Hawaii Healthy Start Program

About the program

The Hawaii Healthy Start program (HSP) is a home visitation program designed to improve family functioning, prevent child abuse and promote child health development. It has two parts:

1. population-based screening and assessment to identify families at-risk of child abuse and neglect
2. home visiting of identified at-risk families.

The home visiting portion of the program is a multi-level system:

• Level one is a weekly visitation
• Level two is a biweekly visitation
• Level three is a monthly visitation
• Level four is a quarterly visitation

Families are monitored for achievement of milestones in healthy functioning and are promoted to service levels with lower expected visit frequency as family functioning improves.

Who does it work for?

The Hawaii Healthy Start program is delivered to mothers and fathers, where possible, who are at risk of child abuse and neglect. Families are deemed eligible for home visiting if they demonstrate certain risk factors (e.g. substance abuse, mental health) and are not already involved with child protection services for the target child.

The program has only been evaluated in the USA (Duggan et al. 2004).

A randomised control trial was conducted with 541 people (320 people were in the intervention group and 221 people were in the control group). The trial was evaluated once per year for three years. On average, parents were 23 years old. One third of parents were Native Hawaiian/Pacific Islander, and another 28% were Asian/Filipino. Two thirds of families were below the poverty level.

The program has not been tested in Australia or with Aboriginal Australians.

What outcomes does it contribute to?

Positive outcomes:

• Harsh parenting: there is a decrease in parents’ common corporal/verbal punishment when receiving the program.
• Neglectful parenting: there are less self-reported episodes of neglect in parents receiving the program.

No effects:

• Child abuse reports: the program has no effect on the number of substantiated child abuse reports.
• Child hospitalisations: the program has no effect on the number of child hospitalisations for trauma or ambulatory care sensitive conditions.
• Harsh parenting: the program has no effect on the number of frequent and severe self-reported abusive behaviours.
• Parenting attitude: the program has no effect on mothers’ acceptance of a child’s behaviour.
• Positive parenting behaviours:
  • The program has no effect on an increase in use of non-violent discipline.
  • The program has no effect on increased warm and nurturing mother-child interaction.
• Removal of child from caregiver: the program has no effect on the rate of children removed from caregivers.

Negative outcomes:

• No negative effects were found.

How effective is it?

Overall, the Hawaii Healthy Start program has mixed effects on client outcomes.

How strong is the evidence?

Mixed research evidence (with no adverse effects):

• At least one high-quality randomised controlled trial (RCT)/quasi-experimental design (QED) study reports statistically significant positive effects for at least one outcome, AND
• An equal number or more RCT/QED studies of similar size and quality show no observed effects than show statistically significant positive effects, AND
• No RCT/QED studies show statistically significant adverse effects.

How is it implemented?

The program is a home visitation program. The frequency of visits depends on the level a family is assessed as:

• Level one is a weekly visitation
• Level two is a biweekly visitation
• Level three is a monthly visitation
• Level four is a quarterly visitation

Assessment: Prenatal care providers refer some families to the program for assessment, but most families are screened and assessed at hospital when their children are born. When a mother’s medical record suggests risk or provides too little information to make a judgment, HSP early identification staff conduct a semi-structured assessment interview with the mother to determine risk more precisely using Kempe’s Family Stress Checklist. The Family Stress Checklist focuses on 10 risk factors for child abuse, such as:

• parental substance use
• poor mental health
• domestic violence
• history of abuse as a child
• unrealistic expectations of the child
• a child who was unwanted or at other risk of poor bonding

The program considers a family to be at risk and, therefore, eligible for home visiting, if either parent scores 25 or higher on the Family Stress Checklist and if the family is not already involved with child protective services for the target child.

Home visitors assist families with:

• setting and reaching family goals
• parenting education and modelling effective parent-child interaction
• ensuring that the child has a medical home
• accessing needed services, such as income and nutritional assistance, education, and services to address risks such as domestic violence, parental substance abuse, and poor mental health.

Home visitors establish a trusting relationship with parents, in part by helping parents address existing crises.

Home visitors are trained paraprofessionals working under professional supervision. Training covers topics ranging from child development and parent-child interaction to the dynamics of child abuse, crisis intervention, problem solving, and domestic violence.

How much does it cost?

Not reported

What else should I consider?

The implementation system has many parts: staff recruitment and training, policies and protocols to facilitate service delivery, and mechanisms to integrate home visiting with community services. If a home visitor has great difficulty meeting with the family, the program has the option of placing the family on Level X, which focuses on creative outreach to establish contact with the family and does not have an expected number of visits.

Where does the evidence come from?

One RCT conducted in the USA, with 541 final participants (Duggan et al. 2004).

Further resources

Duggan, A, McFarlane, E, Fuddy, L, Burrell, L, Higman, S, Windham, A and Sia, C, (2004), ‘Randomized trial of a statewide home visiting program: impact in preventing child abuse and neglect’, Child Abuse & Neglect, vol. 28, no. 6, pp. 597-622.