Healthy Families America Program

Evidence Review:

Preventing child maltreatment: Evidence-informed programs

Evidence Type:

Evidence-informed programs

Client outcomes:

Child maltreatment
Improved Parenting

Location:

North America

Strength of evidence:

Mixed research evidence (with no adverse effects)

Direction of effect:

Mixed

About the program

The Healthy Families America (HFA) program is a long-term home visiting program for families assessed as high risk for child abuse and neglect. Home visiting services begin prenatally or within three months after the birth of a baby and can last from three to five years, depending on the needs of the family. Specially trained paraprofessionals provide the home visiting services to parents.

The overall goals of the program are to promote positive parenting, enhance child health and development, and prevent child abuse and neglect.

The home visitor assists in helping parents with their life circumstances, personal issues, parenting needs, and successful adaptation to new infants. Home visitors are also available to help mobilise critical services to address substance abuse, domestic violence, and mental health issues. They attempt to model good parenting behaviour, review the child's developmental progress, ensure safety in the home, secure a “medical home” for the child, and provide emotional support to the parents as they adapt to the changing circumstances of their home life.

Who does it work for?

The HFA program is designed for families assessed as high risk for child abuse and neglect.

The program has only been evaluated in the USA.

Five randomised control trials were conducted:

Duggan et al. (2007): conducted in Alaska with 249 people (126 people were in the intervention group and 123 people were in the control group). On average mothers were 23 years old. More than 54% were Caucasian and 23% were Alaskan Native. Almost 60% were living below the poverty level.
LeCroy & Krysik (2011): conducted in Arizona with 171 people (85 people were in the intervention group and 86 people were in the control group). On average mothers were 24 years old and most were Hispanic (65%).
Easterbrooks et al. (2013): conducted in Massachusetts with 680 people (numbers in each group were not reported). On average mothers were 18 years old and children were 12 months old. Most were either White (34%) or Hispanic (38%). Almost 60% were welfare recipients.
DuMont et al. (2008): conducted in New York with 971 people (478 people were in the intervention group and 493 were in the control group). On average mothers were 22 years old. The majority of participants were African American (44%) or White (34%) and one third received welfare.
Rodriguez et al. (2010): conducted as a follow up to DuMont et al. (2008), in New York with 522 people (255 people were in the intervention group and 267 people were in the control group). On average mothers were 22 years old. The majority of participants were African American (42%) or White (38%).

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

What outcomes does it contribute to?

Positive outcomes:

General parenting behaviours: families who received HFA are significantly less likely to provide a poor-quality home environment (Duggan et al. 2007).
Harsh parenting:
- mothers who received HFA used fewer types of violent discipline, e.g. shouting, yelling or screaming at an infant, slapping a child’s hand (LeCroy & Krysik 2011).
- mothers who received HFA report significantly fewer instances of engaging in very serious physical abuse, and minor physical and psychological aggression (Duggan et al. 2007; DuMont et al. 2008).
- Families who received HFA use more safety practices, including having a car seat and not having poisons within reach of their children (LeCroy & Krysik 2011).
Neglectful parenting: children at 1 years old had fewer instances of neglectful parenting when families received the program (DuMont et al. 2008).
Positive parenting behaviours: mothers who received the HFA program were more likely to use positive parenting strategies when interacting with their children (Rodriguez et al. 2010).

No effects:

Child abuse reports: the program has no significant effect on rates of substantiated and unsubstantiated reports of child abuse and neglect (Duggan et al. 2007; DuMont et al. 2008; Easterbrooks et al. 2013)
Child hospitalisations: the program has no significant effect on number of hospitalisations and emergency department visits of children (Duggan et al. 2007).
Harsh parenting: the program has no effect on the amount of negative parenting events (Rodriguez et al. 2010).
Intimate partner violence:
The program has no significant effect on amount of family violence (e.g. shoving, slapping, and throwing objects) (LeCroy & Krysik 2011) and partner violence (e.g. psychological and physical abuse, and injuries) (Duggan et al. 2007).
Parenting attitude: the program has no significant effect on parenting attitudes, such as belief in corporal punishment (Duggan et al. 2007; LeCroy & Krysik 2011).
Parenting stress: the program has no effect on parenting stress levels, including personal adjustment problems, and child abuse potential (Duggan et al. 2007).
Removal of child from caregiver: the program has no effect on the number of times mothers relinquish the primary caregiver role, which is an indicator of potential child abuse (Duggan et al. 2007).

The HSP program had mixed research evidence on three different outcomes:

Parent’s mental health: Easterbrooks et al. (2013) found there are fewer numbers of depressive symptoms in mothers who have received the program. However, two other studies showed the program had no significant effect on a mother’s mental health (Duggan et al. 2007; LeCroy & Krysik 2011).
Parent’s substance use: LeCroy & Krysik (2011) found mothers use alcohol less when they are receiving the program. However, another study found the program had no significant effect on maternal substance use, including alcohol use and illicit drug use (Duggan et al. 2007).
Parent’s use of services: LeCroy & Krysik (2011) found mothers have a higher use of available resources when receiving the program (e.g. mental health counseling, financial counseling, and centre-based family assistance). However, Duggan et al. (2007) found the program had no effect on families’ use of community services.

Negative outcomes:

No negative effects were found.

How effective is it?

Overall, The Healthy Families America program has a mixed effect on client outcomes.

How strong is the evidence?

Mixed research evidence (with no adverse outcomes):

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 Healthy Families America program is implemented through regular home visits to families of pregnant mothers and newborn infants. The content of the visits is intended to be individualized and culturally appropriate.

Home visitors are there to:

provide information
make referrals to community resources
help parents prepare for developmental milestones
screen and refer for developmental delay
promote child environmental safety.

During the prenatal period, the home visitor uses curricula such as “Partners for a Healthy Baby” to support expectant women to achieve an optimal pregnancy experience. Prenatal visits generally focus on:

promoting healthy behaviors (e.g., eating nutritious food)
discouraging risky behaviors (e.g., tobacco and alcohol use)
coping with stress
encouraging compliance with prenatal appointments and medical advice
educating the expectant mother about the development of the fetus.

Following the birth of the child, home visitors utilise other curricula, including “Parents as Teachers” and “Helping Babies Learn.” Postnatal home visits concentrate on:

improving the parent-child relationship through instruction, reinforcement, modeling, and parent-child activities
helping parents understand child development and age-appropriate behaviours by providing education and information
promoting optimal health and development by supporting healthy behaviours, improving compliance with scheduled immunizations and well child visits, facilitating linkages to and encouraging appropriate use of health care, and connecting families with Food Stamps, housing assistance, and/or other community resources
enhancing parental life course development and self-sufficiency by developing Individual Family Support Plans that establish goals and reinforce strengths, building problem-solving skills, strengthening family support networks, helping parents address issues such as substance abuse, mental illness and domestic violence, and making referrals to treatment providers and other community services as needed.

How much does it cost?

Not reported

Where does the evidence come from?

Five RCTs:

One conducted in Alaska, USA, with 249 participants (Duggan et al. 2007).
One conducted in Arizona, USA, with 171 participants (LeCroy & Krysik 2011).
One conducted in Massachusetts, USA, with 680 participants (Easterbrooks et al. 2013).
One conducted in New York, USA, with 971 participants (DuMont et al. 2008)
- One follow up to the New York trial, with 522 participants (Rodriguez et al. 2010).