................................................................................69

Tables.............................................................................................................77

Figures............................................................................................................82

Appendix........................................................................................................86

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List of Tables

Table Page

1. Variables for Analysis................................................................................85

2. Maternal Characteristics and Care Usage..................................................86

3. Mother Reported Child Care Arrangements..............................................87

4. Recoded Child Care Arrangement.............................................................88

5. Significant Findings: Maternal Characteristics and Care Type..................89

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List of Figures

Figure Page

1. National evidence-based home visiting programs......................................90

2. Massachusetts home visiting programs......................................................91

3. Thesis sample logic tree based on participants in the MHFE-2 study...... 92

4. Recoded categories of care based on responses from Intake Interview.....93

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Child Care Use among Adolescent Mothers Enrolled in a Massachusetts

Home Visiting Program

Researchers have focused their attention on adolescent pregnancy and

adolescent parenting for decades (Semmens, 1965; Babikian & Adila, 1971;

Rickel, 1989; Kirby, 1999). While adolescent births have been on the decline

overall, “more than one in six adolescent girls is projected to give birth before

turning 20” in the United States (Mollborn & Blalock, 2012, p. 846). Although

many of these babies and their parents do well as they mature, there are also

reasons for public concern for these families. Indeed, young mothers often face

more challenges than do their older counterparts, such as limited financial

resources, housing instability, lack of social supports, depression, and difficulty

coping with high degrees of stress (Letourneau, Stewart, & Barnfather, 2004;

Luster et al., 2000; Mollborn & Blalock, 2012). These compounded challenges

can lead to poor parent and child outcomes, which is why home visiting programs

aim to improve a diverse set of outcomes for both children and their families

(Lanier, Macguire-Jack, & Welch, 2015).

Developmental theorists and researchers, now for generations, have

highlighted the central contributions to young children’s development made by

the multiple contexts in which they live – parents, family, neighborhoods, child

care and schools, and communities as well. (See, for example, attachment theory

[Bowlby, 1969]; ecological theory [Bronfenbrenner, 1979].) Early negative

experiences can result in adverse outcomes, while positive experiences can lay the

foundation for future success. And of course, this is not a zero-sum situation;

1


negative circumstances and experiences can be overcome or mitigated by positive

ones. An increasingly robust literature on resilience in childhood and adolescence

attests to the many opportunities that exist to promote healthy development

(Zolkoski & Bullock, 2012).

There are numerous points of entry for public policy to help support young

families; this thesis focuses on only two – home visiting and child care. Home

visiting programs offer parent education and support to a wide range of families,

many of whom are considered “at-risk.” They represent a diverse set of purposes,

however most often they aim to improve parents’ parenting-related knowledge

and competence, and enhance parents’ sense of confidence. A growing body of

evidence suggests that home visiting –theoretically informed and strategically

implemented – is, indeed, an effective strategy (Avellar et al., 2016; Supplee &

Adirim, 2012; Olds et al., 2004), though programs do also vary considerably in

quality and availability (Sweet & Applebaum, 2004; Caldera et al., 2007).

Decades of research on the effects of child care on early child

development unequivocally reinforce the power of this service to enhance child

development and well being (Zigler, Taussig, & Black, 1992; Vandell & Wolfe,

2000; Zigler, Finn-Stevenson, & Linkins, 2015). The key here, however, is the

quality of the program, and the availability of child care arrangements that

promote growth. High quality early care and education promises significant

benefits, particularly to young children in “risky” circumstances (Landry et al.,

2014). Poorer quality child care can be detrimental (Burchinal, Roberts, Nabors,

& Bryant, 1996). The availability of high quality child care varies dramatically by

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geography, age of child enrolled, and the parent’s ability to pay, to name only a

few of the relevant factors. As regards to this thesis, the situation is even more

complicated, since there is a relative paucity of research on the usual child care

environments for babies and toddlers – in-home family child care, relative care,

etc. Since these situations are often unregulated, there is an assumption that their

quality, in turn, is often compromised.

In sum, adolescent parents and their children often face significant

challenges, but those challenges can be met, often to good effect, with a

combination of personal, familial, and societal resources. Home visiting programs

for young parents, and quality early childhood care environments, are two

promising approaches on the public end of this continuum. However little is

known both about the child care choices young mothers currently are making for

their babies, and whether participating in home visiting programs yields different,

potentially better, ones. This thesis, then, seeks to document the care

arrangements of young mothers and to understand whether and to what degree

participation in a home visiting program, Healthy Families Massachusetts, is

related to the care arrangements selected by mothers. It represents a modest first

step toward improving the options, and the selection of child care for these

families.

This thesis proceeds as follows: First, I present a literature review with

theoretical assumptions grounded in child development and summaries on home

visiting and child care. Next, I examine child care and home visiting in

Massachusetts, providing a local context for policies and programs. I then

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introduce the study by reviewing the research questions and methods of the thesis.

I present the results after performing statistical analysis. I conclude with a

discussion on the findings and offer recommendations for future research and

practice.

4


Chapter One: Literature Review

The review of literature that follows provides a brief roadmap to the

conceptual basis for this thesis. I examine two developmental theories that help

explain the importance of home visiting and quality child care on children’s

development. Then, I discuss briefly what researchers and policy makers know

about teen parenting trends and the outcomes of children of teen parents. Through

examining the conditions under which teens parent, it becomes evident that teens

often are in need of extra support in order to raise healthy, thriving children. One

support that is discussed in this section is home visiting, through which parents

and families receive guidance on how to support their children’s development.

The section on home visiting provides a closer look at a few leading programs,

their efficacy, and the policies that affect home visiting. A discussion on

children’s well-being would not be complete without examining child care, a

basic necessity for all children, whether provided by a parent or someone else. I

review child care policies, types of child care, and conditions under which parents

choose care.

This review concludes with discussing the relationship between home

visiting and child care, which can be offered under a single auspice, as in the case

of Early Head Start (EHS), or operate as separate programs or policies, with an

emphasis on context within Massachusetts. This thesis proposes bridging these

two crucial policies more effectively, to improve the outcomes of children, given

the research covered in this section.

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Theoretical Assumptions

By now an extensive literature of theory-based developmental research

has shown that children’s early experiences greatly affect their future

development (see Shonkoff & Phillips, 2000, for a summary). Of the dozens of

theories that apply, I note two here by way of example: attachment theory and

ecological theory.

Attachment theory pertains to the presence or absence of an emotional

bond between a caregiver and child (see, for example, Bowlby, 1969; Ainsworth,

1978; Harlow & Harlow, 1969). These bonds initially develop from the caregiver

meeting the child’s needs for food, warmth and other essentials, but can be

influenced by other factors such as responsiveness or emotional availability.

Attachment theory serves as a foundation for understanding parent-child

relationships, especially in the early years, though it is seen as relevant to

adolescents and adults as well. Children begin to attach to their primary caregiver

within the first moments of life and continue to develop this bond throughout life.

At the core of the theory is a categorization of the quality of the attachment

between child and mother/parent: secure, insecure avoidant or insecure

ambivalent, and disorganized. The main types of attachment, as defined by

Ainsworth et al. (1978), are briefly described in further detail.

The attachment relationship has been measured in a variety of ways, but

often through the Strange Situation procedure, an experiment during which the

child is separated from the parent, and subsequently reunited (Ainsworth & Bell,

1970; Ainsworth, Blehar, Waters, & Wall, 1978; Main & Solomon, 1990).

6


Observations of the child’s reaction to the separation and the reunion help

characterize the type of attachment the child has. Children who display secure

attachment will generally cry when separated from the mother, but will eagerly

reconnect when the mother returns. Children who have secure attachment can

recover after this separation and resume play, knowing their mother (or other

figure) is nearby in case of need. Children who have insecure avoidant

attachment do not show concern when the parent leaves and avoid the parent

upon return. Children with insecure ambivalent attachment will be highly

emotional upon separation and seek comfort upon the mother’s return, but will

have difficulty in calming down and returning to normal play after the separation.

Children with disorganized attachment may display contradicting behaviors, or

not have a clear method of seeking comfort from the mother.

Secure attachment is commonly associated with positive outcomes, such

as higher cognitive performance. One explanation, provided by West, Matthews,

and Kerns (2013), is that secure attachment is facilitated by responsive, nurturing,

and sensitive care from the mother/attachment figure. These interactions, in turn,

help improve the child’s cognitive ability (measured by academic performance

and IQ). In their research, West and colleagues also found that other forms of

attachment (insecure, disorganized) did not show a positive association with

cognitive performance.

If secure attachment can be associated with positive outcomes, are other

types attachment associated with adverse outcomes? In one study, O’Connor and

McCartney (2007) looked at attachment relationships and cognitive skills of

7


children using data from the National Institute of Child Health and Human

Development Study of Early Child Care and Youth Development. The study

looked at participants who completed a specific measure, an assessment of

maternal attachment patterns, when the child was 36 months old, and remained in

the study until the child was in first grade. Using regression models, the

researchers found that children with ambivalent and insecure/disorganized

attachment scored lower on the cognitive assessments than secure and avoidant

children, meaning maternal attachment has an effect on cognitive skills and is a

strong predictor. They suggest that programs offer services to mothers and

children with insecure attachment to help improve communication, thereby

developing cognitive skills in children, and teachers gain awareness of attachment

to prevent replication of insecure attachment with their students.

Given these possible negative outcomes, understanding attachment theory

is especially important for adolescent mothers, who are a unique population when

it comes to parenting. Flaherty and Sadler (2011) reviewed literature on

attachment in the context of adolescent parenting. One overarching theme in their

research was the conflict between the adolescent – who is still developing – and

the parenting responsibilities that she must assume. Adolescents tend to be

egocentric, often resulting in less sensitivity and responsiveness to others, as

compared adults. This lack of sensitivity and responsiveness can contribute to a

less optimal attachment relationship. The researchers continue by proposing that

certain professionals, like doctors, can coach teen parents to help their child form

8


more secure attachments, like understanding cues from their child and engaging in

positive interactions.

Attachment theory undergirds the practice of many newborn home visiting

programs (see Korfmacher et al., 1997; Olds, 2002, 2006), since these programs

focus on encouraging and strengthening this intimate relationship between a

parent and his/her child in a variety of ways. In one study involving Canadian

families, researchers found that parents benefited from home visiting programs

grounded in attachment theory (Moss et al., 2011). The study involved video

taping parent-child interactions, followed by coaching in maternal sensitivity

provided by college educated “interveners” (Moss et al., 2011). Home visiting

programs, such as the model described by Moss et al., help parents understand the

development of their babies, and by so doing, become more responsive to their

children’s needs. Home visiting also works to validate the challenges of

parenting, which “normalizes” the frustration, impatience, and exhaustion new

mothers feel. By depersonalizing these experiences for the mother – that is, by

conveying the lack of malevolent intentions on the baby’s part – programs argue

that mothers are more apt to maintain a positive view of their children. Newborn

home visiting programs may also address the post-partum depression that

accompanies some mothers’ entry into parenthood; again, when effective, these

steps makes access to a positive relationship between mother and baby more

likely. This, in turn, helps to build secure attachment (Sadler et al., 2013; Nugent,

Bartlett, & Valim, 2014; Tandon, Leis, Mendelson, Perry, & Kemp, 2014).

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Child care, similarly, should attend to issues of attachment between young

children and their non-parental caregiver(s) (Bowlby, 2007). Caregivers can help

foster secure attachment through practicing behaviors that make a child feel safe

and comfortable, and responding to the child’s needs (Drugli & Undheim, 2011).

Physical care, such as providing shelter and food, is not sufficient in developing a

secure attachment; the care provider must also be emotionally supportive,

affectionate and loving. Attachment theory helps to highlight the critical role

caregivers play in children’s lives as children can have multiple attachment

figures. Caregivers can work in conjunction with parents and families to help

children grow. (A more in-depth conversation on child care follows shortly.)

Another developmental orientation that aids in setting the context for this

study is ecological systems theory, first popularized in the field of child

psychology by Urie Bronfenbrenner (1979). Ecological systems theory is the

“scientific study of the progressive, mutual accommodation between an active,

growing human being and the changing properties of the immediate settings in

which the developing person lives, as this process is affected by relations between

these settings, and by the larger contexts in which the settings are embedded”

(Bronfenbrenner, 1979, p. 21). The theory is best represented as a nested model,

with four different levels or structures, and places the child (or person) in the

middle of the structure. The structures, from closest to the child to most removed,

are micro-, meso-, exo-, and macrosystems. The microsystem is a setting where

the child has direct interactions, such as the home, a playground, or daycare, and

is located closest to the child in the structure. A mesosystem is located one layer

10


further in the model and is considered the interactions of multiple microsystems,

for example, the connection between daycare and the home. The exosystem

includes a setting (or multiple) that the child does not interact with directly, but

has an effect on him/her, or that s/he affects (bidirectionality). An example of an

exosystem is parents’ personal and professional network, as their networks can

influence one’s interests, morals, behaviors, all which, in turn, affect the child.

The final tier in the ecological model is the macrosystem, which represents the

characteristics (attitudes, beliefs, lifestyles) of the culture of the child. The culture

can refer to religion, socio-economic class, political party, and more.

Key to Bronfenbrenner’s theory is the bidirectionality of the model, in

which the systems affect the child and the child affects the systems. Because the

model represents human interactions, the relationships the child has with the

various systems, and people within the systems, evolves constantly. For example,

a new sibling can alter the child’s microsystem, and a new legislation can affect

the child’s macrosystem, both of which can alter the child’s behavior

(Bronfenbrenner, 1979). This theory is an appropriate framework to consider here

because it underscores the necessity to attend to the multiple settings in which a

child develops, and to understand more fully how these setting interact with one

another.

Teen Parenting

Social policy for children and families in the U.S. is aimed at ensuring the

best possible outcomes for this population, often for those deemed at-risk. One at-

risk population is teen parents and their children. While parenting can be a

11


challenging endeavor at any age, teens are more likely to have difficulty

parenting, as they themselves are still developing into adults, may have fewer

supports, or are likely experiencing compounded challenges (Letourneau, Stewart,

& Barnfather, 2004). This is concerning as there is a significant population of teen

parents in the U.S. (Mollborn & Blalock, 2012). This section addresses the

frequency at which teens are becoming parents, common challenges or risk

factors associated with being a teen parent, and programs and policies that can

help teens and their children thrive despite common obstacles.

The demographics of teen parenting. The rate of children born to teens

has varied over the past 20 or so years. According to the Center for Disease

Control (CDC), in 2013, the birth rate was 26.5 births per 1,000 women between

the ages of 15 and 19 for a total of 273,105 births (Martin et al., 2015). Only 12.3

births per 1,000 women were to those between 15 and 17 years old, whereas 47.1

births per 1,000 women were to those ages 18-19. Among younger teens, the birth

rate is 0.3 births per 1,000 women ages 10-14. The birth rates in Massachusetts

are the lowest in the nation at 12.1 births per 1,000 teenage women ages 15-19;

the highest birth rates are in Arkansas at 43.5 births per 1,000 women of the same

age (Martin et al., 2015).

These rates have declined over the years likely showing, in part, positive

results in efforts to reduce teen births and pregnancy. The year of 1991 is a pivotal

point because prior to that, teen birth rates had been on the rise; between 1986 and

1991, teen birth rates increased 24% (Donovan, 1998). For teens 15-19 years old,

the birth rate has declined by 10% since 2012, and 57% since 1991. For the

12


younger portion of the group, teens 15-17 years old, the rates have decreased by

13% since 2012 and 68% since 1991. For teens 18-19 years old, the rates have

decreased by 8% since 2012 and 50% since 1991 (Martin et al., 2015).

Concerns. While some national trends show promising change in the

frequency of which teens are becoming parents, there are still many children born

to teen parents each year. Additionally, certain subpopulations show high rates of

teen births than others. For example, while non-Hispanic white women, ages 15-

19, have birth rates of 18.6 per thousand women, Hispanics, blacks, and American

Indian/Alaskan Natives ages 15-19 had almost double the birth rates or more at

41.7, 39.0, and 31.1 per thousand women respectively. Not only are these rates

higher than those of non-Hispanic white women, it is also higher than the average

for women 15-19 years old across all races/origins (26.5 births per thousand

women; Martin et al., 2015). Birth rates to teen women of Asian/Pacific Islander

descent were the lowest, at 8.7 births per 1,000 teen women (Martin et al., 2015).

Additionally, the Center for Disease Control found that one in five teen births is a

repeat birth—having two or more children before age 20 (CDC, 2013). Having

multiple children at a young age can magnify the existing difficulties with

parenting, and can make it more difficult for these young parents to study or

work.

Children born to adolescent mothers are more likely to be considered at

risk, because of the negative outcomes in areas such as physical and mental

health, cognitive and social development, and academic achievement that they

will likely face. For example, teen mothers are at greater risk for mortality and

13


hypertension, while their children are at risk for premature birth, low birth weight,

and mortality within their first year (see East & Felice, 2014). It is difficult to

extract the cause of these outcomes because many environmental factors, such as

poverty, likely contribute to these effects.

One framework that speaks to the challenges teens face as parents is that

of cognitive readiness, an idea that includes understanding how children develop,

approaching parenting with a mature attitude, and knowing what parenting

practices are considered appropriate (Whitman, Borkowski, Keogh, & Weed,

2001). Parents who are more cognitively ready tend to be better parents, while

adolescents, given their generally earlier stage of development, may be less

cognitively ready. This less ready state can be exhibited through reduced maternal

sensitivity, less emotionally responsive to their child and showing hostile

behaviors (Whitman, Borkowski, Keogh, & Weed, 2001; Chico, Gonzalez, Ali,

Steiner, & Flemming, 2014; Rafferty, Griffin, and Lodise, 2011). Children

exposed to these qualities had poorer cognitive and receptive language abilities

than did similar children born to adult mothers (Rafferty et al., 2011).

Resilience and protective factors. Despite challenges and concerns

regarding young parents, of course not all children of teen parents have poor

outcomes. The children (and their mothers) who are able to have positive

outcomes exhibit resilience, that is, achieving positive outcomes despite

experiencing prolonged or repeated stress (Rutter, 2006). Factors that aid in

overcoming adversity are promotive or protective factors, such as social supports

and self esteem, that counter the effects of any harmful factors (Rutter, 2006;

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Zimmerman et al., 2013; Bartlett & Easterbrooks, 2015). It is not always possible

to reduce the exposure to risk, such as poverty, but it is possible to enhance and

develop the strengths or potential strengths that do exist – both within the

individual mothers and children, and in their environments; this might be done,

for example, by creating more supportive social networks.

Given what research has told us about the risks associated with teen

pregnancy, how can existing programs and services work toward promoting

positive development for the mothers and babies alike? Two services are critical

to the conversation. The first is home visiting programs, as many target at-risk

mothers. While the eligibility requirements for programs may vary greatly across

the field, the research presented has illustrated why teen mothers often fall into

several risk categories—poverty, low education attainment, and stress—that these

programs focus on.

The second service that is critical is child care. While most parents will

have a need at some point for child care, young parents, in particular, may be

interested in using child care so they can return to school or work, or because they

need respite from the demands of parenting. Both home visiting and child care

can act as protective factors, helping both parent and child, despite all the

potential risks for negative outcomes they face, and are described in further detail

below.

Home Visiting Practice

Home visiting, in its current basic iteration, has been in existence since the

1880s, and currently boasts a large network of programs around the country

15


(Sweet & Applebaum, 2004). Home visiting programs typically aim to help

children achieve positive outcomes by targeting parents and families, teaching

skills, helping them obtain social services, and providing individual attention and

support.

Home visiting describes how a service is provided, that is, within the

home; however, the service provider and the service can vary from program to

program (Howard & Brooks-Gunn, 2009). There is a wide range of variation

among home visiting models. Some goals of home visiting programs are to

improve maternal and child health, prevent child abuse and neglect, promote

school readiness, reduce crime and domestic violence, improve family economic

self-sufficiency, and enhance the collaboration and referrals of community

resources. Home visiting programs can employ trained professionals or

paraprofessionals to teach parents about basic child development, provide

resources, such as information related to child care, school, work, or public

assistance, and offer social support, giving parents the opportunity to share how

they are feeling (Sweet & Applebaum, 2004; Supplee & Adirim, 2012; Olds et al.,

2004). They may target a specific population, such as teenage parents, or first

time parents. Furthermore, they may implement a specific curriculum or stipulate

the frequency of visits. Regardless of who and what the programs deliver, home

visitation shares the core belief that serving children and their families within

their home will enhance parenting for more positive long-term outcomes for

children (Howard & Brooks-Gunn, 2009).

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Evidence-based models. Over the past 30 years, dozens of home visiting

program models have emerged, some of which – for example, the Nurse Family

Partnerships (NFP), Early Head Start (EHS) and Healthy Families America

(HFA) – are now implemented on a national basis. NFP participants receive

health services at medical facilities and periodic home visiting services from a

nurse, while EHS delivers a combination of home based and center based

activities focused on parent education and child development (Eckenrode et al.

2010; Mayoral, 2013). HFA, the program from which Healthy Families of

Massachusetts, the focus of this thesis, is modeled, aims to reduce child

maltreatment, build community partnerships, promote healthy outcomes for

children and families through almost 600 affiliated HFA program sites in 40

states, US territories, and Canada (Daro & Harding, 1999; Harding, Galano,

Martin, Huntington, & Schellenbach, 2007). The U.S. Department of Health and

Human Services identifies these, as well as 14 other programs as evidence-based

models, as part of the Home Visiting Evaluation of Effectiveness (HomVEE)

review, which examines the research and literature on home visiting programs for

children from birth through age five and their mothers to identify home visiting

programs that are proven to be effective (Avellar et al., 2014). The 17 evidenced-

based programs are detailed in Figure 1.

Avellar et al. (2014) found that these 17 evidence-based program models

showed multiple favorable outcomes and positive impacts that lasted at least one

year post-enrollment, across the total samples; however, these outcomes were not

replicated across the same program using multiple samples (for example, at other

17


service sites) and there were a few unfavorable or ambiguous effects from the

programs. One gap in the research was the ability to measure the effectiveness of

programs on subgroups. Despite diverse samples, often the subgroup samples

were too small to measure for specific types of families, such as immigrant or

military families (Avellar et al., 2014). The evidence for home visiting with first-

time young mothers is particularly spare, though recent findings of HFM – the

program under discussion in this thesis – are promising (Jacobs et al., 2016).

Continued research on these programs will help clarify the knowledge in the field,

and help home visiting maximize its potential effectiveness in serving children

and families.

Federal home visiting policy. Significant federal investment in home

visiting began with the introduction, in 1995, of Early Head Start (EHS), a

downward age extension of the national Head Start program, serving at-risk and

low-income families. EHS combines center-based and home-based services to

support child development, language acquisition, positive family relationships and

more (Paulsell, Kisker, Love & Raikes, 2002; Love et al., 2005). With the

exception of EHS, until recently home visiting has only been funded in a targeted,

discretionary manner by states and localities.

The first federal funding for home visiting appeared in the 2010 Patient

Protection and Affordable Care Act (PPACA), providing $1.5 billion over five

years, to states, territories, non-profits, and Tribal grantees, to implement the

Maternal, Infant, Early Childhood Home Visiting (MIECHV) program.

According to the Health Resources and Services Administration website,

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MIECHV programs target at-risk pregnant women and families to provide them

with resources and skills to raise a healthy child. In addition to funding the

programs, MIECHV also funds research, working in conjunction with HomVEE,

to identify evidence-based programs (U.S. Department of Health & Human

Services, n.d.). In 2015, Congress authorized additional funding until 2017

through a two-year extension (the Medicare Access and CHIP Reauthorization

Act of 2015). This funding stream substantiates the increased visibility of home

visiting, and its promise as a beneficial child and family support.

Child Care Practice

Like home visiting, child care – supervision and support for young

children when their parents are not physically present – has evolved over time,

based on the historical and social contexts in the U.S. In the first part of the 20th

century, especially during the Great Depression, day nurseries were established,

primarily as a way to increase the number of women in the workforce so as to

build the economy (Nourot, 2005). Similarly, publicly funded child care was

broadly available during the Second World War so that women could work in

defense-related manufacturing and contribute to the War effort. Public support for

women’s employment waned after the soldiers returned home, but the number of

working mothers increased steadily over the next half-century. Indeed, some

argue that this shift in the labor force to include mothers has “been the single

biggest demographic shift to influence the demand for early care and education”

(Kostelnik & Grady, 2009, p. 3).

19


More recently, conversations around child care have shifted the focus of

the primary beneficiaries of service from mothers needing to work, to the

children– providing a solid foundation for them, especially those at-risk. A prime

example is the aforementioned Early Head Start and Head Start, which helps

provide low-income children a strong foundation for future learning. Child care,

often viewed as a private matter, became a public issue as there was increasing

concern over the safety particular children in particular circumstances. More

specifically, concerns over the ability of disadvantaged mothers to care for their

children, have generated policies in the form of subsidies, vouchers, and other

programs to help compensate for the perceived inadequate upbringing these

children receive (Danziger, Ananat, & Browning, 2004; Conley, 2010). These

supports are further discussed shortly, when examining the affordability of child

care. The remainder of this section highlights the various types of child care; the

context in which parents make child care choices: quality, affordability,

accessibility; and how parents actually make those choices.

Types of child care. The 2012 National Household Education Surveys

Program, which represents an estimated 21.7 million U.S. children, found that

approximately 60% of children under the age of 5 use at least one weekly, non-

parental care arrangement (Mamedova, Redford, & Zuckerberg, 2013). Forty-six

percent of children under 1 year old had at least one weekly, non-parental care

arrangement, while 54% and 76% of children ages 1-2 and 3-5, respectively,

experienced similar arrangements (Mamedova et al., 2013). I briefly describe

below several types of non-parental child care arrangements based on a similar

20


classification used by researchers (see Burchinal et al., 2015; Pungello & Kurtz-

Costes, 1999; Zigler, Marsland, & Lord, 2009). This includes relative care,

center-based care, family daycare (sometimes referred to as home-based care),

and a “catch-all” category that includes care provided by non-relatives and are not

in a group setting (ie. center-based or family daycare). A discussion of multiple

arrangements is also included, as parents often use several types of care.

Relative care. One common type of care used by families is relative care,

with grandparent care being most common. The use of grandparents as care

providers has increased for many reasons, including: longer life-spans of the

grandparents, greater portions of families living in multigenerational households,

financial circumstances, and cultural practices that consider relative care a

common practice (Burnette, Sun, & Sun, 2013; Mutchler, Lee, & Baker, 2002;

Vandell, McCartney, Owen, Booth, & Clarke-Stewart, 2003). Grandparents are

living longer, and in the case of adolescent mothers, are often becoming

grandparents at relatively early ages. This means they are more likely to be

physically able to help care for young children than past generations of

grandparents.

In addition to grandparents, other relatives may serve as a child care

provider. For example, Mexican-American families in the U.S. tend to live with

or near extended family members to broaden their network of support (Sarkisian,

Gerena, & Gerstel, 2007). In addition to any financial or emotional support they

may receive by living in close proximity to family, these extended family

households or communities can also provide access to affordable or free child

21


care, provided by a relative (Mollborn & Blalock, 2012). Furthermore, some

voucher programs or subsidies allow for relatives who meet program

requirements to receive payment for providing child care services, which may

also affect the use of grandparent care (Blau, 2003). Having these extra supports

speaks to the importance of relative care, especially given some of the challenges

adolescent mothers face when parenting.

Center-based care. Center-based care includes EHS and preschool, tends

to be more formal with a curriculum or instruction activities and heightened

licensing requirements. Although states differ in how they define and regulate this

form of child care, the following Code of Massachusetts Regulation definition of

center-based care contains elements common across states: “A facility… which

receives children, not of common parentage, under seven years of age, or under

16 years of age if these children have special needs, for non-residential custody

and care during part or all of the day separate from their parent(s)” (606 CMR

7.00, 2010).

Some mothers, especially those with set work or school schedules, may

prefer center-based care as centers typically have reliable hours (Fothergill, 2013).

Center-based care tends to have more formally stated care philosophies, and

emphasize social development, discipline or provide a school-like environment

(Lightfoot, Cole, & Cole, 2007). Staff and administrators typically need to have

formal training in early childhood education or a related field. The group setting is

more often based on age, and has organized activities (Zigler et al., 2009).

22


Family child care. Family child care or home-based care operates out of

the provider’s home and provides regular care for a group of 10 children or less

(606 CMR 7.00, 2010). Family child care also has a tendency to engage children

of different ages, offering a more diverse social circle and new setting. This can

aid in the building of skills such as socialization with peers and adjusting to new

routines (Lightfoot, Cole & Cole, 2007). Due to the less stringent regulations than

center based care and wide range of service providers, it is often difficult to

qualify the quality of family child care as a whole (Zigler et al., 2009).

Non-relative/non-group care. A final genre of care can be categorized as

non-relative/non-group care. This includes care by friends (paid or unpaid) or

hired employees such as babysitters or nannies. This care is often provided within

the child’s home and tends to be the least “formal” type of care, with little to no

regulations. While background checks may be a good idea for parents looking to

hire care givers within the home, parents are free to choose their own

Multiple care arrangements. Often times, children experience more than

one type of child care (Gordon, Colaner, Usdansky & Melgar, 2013; Scott,

London & Hurst, 2005). Multiple care arrangements can exist concurrently or

longitudinally. In the first instance, children are cared for in more than one setting

over the course of defined period of time. So, for example, a child may spend the

bulk of each day in a child care center and then be picked up by a babysitter and

tended to for a number of hours each day as well. In the second instance, only one

care arrangement is used for a period of time (e.g., several months, a year, etc.),

but stopped for another care arrangement. This arrangement is considered a

23


sequential multiple situation, as when a child become old enough (i.e., 3 years

old) to enroll in a center, and so leaves the care of his grandmother. This also

pertains when there are different seasonal arrangements.

The child care trilemma. Gwen Morgan (1986), one of the nation’s

premier child care policy experts, offers a framework— the “trilemma of child

care”—that reflects what she sees as the core elements of the challenges of the

child care system that affect consumers (families and children), practitioners, and

policy makers. Morgan and other commentators (see, for example, Brauner,

Gordic, & Zigler, 2004; Gormley, 1995; Zigler et al., 2009) argue that, similar to

a three-legged stool that requires legs of equal length to be sturdy, child care also

needs adequate, equal attention to three of its structural dimensions: quality,

affordability, and accessibility. The following sections examines each of the legs

in greater detail.

High quality child care. Given the variety of child care options that exist,

how can parents determine what constitutes a high quality care arrangement? It is

commonsensical to state that the quality of a child care setting will affect the

quality of the child’s experience in it and their future outcomes. Volumes of

research have been undertaken, however, to tease out the particular characteristics

– for example, physical set-up, staff qualifications, curriculum, etc. – in particular

combinations, that are most consequential for children; practitioners and

policymakers have added their wisdom to the discussion. Additionally, there are

more formal measures of quality, including accreditation by the National

Association for the Education of Young Children (NAEYC) and rating scales like

24


the Early Childhood Environment Rating Scale (ECERS; Harms, Clifford, &

Cryer, 2005 in Burchinal et al., 2015). Across all the indicators of quality care,

most can be organized into three main categories: factors related to child-adult

relationships, structural features of care, and context in which the care is provided

(Phillips & Lowenstein, 2011).

Child-adult relationships. As mentioned earlier, attachment theory

highlights the interactions between an adult and a child. While the theory is most

applicable to children’s relationship to a parent, children may also form

attachment relationships with other adults, especially caregivers. This category

includes the developmental appropriateness of the caregiver’s verbal and

cognitive stimulation, sensitivity and responsiveness to the child, attentiveness,

and support. High quality care in this category may include a caregiver who

listens to and acknowledges a child’s feelings or offers comfort when a child is in

distress (Burchinal et al., 2015).

Structural features of care. Structural features include characteristics of

the program/environment and the provider (Burchinal et al., 2015). The physical

space should be free from harmful objects, incorporate proper health procedures,

and provide learning materials based on an appropriate curriculum. Other factors,

like a low child to adult ratio, may not be directly indicative of high quality care

but may help increase the quality of care through other means. For example,

adults in centers with a lower child to adult ratio have more time to spend with

each individual child and therefore the children may receive more feedback or

attention (Phillips & Lowenstein, 2011).

25


Context of care. Finally, context includes the policies and regulations

under which programs or providers operate. There are variations across states

with licensing requirements to be a child care provider. These licensing

requirements typically include regulations on aforementioned structural features,

such as maximum child to adult ratios or minimum education, and safety

regulations, such as criminal background checks.

Limitations in determining quality of care. These characteristics might not

accurately depict the quality of care experienced by children and families. For

example, most of the policies or regulations that exist apply to center-based or

family child care. Care provided by family, friends, or a hired sitter cannot be

measured to the same degree. Even within these two more “formal” types of care,

it may be difficult to measure the quality because of the inherent differences in

consumers and their individualized experiences using care. For example,

Burchinal et al., (2015) found that while center care is commonly regarded as the

highest quality of care, it ranked the lowest in quality for infants and toddlers. For

older, preschool children, center based care was indeed the highest ranked type of

care. The discrepancy likely stems from the different needs infants and toddlers

have as compared to preschool children. Furthermore, special needs, such as

language spoken at care, or accommodation for disabilities for children, also must

be considered when assessing quality. It quickly becomes evident that there is no

one recipe or rubric for quality, but many factors that influence it.

Care for infants and toddlers is of particular interest in this review.

Research shows that in the early years, children develop attachment to a central

26


figure and form a foundation for their future growth and more. When looking at

infants and toddlers in the care of others, there have been mixed findings in the

research, arguing both that non-maternal care is unsafe, and that it is an

acceptable, even desired, form of care (Belskey, 1986, 1987 in Zigler et al., 2009).

Continued work in understanding care for infants and toddlers shows that

argument of nonmaternal versus maternal care is less important than the quality of

care, for the child’s later development (Zigler et al., 2009). Knowing that many

mothers nowadays must work or attend school, due to policies or choice,

furthering understanding quality care is critical to ensuring positive outcomes for

children.

Affordability. In a study of the affordability of child care of countries

belonging to The Organisation for Economic Co-operation and Development

(OECD), Immervoll and Barber (2006) found that the average cost of care for two

year olds is 16% of the gross earnings of an average production worker (APW).

The U.S. is slightly higher than the average at 18% APW. This amount reflects

what parents pay after subsidies, for a month of care at accredited centers for

children ages two to three. While this statistic may not be alarming at first glance,

for certain populations, child care is less affordable. For single parents who rely

on one income, the cost of care for infants averages to 24% of the median income

across the country in 2014 (ChildCare Aware, 2015). For single parents in

Massachusetts, infant care is approximately 63% of the parents’ income at

$17,000 per year at a center (ChildCare Aware, 2015).

27


Child care subsidies and vouchers. Policies in the form of subsidies and

vouchers exist to make child care more affordable to parents in need, so parents

can provide their child with a high quality early education and care experience. In

theory, this helps the child through providing quality care, and the parents by

giving them an opportunity to study or work, thereby increasing their

socioeconomic resources.

One such policy, the Personal Responsibility and Work Opportunity

Reconciliation Act of 1996 (PRWORA), also known as welfare reform,

restructured welfare eligibility requirements through authorizing the Temporary

Assistance for Needy Families (TANF) program. This change encouraged states

to move people from welfare to work and also supported funding for vouchers

and child care subsidies for early education and care for low-income families

(Scott, London & Hurst, 2005; Danziger, Ananat, & Browning, 2004).

Despite the support available for parents and children in need, few

families receive the full support they need. In 2009, only 18% of federally eligible

children, 2.51 out 13.76 million children, received subsidies or vouchers (United

States Department of Health & Human Services, 2012). This figure dropped

slightly in 2011, with 17% of federally eligible children, 2.4 of 14.26 million

children, receiving subsidies or vouchers (United States Department of Health &

Human Services, 2015). In Massachusetts, there were almost 27,000 children

estimated to be on a waiting for subsidized care (Ebbert, 2015). It is obvious that

the system of subsidies and vouchers is far from a perfect solution to making child

care affordable. In addition to under serving a large population in need, there is

28


also conflicting research on the quality of care that is purchased with subsidies.

Because care can range from center-based to kith-and-kin care, which is often

unregulated besides a background check requirement, it is difficult to regulate the

quality of care (Fuller, Kagan, Loeb, & Chang, 2004).

Accessibility. The issue of accessibility can be interpreted in a number of

ways. The obvious challenge of accessibility is how easy or difficult it is to secure

the care arrangement altogether. The hours available for care may also not match

what the family needs, as is the case when parents work non-traditional hours. In

some areas, especially rural ones, the closest care arrangement might not be

conveniently located (Shoffner, 1986). Children and families may factor in other

requirements, such as accommodations for special needs or disabilities, or

language skills. These practical, logistical needs are factors that contribute to the

challenges parents experience when deciding on care (Vandenbroeck, De

Visscher, Van Nuffel, & Ferla, 2008). Issues with accessibility also affect the

affordability of care; if care is not conveniently located or open during the hours

needed, it can impose added costs in the form of additional travel costs and time,

or lost wages from a limited work schedule (Herbst & Barnow, 2008).

Making child care choices. Now that we have examined the difficult

context in which parents make child care choices, we can take a closer look at

how parents make these choices. Understanding how parents make their choices is

crucial to this thesis as we investigate whether or not home visiting has a

relationship to the types of care arrangements parents use.

29


For example, parents may be influenced by personal beliefs or

preferences, such as the language the provider speaks, or the opinions of friends

and family (Rose & Elicker, 2008; Pungello & Kurtz-Costes, 1999). Or, parents

may choose a type of arrangement because it is a logistical match with their

budget and scheduling (Sosinsky, 2014). Peyton, O’Brien, and Roy (2001)

highlighted three categories reasons that captured why parents choose a certain

type of care: “quality (of care providers, environment/equipment, or program),

practical concerns (fees, hours, location, and availability), and preference for a

specific type of care” (p. 195). More than half the mothers, almost 56%, valued

quality as the most important factor in selecting a care arrangement, followed by

22.4% valuing general preference for a specific type of care and 21.7% of

mothers favoring practical factors.

The reasons presented by these researchers highlight prevailing

frameworks that guide child care choice, related to economics and the social

sciences (Miller, 2016; Meyers & Jordan, 2006). An economics-based framework

assumes parents make choices based on factors such as employment, preferences,

and budgets (Blau, 2001). A social science orientation would suggest that

decision making is complex and takes into account characteristics of the child and

family, home and community contexts and beliefs (Pungello & Kurtz-Costes,

1999). Another model, which integrates all of these components is an

accommodation framework provided by Meyers and Jordan (2006). The

accommodation framework takes into account that child care decisions are

intricate and often subject to multiple constraints– the availability of good care in

30


their neighborhoods, how affordable the tuition is, times and days the center is

open – that all affect the choices parents make.

To add to the difficulty in navigating constraints and preferences, parents

often make their decisions quickly, with little-to-no prior experience, and in an

imperfect child care market with limited information for consumers (Meyers &

Jordan, 2006). Furthermore, relatively little is known about how first time teen

parents of infants and toddlers find quality care; presumably, they experience

more challenges in finding care.

Organized infant and toddler care tends to be more specialized, meaning

that many providers do not offer care for that population. First time mothers do

not have prior experience in choosing child care to fall back on, or may not have

peers who are also going through the same experience. Ultimately, due to their

inexperience and youth, adolescent mothers may make less informed choices than

do other mothers, have limited resources to pay for care, or not know to look for

care (Rose & Elicker, 2008). These challenges speak to the purpose of this thesis:

While there is considerable research on child care utilization and the reasons most

parents choose child care, we do not know how teen mothers make these

decisions for their infants and toddlers.

Current Study in Relation to the Reviewed Literature

The literature reviewed here provides the bases and rationale for this

study. Although there is extensive theoretical and empirical support for both high

quality child care and home visiting services, the choices that teen mothers make

at the intersection of these two, potentially growth-promoting services are not

31


well-documented. This thesis looks at the relationship between home visiting and

teens’ child care choices in Massachusetts. Before I present the research, I present

additional information on specific usage of and policies related to child care and

home visiting in Massachusetts.

32


Chapter Two: Child Care and Home Visiting in Massachusetts

This chapter highlights the program and policy context for this thesis –

that is, the current landscape of child care and home visiting in Massachusetts.

There is a greater need for child care services than there is availability in the state,

with almost 300,000 children under the age of 6 in need of care, and almost

213,000 spots in child care centers, family child care homes, and other programs

(ChildCare Aware, 2015a). In addition to the demand outstripping the supply, and

although there are programs and policies in place to help parents acquire care, the

existing services also fall short of what parents need. Another challenge in the

landscape of child care is the cost; while we know child care is quite expensive, it

is more expensive in Massachusetts than in many other parts of the country

(ChildCare Aware, 2015b).

As regards to home visiting in the Commonwealth, there are numerous

home visiting programs operated by various public and non-profit agencies,

serving over 47,000 children, some of which are described in further detail later in

this chapter (Massachusetts Department of Public Health, 2010). The

Massachusetts Home Visiting Initiative (MHVI), under the Department of Public

Health provided additional funding to the field of home visiting in 2010. Even

though home visiting programs (EHS for example) have long been serving

children and families prior to the Affordable Care Act, there are still areas of

home visiting that are unknown. For example, it is difficult to measure those who

qualify for but do not receive services as programs target different families. The

Pew Charitable Trusts estimated that funding in 2010 served only 6-10% of the

33


low income toddler population, using the measure of low-income as a proxy for

multiple risk factors (Caudell-Feagan, Doctors, & Newman, 2011).

This chapter discusses the both child care and home visiting in greater

detail. While the literature review provides a theoretical and historical view of

child care and home visiting, this chapter offers a glimpse of how these services

are applied. Understanding how these programs and policies serve families in

Massachusetts helps to further enhance the work of this thesis.

Child Care in Massachusetts

ChildCare Aware of America (2015a) publishes state level data on child

care usage, trends, and costs. Using data from the American Community Survey

from the U.S. Census Bureau, researchers found that in 2015, there were almost

300,000 children under the age of 6 in need of child care but only about 212,000

spaces or slots available across child care centers/programs and registered family

child care homes in Massachusetts. This results in a large number of children and

families having unmet child care needs.

Child care policy. To understand the landscape of child care in the

Commonwealth, we must examine the related policies, namely vouchers and

subsidies for care. For families with limited financial resources, vouchers or

subsidies provide support in accessing child care. In addition, there are provisions

for specific populations, such as those involved with the Department of

Transitional Assistance (DTA), the Department of Children and Families (DCF),

and the Department of Housing and Community Development (DHCD), or in the

case of this thesis, teen parents (Isaacs, Katz, Minton, & Mitzie, 2015).

34


Within Massachusetts, there are several types of child care assistance

available for families, outlined in the Code of Massachusetts Code of Regulation,

606 CMR 10.00. Through Child Care Resource and Referral Agencies

(CCR&Rs), the Department of Early Education and Care administers its financial

aid system and waitlist program. In addition to meeting income requirements,

parents must also have a need for part time or full time care because of

employment or education/training. Financial aid available to those who

demonstrate need come in the form of vouchers or subsidies that pay for all or

part of care, or contract slots, which are located at specific centers and have

eligibility requirements associated with them (606 CMR 10.00). In addition to

financial need, certain populations, such as teen parents, are prioritized for

subsidies. Teen parents (under 20 years old) can apply for child care services

through contracted providers provided that they meet education (attending full

time high school or a GED program) or other approved activity requirements and

family income requirements (Isaacs et al., 2015).

Unfortunately, these services do not cover the need for care. There are

more children in need of subsidized care than there are available slots. Isaacs and

colleagues (2015) looked at the child care needs of families eligible for subsidies

in Massachusetts. Calculating the unmet need of child care is often difficult to

capture accurately because there is no precise formula for those who need

subsidized care but are not receiving it. Furthermore, not all who are eligible are

interested in using the subsidy. Parents may have another type of care they prefer,

such as care provided by a grandparent. The researchers estimate the unmet need

35


by looking at different ratios, including the number using vouchers to the number

eligible and an estimated take-up rate of 65% for infants and toddlers. They found

almost 16,000 infants and toddlers would apply for subsidized care if more

funding was available (Isaacs et al., 2015).

Costs. We know child care can be expensive, but some types of care are

more expensive than other types. As of 2014, for example, the average cost of

care for an infant at a center-based program in Massachusetts was $17,602, the

most expensive in the nation, while family child care was $10,666 (Child Care

Aware, 2015a). Additionally, single mothers often pay a larger percentage of their

income for care than a co-parenting family. Without the use of subsidies, care can

cost single mothers 63% of their income (for infants and toddlers), compared to

only 15% of the family’s income for a married couple (Child Care Aware, 2015a).

Indeed, infant and toddler care can cost more than, or almost as much as, a one

year of tuition at an in-state four-year college in Massachusetts (Child Care

Aware, 2015a).

Home Visiting in Massachusetts

While the first stream of significant federal funding of home visiting

emerged through the aforementioned MIECHV, under the Affordable Care Act of

2010 (entitled the Massachusetts Home Visiting Initiative; MHVI), home visiting

services in Massachusetts have been in operation long before. Early intervention

for infants and toddlers was formalized as part of the 1986 amendment to the

Education for All Handicapped Children Act (Shonkoff & Meisels, 1990). EHS

was established in 1994 as an expansion of Head Start (Ayoub, Bartlett, Chazan-

36


Cohen, & Raikes, 2015). Boston’s Healthy Start program was one of the original

15 sites, which began in 1991 and the Healthy Families Massachusetts began in

1997 (National Healthy Start Association, 2015; Jacobs, Easterbrooks, Brady, &

Mistry, 2005).

Programs. There is a wide variety of community-based and statewide

home visiting initiatives in Massachusetts as outlined by the Massachusetts

Department of Public Health (2010). Home visiting programs serve a wide variety

of populations and have a range of goals, and in total, these programs served an

estimated 47,952 families in 2010 (Massachusetts Department of Public Health).

The five evidenced based programs in Massachusetts are: Early Head Start,

Healthy Families America: Healthy Families Massachusetts (HFM), Healthy

Steps, Parent-Child Home Program, and Parents as Teachers (Massachusetts

Department of Health and Human Services, 2016). These five programs, and

others (non-evidence based) in Massachusetts, are outlined in further detail in

Figure 2. While there are many other, community-based home visiting initiatives,

this section focuses on the evidenced based programs of MHVI that target the

highest need communities within Massachusetts.

Of particular interest to this thesis is the HFM program. HFM, initiated in

1997, serves first time parents ages 20 and under, across Massachusetts (Tufts

Interdisciplinary Evaluation Research [TIER], 2015). Participants enroll while

pregnant or within the child’s first year and may continue until their child’s third

birthday. According to HFM, the program administered approximately 36,000

home visits to participants in fiscal year (FY) 2016 (Rogers, personal

37


communication, 2015). HFM also estimates that in FY 2017, it will serve 3,200 of

the eligible (first-time parents age 20 and under) 4,100 families. HFM’s program

goals include:

to prevent child abuse and neglect by supporting positive, effective parenting skills and a nurturing home environment;

to achieve optimal health, growth and development in infancy and early childhood;

to promote maximum parental educational attainment and economic self-sufficiency;

to prevent repeat teen pregnancies; and to promote parental health and well-being (Jacobs et al., 2005; TIER,

2015).TIER conducted a longitudinal randomized controlled trial (RCT)

evaluation of the HFM program, looking at both process and outcomes (2015).

The study collected data at three time points, approximately one year apart. On

average, participants were 18.6 years old, spoke mostly English (74%), pregnant

at the time of enrollment (65%), were non-Hispanic White (37%) or Hispanic

(36%). Children were on average were 4.5 months old at T1, 11.6 months old at

T2, and 24.6 months old at T3.

Goldberg, Bumgarner, and Jacobs (2016) looked at the extent to which

HFM was being implemented as intended. They found that on average, mothers

participated in the program for 15 months and received 24 home visits, with a

range of 1-46 months of program participation, and 1-118 home visits, although

about 14% did not use any services despite being eligible. Mothers who were less

active in HFM (received fewer visits or enrolled for a shorter period of time) were

also less likely to live with an older relative/guardian, less residentially and

financially stable, and less likely to participate in public programs. Perhaps

38


mothers were stretched thin, because of the lack of extra supports and had

difficulty maintaining program participation.

In terms of outcomes, TIER researchers looked at the difference between

mothers who were randomly assigned to receive HFM services and those who

were randomly assigned to received referrals and information only, in particular,

if the program achieved positive effects for those enrolled across HFM’s five

goals across the three time points (Goldberg et al., 2016; TIER, 2015). While

there were mixed findings across all outcome areas, some promising positive

results emerged (see Jacobs et al., 2016). Mothers enrolled in HFM reported less

parenting stress than other mothers, possibly pointing to the role of HFM in

providing support to mothers early on, and reducing negative attitudes or

behaviors. There were no effects found on the promotion of optimal health,

growth and development of children whose mothers received HFM and those who

did not. This is likely because mothers, regardless of participation in HFM,

qualified for health insurance in Massachusetts. Additional effects were found in

education attainment, but not in employment, and in the report of risky behaviors.

Subsequent analyses suggested that subgroups of mothers who received HFM

posted positive effects in other outcomes, such as delivering a healthy baby,

completing high school/GED and preventing repeat births (Mistry et al., 2016).

HFM may in fact be an ideal channel to promote quality child care choices for

teen parents, given its effectiveness in other areas.

39


Coordination Between Home Visiting and Early Childhood Education in

Massachusetts

So far, this thesis has highlighted the ample research on the positive

effects high quality child care can have on early child development and well-

being. It has also highlighted the promising benefits of high quality early care and

education. Unfortunately though, research has seldom been able to document the

quality of family child care or relative care, given its informal setting. Since these

situations are often unregulated, or have minimal requirements for licensing, there

is an assumption that their quality is often lower. We also know that any

challenges that adolescent parents and their children face can be reduced with a

combination of personal, familial, and societal resources. Home visiting programs

and high quality early childhood care serve as two promising approaches yet

relatively little is known about the child care choices young mothers make for

their children, and if participating in home visiting programs yields different,

potentially better, choices.

Early care and education policymakers and practitioners have

increasingly, over the past decade, promoted the integration of community early

childhood programs into systems of care; initiatives such as Promise

Neighborhoods, the ECE and home visiting services at the Port

Gamble/S’Klallam tribe in Washington State, the Strive Partnership of Cincinnati-

Northern Kentucky (Horsford & Sampson, 2014; Bohanon, 2016; Bathgate,

Colvin, & Silva, 2011) are several examples. These initiatives offer a continuum

of care, where multiple public, non-profit and community agencies coordinate

40


services to support children and families throughout various stages of

development. It is the hope that families enrolled in one program are

knowledgeable about, and helped to participate in, others that are relevant to

them.

Coordinating of, and integration among, early childhood programs at the

community level is at the core of this thesis. While both child care and home

visiting share many goals, there is little evidence of the extent to which, if at all,

they work together to promote the wellbeing of young mothers and their families.

This thesis hopes to bridge the gap of what is known about how mothers choose

child care and the role, if any, home visiting plays. By understanding the child

care choices young families in Massachusetts make, and the factors that are

related to them, including enrollment in home visiting programs, this thesis

contributes to an area, about which relatively little is known.

41


Chapter Three: Methods

This chapter first presents this study’s hypotheses and core research

questions, and then describes the program (Healthy Families Massachusetts –

HFM) under discussion and the accompanying evaluations (MHFE-1, MHFE-2);

the data used here are derived from MHFE-2. Next I focus on the design, sample,

and variables used in this thesis. Finally, I present the analytic approach that was

used to generate the study’s findings.

Research Questions and Hypotheses

The following research questions guide this thesis:

1. What are the maternal background and demographic characteristics

of young mothers in the Massachusetts Healthy Families Evaluation-2

(MHFE-2)? Are there differences in child care usage according to maternal

background and demographic characteristics?

Hypothesis: The background and demographic profile of mothers who are

regular child care users is different than those of non-users. Specifically, I

hypothesize that mothers who attend school or are employed are more likely than

mothers who are not in school or employed to be regular child care users, as they

have obligations away from the home. Similarly, I theorize that voucher use

promotes regular child care usage, as vouchers pay for child care, suggesting

higher rates of regular child care usage among voucher users compared to non-

users.

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2. What are the regular child care arrangements of mothers enrolled in

the MHFE-2 study? That is, to what extent are mothers using relative care,

group care, or non-relative/non-group care?

Hypothesis: Mothers with regular child care arrangements use

predominantly relative care, as it may be most accessible, affordable, and in-line

with personal beliefs – all criteria relevant to making child care choices (Rose &

Elicker, 2008; Pungello & Kurtz-Costes, 1999; Sosinsky, 2014).

3. To what extent are selected maternal background and demographic

characteristics related to the selection of child care arrangements (i.e.,

relative and group care)?

Hypothesis: Certain maternal characteristics are associated with mothers’

choices of child care: non-Hispanic Black are less likely than White mothers to

use relative child care, and Latino mothers are more likely than White mothers to

use relative care, based on the previously mentioned research (Miller, 2016;

Gibson, 2014; Sarkisian et al., 2007). It would be logical that those living with an

older adult relative are more likely than those who do not to use relative care, as

relative care may be easy to access for young mothers living with their families. I

also expect that TANF use and voucher use (which are also tied to

education/employment) are associated with the use of group care, which includes

center-based and family child care, given that both subsidies have related child

care components (606 CMR 10.00; Scott et al., 2005). Thus, I expect to see lower

rates of relative care among TANF and voucher users compared to non-users.

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4. Do the child care choices of young mothers who were randomly

assigned to receive HFM home visiting differ from those of a comparable

group of young mothers who did not receive HFM? If so, in what ways?

Hypothesis: There is no statistically significant difference in regular child

care use between mothers enrolled in HFM and those who are not. While it would

be noteworthy if HFM participants were more likely to use regular child care than

and mothers who did not receive HFM, I do not believe that is the case. Despite

the program’s goals related to education and employment, which arguably would

increase the need for child care, there is no required child care component to its

home visiting services. Home visitors may make referrals to various services,

including child care, but this would be based on the individual’s need. Therefore,

the lack of an explicit child care focus to the home visiting curriculum of HFM

makes me hypothesize that there is no association of program participation and

the child care choices of mothers.

The Healthy Families Massachusetts (HFM) Program

To answers to these research questions, I used data from a randomized

controlled trial (RCT) evaluation of HFM. HFM is an affiliate of Healthy

Families of America, the national home visiting initiative aimed at supporting

families who may be at-risk of adverse outcomes, though it is the only statewide

program based on the HFA model that is targeted to young families (Cullen,

Ownbey, & Ownbey, 2010).

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HFM works toward the program goals by connecting participants with

trained home visitors, parenting groups, and referral services (TIER, 2015).

Program goals are:

to prevent child abuse and neglect by supporting positive, effective parenting skills and a nurturing home environment;

to achieve optimal health, growth and development in infancy and early childhood;

to promote maximum parental educational attainment and economic self-sufficiency;

to prevent repeat teen pregnancies; and to promote parental health and well-being (Jacobs et al., 2005; TIER,

2015).Home visitors are paraprofessionals who model positive parent/child interactions,

teach parents about child development and how to provide a safe and nurturing

home environment, and serve as a support to parents, guiding them through their

personal, professional, and academic goals. When applicable, the home visitors

also connect participants to community services that might help support their

parenting. Based on the family’s need and preferences, home visitors can visit as

often as multiple times a week to as few as every few months. The Massachusetts

Children’s Trust (formerly, the Children’s Trust Fund) oversees programs and

agencies that administer the program across the state (TIER, 2015).

The Massachusetts Healthy Families Evaluation, First Cohort (MHFE- 1)

In 1998, the Children’s Trust contracted with a team of Tufts University-

based researchers1 to evaluate Healthy Families Massachusetts, the first home

visiting program to be offered across an entire state (Jacobs et al., 2005). The first

phase of the evaluation (MHFE-1), completed in 2005, used a mixed-methods

approach, and was based on Jacobs’ Five Tiered Approach (FTA; Jacobs, 1988),

1 Co-Principal Investigators: M. Ann Easterbrooks, Ph.D., Francine Jacobs, Ed.D.

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to describe the families and the ways they experienced the program, and

ultimately to measure positive change among program participants. The

evaluation established that change in three of the goal areas: educational and

economic attainment, healthy child development, and reducing child abuse and

neglect. Eighty-three percent of mothers were in school, graduated, or attained a

General Equivalency Diploma (GED) by the end of the evaluation. More mothers

breastfed their child than a national sample of teen mothers (63% versus 55%)

and were developing well in the five developmental domains based on the

screening tool used by the project. Twelve percent of study participants were

identified as perpetrators of child maltreatment, compared to a Rhode Island study

that had a 33% maltreatment rate by teen mothers. For a more detailed description

of MHFE-1 study design, findings, and policy recommendations, please reference

the MHFE-1 Final Report (Jacobs et al., 2005).

The Massachusetts Healthy Families Evaluation, Second Cohort (MHFE-2)

MHFE-2, the second phase of the evaluation and the source of the data

used in this current study, was launched in 2007. Like MHFE-1, MHFE-2 used

Jacobs’ FTA to inform its overall design. Through the use of a RCT, MHFE-2

sought to establish whether, and to what extent, HFM had achieved its intended

effects in its five goal areas, as well as whether these outcomes were associated

with particular aspects of program participation and delivery among the mothers

who were randomly assigned to receive and took up HFM services. As noted

earlier, mothers in the HFM program were less likely to report parenting stress

and have more positive attitudes towards parenting, more likely to have finished

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at least one year of college, more likely to use particular family planning methods,

and less likely to engage in risky behaviors.

MHFE-2 sample. MHFE-2 researchers recruited participants for the study

based on the following criteria: being 16 years or older, not having received prior

home visiting services, ability to speak English or Spanish, and ability to provide

informed consent. Participants were then randomly assigned to the treatment

group, Home Visiting Services (HVS), or control group, Referral and Information

Only (RIO). There were 704 participants enrolled in the study, with 433 (62%)

enrolled in the HVS group, and 271 (38%) in the RIO group (TIER, 2015). An

intent-to-treat approach was applied to analysis of HFM program effects, meaning

regardless of actually receiving home visiting services, their assignment was

maintained for analysis purposes.

Data were collected from participants, using a range of methods and

sources, from April 2008 to August 2012, over the three time points: Time 1 (T1),

Time 2 (T2), and Time 3 (T3). Data collection for T1 took place approximately

one month after enrollment in the evaluation project; T2, about a year after

enrollment; and T3, approximately two years after enrollment. The data were

collected using a range of instruments, including phone and in-person interviews,

surveys, observations of parent-child interactions, Census information,

information from the HFM participant database (PDS), and other state-agency

databases including the Departments of Children and Families (DCF), Elementary

and Secondary Education (DESE), Public Health (DPH), and Transitional

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Assistance (DTA2). This current study focuses on the one instrument in particular,

the Intake Interviews, which entailed administration of a 30-minute structured

telephone survey.

Design of this Study

A majority of the data used for this thesis were taken from the T2 Intake

Interview, with exception of the time invariant variables.3 I chose T2, first,

because since about 65% of the study participants were still pregnant at T1, they

did not have a need for child care yet. Additionally, many did have sufficient time

to experience, and potentially benefit from HFM by this second data point.

Finally, at T2, children averaged 11.6 months of age (SD 5.5 months, range = 2.8

to 29.6 months), an age when many parents are returning to work or school. T2

included 80% of the original study sample.

Thesis sample. Of the 565 mothers who were active at T2, approximately

62% (n = 349) were HVS participants, and 38% (n = 216) were RIO members.4

To begin narrowing down my sample, I first looked at participants who used

“regular” non-maternal care, according to their responses to the question “Who

takes care of your baby when you are unable to?” Here, mothers were asked to

note the number of hours each week that arrangement was implemented. To

determine regularity of care, I adopted a minimum threshold of 10 hours per

week, a common basis for “regular care” in other child care research (Lamb &

Ahnert, 2006; Sosinsky & Kim, 2013; the NICHD Early Child Care Research

2 DTA provides food (Supplemental Nutrition Assistance Program, SNAP), cash (Temporary Assistance for Needy Families, TANF), and job assistance. 3 The time invariant variables were based on the T1 Intake Interview.4 This distribution between HVS and RIO reflects the intended 60%/40% assignment distribution of MHFE-2.

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Network, 2002). Regular users consisted of approximately, 57% (n=322) of the

T2 sample, non-users consisted of almost 43% (n=241).5 Among the regular care

users, the sample was further distinguished by the types of care used in mutually

exclusive categories. Relative care was used by 66% (n=213), group care by 29%

(n=94), and other types of child care by almost 5% (n=15). Regular care users

were appropriately split between HVS (61%) and RIO (39%) participants. The

thesis sample is presented in Figure 3.

Variables

Several variables from the T2 Intake Interview were selected for inclusion

in analyses, while time invariant variables were taken from the T1 Intake

Interview. I note below which variables were already defined and prepared for my

use (MFHE-2), and which I defined and prepared for the thesis (Thesis). These

variables are outlined in Table 1 and the full T2 Intake Interview is available in

the Appendix.

Child care arrangements. As described above, 52% of the T2 sample

were classified as regular child care users (Thesis; 1= 10 hours or more per week)

and 43% as non-users (0= less than 10 hours per week). To identify care

arrangements (MHFE-2), participants were asked, “Who takes care of your baby

when you are unable to?” There were 12 response options, including maternal,

paternal, grand parental, great grand parental care, other family, friends,

babysitter, family child care provider, child care center (including school based),

Early Head Start, and other. Each response option was coded either 0=no or

5 Less than 1% (n=2) were excluded based on their responses totaling more than 168 hours per week, which exceeds the number of hours in a week.

49


1=yes. These answers are not mutually exclusive. Their care arrangements were

further analyzed according to the following criteria.

Primary category of care (Thesis). Through identifying similarities

among the response options above, I selected four categories to describe the

primary care arrangements. The primary care arrangement is the category

(described below) with the greatest total number of hours; therefore, the

categories of care are mutually exclusive and reflect the category of care used

most frequently. The categories of care (each of which presume a minimum total

of 10 hours, to reflect the regular use of care) are: 1= relative care (includes those

who selected maternal, paternal, grandparental, great-grandparental care, or other

family care6), 2= group care (family child care provider, child care centers, or

Early Head Start)7, 3= nongroup/nonrelative care (includes friends and

babysitters), and 4= two or more categories (equal hours, over 10) in two or more

categories.

Due to small sample sizes for the non-group/non-relative category (n=9)

and two or more categories (n=7), I omitted those samples from later analyses and

focused on families using relative care and group care. The final analytical sample

includes only those who used relative care or group care. These categories of care

are outlined in Figure 4.

6 Also includes responses under the “other” arrangement if care was provided by a member of a foster family or a family member of a partner. Foster families represent the state as legal custodians. Families of partners were also included in the relative category as a partner can serve as a parent figure, regardless of biological or legal relation. 7 While family child care and center-based care (inclusive of EHS) are typically examined differently, it made sense to group these together. Group care is subject to public enforcement and public funding (through vouchers or other subsidies), while relative care is typically internal (within child or relative’s home) and not subject to the same set of regulations. As this thesis examines the policies associated with child care use, it made sense to use this determinant.

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Maternal background and demographic characteristics. The following

maternal background and demographic characteristics were selected for the

present study.

Maternal characteristics. Based on research shown to be related to child

care usage (Child Trends Data Bank, 2013), the following variables were selected

for inclusion in the present study. Because most of these variables are time

invariant, they were taken from the T1 Intake Interview as opposed to the T2

Intake Interview (except where noted).

Age of mother at enrollment (MHFE-2). The mother’s age at the time of

enrollment is recorded in years, rounded to the nearest whole year. This variable

is continuous.

Community context (MHFE-2). Using the participants’ addresses at

enrollment, 2010 U.S. Census data on block group median household income,

racial/ethnic diversity, and population density was used to create profiles

illustrating the neighborhoods in which mothers and children live were created.

This variable consists of three community types and is defined as: 1=moderate

income (median income approximately $60,000), low population density,

homogeneous European ethnicity; 2= low to moderate income (median income

approximately $40,000), moderate population density, ethnically diverse; and 3=

low income (median income approximately $33,000), high population density,

majority of minority ethnicity.

Education and employment (MHFE-2). Mothers’ education and

employment were captured using a composite variable at T2. Education includes

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all types of school and training programs. The categories are 0= employed, in

school; 1= employed, not in school; 2= not employed, in school; 3= not

employed, not in school.

Living arrangements (MHFE-2). Participants were asked with whom they

lived at T2. Answers included combinations of partner, parents, guardian/older

relative, institution, other, and roommates. These answers were then recoded to

reflect the mother living with 1=adult relative, 0= all other living arrangements.

Race and ethnicity (MHFE-2). Participants self-identified race and

ethnicity, and a composite variable was created based on the following categories:

1= non-Hispanic White, 2= non-Hispanic Black 3=Hispanic, and 4= non-Hispanic

other.

Parenting vs. pregnant at enrollment (MHFE-2). At the time of

enrollment, mothers were either 0=pregnant or 1= parenting, which was

calculated from enrollment date and child’s birthday.

Maternal Depression (MHFE-2). Maternal depression was measured using

the Center for Epidemiological Studies Depression Scale (CES-D). At T2,

participants indicated how often they experience depressive symptoms over the

past week (for example, “I felt lonely” and “I could not get going”). Their

responses were based on a 4-point Likert scale (0 = not at all, 3 = a lot), with a

total score created by adding the 20 items (possible range = 0–60). The maternal

depression variable reflects a score of 16 or higher, where 0=no depression and

1=depression/clinically significant symptoms.

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Maternal resources. To help understand the conditions under which

mothers are parenting, the variables below were selected to capture the

availability of resources, particularly, in relation to child care. Maternal resources

variables were measured at T2.

Child care vouchers and TANF receipt (MHFE-2). Child care vouchers

allow eligible parents to purchase child care at a subsidized rate. Temporary

Assistant for Needy Families (TANF), commonly known as welfare, provides

financial support to needy families to help them achieve self-sufficiency (Office

of Family Assistance, 2015). Mothers reported current (at the time of the T2

interview) child care voucher use and TANF receipt, where 0=No, 1= Yes.

Family resources scale (MHFE-2). To gain a better idea of a family’s

financial state, participants were asked how well they were able to meet a list of

basic needs on consistent basis (for example, paying for food, utilities, housing,

child care), selecting answers ranging from 1= “Not at all enough” to 5= “Almost

always enough”. A mean score (0-100) was calculated from 14 questions that

represent “basic resources”, which includes food for two meals a day, house or

apartment, money to buy necessities, enough clothes for your family, heat for

your house or apartment, indoor plumbing/water, money to pay monthly bills,

medical for your family, dependable transportation (own car or provided by

others), furniture for your home or apartment, telephone or access to a phone,

money to buy special equipment/supplies for child(ren), dental care for your

family, and toys for your children. An indicator variable was created using a

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rescaled mean score denoting 1=adequate basic resources (scores >75),

0=inadequate basic resources (scores <75).

Program participation (MHFE-2). Participants were randomly assigned

to RIO or HVS at the time of enrollment, where 0=RIO, 1=HVS.

Analysis Strategy

In preparation for analyzing the data, I cleaned the data and recoded

selected variables. Similar to the MHFE-2 study, an intent-to-treat approach was

also adopted when examining program differences on child care usage. To answer

the research questions posed, a series of descriptive analyses were conducted to

assess differences in child care usage (regular child care users vs. non-users) and

primary child care arrangements among regular child care users (relative vs.

group) according to maternal characteristics, functions, and resources, and

program participation (HVS vs. RIO). Pearson’s chi-square tests were used to test

associations between variables.

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Chapter Four: Results

The following chapter presents findings according to the thesis questions.

Research Question 1: What are the maternal background and demographic

characteristics of young mothers in the Massachusetts Healthy Families

Evaluation-2 (MHFE-2)? Are there differences in child care usage according

to maternal background and demographic characteristics?

First, analyses examined differences between regular child care users and

non-users (remainder of MHFE-2 sample) based on their background and

demographic characteristics. Significant differences between regular child care

users and non-users emerged for three of the 10 applicable characteristics:

race/ethnicity, education/employment status, current voucher use. The significant

findings are presented in Table 2 and described in greater detail below.

The relationship between care use and race/ethnicity was found to be

significant. Non-Hispanic Black and other, Hispanic mothers (both 68%) were

more likely than non-Hispanic White mothers (49%) to be regular child care

users. Education/employment was also found to be significant. In relation to

education/employment, almost all mothers who were both employed and in

school used regular child care (96%). Mothers who were employed but not in

school (92%), and mothers who were not employed but in school (83%) were also

quite likely to be regular care users, compared to only 40% of mothers who were

neither employed nor in school. Predictably, the association between use of

vouchers and regular child care use was also found to be significant. Mothers who

used child care vouchers were more likely to use regular child care (93%),

55


compared to mothers who did not use child care vouchers (66%). These results

reflect the two characteristics hypothesized to influence the use of child care,

notably, employment and education and child care voucher use, while an

additional characteristic, race/ethnicity, was unexpectedly related to related child

care usage.

Age, community cluster, living with an adult, maternal depression,

parenting/pregnant at enrollment, TANF use, and financial resources to cover

basic needs were not related to regular child care usage.

Research Question 2: What are the regular child care arrangements of

mothers enrolled in the MHFE-2 study? That is, to what extent are mothers

using relative care, group care, or non-relative/non-group care?

Mothers using regular child care reported their arrangements at T2. (See

Table 3.) These arrangements are not mutually exclusive as children can have

several types of care at once. Of the reported types of care, maternal grandparents

provided the greatest amount of care, with 31% of arrangements. Care provided

by the father was the most common after maternal grandparents, comprising 20%

of all care arrangements. More formalized care including EHS, child care centers

and family child care were used less frequently at <1%, 14%, and 4%

respectively. This is consistent with my hypothesis that mothers primarily relied

on family members for support, given the multiple difficulties in acquiring care.

As previously described, from the above responses, each participant was

then assigned a recoded type of care, based on the category with the greatest

number of aggregated hours (see Table 4). After recoding, relative and group care

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were the most common types of care used, 66% and 29% respectively. Only

approximately 5% of participants used non-group/non-relative or an equal amount

across two categories; subsequently the remainder of the analysis focuses on the

use of relative or group care exclusively.

Research Question 3: To what extent are selected maternal background and

demographic characteristics related to the selection of child care

arrangements (i.e., relative and group care)?

This section examines the differences, if any, in type of regular child care

arrangements across the maternal characteristics/indicators outlined in the

Methods chapter. Overall, the results reflect the findings of Research Question 2,

which examine the characteristics that predict use of relative care.

Of the 10 characteristics used in this analysis, seven proved to have a

relationship with the use of relative care or group care. These

characteristics/indicators included race/ethnicity, parenting/pregnant at

enrollment, education attainment/employment, maternal depression, living with

an adult, current use of child care vouchers, and current receipt of TANF (see

Table 5).

Non-Hispanic White (79%), non-Hispanic other (72%) and Hispanic

(67%) mothers were more likely to use relative care than non-Hispanic Black

mothers (58%).

Mothers pregnant at enrollment were more likely than mothers who

enrolled while parenting to use relative care (75% vs. 61%, respectively), and less

likely to use group care.

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When looking at mothers’ education/employment status, mothers not in

school used relative care (88% of those not employed and 83% of those

employed) more than mothers who were in school (61% for those not employed,

52% for those employed). This might speak to the fact that group care is often

more expensive than relative care (possibly free), and that some schools have

their own child care centers.

Mothers who were depressed (78%) used relative care more than mothers

who were not depressed (65%).

Mothers who lived with an adult relative/guardian used relative care

(76%) more than mothers who did not live with an adult relative/guardian (56%).

Mothers who do not live with an adult may not have an adult relative/guardian in

their lives, thus requiring other types of care, like group care, more.

In terms of subsidies, mothers who used vouchers used group care (70%)

more than mothers who did not use vouchers (15%).

TANF receipt also had a statistical association with care arrangements.

TANF non-recipients used relative care (75%) more than did TANF recipients

(62%).

These findings partially reflect the hypothesis. While the hypothesis

proposed that Hispanic mothers would be most likely use relative care, non-

Hispanic White were most likely to use relative care. No hypotheses were made

in relation to maternal depression and enrollment status, however both of these

were found to be statistically significant. The other findings were congruent to

the hypothesis. Non-Hispanic Black mothers were more likely than mothers from

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other racial/ethnic groups to use group care, as were mothers who are in school

and mothers who used vouchers and received TANF, whereas mothers who lived

with an adult relative were more likely than their counterparts to use relative care.

The age of mother at the time of enrollment, the profile of the community

in which she lived, and her reported availability of financial resources were not

related to child care type.

Research Question 4: Do the child care choices of young mothers who were

randomly assigned to receive HFM home visiting differ from those of a

comparable group of young mothers who did not receive HFM? If so, in

what ways?

The final research question asks if there were any differences between

mothers assigned to receive HFM home visiting services and those assigned to the

control group on child care use. HVS and RIO mothers were equally likely to be

regular child care users, and the groups did not differ from one another on their

regular child care arrangements (i.e. group care or relative care). This finding

reflects the hypothesis.

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Chapter Five: Discussion

Research shows that children of teen mothers are considered an at-risk

group due to the multiple challenges they face. Home visiting services can play a

role in mitigating some of these risks, but the actual effect of home visiting

services on another valuable service, child care, is unknown.

Mothers in this study were first time teen parents, and their children were

about one year old at the time the data were collected for this study. The mothers

likely had little to no experience in finding care for their infant/toddler, as this

was their first child. This thesis considered the child care choices of young

mothers who also participated in home visiting services.

Highlights of Findings

Mothers who were employed or in school, non-Hispanic Black or non-Hispanic

other, and received child care vouchers were most likely to be regular care users.

These findings reiterate the research on what is known about child care usage

among specific groups—that in Massachusetts, vouchers enable parents to pay for

part time or full time care provided that they are employed or in school and that

non-Hispanic Black and other mothers are more likely to use regular care than

non-Hispanic white mothers (606 CMR 10.00; Child Trends Data Bank, 2013).

The non-significant findings may indicate that another factor may be at play.

That is, even if mothers live with an older adult relative or have the financial

resources, perhaps mothers simply do not need regular care.

Not surprisingly, relative care was twice as prevalent among mothers who

used regular care, with grandparent care being most common within relative care.

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This thesis was interested in looking at care for infants and toddlers in particular.

The findings support previous research that highlights a preference for relative

care (and other forms of in-home care) for younger children (Rose & Elicker,

2008). This also supports the analyses that mothers who were pregnant at time of

enrollment in MHFE-2—the younger mothers in the sample—were more likely to

use relative care than mothers who were parenting at the time of enrollment.

Mothers who were not participating in educational opportunities or

employment, as well as those who did not use child care vouchers or cash

assistance. were also more likely to use relative care. These characteristics may

speak to the public supports and financial resources a mother is lacking. While

many mothers indeed have a preference for relative care, it also seems that certain

mothers may simply be unable to afford more expensive types of care, as in the

case of group care.

Two findings were not expected based on previous research. Mothers

with depression also used relative care more, although other research shows an

even distribution between depressed and non-depressed mothers’ use of

grandparent (of child) care (Brown, Harris, Woods, Buman, & Cox, 2012).

Additionally, I hypothesized that racial minority families were more likely to use

relative care, because of familiarity or beliefs, but in this case, White mothers

were the most likely users of relative care (Meyers & Jordan, 2006). However, as

Meyers and Jordan (2006) state, it is often difficult to separate out preferences

from limited access. It is possible that in this case, White mothers did not have

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access to other types of care (especially if they live in rural areas) and had to use

relative care.

As for the non-significant findings, the age of the mother, the profile of

the community in which she lived, and her perceived availability of financial

resources for child care were not indicators of relative or group care use. The

financial resources variable may have produced a non-significant finding because

the measure may not accurately capture poverty. The responses self reported

responses are highly subjective, and teens are often not well informed (especially

if living with a guardian) of their family’s financial resources. So, while they may

be considered “low-income” by more formal standards, they may have reported

feeling comfortable covering their basic expenses. Overall these results may

indicate that child care choices are made under on a wide range of circumstances,

and these variables were not as significant as other factors.

The collective findings on relative care highlight an important area of

opportunity, which will be further discussed in the next section. While relative

care is not necessarily a bad choice of child care, less is known about relative care

given its informality. Building a better understanding of relative care can also

uncover additional information about care for infants and toddlers.

Finally, as hypothesized, the results did not show differences in child care

choices between home visiting clients and the control group. While the role of the

home visitor is important to the client’s engagement in HFM, the program does

not explicitly focus on providing recommendations or referrals for child care

(TIER, 2015). This is, perhaps, a “missed opportunity,” as the home visitor is

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positioned to provide helpful information and guidance on what to look for in care

arrangements to the mother.

Recommendations and Future Directions

In considering possible implications for future policy and practice, I

revisited the idea of the trilemma of child care: need for quality, affordability, and

accessibility. The following discussion centers on these three themes.

Quality care. Although this thesis did not examine the quality of care

received by participants in the evaluation, the aforementioned research shows

how important quality care is to the development of children. High quality care is

associated with positive outcomes for children; however, parents make choices

for child care based on a variety of factors, not always having enough information

to be informed consumers.

Home visiting can further help parents be positive parents through

promoting high quality child care choices. Home visitors are well positioned for

this task, as they are building a relationship with their clients, making referrals for

other services, and are knowledgeable about positive child development.

Teaching participants explicitly about high quality care is a natural extension of

the work they already do. Furthermore, there is existing research on home

visiting as a vehicle for promoting child care. Barlow et al. (2006), looked at

home visiting as a way to improve child care among pregnant American Indian

teens, through promoting child care knowledge, skills, and involvement. Though

the study sample and length of trial were small, researchers found that parents

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who received home visiting interventions had higher child care knowledge and

involvement compared to the control group.

Accessibility and availability. This thesis found that certain groups used

child care more regularly than others, and less formal care (relative) than

formalized (group) care, but did not look at the reasons why. It is unclear if non-

users did not need/want care or if it was not available/accessible. Similarly, this

thesis did not look at why relative care users chose that option, and does not

highlight if users chose relative care when group care was available.

Despite this, the literature does highlight some challenges families face in

acquiring care and therefore better understanding the accessibility and availability

of care is important in helping families acquire care. For example, Massachusetts

has Child Care Resource and Referral Agencies (CCR&R) that help facilitate care

acquisition. Each region has its own CCR&R, meaning different information is

available at different websites and some are more comprehensive than others.

Visiting a CCR&R website will redirect you to the Massachusetts Department of

Early Education and Care’s online database of care providers. This may be

difficult for parents who have limited literacy or English proficiency, or for

families without computer/internet access. While there are many other ways to

access the information, a home visitor may be able to help parents navigate

through and understand the information. This example is just one way of

furthering collaboration between home visiting and child care.

Affordability and voucher policy. Another recommendation is to review

the affordability of care and the existing voucher policy. As highlighted in the

64


literature review, child care is expensive, and only 18% of federally eligible

families are receiving subsidies or vouchers (United States Department of Health

& Human Services, 2012). This no doubt is part of the explanation to why relative

care (typically free or low cost) users were less likely to use child care vouchers,

and more likely to not be employed or in school.

While voucher use makes child care more affordable, there are challenges

that plague voucher use, as highlighted by Pearlmutter and Bartle (2015). The

voucher system can be complicated—recipients complained of a six-week waiting

period before payments were made. There may be gaps in payment to the provider

or co-payment requirements, both, which pose emotional and financial strain on

parents. Providers often receive lower reimbursement payments than the market

rate, forcing them to sacrifice the quality of staff or resources for children. A

recommendation to help improve the existing voucher system is to take into

account these challenges and offer steps to rectify them. Streamlining the voucher

system and making payments more efficient would help parents pay for care.

Making sure payments are timely and appropriately priced for the market rate can

enable providers to offer better care.

Future directions. No amount of guidance from home visitors can

influence parents’ care choices if child care is simply not available. If I were to

conduct the research for this thesis again, I would use Geographic Information

System (GIS) to plot residences of participants with available child care options.

It would be helpful to know where there are child care “deserts,” or regions where

there are few options or care is located far away from families. Not only would

65


this help home visitors make knowledgeable recommendations, but also the

information might enrich the analysis conducted by this thesis by showing care

usage based on available options.

Additionally, a significant portion of mothers in this study use care,

especially relative care. However, this thesis was limited in the discussion of child

care as it is difficult to understand relative care, given its informality. While there

are modest regulations around relative care, especially through public domains

such as foster care, child protective services, or criminal background checks for

those who receive government reimbursements, for the most part, relative care is

largely unregulated. To learn more about the effects of relative care, and the

overall quality, additional efforts to expand on the existing knowledge and

regulations surrounding relative care can help inform future work regarding

relative care. For example, home visitors can aid in collecting data during visits,

or help relative care providers in building their knowledge of child development

practices through disseminating information.

Limitations to the Study

This thesis is limited in that the results give no indication of the quality of

the care used, only the type of care used. While different types of care are

desirable for various reasons (curriculum at center-based, home like environment

at family child care center, or relationship/bond with a relative care provider), it is

difficult to measure the overall quality of care. Research does tell us that there are

potential benefits to relative care, such as offering comfort in the language

spoken, knowing and trusting the person, or holding similar cultural values or

66


beliefs (Broad, Hayes, & Rushforth, 2001). However, not all relatives may

provide attentive care, or have the child development knowledge a professional

may have. While group care can offer its own advantages, like socialization with

other children and more structured play, the quality also varies widely based on

program. Thus, quality really comes down to assessing the specific arrangement.

Not having a measure for quality makes it difficult to assert that, for the

categories this thesis examined, group care (center-based and FCCs) is better or

preferred over relative care. Home visiting can be the support needed in teaching

young first time parents how to determine if a care arrangement is high quality.

Other limitations are in the design of the study. A specific time point (T2)

was used to measure child care usage. Mothers may have used different child care

arrangements prior to and/or after their T2 interview that were more in line with

their preferences (or more accurately depicted their overall child care usage

patterns). As opposed to other time points, there were benefits and drawbacks to

using T3 data. There were more participants who completed the Intake Interview

at T3 (594 as opposed to the 565 at T2) however, most participants had, much

earlier, stopped receiving home visits, making it difficult to understand the

relationship of home visiting on participants. Instead, I could have looked at T3

child care usage based on variables from T2, to see if services at T2 had a

relationship on future choices.

Another limitation is that this thesis used the 10-hour threshold for

assignment to the category of regular care. While other studies used this as a

threshold for regular care, it certainly does not reflect full time care. Another

67


measure, either a different number of hours, or adding a question to the interview

that asks parents directly, “do you use child care on a regular basis?” may be a

better alternative. The instrument (Intake Interview) also did not measure the

reasons why mothers chose the type of care they did. While the analysis gave us a

better idea of the types of mothers who use certain types and amounts of care, we

still do not know what ultimately went into their decision to be regular care users

(or not) or relative care users (or group).

Finally, the current study would have profited from more sophisticated

analyses. For example, I would also conduct additional statistical tests to better

understand the data. I would conduct post-hoc test for the categorical variables

with more than two categories to determine which groups are significantly

different from one another. I would also run logistic regressions with all of my

predictor variables (maternal background and demographic characteristics and

program participation) simultaneously to see which variables are the strongest

predictors of care use and type of care.

Concluding Thoughts

Home visiting programs are increasingly being seen as effective in

preventing child maltreatment and improving outcomes for children and families.

Adding an emphasis on supporting use of high-quality child care is one way to

amplify the positive effects. Quality child care can also support effective

parenting, optimal growth and development, maternal self-sufficiency, and

parental health and well-being; these are commonly goals of home visiting as

well.

68


Placing an emphasis on child care in home visiting services could not only

help achieve home visiting program goals, but would also enable parents to make

educated child care decisions. Making parents educated consumers of child care

by providing them with information and resources should be a priority (Zigler et

al, 2009, Clarke-Stewart & Allhusen, 2005). Programs should consider how the

trilemma of child care can be shared with parents as a resource or tool.

69


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Table 1

Variables for Analysis

MHFE-2 (Coded by MHFE-2) Thesis (Coded by L. Hoysgaard for

Thesis)

Care arrangement

Age of mother at enrollment

Community context

Education/employment

Living arrangement

Race and ethnicity

Pregnant or parenting at enrollment

Maternal depression

Child care vouchers and TANF receipt

Family resources scale

Program participation

Regular child care

Primary category of care

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Table 2

Maternal Characteristics and Care Usage

Regular Users Statistic p

n=322

Characteristic %

Race and Ethnicity χ2(3)=11.793 0.008

White, non-Hispanic 49.3

Black, non-Hispanic 67.6

Hispanic 58.0

Other, non-Hispanic 67.5

Education/Employment χ2(3)=112.547 0.000

Employed, in school 95.8

Employed, not in school 92.2

Not employed, in school 83.2

Not employed, not in

school

40.5

Current Voucher Use χ2(1)=27.247 0.000

No 66.3

Yes 92.9

Note: Only p values significant at p <.05 are reported.

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CHILD CARE USE AMONG ADOLESCENT MOTHERS 88

Table 3

Mother Reported Child Care Arrangements

Arrangements Frequency Percent

Father 130 20%

Maternal Grandparent(s) 201 31%

Paternal Grandparent(s) 64 10%

Maternal Great Grandparent(s) 17 3%

Paternal Great Grandparent(s) 2 <1%

Other Family 71 11%

Friends 20 3%

Babysitter 4 1%

Family Child Care Center 23 4%

Child Care Center 77 12%

Early Head Start 3 <1%

Child Care Center at School 13 2%

Other 32 5%

Total 657 100%

Table 4

Recoded Child Care Arrangement

Arrangements Frequency %

Relative care 213 66.1

Group care 94 29.2

Non-group/non-relative 10 3.1

Two or more 5 1.4

Total 322 100


Table 5Significant Findings: Maternal Characteristics and Care Type

Relative Statistic pn=213

Characteristic %Race and Ethnicity χ2(3)=8.869 0.031

White, non-Hispanic 79.2%Black, non-Hispanic 58.0%Hispanic 67.2%Other, non-Hispanic 72.0%

Education/Employment χ2(3)=25.332 0.000Employed, in school 52.3%Employed, not in

school 82.6%Not employed, in

school 61.0%Not employed, not in

school 87.7%Maternal Depression χ2(1)=5.479 0.019

Not depressed 64.9%Depressed 77.9%

Lives with adult χ2(1)=11.963 0.001No 55.8%Yes 75.5%

Parenting/Pregnant χ2(1)=6.271 0.012Pregnant 74.5%Parenting 60.9%

Current Voucher Use χ2(1)=89.939 0.000No 85.3%Yes 30.3%

Current TANF Use χ2(1)=5.972 0.015No 74.9%Yes 61.8%

Note: Only p values significant at p <.05 are reported.

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Program Name

(1) Child FIRST

(2) Durham Connects/Family Connects

(3) Early Head Start-Home Visiting

(4) Early Intervention Program for Adolescent Mothers (EIP)

(5) Early Start (New Zealand)

(6) Family Check-Up ®

(7) Family Spirit®

(8) Healthy Families America (HFA)®

(9) Healthy Steps

(10) Home Instruction for Parents of Preschool Youngsters

(HIPPY)®


Figure 1. National evidence-based home visiting programs (Avellar et al., 2014).

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Program Name

Number of

Families Served

Boston Healthy Start Initiative* 1,792

Boston Home Visiting Collaborative 38

Early Connections 83

Early Head Start* 358

Early Intervention 33,346

Early Intervention Partnership Program 669

F.O.R. Families 3,196

Good Start 338

Healthy Baby Healthy Child 1,414

Healthy Families Massachusetts* 3,131

Parent Child Home Program* 1,500

Parenting Works 20

Parents as Teachers* 279

Visiting Moms 190

Young Parents Support Program 1,122

Total Families 47,592


Figure 2. Massachusetts home visiting programs (Massachusetts Department of

Public Health, 2010).

*Denotes evidence-based model

Note: Median number of 669 families per program (min = 20 ; max = 33,346). Median cost per family for the programs is $2,750 per family (min = $781 ; max = $10,000).

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Figure 3. Thesis sample logic tree based on participants in the MHFE-2 study

(TIER, 2015). The overall sample of T2 MHFE-2 participants is highlighted in

green, with number of participants in parentheses. The participants in the blue

boxes were excluded. The orange boxes reflect the thesis sample.

T2 Intake (565)

Non childcare users, <10 hours per week

(241)Childcare users, >10 hours per week (322)

RIO- Control Group (155)

HVS- Sample Group (245)

Excluded, >168 hours per week (2)

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Intake Interview Response Options Category of Care for Thesis

Figure 4. Recoded categories of care based on responses from Intake Interview.

All legal and biologically-related family members, stepparent-like

figures, godparents, non-FOB significant others and their families, and foster families

Relative care

Childcare CenterEarly Head Start

Childcare Center at SchoolFamily Child Care

Group care

FriendsNannies

BabysittersOthers not identified as family or a group

arrangment

Non-relative/Non-group

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Running head: CHILDCARE USE AMONG ADOLESCENT MOTHERS THESIS DRAFT

Appendix

T2 Intake Interview

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official final ma thesis

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