Desirae Sylvia takes her daily walk with her daughter, LaRose Leigh.

At 36, Desirae Sylvia is making plans for a new chapter in her life.

She and her toddler daughter, LaRose Leigh, live in Desirae’s childhood home on Wyoming’s Wind River Indian Reservation, land of the Northern Arapaho and Eastern Shoshone Native American tribes. It’s a world away from the Colorado prison where LaRose Leigh was born just 18 months earlier.

Today, Desirae is meeting with Elsie Charging Crow from Wind River’s Family Spirit program, an early childhood home visiting program designed to strengthen the health and development of Native American families. The two have been meeting regularly for almost a year now. Most recently, they talked about the importance of balanced nutrition, how to manage infant-mother separation, and dental care for toddlers. Now, they’re discussing how to create a family budget.

Elsie hands Desirae a worksheet on the topic to fill out as they talk, which Desirae will soon add to her bulging binder of completed worksheets she references as needed.

“How do you feel about your day-to-day financials?” Elsie asks.

“Everything depends on my driver’s license right now,” says Desirae, whose father drops her off for her dishwashing job at 5:30 a.m. six days a week. She also earns money from odd jobs, like working security at pow wows. So far, she’s saved enough to put down 3 months’ rent on a two-bedroom trailer. “If I don’t get my license, I won’t be able to move . . . and I need my CNA [Certified Nursing Assistant certification] in order to afford the place.”

Desirae has already passed her CNA exam and delivered letters attesting to her character—including one Elsie wrote—for the program’s licensing. She wants to stay on the reservation and live as a family with her daughter and fiancé. And she wants LaRose Leigh to know where she comes from, to teach her what it means to be Northern Arapaho.

As her home visitor, Elsie will support and guide Desirae as she turns her vision into reality.


Benefits of Home Visiting

Home visiting provides a support person—a nurse, social worker, early childhood specialist, or trained paraprofessional—to help parents of young children and expectant mothers access prenatal care, practice healthy behaviors during and after pregnancy, understand developmental milestones in their child’s life, and become more financially self-sufficient. Services include everything from screening parents for issues such as postpartum depression to educating them about how make their homes safer to connecting them with job training opportunities.

Last year, more than 300,000 families across the country received such support through evidence-based home visiting programs, including more than 4,000 Native American families, according to the National Home Visiting Resource Center’s (NHVRC) 2018 Home Visiting Yearbook. The Yearbook estimates that close to 18.1 million pregnant women and families with children younger than 6 not yet in kindergarten could potentially benefit, but were not reached. This includes an estimated 342,100 American Indian/Alaska Native families.

An estimated 342,100 American Indian/Alaska Native families could benefit from home visiting but were not reached in 2017.

Home visiting has proven benefits for children, parents, and their communities. Evidence shows that mothers who receive home visiting are more likely to access prenatal care and breastfeed longer; participating parents have higher incomes and are more apt to be enrolled in school or employed. Children’s early language and cognitive development also improve, as does their academic achievement in grades 1 through 3.

“Decades of research show us that home visiting can lead to better outcomes for two generations,” says Allison Meisch, deputy project director of the NHVRC. “These changes spur ripple effects across entire communities as parents and children receive the support they need to lead healthier, more productive lives.”

Adapting Models for the Tribal Context

The U.S. Department of Health and Human Services recognizes 20 home visiting models as evidence based because of their demonstrated positive effects on child and family health and development. Each model has a slightly different objective, target population, and approach, but all strive to improve outcomes in children’s early years and ultimately, throughout their lives. Each is delivered in diverse settings, from rural towns to urban enclaves, and among various racial and ethnic groups.

The Family Spirit model used in Wind River is the only evidence-based home visiting model designed specifically for Native Americans. However, many other evidence-based models are carried out in tribal settings. In those cases, communities often enrich home visiting with components that help preserve cultural identity and traditions. Examples include consulting with tribal cultural leaders and hiring Native staff, or incorporating storytelling into visits and connecting families to traditional cultural events.

Communities often enrich home visiting with components that help preserve cultural identity and traditions.

“There’s a lot of evidence that having culturally specific content enhances the effectiveness of the intervention. People are more likely to engage with it if it feels culturally relevant to their own lives,” says Moushumi Beltangady, senior policy analyst for early childhood development, Administration for Children and Families.

For instance, in Arizona, NATIVE HEALTH of Phoenix is implementing the Parents as Teachers model through three Native American home educators who work with families from 16 different tribes. The agency is assessing the cultural needs of families and considering home visiting enhancements that can help children learn their Native language, families feel more connected to tribal traditions, and communities become more cohesive, says Samantha Highsmith, maternal and child health program manager.

One strategy is bringing home visiting participants together for monthly discussions and presentations, such as traditional cooking classes. The gatherings provide families an opportunity to meet and build a support network. “We’re trying to figure out what it means to be culturally engaged,” as well as how to tailor services in meaningful ways, Highsmith says.

There’s a lot of evidence that having culturally specific content enhances the effectiveness of the intervention. People are more likely to engage with it if it feels culturally relevant to their own lives.

Moushumi Beltangady

Administration for Children and Families

Research Gaps in Tribal Home Visiting

As communities determine which home visiting approaches work best for them, they also must figure out resources to support their efforts. The Tribal Maternal, Infant, and Early Childhood Home Visiting Program (Tribal MIECHV) has provided federal grants since 2011 to a select number of Indian tribes, tribal organizations, and urban Indian organizations. In communities without a Tribal MIECHV grant, services are funded through and operated by tribes or with blended sources of funding.

Differences in funding, reporting mechanisms, and research capacity contribute to gaps in evidence on Native American families’ maternal and child health needs and the current home visiting landscape.

“Native American families are among the most underserved,” says Urban Institute Senior Research Associate Heather Sandstrom, who provides research support to the NHVRC. “We are learning more about their unique needs, but we don’t have enough data to paint a complete picture and to point to where more services are needed.”

Although gaps in the research exist, several initiatives are underway to fill them. Tribal MIECHV provides funds for awardees to conduct rigorous evaluations. The Multisite Implementation Evaluation of Tribal Home Visiting (MUSE) project, which is exploring the implementation of home visiting in 17 tribal communities, is another example of research to further understand how home visiting can be enhanced to meet the needs of Native American families.

Native Culture as a Protective Force

Even in its first year, Wind River’s Family Spirit home visiting program—which serves members of any federally recognized tribe living on the reservation, not just Northern Arapahos— is already showing anecdotal success in improving the health and development of participating families. There is much more work to be done. Nearly 70 percent of women in the program are unemployed, according to data collected by the program. A third are experiencing postpartum depression, and many have struggled with addiction. Domestic violence is another painful reality for many women in the program.

With the support of Wind River’s tribal elders, the program is helping ground participants in their history and traditions so they can better manage the effects of historical and intergenerational trauma on their daily behaviors.

“It’s [about] reclaiming their culture and their identity, and building it back up. When you have a strong community, there’s less alcohol problems, there’s less drug problems, there’s less suicide,” says Family Spirit Program Director Kim Clemetson, who also works as a maternal and child health nurse at Wind River Family and Community Health Care.

The Family Spirit program takes a strengths-based approach, meaning that educators try to “meet that mommy right where she’s at,” Clemetson says. “Not with expectations of ‘this is how you need to perform,’ but … [to] help support her where she may not have that support of the community to be successful in her parenting.”

Desirae Sylvia talks with home educator Elsie Charging Crow about her family’s budget.

The program is currently reaching 98 families in Wind River through three home educators who are certified nursing assistants (CNAs).

Each educator is Northern Arapaho and grew up on the reservation. They know this place, its common hardships, and its Northern Arapaho customs and traditions—like how looking your elders in the eyes is disrespectful. Elsie, who is raising her nine grandchildren, has already experienced many of the same challenges as the mothers she visits.

Elsie often reminds moms of how the Northern Arapaho tribe in the past held women in high esteem because they create life, “like the Creator.” They were respected and protected from harm.

“I want our men to be warriors again, and our women, too,” she says. “I want to help make a change so our community can be healthier and stronger.”

I want our men to be warriors again, and our women, too. I want to help make a change so our community can be healthier and stronger.

Elsie Charging Crow

Wind River Family Spirit

Embarking on a New Life

It is almost 5:30 p.m. back at Desirae’s parents’ home. Elsie has gone, and Desirae begins her daily 2-mile walk with LaRose Leigh along the road where she once made $12.50 selling lemonade as a child.

She started this routine when she first returned to Wind River. It helps to keep her mind strong. “I didn’t want to think about the things that put me in the spot I was in,” she says. “I just want [LaRose Leigh] to have a good life and understand that this is what we do as a family.”

Home visiting has been instrumental in helping Desirae shape her vision of a healthy life and to reconnect with her Northern Arapaho traditions. “Every module we work with, it’s been like the cycle of my life,” she says of the program. “Elsie kept on encouraging me. She’d tell me, ‘you can do it.’”

As the week unfolds, Desirae sees evidence of her hard work. She passes her driving test and written exam. And she gets the call confirming her CNA license.

She’s making it.

This feature story was developed by the Urban Institute and is also available on its website.