ACF OPRE: Building Strong Families (BSF)

Chapter I: Introduction

As nonmarital childbearing has increased, so has concern for the attendant consequences. One-third of all children in the United States are now born to unwed parents, a rate that is even higher among some population groups. Although many children of unwed couples flourish, research shows that, on average, compared with children growing up with their married biological parents, they are at greater risk of living in poverty and developing social, behavioral, and academic problems (McLanahan and Sandefur 1994; Amato 2001).

Research suggests that there may be opportunities to address this concern. The 20-city Fragile Families and Child Wellbeing Study showed that most unwed parents are romantically involved during the time that their children are born, and many anticipate marrying each other. Most agree that it is better for children if their parents are married. Nevertheless, the Fragile Families study showed that only a small fraction of such couples are married a year after their children are born (Carlson, McLanahan, and England 2004).

“Fragile families” often face circumstances that can function as barriers to healthy marriage and sustained relationships, such as unemployment, low educational attainment, children from previous partners, substance use, and domestic violence. In addition, many such couples have not experienced healthy intimate relationships, in either their families of origin or adult lives. Without this experience as a guide, an intimate relationship can be a struggle, and can be compounded by the additional stresses and responsibilities created by a new child. Although research has found that instruction in relationship skills can improve couples’ relationships and marriages, including those of couples expecting children, these programs typically are not available to low-income, unwed parents.

The Building Strong Families (BSF) project originated from these bodies of research, and is one of the centerpieces of a broader policy strategy to support healthy marriage. BSF is a multi-year, multi-site project sponsored by USDHHS/Administration for Children and Families (ACF). Its goal is to learn whether well-designed interventions can help interested, romantically involved, unwed parents to build stronger relationships and fulfill their aspirations for a healthy marriage if they choose to wed. The BSF program is entirely voluntary—participation is neither a condition for receiving public benefits nor is it mandated by any government authority. BSF targets parents at around the time of their children’s birth and provides instruction and support to help couples develop the relationship skills that research has shown are associated with a healthy marriage. Ultimately, healthy marriage between biological parents is expected to enhance child well-being.

Demonstration and Evaluation

The BSF project is both a demonstration and a rigorous evaluation. The evaluation will thoroughly analyze whether the intervention is successful in improving the outcomes of the couples and their children. Interested and eligible couples are randomly assigned to either the program group or to a control group. Program group couples are invited to participate in the BSF intervention; control group couples are free to receive whatever services may be available except the BSF program. Randomly assigning couples in this way eliminates the concern that differences between couples who choose to participate in the program and those who do not would generate differences in outcomes that would obscure the true effects of the program. This could happen, for example, if these couples had greater commitment or stability in their relationship compared to couples who did not express interest in the program. With random assignment, differences in outcomes are unbiased and can be attributed to the program.

An initial pilot stage offered seven local sites the opportunity to develop programs in accordance with the BSF model and make refinements based on early experiences. At the end of the pilot, sites were selected for the evaluation. To be selected, sites had to demonstrate that they could effectively implement the program model and recruit and retain a sufficient number of couples. All seven pilot sites qualified for the evaluation, although some conditions must still be fulfilled in some sites.

In the full-scale study, sites will expand their recruitment efforts beyond the pilot to serve a larger number of couples, and all sites will be randomly assigning couples to the program and control groups. The full-scale study will include an extensive process analysis and a rigorous analysis of impacts. The process analysis will examine the implementation of BSF, including the successes and challenges faced by the sites. The impact analysis will examine the effects on couples and their children, based on follow-up surveys 15 months after couples are randomly assigned, and again when their children are 36 months old. A wide range of outcomes will be studied, including the parents’ relationship quality and stability, marital status, and economic and family well-being. In addition, we will gather information about the children’s social, emotional, and cognitive development.

Overview of Report

This report documents early lessons from the program development and pilot stages of the project. The information we draw on was gathered during the pilot period, which generally ran from February 2005 to February 2006. Since that time, all sites have expanded into full-scale operations, and changes may be occurring as a result of ongoing experience and technical assistance. Therefore, current practices may differ somewhat from what is reported here.

Although this report is based on a very early stage of the BSF project, it represents a policy-relevant advance in our understanding of the field of healthy marriage initiatives—particularly in terms of the strategies that hold promise for supporting low-income unwed couples as they strive to achieve their aspirations for a healthy marriage. The report does not analyze impacts, nor does it replace a full-scale implementation study, which will not be available for another year. It does, however, document the successes and challenges experienced by the BSF pilot sites and the approaches they took to address these challenges.It also sheds some light on the types of families that are attracted to the BSF program and on their responses to it. As such, the report offers lessons not only for federal policymakers, but also for other states, agencies, and program practitioners seeking to develop similar programs.

The remainder of this report comprises four chapters. Chapter II, Implementation Approaches, describes the organizational context of the pilot sites, such as the host program or infrastructure, presence in the community, and experiences with hiring and training. It examines how the context facilitates or hinders the start-up and success of early implementation, and describes the different approaches sites have taken to developing a system for delivering BSF services.

Chapter III, Recruiting Couples, illustrates why recruitment strategies are critical to the effective implementation of a program such as BSF. Sites must identify a steady flow of potential participants, which can be difficult given the very specific segment of the population that is eligible for BSF. In addition, sites have had to confront the challenge of recruiting two people for every eligible case, as the couple—not the individual—is the unit of interest. The chapter describes recruitment issues and tradeoffs, and reports on the number and characteristics of couples that enrolled during the pilot period.

In Chapter IV, Program Participation, we discuss the challenges involved in engaging clients in a BSF program and maintaining participation. Given the length and intensity of BSF, there are numerous opportunities for participants to withdraw. Other obstacles to retention include the often chaotic lives of low-income couples, and the stresses and responsibilities of new or expecting parents. These factors, among others, mean that high levels of ongoing attendance may be more difficult to achieve, compared with other programs.

Chapter V, Participant Reactions, documents how BSF participants themselves perceive the program. Through focus groups with participants and discussions with staff, we collected information on couples’ satisfaction with the program, whether they feel connected to and invested in BSF, and how actively they participate in group sessions. It is important to remember that there may be selection bias in this analysis; that is, the couples who are most satisfied with BSF are more likely to remain engaged in the program. However, BSF can be successful only if it appeals to the targeted couples. This chapter begins the examination of whether or not, from the couples’ perspectives, the intervention is helping their families.

A. THE BSF PROGRAM MODEL

One of the first steps in the BSF project was the development of a program model. To do this, we first developed a conceptual framework for why and how we might intervene with unmarried and romantically involved parents, and then translated the conceptual framework into more detailed program guidelines for organizations wishing to implement the model (Hershey, Devaney, Dion, and McConnell 2004). These guidelines are available at the BSF website, www.buildingstrongfamilies.info. As described in the program guidelines, the BSF model has three components:

Healthy Marriage and Relationship Skills Education: Instruction in the relationship skills found by research to be essential to a healthy marriage, and information to enhance couples’ understanding of marriage. This instruction is provided in group sessions with the BSF couples, usually held weekly. This is the core distinctive component of BSF programs.
Family Support Services: Services to address special issues that may be common among low-income parents and that are known to affect couple relationships and marriage. These services might, for example, help to improve parenting skills or provide linkages to address problems with employment, physical and mental health, or substance abuse.
Family Coordinators: Staff who provide individualized support to couples by assessing couples’ circumstances and needs, making referrals to other services when appropriate, reinforcing relationship and marriage skills over time, providing ongoing emotional support, and promoting sustained participation in program activities.

The programs are intensive. The core component of BSF—the group instruction in marriage and relationship skills education—requires up to 44 hours and typically is provided over a sustained period of time (up to five or six months). Program sites differ in how long the couples meet with the family coordinators, but it may be as long as three years.

Couples are recruited for BSF either during pregnancy or shortly after their children are born. To be eligible for BSF, both the mother and father must be:

Either the biological parents of an infant 3 months of age or younger or expecting a child together (i.e., currently pregnant)
At least 18 years old
Unmarried (or married since the conception of the baby)
In a romantic relationship with each other
Not involved in domestic violence that could be aggravated by participation in the program
Available to participate in BSF and able to speak and understand a language in which BSF is offered

1. Marriage and Relationship Skills Curricula

Although sites were free to select whatever curriculum they preferred, the BSF project team laid out criteria that curricula had to meet for the site to be considered part of the BSF pilot. This step ensured that there would be a reasonable degree of consistency across sites to facilitate evaluation, while at the same time providing local sites with some flexibility and choice. The curriculum criteria are described in the BSF Program Model Guidelines, and include guidance on the desired intensity and duration, instructional format, and specific topics to be covered.

The unique circumstances and needs of low-income unmarried parents having a baby meant that a curriculum development effort was needed. Almost all existing relationship skills curricula had been written for married, middle-income couples. To provide sites with several alternatives, we identified three curricula that research had shown to have positive impacts on couples’ relationships, and encouraged the curriculum developers to modify the material for BSF couples (see Table I.1).

The three modified curricula selected by pilot sites retain the substance and the emphasis on skill building in the original curricula, with important modifications. Early focus groups, held as part of BSF program planning with members of the target population, indicated that many couples have had negative experiences with educational institutions and do not want to be lectured on the “correct” way of doing things. Consequently, the modified curricula minimize didactic methods and aim for a more experiential approach, allowing couples to share and learn from their own and each other’s life experiences and knowledge. To make the material more accessible to those with lower levels of education, the curricula favor concrete illustrations to convey abstract concepts, and are written at a fifth-grade level. The curricula have been revised with particular sensitivity to a range of cultural backgrounds, as well as relevance to the BSF population.

In addition, we identified topics that get little attention in standard curricula but that research on fragile families suggests are particularly important for this population. A group of curriculum experts developed materials addressing these topics, such as how to build trust and commitment, dealing with children and parents from previous unions, communicating about finances, and understanding the challenges and benefits of marriage. Authors of the three curricula either included these supplemental modules in their revised curriculum, or developed comparable materials on their own. The curricula selected by BSF pilot sites were Loving Couples, Loving Children, by Drs. John and Julie Gottman; Love’s Cradle, by Mary Ortwein and Dr. Bernard Guerney; and the adapted Becoming Parents Program, by Dr. Pamela Jordan. The titles of each session covered in the three curricula are shown in Appendix A.

Although the three curricula are roughly the same in terms of content and general features, they vary in several ways. The Loving Couples, Loving Children curriculum begins each group session with a focus on group process and community-building. The group discussion is a pivotal element, giving couples the opportunity to relate to each other and discuss their experiences, thoughts, and feelings. This is not group therapy, but an opportunity for voluntary disclosure and the chance to be heard and supported by the group. The session begins with a video in which real couples discuss their issues, such as recovering from infidelity or preventing harmful fights. The couples then discuss their reactions to the video and whether they can relate to the issues raised. After the discussion, the group facilitators provide information about the themes that emerged in the discussion and suggest empirically-proven ways in which couples can successfully deal with the issue. The couples are then given exercises through which they apply what they learned in the information section. That is, with their partners, they practice specific skills to address the issue and improve their interaction and communication surrounding the theme. So while the session thus appears to be group-driven, it is in fact highly structured.

Table I.1. Key Features of Marriage and Relationship Skills Curricula
	Loving Couples, Loving Children	Love’s Cradle	Becoming Parents Program (adapted)
Developers	Drs. John and Julie Gottman	Mary Ortwein and Dr. Bernard Guerney	Dr. Pamela Jordan
Original Curriculum	Bringing Baby Home	Relationship Enhancement	Becoming Parents Program
Length of Training for Group Leaders	5 days, about 40 hours	2 two-day sessions, about 32 hours	4 days, about 32 hours
Recommended Minimum Qualifications of Group Leaders	Master’s degree and experience working with groups or couples	Master’s degree or 5 years experience with population	Master’s degree and experience working with groups or couples
Recommended Group Size	4-6 couples	6-8 couples	10-15 couples
Total Hours	44 hours	42 hours	30 hours prenatal + 12 hours postnatal
Length of Sessions	2.5 hours	2 hours	3 to 6 hours
Frequency of Sessions	Weekly	Weekly	Weekly

In Love’s Cradle, group leaders spend the first two months of the weekly sessions teaching couples a series of skills focused on the development of empathy and positive communication, such as listening without defensiveness and showing understanding of the other’s perspective. The skills are divided into specific steps; this allows the couples time to practice and master each part before adding the next component of the skill. There is less sharing among group members compared to Loving Couples, Loving Children, but partners are given ample opportunities to practice skills and communicate with each other during the session. Most of the time in the session is spent on couple exercises, often with the help of communication “coaches,” who circulate among participants and offer each couple individualized attention. The second two months of group sessions focus on the supplementary curriculum modules developed specifically for the target population. In these later sessions, couples focus on using their relationship skills to address the module topics of trust, marriage, finances, and complex families.

The Becoming Parents Program begins with group leaders teaching a foundational skill called the speaker-listener technique, which is intended to improve communication and interaction, and prevent the escalation of conflict. Like Love’s Cradle, it uses coaches to teach this skill. The group sessions can be larger than for the other two curricula, in part because the curriculum relies more on presentations by the group leader. Unlike the other two curricula, the Becoming Parents Program is designed specifically to begin before couples have delivered the baby (although they may have other children). The sessions start with building relationship skills, such as communication and having fun together, to strengthen and solidify the relationship before the birth of the baby. After the baby is born, several “booster sessions” are offered to any couples that have completed the earlier prenatal series. These sessions focus on child development and parenting, which the author likens to an “owner’s manual” for parents. The information is targeted to the age of the new child and may help the adjustment of couples to their new parent status after birth.

Although the approaches differ, all three curricula emphasize the skills that are crucial to effective communication and connection, which are the cornerstones of successful marriages and healthy relationships. The curricula include topics such as listening to one’s partner, minimizing criticism, preventing escalation, and working as a team rather than as adversaries. All three of the curricula take a psycho-educational approach; group leaders facilitate and educate, but do not try to solve the couples’ problems. The curricula aim to provide couples the opportunity to develop skills in a safe, structured environment and offer specific tools to improve their interactions in preparation for entering or sustaining a healthy marriage.

2. Family Support Services

Family support services are included as a component of the BSF model because many unmarried couples face serious barriers to family stability. Parents may benefit from services that help them address these issues and remove impediments to healthy long-term marriage and relationships. To help those who need such services, BSF programs provide referrals and linkages to existing community programs and help couples access the services they need. This assistance is generally available to participants before, during, and after their participation in the marriage and relationship skills component. The specific services and their accessibility vary across the pilot sites. Across all sites, these include:

Employment services (job training, placement)
Educational services (GED preparation, literacy programs, vocational training, college)
Treatment or counseling for mental health problems
Substance abuse treatment
Infant care and parenting education
Child care, health care, housing services
Domestic violence programs

3. Family Coordinators

Family coordinators, the third component of the model, provide individualized support to couples in BSF. Each family is assigned a coordinator who meets with the couple on a regular basis over an extended period of time of up to three years, depending on the site. Family coordinators assess the family’s needs and link them to appropriate services, in some cases serving as the liaison between the couple and other agencies. The family coordinator also encourages participation in BSF groups, reinforces development of the relationship skills that couples learn in group, and provides sustained emotional support to the family.

At some program sites, meetings with the family coordinator are conducted through home visitation. During these home visits, which typically occur between two and four times a month, coordinators spend a substantial portion of the time on topics related to child development or parenting. At several sites, these weekly home visits already were a feature of an existing program that became the foundation for the addition of BSF services. In other sites, the meetings more often are held at a community center, either before or following a group session, or through a mix of regular telephone conversations and in-person visits. At these other sites, the nature of interactions with the family coordinator is less focused on parenting and child development and more devoted to supporting the couple’s relationship and addressing their other needs.

B. THE PILOT SITES

The BSF pilot sites were selected through a process that involved both technical assistance and scrutiny of their implementation progress and capacity. We first cast a wide net to identify organizations and agencies interested in implementing the BSF model, providing information and guidance in areas throughout the country. After working with a larger number of potential sites, the field was narrowed to those that seemed the most promising; we worked with this smaller number of sites to develop detailed plans for implementation. This intensive program design period helped sites systematically consider and plan for such operational needs as recruitment sources, staffing structure, domestic violence screening, a management information system, and curriculum selection and training. As each site completed its program planning, it moved into implementing the model. Ultimately, organizational sponsors in seven states implemented the BSF model during the pilot period. Throughout the pilot phase, each site’s operational progress was closely and regularly monitored by the research team, who also continued to provide assistance.

The BSF pilot sites include: Atlanta, Georgia; Baton Rouge, Louisiana; Baltimore, Maryland; Florida (Orange and Broward counties); Indiana (Marion, Allen, Miami, and Lake counties); Oklahoma City, Oklahoma; and Texas (San Angelo and Houston). All sites were located in urban areas, with two exceptions: the San Angelo site was in a small city with a surrounding rural catchment area; and one of the Indiana counties was largely rural (Miami County). The sites varied in a number of aspects, particularly the infrastructure in which BSF was implemented, the recruitment and referral sources, characteristics of the population served, and the chosen curriculum. Three of the sites built upon their Healthy Families programs, a nationally known intervention for preventing child abuse and neglect through intensive home visiting. Table I.2 summarizes some of the main similarities and differences.

Table I.2. Key Features of BSF Pilot Sites
Pilot Site	Host Organization	Primary Recruitment Sources	Race/Ethnicity of Main Population Served	Timing of Recruitment	Selected Curriculum
Atlanta, Georgia	Georgia State University, Latin American Association	Public health clinics	African American and Hispanic	Prenatal	LCLC
Baltimore, Maryland	Center for Fathers, Families and Workforce Development	Local hospitals, prenatal clinics	African American	Pre- and postnatal	LCLC
Baton Rouge, Louisiana	Family Road of Greater Baton Rouge	Prenatal program for low-income women	African American	Prenatal	LCLC
Florida: Orange and Broward counties	Healthy Families Florida	Birthing hospitals	African American and Hispanic	Postnatal	LCLC
Indiana: Allen, Marion, Miami, and Lake counties	Healthy Families Indiana	Hospitals, prenatal clinics, WIC	African American, White	Pre- and postnatal	LCLC
Oklahoma City, Oklahoma	Public Strategies Inc.	Hospitals, health care clinics, direct marketing	White	Prenatal	Becoming Parents Program
Texas: San Angelo and Houston	Healthy Families San Angelo and Houston	Hospitals, public health clinics	Hispanic and White	Pre- and postnatal	Love’s Cradle

Atlanta, Georgia: Georgia Building Strong Families. The Health Policy Center at Georgia State University (GSU) took the lead in developing the BSF pilot in Atlanta, in collaboration with the Latin American Association. GSU provided services to English-speaking clients, while the Latin American Association, a non-profit community organization, provided BSF services in Spanish. Prenatal couples were recruited through neighborhood public health clinics in Dekalb, Fulton, and Gwinnett counties. These counties agreed to describe BSF to interested women and obtain their consent to be contacted by BSF staff as a part of routine assessments following positive pregnancy tests. Georgia BSF began enrolling couples for its pilot in July 2005.
Baltimore, Maryland: Baltimore Building Strong Families. The nonprofit Center for Fathers, Families and Workforce Development (CFWD) created the Baltimore BSF program. CFWD has a history of and reputation for providing employment services and responsible fatherhood programs for low-income men and, more recently, a workshop-based co-parenting program for low-income parents in the Baltimore area. With its strong focus on men, CFWD has ample experience in reaching out to and engaging the participation of low-income fathers. To enroll BSF couples, local hospital and prenatal clinics identified likely BSF-eligible women, and CFWD conducted active outreach to reach their partners and determine the eligibility of interested couples. Baltimore BSF began enrolling couples in late September 2005.
Baton Rouge, Louisiana: Family Road Building Strong Families. Family Road of Greater Baton Rouge is a non-profit organization that provides access to a wide array of services for expectant and new parents. These include childbirth education, fatherhood programs, parenting and child development classes, money management, job placement, counseling, home visiting for at-risk mothers and children, and other programs. Access to these services is through Family Road’s “one-stop shop,” a center fostering the collaboration of more than 104 agencies that provide social services for families. Family Road recruits most of its BSF couples by inviting expectant parents who come into its center for the Better Beginnings program, which links Medicaid-eligible pregnant women to prenatal and pediatric services. Family Road BSF began enrollment in April 2005.
Florida: Healthy Families Plus. Healthy Families Florida, operated by the Ounce of Prevention Fund of Florida, integrated BSF services into its Healthy Families program, a home-visiting child abuse prevention program. The BSF pilot was implemented in Orange and Broward counties (Orlando and Ft. Lauderdale). For BSF, staff assess the eligibility of new mothers at area birthing hospitals as part of their routine intake procedure for Healthy Families. The family coordinator role is assigned to staff who conduct regular home visits for the host Healthy Families program. Healthy Families Plus, Florida’s BSF program, began to enroll participants in February 2005.
Indiana: Healthy Couples, Healthy Families Program. Indiana also combines Healthy Families and BSF. For the pilot, eight local Healthy Families Indiana sites were grouped in three pilot areas: (1) four local sites in Marion County (Indianapolis), (2) two sites in Allen and Miami counties (Fort Wayne), and two sites in Lake County (Gary). The recruitment process involves referrals from birthing hospitals, social service agencies, prenatal care centers, and the Women, Infants, and Children (WIC) program. As in Florida, intake and family coordinator roles were fulfilled by existing Healthy Families staff. Healthy Couples, Healthy Families, Indiana’s BSF program, initiated enrollment in February 2005.
Oklahoma: Family Expectations. As part of the Oklahoma Marriage Initiative, Public Strategies, Inc., under contract to the Oklahoma Department of Human Services, created a BSF program, Family Expectations, from the ground up. Referrals are solicited through hospitals, health care centers, and direct marketing, and intake is conducted at the location of the referral source, or at Public Strategies’ offices. Family Expectations began to enroll its pilot couples in August 2005.
Texas: Building Strong Families, Texas. The two Texas sites, San Angelo and Houston, transformed their Healthy Families programs into BSF programs, serving only couples who meet BSF eligibility requirements. Assessments for eligibility are done in the hospital shortly after delivery in San Angelo. At the Houston site, assessments are done in the home after referrals from hospitals, health clinics, and community-based organizations. During the pilot, families participated in home visits for several months before beginning BSF workshops. Houston offers groups in English and Spanish, and San Angelo so far has offered groups in English. Building Strong Families Texas began to recruit couples in February 2005.

C. FUTURE OF THE BSF EVALUATION

The information and data on which this report is based are drawn from several sources, including electronic tracking systems maintained by sites, discussions with program staff and participants, site visits, direct observation of program operations, and reviews of documents. Because most sites were at an early stage at the time of our study, however, not all operational components were completely implemented in each program. For this reason, this report focuses primarily on the marriage and relationship skills component, which is the core element of the BSF program.

Although the pilot offers a rich opportunity to identify strategies that hold promise for a wide audience, it is just the first and somewhat limited chance to examine program operations on a broad scale. When interpreting the information presented here, readers should therefore be mindful of four caveats. First, the programs were all in an early stage of implementation, and it is likely not only that their approaches will change in later stages, but also that the implementation outcomes may change as well. Second, the sites began their respective pilots at different times, so some of the programs had more experience than others. Consequently, the sites vary in terms of the opportunity they have had for confronting challenges and for modifying and adapting their practices. Third, we cannot make any causal arguments in this report. Although we identify promising operational approaches and strategies, we cannot link these processes definitively to implementation outcomes, such as the extent of program participation. Sites operate in different environments, and vary in their regional context, employment rates, population served, and in numerous procedures not described here. Fourth, our observations of the pilot are limited to operations and do not address the ultimate questions of how, whether, and the extent to which the BSF programs will affect the well-being of couples and their children. Answering that question will require comparing outcome data for the program and control groups, information that will be collected for the first time at 15 months after random assignment. Caveats aside, however, the value of the pilot should not be underestimated. It is a wholly unique opportunity to observe and learn from the BSF program in its infancy, providing seminal information on the still-unanswered question of how to improve couple relationships and family well-being in the low-income population. Later stages of the evaluation will address program operations in more detail and assess the outcomes and impacts of the program on couples and their children.

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