Excerpted from Chapter 4 of Life Skills Progression™ (LSP)
An Outcome and Intervention Planning Instrument for Use with Families at Risk, by Linda Wollesen, RN, M.A., LMFT & Karen Peifer, Ph.D., M.P.H., RN
Copyright © 2006 by Paul H. Brookes Publishing Co. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
PURPOSE, TARGET POPULATION, AND DEVELOPMENT
One purpose of the LSP is to describe the progressive outcomes of individual parents and
children and of the caseloads served by home visitation programs. The young families
enrolled in visitation programs usually are low-income households and have the various
risk factors associated with poverty.
Most evaluation tools are developed in research settings located in universities or in
private corporations specializing in field research consultation. The LSP was developed
in the field primarily for clinical and outcome use and secondarily for use in research settings.
It was written by Linda Wollesen as a distillation of more than 35 years of home
visitation experience in public health nursing programs and was created in response to
the need for a comprehensive outcome tool for home visitation services. The existing
family outcome tools, the California Matrix, the Automated Assessment of Family Progress
(AAFP), and the North Carolina Family Assessment Scale (NCAFS), focus on family
outcomes rather than the individual parent and infant/toddler outcomes, which are
needed by most home visitation programs (Endress, 2000; Kirk, 1998; NRCFCP, 1994).
The AAFP, the Matrix, the nursing home visitation research of David Olds, and the home
visitation articles edited by Deanna Gomby for the Packard Foundation became the main
catalysts for the design of the LSP scales.
The thought process that was the basis for the content of the LSP consisted of four
primary design components. The first component was to define which parent and child
outcomes are unique to home visitation services versus which are the primary responsibilities
of health care, child development, education, and/or other service programs.
Among the community of care, there are many shared outcomes for healthy pregnancies
and good child development, and the interventions by the various programs overlap
in many cases. Home visitation services provide collaborative and supportive roles to
the direct care providers and offer an array of unique approaches. The second component required in the design of the LSP was to identify what are basic parental life skills and
to describe the range of progress or characteristics seen in each of these skill areas.
For the purposes of the LSP, a life skill is defined as a behavior, ability, attitude, or
characteristic used to achieve and maintain a satisfying and healthy life, free from the
negative effects of poverty. It includes the ability to
Have nurturing relationships
Provide for health care and healthy life styles
Utilize resources and information
Complete a basic education
Have regular gainful employment
Provide for basic needs (housing, transportation, nutrition)
Raise children who have optimal health and development
A third design goal was to produce a tool to quantify outcomes and have high content
validity and interrater reliability. The tool also needed to capture the sequential comparison
of situational progress of individual parent–child dyads and for program caseloads.
This chapter describes the reasoning behind each scale and what material is and is not
covered in the LSP as a whole. An underlying premise of the LSP is that behavior is
learned, relationships and life skills are learned, and progress can happen and be described
Purpose of the LSP
The LSP has a number of clinical and outcome specific purposes:
To profile service population characteristics, including an individual parent or child,
a caseload, or a caseload subset
To document baseline characteristics and quantify sequential change by comparing
baseline profiles with ongoing and closing data
To identify parent and child strengths, needs, and goals for thoughtful, collaborative
To compare service populations enrolled in different programs within an agency, visitation
system, or community
To demonstrate long-term outcomes, accounting for variables such as service dose
(months of service and number of visits, type of staff or service model)
To provide an information resource for reflective supervision
To identify life skills categories and types of clients showing the most and least
To support outcome data analysis using multiple psychosocial and health-related
To provide data and a perspective for program improvement, funding, community
planning, and training
The LSP targets at-risk and high-risk parents and their children from pregnancy to age 3
years who are living in poverty. The health, social services, justice system, and educational
costs related to impoverished families are extremely expensive to our society.
Unfortunately, the programs bearing the costs of preventive services usually are not the
ones incurring the benefit of the costs saved. This makes funding for home visitation services
In the now classic 1989 book, Within Our Reach: Breaking the Cycle of Disadvantage, Lisbeth
B. Schorr describes “the high cost of rotten outcomes,” defines risk factors associated
with poverty, and makes a powerful case for reforming national policies. Unlike other
advanced countries, the United States does not have the elimination of poverty as a goal,
although some would argue that welfare reform was intended to do this (Schorr & Schorr,
1989). Inadequate funding for poverty prevention exists in spite of spiraling costs related
to poverty–associated health care, child development, and early failure in school; welfare
and foster care costs; and justice system, violence, and substance treatment.
The impressive outcomes of the research by Olds and associates and the cost–benefit
study of the Olds and the Perry Preschool models by the RAND Corporation resulted in
national acclaim for these models. Since then, the combined impact of the attacks of September
11, 2001, the depressed economy, and the costs of antiterrorism measures and
war have combined to create funding cuts and cause programmatic changes even to well established
and effective programs. Funding shortfalls for foundations and governmental
resources emphasize the challenge facing the field of home visitation to clearly describe
complex skills that are needed by families in order to prevent “rotten” outcomes. A related
challenge is to demonstrate how much positive family change is possible and to show
which programs are effective in supporting the development of these skills. A common
parent/child outcome tool and data bank, which spans programmatic boundaries, may
contribute to the ability of the home visitation field to advocate effectively for funding
for the services needed to eradicate poverty.
LSP Pilot Study Environment
The pilot study for the LSP was originally conducted in several community-based home
visitation programs in one California county. The LSP is now used by a variety of programs
in many states, including several of the nationally linked programs (HFA, National
Healthy Start [NHS], PAT, EHS) and statewide systems.
Field testing and academic support from experts in evaluation and early childhood
came after the initial development and as the result of other clinicians hearing about the
LSP at conferences or from colleagues. Word spread among evaluators providing consultation to local programs through Federal or State grants such as EHS, Safe Schools, and
First 5 of California. Valuable support came from ZERO TO THREE/National Center for
Clinical Infant Programs, an organization that provided the LSP’s author with a Fellowship
in 2000–2002 that resulted in access to national experts. The collaborative thinking
and ongoing dialogs, which developed between the LSP’s author and the pilot sites using
the LSP, resulted in valuable clarifications to the scales and training materials.
Field testing was conducted by each site or cluster of programs using separate databases
that were designed in response to site–specific program goals, funding requirements,
and technical ability. Each site had to develop its own database using Access (Microsoft
Corporation) or SPSS (SPSS Inc.) software. Some sites were fortunate enough to have
Grant–linked evaluator assistance from private consultants or university-based research
The LSP was written originally in 1998&ndash1999 when the author was a supervising
public health nurse with management and supervision responsibility for four home visitation
programs run by the Monterey County (California) Public Health Department.
The programs included public health nursing, a state-funded high-risk infant follow-up,
an Adolescent Family Life Program (AFLP), and the NFP program. The latter was an
approved replication site for the “best practice” model developed by David Olds and colleagues
at the University of Colorado. The health department programs were joined under
consultation agreements by other countywide visitation programs, which included PAT
and a new EHS site. All of these programs participated in the pilot study for the LSP. They
used a common database and had interagency agreements and informed parental consents.
This collaborative effort gave a countywide snapshot of the baseline profiles of families
being served by home visitation. The experience provided a population of about 800
families in the open caseloads for anonymous study as each program's data became available.
Substantial grant–based funding was acquired by programs using the LSP for sequential
outcome data. The analysis of some of the anonymous versions of LSP pilot database
will be used to provide the examples of evaluation described in Chapter 7.
History of LSP Development and Testing
LSP written with 37 scales
Preliminary inter- and intrarater reliability estimated at 90% by Brad Richardson,
Ph.D., lead evaluator for the National Resource Center for Family Centered Practice
at the University of Iowa School of Social Work
LSP use and Access database piloted internally in Monterey County public health
nursing and associated community programs
LSP expanded to 43 scales
LSP used to demonstrate Monterey County NFP and PAT outcomes for California
First 5 grants
LSP training began for 11 other California programs, counties, and First 5 sites, and
expanded to sites in Montana and Pennsylvania
ZERO TO THREE National Fellowship awarded to the LSP’s author, to refine and publish
the LSP. Kathryn Barnard, Ph.D., R.N., was Board Member and mentor for the LSP.
Content validity study carried out using 46 multiethnic expert reviewers representing
nine disciplines and consisting of ZERO TO THREE Fellows, trainers from national
home visitation programs, evaluators, and staff from sites using the LSP
LSP instructions for use in reflective supervision completed in collaboration with
Sandra Smith, M.P.H., C.H.E.S.; the work was funded by two ZERO TO THREE grants
and incorporated into reflective function training and materials. The materials are
linked to the Beginnings Guides curriculum, illustrated by Laurel Burch, and subsequently
published in 2004 as a CD with training required for use.
LSP database designed using MS Access XP Professional 2000 software and available
for programs that do not wish to develop their own LSP software
LSP data web site for data entry and analysis reports is being considered in collaboration
with the University of Washington, Center for Health Education and Research
(CHER), in Seattle. This will create easy access to sophisticated data analysis for individual
home visitation programs or systems of programs. It is expected that the Access
data entry screens currently used by most programs using the LSP will form the basis
for entry into a web-based system. Plans are being made to transfer existing LSP data
into the Web data banks to provide important continuity for programs. CHER at the
University of Washington in Seattle is considering management of the Beginnings &
Life Skills Progress trainings to ensure reliability and for related trainer trainings.
RELIABILITY AND VALIDITY TESTING
Definition of Reliability and Validity
It is important to understand the difference between validity and reliability. A valid instrument
measures the constructs it says it is measuring in a clear and consistent way.
The Weiss definition of validity is “the extent to which a measure captures the dimension
of interest” (Weiss, 1998). Reliability means “the consistency or stability of a measure
over repeated use” (Weiss, 1998). It is measured by the proportion between the true
score variance and the total variance. This is called partial correlation and indicates the
proportional relationship between item measurements.
Validity and item analysis are used to construct measurement scales, to improve
existing scales, and to evaluate the reliability of scales already in use. Specifically, validity
and item analysis aid in the design and evaluation of the scale that is made up of multiple
individual measurements (e.g., different items, repeated measurements, or different
measurement devices). The LSP has 43 different scales that measure different constructs.
Some scales are related directly to each other and other scales are related indirectly or
are related sequentially in time to each other. For example, a pregnant mother would
not have an infant scale scored until after the birth of the baby. A mother with depression
might show a high correlation score on the relationship with spouse scale.