Impact of a statewide home visiting program to prevent child abuse☆
Introduction
Based on the promising results of early research (Breakey & Pratt, 1991; Gray, Cutler, Dean, & Kempe, 1979; Olds, Chamberlin, & Tatelbaum, 1986), influential reports in the early 1990s endorsed home visiting to prevent child maltreatment. In 1991, the U.S. Advisory Board on Child Abuse and Neglect reported that home visiting along the lines of Hawaii's Healthy Start model was the most promising child abuse prevention strategy (United States Advisory Board on Child Abuse and Neglect, 1991). Two years later, the National Research Council endorsed home visiting (National Research Council and Panel on Research on Child Abuse and Neglect, 1993).
These reports stimulated great interest in home visiting (Gomby, Culross, & Behrman, 1999). National initiatives arose to assist communities wishing to implement home visiting. Healthy Families America (HFA) is perhaps the most prominent. It was inspired by Hawaii's Healthy Start Program (HSP) and is defined by critical elements of training, staffing and service delivery (Frankel, Friedman, Johnson, Thies-Huber, & Zuiderveen, 2000). HFA recommends voluntary home visiting targeted to at-risk families identified using standardized protocols to assess psychosocial risks. By 2002, 39 states and the District of Columbia had developed home visiting programs through HFA (Healthy Families America, 2002).
Two recent systematic reviews of the literature conclude that home visiting can be effective in preventing child abuse (Centers for Disease Control and Prevention, 2003; Sweet & Appelbaum, 2004). The reviews considered studies using actual abuse (reports) and potential abuse (e.g., emergency department visits) as outcomes. The Task Force on Community Preventive Services concluded that home visiting decreased child maltreatment and that programs staffed by professionals versus paraprofessionals yielded stronger, more consistent results (Centers for Disease Control and Prevention, 2003). Sweet and Appelbaum did not find a significant impact on child abuse reports, partly because few studies used this as an outcome. They found a significant but small decrease in potential abuse measures. In contrast to the Task Force, they found that impact was greater for programs staffed by paraprofessionals, targeting at-risk families, and focusing on child abuse prevention.
There are substantial gaps in the understanding of how to achieve this potential. The American Academy of Pediatrics has recommended experimental study of home visiting and the use of results from careful research in advocating for home visiting (American Academy of Pediatrics Council on Child and Adolescent Health, 1998). Gomby, Culross, and Behrman have made similar recommendations based on home visiting trials in which the impact was modest and actual service delivery departed from program models (Gomby et al., 1999). As Guterman has noted, the actual duration and intensity of home visiting is key to achieving intended outcomes (Guterman, 2001). We found that randomized trials of home visiting programs to prevent child abuse rarely described the services actually delivered (Duggan et al., 2000).
Home visiting programs to prevent child abuse usually aim to achieve this goal by improving family functioning and parenting. Substantial research has demonstrated the link between unmanageable environmental stress and child maltreatment (Garbarino & Gilliam, 1980; Guterman, 2001). Social support makes stress more manageable; coercive relationships have the opposite effect. The perception of stress as unmanageable is linked to psychosocial problems such as depression and substance abuse (Guterman, 2001), and so depression and substance abuse treatment can be a pathway to child abuse prevention (Peterson, Gable, & Saldana, 1996; Scott, 1992). The peer-reviewed home visiting literature provides little empirical evidence of home visiting effectiveness in reducing malleable parental risks for child abuse. Of experimental studies of programs that targeted families for partner violence, poor mental health or substance use (Barth, 1991, Black et al., 1994; Booth, Mitchell, Barnard, & Spieker, 1989; Fraser, Armstrong, Morris, & Dadds, 2000; Infante-Rivard et al., 1989; Marcenko & Spence, 1994), only one (Marcenko & Spence, 1994) reported change in maternal risks. However, it reported change in outcomes from baseline to follow-up within each group, rather than testing for a difference in change between groups. Thus, one cannot draw conclusions about program impact. Eckenrode et al., in reanalysis of outcomes in the Elmira Study of nurse home visiting, found that domestic violence attenuated impact in preventing child abuse (Eckenrode et al., 2000).
Our randomized control trial (RCT) of Hawaii's Healthy Start Program revealed that program services deviated from the model and varied among program sites (Duggan et al., 1999, Duggan et al., 2000), that the program did not significantly prevent or reduce most indicators of child maltreatment (Duggan, McFarlane et al., 2004) and that this was due in part to its failure to reduce malleable parental risks (Duggan, Fuddy, Burrell et al., 2004). This study replicated the Hawaii RCT, using similar methods and focusing on a statewide HFA program. Its aims were to assess the impact in achieving the intended outcomes, to relate impact to service delivery, and to explain service delivery in terms of the program model and implementation system. This paper focuses on the impact in preventing child maltreatment and reducing parental risks for maltreatment.
Section snippets
Methods
The study was a collaboration of Johns Hopkins University, the Alaska Department of Health and Social Services (DHSS), and Healthy Families Alaska (HFAK) sites. A Steering Committee guided study design, study implementation and interpretation of findings.
Results
Study families were representative of HFAK families overall. Families with versus without a baseline interview were comparable on the FSC. Participants’ mean total FSC score (42.9) was similar to that of families assessed positive in the 18 months following study recruitment (44.1).
Table 1 shows baseline characteristics of the HFAK and control groups. Both groups had similar demographic characteristics. Depressive symptoms, substance use and partner violence were common at baseline. HFAK
Discussion
This study assessed the impact of a statewide HFA program in preventing child abuse. It examined outcomes, compared actual services to the program model, and related impact to the model and implementation system. Because our earlier research in Hawaii had shown lack of fidelity to the model, we designed the study to estimate efficacy and to explain how the implementation system influenced service delivery.
There was little evidence of effectiveness in preventing child abuse although this was
Acknowledgements
The authors thank the Healthy Families Alaska programs for their commitment to careful collaborative study of accomplishments and challenges. We thank the members of the study Steering Committee (listed below), who provided feedback on methods, progress and interpretation of findings. The collaborating groups were highly motivated to conduct the study faithfully and to learn from their shared experience. Every individual involved—from parent visitors, family support workers and supervisors to
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2019, American Journal of Preventive MedicineCitation Excerpt :Parent mental illness/depression was the most common C-ACE measured (16 studies), followed by parent alcohol or drug abuse (15 studies) and domestic violence (12 studies). Studies varied in the identification of subjects from one C-ACE22–27 to five C-ACEs.28–33 The majority of studies collected data on infants and children up to age 5years, but three studies included older children.25,32,34
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This work was supported in part by the Alaska Mental Health Trust Authority and Alaska State Department of Health and Social Services.