Loretta Fuddy

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.

Comparison of manual and electric breast pumps among WIC women returning to work or school in Hawaii.

INTRODUCTION The Women, Infants, and Children (WIC) branch of the Hawaii Department of Health encourages and assists mothers in breastfeeding. A study was done to determine whether an electric breast pump (vs. a manual pump) would increase breastfeeding duration in those returning to work or school full-time. MATERIALS AND METHODS During 2002-2003, a randomized trial was conducted among 280 women, with the duration of breastfeeding analyzed in 229 of these women. Descriptive analyses and a multivariate logistic regression analysis assessed factors associated with breastfeeding at 6 months. Unadjusted and adjusted survival analyses were performed to estimate the duration of breastfeeding. RESULTS In all, 76.8% of women using the manual breast pump and 72.3% of those using the electric breast pump breastfed for at least 6 months. This difference did not reach statistical significance. In the survival analysis adjusted for pump assignment, maternal age, race/ethnicity, marital status, and parity, women with at least some college education breastfed for a 38% shorter time than women with a high school or lower education. CONCLUSIONS Our findings suggest that the manual breast pump may work as well as the electric breast pump when breastfeeding is encouraged and supported among women returning to work or school full-time. Particular attention should be given to examining reasons why women with greater education breastfed for a shorter duration. Further research is needed to validate these results to better inform breastfeeding women returning to work or school.