Elizabeth McFarlane

Evaluation of Hawaii's Healthy Start Program

Hawaiis Healthy Start Program (HSP) is designed to prevent child abuse and neglect and to promote child health and development in newborns of families at risk for poor child outcomes. The program operates statewide in Hawaii and has inspired national and international adaptations, including Healthy Families America. This article describes HSP, its ongoing evaluation study, and evaluation findings at the end of two of a planned three years of family program participation and follow-up. After two years of service provision to families, HSP was successful in linking families with pediatric medical care, improving maternal parenting efficacy, decreasing maternal parenting stress, promoting the use of nonviolent discipline, and decreasing injuries resulting from partner violence in the home. No overall positive program impact emerged after two years of service in terms of the adequacy of well-child health care; maternal life skills, mental health, social support, or substance use; child development; the childs home learning environment or parent-child interaction; pediatric health care use for illness or injury; or child maltreatment (according to maternal reports and child protective services reports). However, there were agency-specific positive program effects on several outcomes, including parent-child interaction, child development, maternal confidence in adult relationships, and partner violence. Significant differences were found in program implementation between the three administering agencies included in the evaluation. These differences had implications for family participation and involvement levels and, possibly, for outcomes achieved. The authors conclude that home visiting programs and evaluations should monitor program implementation for faithfulness to the program model, and should employ comparison groups to determine program impact.

Evaluating a statewide home visiting program to prevent child abuse in at-risk families of newborns: fathers' participation and outcomes

This study sought to describe fathers’ participation in a statewide home-visiting program to prevent child abuse and to assess program impact on their parenting. This randomized trial followed 643 at-risk families for 3 years. Data were collected through program record review, staff surveys, and annual maternal interviews. Participation in visits varied by the parents’ relationship and paternal employment, violence, and heavy drinking at baseline. Overall, the program had no apparent impact on fathers’ accessibility to the child, engagement in parenting activities, and sharing of responsibility for the child’s welfare. The program promoted parenting involvement for nonviolent fathers in couples who lived together but also for violent fathers in couples with little contact at baseline; it decreased the father’s accessibility to the child in couples who lived apart but saw each other frequently at baseline. Infrequent participation in visits and differential program impact on violent versus nonviolent fathers demonstrate the need to consider family context in developing, implementing, and studying home-visiting models.

Hawaii's healthy start home visiting program: Determinants and impact of rapid repeat birth

Objective. Healthy People 2010 calls for reductions in rapid repeat births (RRBs), defined as births occurring within 24 months after a previous birth for women of all ages, and prevention of repeat births during adolescence, regardless of the birth interval. Home visiting has been promoted as a mechanism to prevent child abuse and neglect and to improve pregnancy outcomes. This study aims to assess the impact of home visiting in preventing RRB and its malleable determinants and assesses the influence of RRB on the mother and the index child. We hypothesized that maternal desire to have a RRB, access to a family planning site, and use of birth control would be significant malleable determinants and that the effects of the program in preventing RRB would be mediated through its influence on these variables. We also hypothesized that the occurrence of RRB would result in increased stress and family dysfunction, resulting in adverse maternal and child outcomes such as severe maternal stress, maternal neglect of the index child, decreased maternal warmth toward the index child, and increased behavior problems of the index child. Methods. The Healthy Start Program (HSP) is a home visiting program to prevent child abuse and neglect and to promote child health and development among newborns of families identified as being at risk for child maltreatment. This study was a randomized, controlled trial of Hawaiis HSP, in which eligible families were randomly assigned to home-visited and control groups. A total of 643 families at risk for child abuse were enrolled between November 1994 and December 1995. Data to measure RRB and malleable determinants were collected through structured maternal interviews and observation of the home environment. We measured RRB through maternal self-report by asking about a subsequent birth in follow-up interviews at 1, 2, and 3 years. To measure the malleable determinants, we measured the mothers desire for a RRB at baseline and at the 1-year interview and determined whether she had access to a family planning site. The mother was also asked which contraceptive methods she had ever used in the past and which methods, if any, she used in the year following the index childs birth. We measured 3 maternal parenting outcomes at the year 3 follow-up interview, ie, parenting stress, neglectful behavior toward the index child, and warmth toward the index child. We used odds ratios with 95% confidence intervals (CIs) to measure the strength of associations. Multiple logistic regression was used to assess 1) program effects on RRB and its malleable determinants, 2) the impact of the malleable determinants on RRB, and 3) the association between RRB and adverse maternal and child outcomes. Results. Each year, 88% of the sample completed a follow-up interview; 81% completed all 3 follow-up interviews. There was no program impact on RRB for mothers overall (HSP: 21%; control: 20%; adjusted odds ratio [AOR]: 1.05; 95% CI: 0.69–1.58). HSP and control groups did not differ significantly in any of the malleable determinants of RRB. When we combined the 2 study groups, malleable determinants had significant effects on RRB. Mothers with a desire to have a child within 2 years after the index birth were significantly more likely to have a RRB, whether this desire was expressed at baseline (AOR: 2.48; 95% CI: 1.32–4.64) or at the year 1 interview (AOR: 2.86; 95% CI: 1.57–5.22). Lack of access to a family planning site at baseline was not associated with RRB, but there was a trend toward a greater likelihood of RRB among those lacking a site at 1 year (AOR: 1.61; 95% CI: 0.93–2.79). Women who had never used birth control before the index birth were more likely to have a RRB (AOR: 1.89; 95% CI: 1.20–2.98), and there was a trend toward a greater likelihood of RRB among women who did not use birth control in the year following the index childs birth (AOR: 1.67; 95% CI: 0.98–2.82). At the 3-year follow-up interview, mothers with a RRB were more likely to have adverse maternal and child outcomes. There was greater likelihood of severe maternal parenting stress (AOR: 2.29; 95% CI: 1.17–4.48), neglectful behavior toward the index child (AOR: 2.42; 95% CI: 1.41–4.18), and poor warmth toward the index child (AOR: 2.84; 95% CI: 1.71–4.42). In families with a RRB, the index child was more likely to exhibit internalizing behavior (AOR: 1.64; 95% CI: 1.04–2.58) and there was a trend toward higher odds of externalizing behavior (AOR: 1.56; 95% CI: 0.98–2.49). Conclusions. Overall, 20% of the mothers in our sample of at-risk families had a RRB, which was far greater than the national average of 11%. RRB was associated with a greater likelihood of adverse consequences for both the mother and the index child. The lack of program effects can be traced to shortcomings in the programs design and implementation system. HSP contracts required only that family planning be introduced any time during a familys first year of enrollment. Because conception can occur very soon after the index birth, a better design would be to introduce family planning counseling early in a familys enrollment in home visiting. Another shortcoming was that, although fathers could be included in counseling, they took part in only approximately one-fifth of home visits. It is possible that program effects were attenuated in families in which the father wanted a child. In conclusion, the Hawaii HSP did not reduce RRB or alter its malleable determinants. RRB was associated with adverse outcomes for both the mother and the index child. This is particularly relevant for this population of families that are already at risk for child maltreatment, for which we have found parenting stress to be associated with abusive parenting behavior by the mother. Our findings support and broaden the rationale for the Healthy People 2010 objective to reduce RRB. We think our findings are valuable for guiding the future development of home visiting in general and this widely replicated paraprofessional model in particular.

Prevalence and early identification of language delays among at-risk three year olds.

ABSTRACT. The aims of this study were fourfold: to document the prevalence of language delays in a sample of at-risk 3 year olds; to assess the effectiveness of a home visiting program in preventing early language delays; to determine how often parents, pediatric providers, and home visitors identified early language delays; and to assess the effectiveness of a home visiting program in improving early identification of language delays. The Preschool Language Scale, Third Edition (PLS-3) was administered to 513 at-risk 3 year olds participating in a randomized trial of home visiting services. Families randomized to home visiting were expected to receive weekly to quarterly visits throughout the 3 years of this study. The content of home visits included teaching parents about child development, role-modeling parenting skills, and linking families to a medical home. Identification of delays was measured using structured parent interviews and review of primary care and home visiting records. At age 3 years, 10% of children had severe language delays, defined as scoring ≥2 SD below the national mean on the PLS-3, whereas 49% scored ≥1 SD below the national mean. No differences in prevalence were seen between children who did and did not receive home visiting. Among children with severe delays, 42% were identified by parents, 33% by pediatric providers, and 24% by home visitors. Among children with any delays, 24% were identified by parents, 25% by pediatric providers, and 17% by home visitors. No differences in rates of identification were seen between children who did and did not receive home visiting. Thus, while language delays were highly prevalent among these at-risk children, rates of identification were low, even among children with severe delays. Home visiting was not effective in either preventing language delays or improving early identification. This suggests that pediatric providers and home visiting programs need to reexamine their approaches to recognizing and intervening with early language delays.

Concurrent and Long-Term Impact of Intimate Partner Violence on Employment Stability

Previous research suggests that experiencing intimate partner violence (IPV) may negatively affect employment outcomes. This study explores the relationship between IPV and employment stability both concurrently and longitudinally among a sample of 512 predominantly Asian American and Pacific Islander young women living in Hawaii. Women in this study were identified as being at risk of child maltreatment. About half of women indicated that their current relationship status was married or living together. More than two-thirds of women had graduated from high school and half had worked in the past year. The study explored the concurrent association of IPV and employment by assessing them simultaneously over a 12 month time period. The study examined the longitudinal impact of IPV by analyzing violence at two time points as predictors of unstable employment 6 to 8 years later. The study also explored the mediating effects of depression. Study results demonstrated both concurrent and longitudinal negative associations of IPV with employment stability. Women who experienced violence were more likely to be experiencing unstable employment concurrently. Women who experienced IPV at one point in time had lower levels of employment stability six years later. This decrease was partially mediated by experiencing depressive symptoms. Women who identified their primary ethnicity as Native Hawaiian or Pacific Islander were much more likely to experience unstable employment than Asian American women. More research is needed to explore the roles of mental health, race and ethnicity, and types of violence in the relationship between IPV and employment.

The Importance of Early Parenting in At-Risk Families and Children's Social-Emotional Adaptation to School

OBJECTIVE The aim of this study was to determine the specific aspects of early parenting in psychosocially at-risk families most strongly related to childrens social-emotional adaptation to school. METHODS A cohort study of families (N = 318) identified as at risk for maltreatment of their newborns was conducted. Quality of early parenting was observed in the home when the child was 1 year old. Social-emotional adaptation to school was reported by teachers in first grade. Multivariable models assessed the independent influence of early parenting variables on social-emotional adaptation. RESULTS Early parenting and social-emotional adaptation to school varied greatly across families. Parental warmth was associated with lower teacher ratings of shyness, concentration problems, and peer rejection. Parental lack of hostility was associated with decreased teacher ratings of concentration problems and peer rejection. Parental encouragement of developmental advance was associated with lower ratings of aggression and peer rejection. Provision of materials to promote learning and literacy was associated with lower ratings of concentration problems. CONCLUSIONS In this sample of families with multiple psychosocial risks for child maltreatment, specific aspects of early parenting were associated with better social-emotional adaptation to school in the first grade in theoretically predicted ways. Improving parental knowledge about positive parenting via anticipatory guidance should be a focus of well-child visits. Well-child visit-based interventions to improve the quality of early parenting, especially among at-risk families, should be studied for their impact on parenting behavior and on childrens successful social-emotional adaptation to school. Primary care providers should reinforce complementary services, such as home visiting, that seek to promote positive parenting.

Language Delays and Child Depressive Symptoms: the Role of Early Stimulation in the Home

The present study investigated the role of early stimulation in the home and child language delays in the emergence of depressive symptoms. Data were from a longitudinal study of at-risk children in Hawaii (n = 587). Low learning stimulation in the home at age 3 and language delays in first grade both significantly increased risk for child depressive symptoms in third grade. Structural equation modeling supported the hypothesized path models from home learning environment at age 3 to depressive symptoms in third grade controlling for a host of correlated constructs (maternal depression, child temperament, and child internalizing symptoms). Total language skills in the first grade mediated the effect of home learning environment on depressive symptoms. The study and findings fit well with a nurturing environment perspective. Implications for understanding the etiology of child depression and for designing interventions and prevention strategies are discussed.

Using latent profile and transition analyses to understand patterns of informant ratings of child depressive symptoms

The present study examined the latent profiles of child, parent, and teacher ratings of child depressive symptoms in a developmental sample of children from Hawaii at two time points (2nd and 3rd grade). The study attempted to identify patterns of agreement and discrepancy among raters and correlates of these patterns to test a new theory for understanding rating disagreements as Divergent Operations. Three profiles best described the ratings at both time points: Child-Only High Depression, Child-Only Mild Depression, and Normative (non-depressed). Second and third grade measures of child social skills, externalizing symptoms, attention problems, and language and academic competence confirmed the distinctiveness of these classes which provides support for a Divergent Operations perspective. Latent transition analyses suggested that depressive symptoms were relatively transient for each class. Implications regarding the measurement and identification of child depressive symptoms across development and the meaning and use of discrepant ratings are discussed.

In memoriam: Loretta "Deliana" Fuddy (1948-2013).

The Maternal and Child Health Journal recognizes the substantial contributions of Loretta ‘‘Deliana’’ Fuddy from the State of Hawaii Department of Health (DOH) to the well-being of women, children, and families in Hawaii and nationally. On December 11, 2013, Director Fuddy died after the plane she was a passenger in made an emergency water landing shortly after take-off. The plane was returning to Honolulu from Kalaupapa, Molokai where Director Fuddy had visited the Kalaupapa Leprosy Settlement and National Historical Park as honorary ‘‘Mayor’’ of Kalawao County as part of her role as Director of Health. Deliana began her public health career in 1975 as a medical social worker in the Crippled Services Branch which evolved into the Family Health Services Division (FHSD). She advanced and held several positions within FHSD that included serving as FHSD Chief for 10 years, until her appointment as Director of the Hawaii State Department of Health in March 2011. Her degrees included work in sociology, social work, and public health from the University of Hawaii and she completed doctoral studies (all but dissertation) at the Johns Hopkins Bloomberg School of Public Health. Deliana was a defining part of Hawaii’s Healthy Start Program (HHSP). HHSP is designed to prevent child abuse and neglect and to promote child health and development in newborns of families at risk for poor child outcomes. She worked closely with community partners among them, Parents and Children Together, Hawaii Family Support Center and with Dr. Calvin Sia of the Hawaii Chapter of the American Academy of Pediatrics, to build state and national support for home visiting services for struggling families. By the 1990’s her advocacy and leadership helped to build a statewide service system that included identification and engagement of families eligible for services and a system of care to support them. The collaborations and partnerships she helped to shape remain as examples of how states can design and develop systems of care to improve child health and eliminate disparities. HHSP inspired national and international adaptations, including Healthy Families America, an evidenced-based home visiting program operating across the country and endorsed by the Health Resources and Services Administration’s Maternal Infant and Early Childhood Home Visiting (MIECHV) program. D. Hayes (&) Family Health Services Division, Hawaii Department of Health, Honolulu, HI, USA e-mail: don.hayes@doh.hawaii.gov