Elsevier

Child Abuse & Neglect

Volume 31, Issue 8, August 2007, Pages 829-852
Child Abuse & Neglect

Impact of a statewide home visiting program on parenting and on child health and development

https://doi.org/10.1016/j.chiabu.2007.02.008Get rights and content

Abstract

Objectives

To assess the impact of a voluntary, paraprofessional home visiting program on promoting child health and development and maternal parenting knowledge, attitudes, and behaviors.

Methods

This collaborative, experimental study of 6 Healthy Families Alaska (HFAK) programs enrolled 325 families from 1/00 to 7/01, randomly assigned them to HFAK and control groups, interviewed mothers at baseline, and followed families until children were 2 years old (85% follow-up). Child outcomes included health care use, development and behavior. Parent outcomes included knowledge of infant development, parenting attitudes, quality of the home environment, and parent-child interaction. HFAK records were reviewed to measure home visiting services. Home visitors were surveyed to measure knowledge, perceived effectiveness and perceived training adequacy.

Results

There was no overall impact on child health, but HFAK group children had more favorable developmental and behavioral outcomes. HFAK and control mothers had similar parenting outcomes except that HFAK mothers had greater parenting self-efficacy (35.1 vs. 34.6 based on the Teti Self-Efficacy Scale, p < .05). Fewer HFAK families had a poor home environment for learning (20% vs. 31%, p < .001). HFAK families were more likely to use center-based parenting services (48% vs. 39%, p < .05). The impact was greater for families with lower baseline risk (Family Stress Checklist scores < 45). There was little evidence of efficacy for families with a higher dose of service.

Conclusions

The program promoted child development and reduced problem behaviors at 2 years. Impact could be strengthened by improving home visitor effectiveness in promoting effective parenting. Future research is needed to determine whether short-term benefits are sustained.

Introduction

Home visiting is a widely used strategy that has been targeted to a broad range of populations to achieve an equally broad range of parent and child outcomes. The American Academy of Pediatrics has recommended experimental evaluation of home visiting and the use of results from carefully conducted evaluative research in advocating for home visiting (American Academy of Pediatrics Council on Child and Adolescent Health, 1998). Gomby, Culross, and Behrman (1999) have made similar recommendations. However, research on home visiting impact has yielded mixed results, raising questions of how best to design, target and implement home-based services.

Two recent meta-analyses conclude that home visiting can promote effective parenting behavior and child developmental outcomes (Centers for Disease Control & Prevention, 2003; Sweet & Appelbaum, 2004). However, they differed in their conclusions about how effect sizes are influenced by broad program design features, targeting of specific populations, and articulation of program goals. An example relates to program staffing. The first meta-analysis concluded that the impact on preventing child maltreatment indicators was more consistent for programs staffed by professionals (Centers for Disease Control & Prevention, 2003). In contrast, the second review determined that the impact on preventing indicators of abuse was greater for programs staffed by paraprofessionals (Sweet & Appelbaum, 2004). However, it found that the impact on promoting child cognitive development was greater for programs staffed by professionals and that impact in promoting effective parenting was not associated with program staffing. Sweet and Appelbaum conclude that research is needed on other factors that can contribute to program efficacy, such as home visitors’ perceptions of program goals, fidelity of implementation, and moderation of program impact by family attributes.

Hebbeler and Gerlach-Downie examined home visitors’ perceptions of program goals and the mechanisms for achieving them—the program's “theory of change”—in a qualitative study to explain the results of a concurrent randomized trial of home visiting (Hebbeler & Gerlach-Downie, 2002). The randomized trial found limited program success in promoting child development, its primary goal (Wagner & Clayton, 1999). Hebbeler and Gerlach-Downie determined that the program's limited impact was consistent with the home visitors’ actions during visits; the home visitors’ actions, in turn, were consistent with their understanding of the program's theory of change. Based on the program's underlying assumptions—for example, that if the mother feels good the child feels good and that parents have within themselves the knowledge to be good parents—the home visitors emphasized family support, placed less emphasis on information-sharing around effective parenting practices, and de-emphasized expectations for parent-child interaction.

Guterman has noted that the actual duration and intensity of home visiting services is key to achieving intended outcomes (Guterman, 2001). Our own review of randomized trials of home visiting programs found, however, that few describe delivery of actual services (Duggan et al., 2000). Thus, there is need for research comparing actual services to program models to aid in interpreting outcomes.

One widely replicated model to prevent child maltreatment and promote child health and development is Healthy Families America (HFA), which targets families with multiple risks for child maltreatment of their newborns. The HFA model was inspired by Hawaii's Healthy Start Program and is defined by critical elements of training, staffing and service provision (Frankel, Friedman, Johnson, Thies-Huber, & Zuiderveen, 2000). HFA recommends using standardized protocols to identify and target at-risk families on the basis of malleable psychosocial risks. Currently, there are HFA programs in 35 states; in some states, this represents sites in a few communities, while in other states it represents statewide systems of care in nearly every community (L. Schreiber, personal communication, November 4, 2006).

Findings from our experimental study of Hawaii's Healthy Start Program (HSP) have been widely published (Duggan et al., 2000, Duggan et al., 1999, Duggan et al., 2004a, Duggan et al., 2004b, Duggan et al., 2004c, El-Kamary et al., 2004, King et al., 2005, Nelson et al., 2005, Windham et al., 2004). This study of Alaska's HFA program replicates our Hawaii study, though with a different population and with a national program whose implementation system was more mature than Hawaii's HSP. The HSP and Healthy Families Alaska (HFAK) randomized trials address issues raised in the home visiting research described earlier. The studies assess impact on achieving intended outcomes, relate impact to service delivery, assess parent outcomes as mediators of impact on child outcomes, explain service delivery in terms of the program model and implementation system, and examine family attributes as moderators of program impact.

This paper focuses on HFAK's impact on promoting child health and development as mediated by its impact on parenting attitudes, knowledge, and behaviors. A companion paper reports impact on preventing child maltreatment and parent risks for maltreatment (Duggan et al., 2007).

Section snippets

HFAK program model

The Alaska Legislature established the state's first HFAK program in 1995. HFAK was designed using HFA site development guides, training and technical assistance. Like HFA, it aims to promote positive parenting, child health and child development (Frankel et al., 2000, Healthy Families America, 2001). A companion article in this volume includes a complete description of the HFAK program model, including home visitor and supervisor training; the role of the home visitor; screening and

Results

Study families were representative of HFAK families overall. Families with versus those without a baseline interview were comparable on FSC items (all p > .20). Participants’ mean total FSC score (42.9) was similar to that of families assessed positive in Alaska in the 18 months following study recruitment (44.1).

Poor maternal mental health, substance use and partner violence were common among both groups at baseline because HFAK targets at-risk families. At baseline, HFAK and control group

Discussion

This study assessed the impact of a statewide HFA program in promoting positive parenting, child health and child development. HFAK had a positive impact on some parenting outcomes. The program promoted child development and reduced problem behaviors but did not improve measures of child health. HFAK's impact on child and parent outcomes was consistent with actual service delivery.

Conclusion

This experimental study found that a home visiting program targeted to families at-risk of child maltreatment improved some aspects of parenting, child development and child behavior, but not child health. Outcomes were consistent with the program model and implementation system. The program was less effective in families at greatest risk, suggesting that it might not be appropriate for such families. Unintended variations in service content and quality underscore the need for stronger

Acknowledgments

The authors thank the Healthy Families Alaska program leadership and staff and the study Steering Committee members (listed below) for their contributions to study methods, execution, and interpretation of findings. The collaborating groups were highly motivated to conduct the study faithfully and to share lessons learned. Their contributions assured the relevance, timeliness and validity of study findings.

DHSS staff members on the Steering Committee included the following, in alphabetical

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    Support was provided by the Alaska Mental Health Trust Authority and the Alaska State Department of Health and Social Services.

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