Healthy Start Program (HSP)

OVERVIEW

Healthy Start is a home-visiting program for families with newly born children. The program is designed to prevent child abuse and neglect. Healthy Start uses population-based screening to identify high-risk mothers who are eligible for the program. In this program, trained paraprofessionals visit homes weekly. They model effective parent-child interactions, provide access to social services, and offer parent education. Home visits occur less frequently as family functioning improves. Evaluation findings are mixed. One study found no impacts on child abuse or the use of nonviolent discipline; yet reported neglect by program mothers was significantly reduced. Another evaluation found the program to decrease the use of harsh parenting and abuse/neglect, and a third study found no impacts on abuse/neglect. Lastly, fewer health problems were found in one study, but not another.

DESCRIPTION OF PROGRAM

Target population: Families who are determined to be at risk of child abuse and neglect. Risk factors include maternal health, maternal mental health, maternal substance use, and partner violence.

Healthy Start is a home-based intervention intended to prevent child abuse and neglect, by offering family support and parent education services. Home visits are conducted by trained paraprofessionals working under professional supervision. Home visitors establish trust with the parents of the child by addressing current crises they may have. Income, nutritional, and problem-solving assistance is provided, as well as access to services that address domestic violence, substance abuse, and poor mental health. Home visitors also model effective parent-child interaction and offer parental education.

The home visitors are paraprofessionals who work under professional supervision. All home visitors have at least a high school diploma or equivalent and supervisors have a master’s degree and three years of experience in the field or a bachelor’s degree and five years of experience. Home visitors are also trained in the national Parents as Teachers Program. This training focuses on helping parents support their children’s development in four areas: language, intellect, and motor development; social-emotional issues; safety and health issues; and building social support networks.

The home visits centered around setting and reaching family goals, obtaining quality health care and other services, obtaining skills for successful parenting, managing money matters, and obtaining other services to reduce the stresses of parenting and to promote family well-being.

Home visiting is provided for three to five years, with visits occurring less frequently as family functioning improves. Visits may be weekly, biweekly, or quarterly. If a home visitor has problems meeting with the family, they use ‘creative outreach’ to establish contact.

EVALUATION OF PROGRAM

Duggan, A., McFarlane, E., Fuddy, L., Burrell, L., Higman, S. M., Windham, A., Sia, C. (2004). Randomized trial of a statewide program of home visiting to prevent child abuse: Impact in preventing child abuse and neglect. Child Abuse & Neglect, 28, 597-622.

Evaluated population: Six-hundred and forty-three families in Oahu, HI were evaluated.

Approach: Of 1,803 families identified as at-risk through a pre-natal care provider referral or assessment of the family at the child’s birth, 643 were randomly assigned to HSP or to a no-treatment control group. At-risk was defined by scores on parental substance use, poor mental health, domestic violence, history of abuse as a child, unrealistic expectations of the child, and unwanted children. Eligible families of this pool were chosen because the mother understood English, the family was not currently enrolled in the program, the family was able to be assigned to a community site, and they agreed to take part in the program and evaluation.

HSP evaluation staff completed a baseline interview with mothers at the hospital or within a month of delivery of their child, then completed assessments at one- and two-years following baseline. Data were collected from parent report, observation, and administrative records from Child Protective Services and hospitals.

Data were collected from parent reports, observations, the Current Population Survey, and hospital records.

Results: Analyses showed that the program had no impact on preventing child abuse. HSP and control groups did not differ in severe abuse indicators, and home visitors were not found to be alert to mothers with high abuse behavior levels. There were no significant differences in measures of less severe abuse among the two groups. HSP mothers were no more accepting of their child’s behavior than control mothers nor did they differ in use of nonviolent discipline. HSP mothers were less likely to report neglectful behavior.

Bugental, D. B., P. C. Ellerson, et al. (2002). A Cognitive Approach to Child Abuse Prevention. Journal of Family Psychology 16(3), 243-258.

Evaluated Population: Ninety-six high-risk families participated in the program. Ninety seven percent of the families in the study were Latino, 48 percent were single-parent families, half of mothers had been abused as children. The average age of mothers was 25.5 years old, and the average education of mothers was 7.8 years.

Families’ risk status was determined by pediatricians, obstetricians, and local health clinicians. If families answered “yes” to at least two items in a preliminary screening questionnaire, then they underwent a semi-structured interview. Items include parental unemployment, low income, unstable housing, and low education.

Approach: The 96 families were randomly assigned to one of three conditions, control, HSP, and enhanced HSP. Parents in all conditions were visited by a home visitor over a one-year period. Families in the control condition only received information about services available in their community. The enhanced HSP condition added a problem-solving discussion to the beginning of each home visit. Data on harsh parenting (legally non-abusive, but harmful, methods) and child health (no injuries, feeding problems or illnesses in the first year). Definitions of pre-test, post-test, and follow-up are not provided.

Results: Parents in the enhanced home-visitation condition were the least likely to use harsh parenting (four percent did). Then the unenhanced home-visitation condition was more likely than that (23 percent), and the control condition was most likely to use harsh parenting (26 percent). However, the unenhanced home-visitation and the control conditions were not significantly different from one another. The enhanced home visiting group also had fewer incidences of physical abuse than the other two groups, individually and combined. Children had the fewest health problems in the enhanced home-visitation condition, then in the unenhanced condition, and then the most problems in the control condition.

In most of the analyses, the authors combined one of the comparison groups with the control group. The results from these analyses are omitted from this report.

Duggan, A. K., McFarlane, E. C., Windham, A. M., Rohde, C. A., Salkever, D. S., Fuddy, L., et al. (1999). Evaluation of Hawaii's Healthy Start Program. The Future of Children, 9(1), 66-90.

Evaluated Population: Six-hundred eighty-four at-risk families in Oahu, Hawaii served as the sample for this evaluation. Two-thirds of the mothers were high school graduates, and two-thirds of the family household incomes were below the poverty level. Twelve percent of mothers did not have relationships with their children’s fathers, while 36 percent were friends with or dating the fathers, 29 percent lived with the fathers, and 24 percent were married to the fathers.

Approach: The 684 families were randomly assigned to one of three conditions: HSP; main, no-treatment control; and testing, no-treatment control. Families in the control condition only received information about services available in their community. The dosage of visitation was one year. The enhanced HSP condition added a problem-solving discussion to the beginning of each home visit. Parents in all conditions were visited by a home visitor who reported to a licensed clinical social worker.

Families in the testing control group were only evaluated at the three-year follow-up. So the results presented in this write-up are for differences between the HSP and the main, no-treatment control group. Data on child abuse and neglect, child health, parents’ response to child with the Parent Attribute Test (PAT), parent affect, parent social support, and harsh parenting were collected at pre-test, post-test, and follow-up at 2 years past baseline.

PAT aims to capture the types of thoughts a parent has about his or her child through a series of self-report questions testing the respondents’ beliefs about control or power within their relationships. Parents also drew a picture of themselves and of their child as a possible indicator of perceptions of the relationship between them and their infant.

Results:

Linkages to primary care providers and other community resources.

At the two-year follow-up, HSP participants were more likely than controls to report having primary care providers who know the family concerns about the child, but this difference was not apparent at the one-year follow-up. There were no significant differences across HSP and control groups on likelihood of having primary care providers, having providers that handle most of the family healthcare needs and know all aspects of the children’s care, having an adequate number of well-child visits, or having up-to-date immunizations. Furthermore, HSP and control participants reported the same rates of linkages to the following services: adult health care, child care, respite care, transportation, adult education, housing, nutrition, counseling, substance-abuse treatment, support groups, women’s shelters, legal assistance, material assistance, and financial assistance.

Maternal lifecourse.

There were no differences across groups on the mother’s likelihood to have attended school, high school degree attainment, employment rates, or household employment rates at the one- or two-year follow-ups.

Home environment.

At the one-year follow-up, mothers in the HSP group reported poorer general mental health than mothers in the control groups; however, this difference did not exist at the two-year follow-up. Additionally, at the two-year (but not the one-year) follow-up, mothers in the HSP groups were significantly less likely than control mothers to have reported incidents of partner violence resulting in injury. There were no differences across groups on the following indicators: life skills, maternal social support, confidence in adult relations, maternal substance abuse, maternal depressive symptoms, and incidents of general physical partner violence.

Parenting behaviors and attitudes.

There were no differences across groups at the one- or two-year follow-ups on providing a learning environment or parent-child interactions. At the one-year follow-up, HSP mothers were more likely than control group mothers to use moderate amounts of nonviolent discipline over not using nonviolent discipline. At the two-year follow-up, HSP mothers were more likely than controls to use nonviolent discipline strategies frequently or moderately over not using nonviolent discipline. Additionally, at the two-year follow-up (but not the one-year follow-up) HSP mothers reported less parenting stress and more parenting efficacy than control mothers.

Child health and development.

There were no differences between children in the control and HSP groups at the one- or two-year follow-ups on the following indicators: ever used an emergency room, ever hospitalized for any reason, ever had an injury needing medical care, or physical, mental, or psychomotor development.

Child abuse and neglect.

At the one-year follow-up, control mothers were more likely to have engaged in child neglect than HSP mothers; however, this difference disappeared at the two-year follow-up. There were no significant impacts on psychological aggression at the one-year or two-year follow-ups. There were no differences at the one- or two-year follow-ups on incidents of minor or severe physical assault.

El-Kamary, S. S., Higman, S. M., Fuddy, L., McFarlane, E., Sia, C., & Duggan, A. K. (2004). Hawaii’s Healthy Start home visiting program: Determinants and impact of rapid repeat birth. Pediatrics, 114(3), e317-e326.

Evaluated Population: Six-hundred and eighty-four families participated in the study. The mean maternal age was 23 and about one third of the women were teen mothers. Two-thirds of the families had a household income below the poverty level. Less than one third of the families had access to a family planning site, and about one-fifth of the mothers had poor general mental health.

Approach: Families were randomly assigned to HSP or to a no-treatment control group. The families were measured on whether the mother had a “rapid repeat birth” (a birth that occurred within two years after another birth), maternal desire for a rapid repeat birth, lack of a family planning site nearby, birth control use after the first birth, parenting stress, maternal neglect, warmth toward the first birth, internalizing behavior in the first child, and externalizing behavior in the first child.

Results: No impacts were found (e.g., desire for a rapid repeat birth, lack of family planning site, and use of birth control). The authors analyzed first-time mothers separately also and found no significant impacts.

SOURCES FOR MORE INFORMATION

Link to program curriculum:

http://hawaii.gov/health/family-child-health/mchb/programs/hs.html

http://www.healthystartassoc.org

References

Bugental, D. B., P. C. Ellerson, et al. (2002). A Cognitive Approach to Child Abuse Prevention. Journal of Family Psychology 16(3), 243-258.

Duggan, A. K., McFarlane, E. C., Windham, A. M., Rohde, C. A., Salkever, D. S., Fuddy, L., et al. (1999). Evaluation of Hawaii's Healthy Start Program. The Future of Children, 9(1), 66-90.

Program categorized in this guide according to the following:

Evaluated participant ages: Early Childhood (0-5)

Program components: Home Visiting

Measured outcomes: Behavior Problems, Physical Health, Mental Health

KEYWORDS: Infants (0-12 months); Toddlers(12-36 months); Children (3-11); Native Hawaiian or other Pacific Islander; Hispanic or Latino; Nutrition; High-Risk; Child Maltreatment; Home Visitation; Manual; Aggressive/Externalizing; Depression/Mood Disorder; Parent Training; Social Skills; Parent-Child Relationship; Condom Use & Contraception; Teen Pregnancy; Adolescent Mothers.

Program information last updated 11/3/10

		© Child Trends 2004