Journal Issue: Home Visiting: Recent Program Evaluations Volume 9 Number 1 Spring/Summer 1999
The Evolution of Hawaii's Healthy Start Program
In 1975, Dr. Calvin Sia established the Hawaii Family Stress Center (or HFSC, later renamed the Hawaii Family Support Center) with funding from the National Center on Child Abuse and Neglect. HFSC established several child abuse and neglect programs on Oahu, including a home visiting program based on Kempe's lay therapy model for families already known to child protective services (CPS).The Early Identification Component
HFSC also initiated a child abuse prevention program focusing on vulnerable families without a history of CPS involvement. Like today's HSP, and as illustrated in Figure 1, the program was intended to improve parent and child outcomes in at-risk families by providing services directly and by promoting family use of preventive and early intervention services. Also like today's HSP, this early prototype had two components: (1) early identification (EID) of families with newborns at risk of child abuse and neglect, and (2) home visiting by trained paraprofessionals.
The EID component focused on families living in any one of four communities on Oahu and delivering a child at Kapiolani Maternity Hospital. Screening was carried out daily at the obstetrical unit by reviewing mothers' medical records to measure family risk for abuse in 15 areas: parents not married; unemployed partner; inadequate income; unstable housing; lack of telephone; less than high school education; inadequate emergency contacts; marital or family problems; history of abortions; abortion unsuccessfully sought or attempted; adoption sought; history of substance abuse; history of psychiatric care; history of depression; and inadequate prenatal care. When a mother's record suggested risk or provided too little information to make a judgment, the EID worker interviewed the mother to determine risk more precisely using Kempe's Family Stress Checklist.3The Home Visiting Component
The home visiting component focused on those families classified through the early identification as at risk of child abuse and neglect. Families so identified were invited by EID workers to participate in a home visiting program designed to help family members cope with the challenges of child rearing. If the mother agreed to participate, the EID worker contacted the home visiting component of the program to arrange a first visit. Home visitors were trained paraprofessionals recruited from the community, with qualities essential for working with vulnerable families: warmth, self-assurance, cultural sensitivity, and good parenting skills.
Home visitors sought first to establish trusting relationships with parents, using an empathetic, nonjudgmental listening style and actively assisting parents to address existing crises. Once immediate crises were resolved, home visitors helped families identify and build on their strengths to improve family functioning. Home visitors role modeled problem-solving skills and helped link families with needed services, such as housing, income and nutritional assistance, child care, and educational and vocational training. At the same time, home visitors worked to promote child health and development by providing parenting education, modeling effective parent-child interaction, and ensuring that each child had a "medical home," that is, a continuing source of pediatric primary care. HSP services were offered to families for the child's first three to five years. No formal evaluation of this earliest HSP model was done, but anecdotal evidence suggested that the home visitors were able to build family trust and promote effective parenting.
Encouraged by the Oahu experience, the Statewide Council on Child Abuse, an Oahu-based child advocacy group, created a structure for program replication on the other Hawaiian islands (the "Neighbor Islands"). Community-based family support centers were developed with staff trained by HFSC, and six home visiting programs were launched. From 1977 to 1984, these six programs were financed by local fundraising events, foundation grants, and up to $1 million in state government monies administered through the state health department's Maternal and Child Health Branch.The Healthy Start Pilot Program
HFSC coordinators felt that the early child abuse prevention programs on Oahu and the Neighbor Islands had several limitations: the 12-month programs were too brief to lead to lasting changes; caseloads were too high; and the parenting education curriculum needed a greater emphasis on child development, healthy parent-child interaction, and linking families with medical homes.
To address these issues and test the effectiveness of the revised model, the Hawaii state legislature in 1984 authorized a Healthy Start Pilot Program carried out by HFSC in collaboration with the Hawaii Department of Health. The pilot program focused on a neighborhood in the Ewa community on Oahu, a community with relatively high rates of child abuse and neglect. The three-year pilot began in July 1985.
The pilot program had EID and home visiting components like the family support center programs, but it also sought to expand home visiting services to all at-risk families in a broad geographic area. In addition, home visiting services were to be more intensive, of longer duration, and more structured, with weekly home visits at first, gradually decreasing to quarterly visits as family functioning improved. Families were expected to remain in the program for at least three years.
Service provision protocols for the pilot program were much more detailed, addressing parenting education; parent problem-solving skills; and links with community services such as housing, education, child and respite care, and substance-abuse and domestic violence services. Staff supervision was more structured than in the older programs, with set ratios of families to home visitors and of home visitors to supervisors. The program director was a public health nurse. Supervisors were professionals with formal training and experience in early childhood education, social work, or nursing. The supervisors met formally with each home visitor at least weekly to review the progress of each family.Healthy Start Pilot Program Evaluation Results
Program reports show that 248 (15%) of 1,693 families with newborns were identified as at risk and that 234 (94%) of them enrolled in the program. Interviews with a small sample of participating families found that they thought highly of the program.
HSP effectiveness in reducing child abuse and neglect was measured by CPS reports and changes in risk of abuse in participating families. During the three-year pilot, there were no reports of physical abuse, and only four reports of neglect and four reports of imminent harm for program participants. Because evaluations of other home visiting programs4 had found much higher rates of reported abuse in comparison group families, these results were viewed as strong evidence of a positive program impact. However, as will be illustrated by the current study, the pilot study results might have been given too much weight, given the lack of a control group and the short period of follow-up for most families.
In a pretest/posttest design, EID staff readministered the Family Stress Checklist to families and compared the new scores with the scores obtained at the time of each child's birth. Most families were found to have significant decreases in their scores, which was taken as evidence of decreased family risk of child abuse and neglect.
However, this approach was flawed in at least two important ways. First, the follow-up assessments might have been biased by the EID workers' knowledge that all the families had been receiving home visiting. Second, because all the families had been selected for the program as a result of their high stress scores, a decline in scores would be expected with or without an intervention because of a phenomenon called "statistical regression." Simply put, individuals defined by extreme scores on a measure at one time will show a shift in scores over time toward the average for all individuals even without an intervention. Families with high Family Stress Checklist scores at the time of a child's birth would be expected to have scores that would drift lower over time because of statistical regression alone. Again, a control group would have provided a means of judging how much, if any, of the reduction in risk could be attributed to the program.
Nevertheless, the generally positive findings from the Healthy Start Pilot Program were sufficient to lead legislators to expand HSP and its model throughout Hawaii. State funding for HSP increased annually from 1989 until 1995, when a prolonged downturn in the state economy forced across-the-board cuts in state spending. Since then, state support for HSP has continued, but at a level of about $6 million annually, as compared with the $8 million budget of 1995. Overall, 68% of families with newborns live in the HSP network's catchment communities. Funding is adequate to provide home visiting to about 40% of identified at-risk families.Exporting the Healthy Start Model to the Mainland
National interest in home visiting in general and the HSP model in particular paralleled its expansion within Hawaii. Two years after the pilot program results became public, the General Accounting Office issued a report promoting home visitation as a means to prevent child abuse.5 The next year, the U.S. Advisory Board on Child Abuse and Neglect issued a report concluding that home visiting along the lines of Hawaii's model was the most promising strategy for child abuse prevention.6
In 1993, the the National Committee to Prevent Child Abuse (NCPCA—since renamed Prevent Child Abuse America), with initial funding from the Ronald McDonald House Charities and technical assistance from the HFSC, established Healthy Families America (HFA), a training and technical assistance program to help localities develop home visiting programs of their own. Although HFA is not, strictly speaking, a replication of the Hawaii program, the more than 270 HFA sites nationally share common roots with Hawaii's Healthy Start. (See the article by Daro and Harding, and Appendix A in this journal issue, for discussions of the HFA program.)