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 ii
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.

CHILD CARE USE AMONG ADOLESCENT MOTHERS iii
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.

CHILD CARE USE AMONG ADOLESCENT MOTHERS iv
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

CHILD CARE USE AMONG ADOLESCENT MOTHERS v
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

CHILD CARE USE AMONG ADOLESCENT MOTHERS vi
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

CHILD CARE USE AMONG ADOLESCENT MOTHERS 1
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;

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

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

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.

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.

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).

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

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

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).

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

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

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

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 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;
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
(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).
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
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,
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).
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
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
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).
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
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
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).
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
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).
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
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.
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
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 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.

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

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).

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

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-

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

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

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.

Coordination BetweenHome 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 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.

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.
ResearchQuestions 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.

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 selectedmaternal 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.

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).

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.

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

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

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.
Designof 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 Network,
2 DTA provides food (Supplemental Nutrition Assistance Program, SNAP), cash (Temporary
Assistance forNeedy 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.

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 1=yes.
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.

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 underthe “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 othersubsidies),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.

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

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.

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

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.

Chapter Four: Results
The following chapter presents findings according to the thesis questions.
ResearchQuestion 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%),

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.
ResearchQuestion 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

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.
ResearchQuestion 3: To what extent are selectedmaternal 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.

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

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.
ResearchQuestion 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.

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.

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

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

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

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

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

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 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

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.

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.

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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

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.

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 5
Significant Findings: Maternal Characteristics and Care Type
Relative Statistic p
n=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 0.000
Employed, 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 0.001
No 55.8%
Yes 75.5%
Parenting/Pregnant χ2(1)=6.271 0.012
Pregnant 74.5%
Parenting 60.9%
Current Voucher Use χ2(1)=89.939 0.000
No 85.3%
Yes 30.3%
Current TANF Use χ2(1)=5.972 0.015
No 74.9%
Yes 61.8%
Note: Only p values significant at p <.05 are reported.

Figure 1. National evidence-based home visiting programs (Avellar et al., 2014).
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 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).
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 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)

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 Center
Early Head Start
Childcare Center at School
Family Child Care
Group care
Friends
Nannies
Babysitters
Others not identified as family or a group
arrangment
Non-
relative/Non-
group

Running head: CHILDCARE USE AMONG ADOLESCENT MOTHERS
THESIS DRAFT
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Official Final MA Thesis

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