Implementing Early Start (New Zealand) Meets HHS Criteria

Last updated: July 2012

Implementation experiences

Summary of sources

Information in this section is based on studies included in the HomVEE review. For the Early Start (New Zealand [NZ]) Program, we reviewed one randomized controlled trial (RCT) with a moderate rating. (Please see Studies for Implementation Experiences for a list of the studies and to link to the characteristics of the samples examined in the effectiveness studies.)

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Characteristics of model participants

The study reported that 206 families were enrolled in the Early Start (NZ) program at the program’s onset. Mothers were 25 years old and fathers were 27 years old, on average. Children were enrolled as infants and were eligible for up to 5 years; the study did not report the average ages of children or their genders.

The study indicated that 25 percent of mothers and 31 percent of biological fathers identified as Māori, an indigenous population of New Zealand.

According to the study, the Early Start (NZ) program targeted families facing difficult circumstances. Mothers were on average 19 years old during their first pregnancy, and 14 percent had been pregnant before age 16. About 14 percent of mothers who had a previous child reported that the child was in foster care, and 35 percent of current male partners were reported to have assaulted their partner.

Most parents (71 percent of mothers and 78 percent of fathers) lacked formal education credentials. Nearly two-thirds of families (64 percent) were headed by a single parent, most families (88 percent) received public assistance, and 40 percent had income that was considered inadequate or very inadequate to meet the costs of daily living. The study also reported that 46 percent of mothers experienced impoverished family circumstances in their own childhoods.

The study reported that participants enrolled in the program voluntarily.

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Location and setting

The Early Start (NZ) program was located in Christchurch, NZ. The study did not report whether Christchurch is urban, rural, or suburban.

The study reported that nurses from the Royal New Zealand Plunket Society were involved in identifying and recruiting mothers, but it did not describe the agency responsible for delivering program services.

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Staffing and supervision

According to the study reviewed, there were four types of program staff: (1) professional home visitors, known as family support workers (FSWs); supervisors who worked with FSWs to determine families’ levels of need and develop family support plans; community nurses who identified and referred participants; and a liaison to local agencies who helped connect families to local services for a range of health, social, emotional, and financial issues.

FSWs had college-level training in nursing, social work, or related disciplines, as well as experience working with high-risk families. Māori staff were recruited to work with Māori clients. The study did not describe the education or characteristics of other program staff.

Referring nurses were trained on the principles of screening, including ethical issues. FSWs underwent a five-week training program to familiarize them with the program principles and a range of issues relevant to their role in supporting families. An important condition of the program was that Early Start services were available to Māori and delivered in a culturally competent manner. Marae-based cultural training was provided by Māori board members and Kaumatua, or tribal elders.

The study reviewed included information on supervision. Each FSW received two hours of clinical supervision a week, during which supervisors reviewed workers’ caseloads, checked their case notes, and discussed future plans for each family. The study did not indicate the ratio of supervisors to FSWs.

According to the study, caseload size was determined by a formula that weighted families based on their level of need. The typical caseload for a full-time worker was 10 to 20 families.

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Model services

The study reviewed reported that Early Start (NZ) consisted of home visits and parenting classes. Community nurses, who encountered 95 percent of local mothers shortly after birth, referred clients to the program based on an oral assessment. Referred families then participated in a one-month assessment period during which they could learn about the program without making a long-term commitment; program staff could conduct a more in-depth needs assessment during that time to determine whether the family would benefit from the program. After this one-month period, families that did not exhibit a high need received a telephone call every three months.

Home visits for other families focused on two family plans. A family support plan, prepared by FSWs and their supervisors, described common issues to address over the next three months (such as child abuse or neglect) and steps to address them. Second, families prepared an individual family plan in conjunction with their FSW that delineated their goals for the same period. FSWs used a collaborative, problem-solving approach in working with families to carry out these plans.

The frequency of home visits corresponded with the families’ need.

  • High-need families (level 1) received one to two hours of home visits per week.
  • Moderate-need families (level 2) received up to one hour of home visits every two weeks.
  • Low-need families (level 3) received up to one hour of home visits per month.
  • Graduate-level families (level 4) received up to one-hour of contact with a worker by telephone or through a home visit every three months.

All families began at level 1 and moved to other levels based on their individual progress. Services were offered for up to five years.

The study reported that parenting classes used the Triple P: Positive Parenting Program curriculum. The Triple P program was designed to introduce parents to principles of effective parenting in 10 one-hour weekly sessions.

In the study reviewed, referring nurses conducted an oral assessment using an 11-item screening tool that covered maternal age, extent of family support, the degree to which the pregnancy was wanted, substance use, family violence, and child abuse risk. Nurses referred any family that scored positively for two or more risk factors, or those the nurses felt could benefit from Early Start. During the one-month assessment period, Early Start staff administered a modified version of the Kempe Family Stress Checklist.

The study did not report whether materials were available in languages other than English, or whether Māori staff communicated with Māori families in their native language.

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Model adaptations or enhancements

The study did not provide information on whether adaptations or enhancements to the model were implemented.

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According to the study, Early Start families participated in the program for a median duration of 14 months. Almost three-fourths (74 percent) of families actively received services after 12 months, 65 percent were active after 24 months, and 60 percent still received services at 36 months. The study did not report the actual frequency or length of visits.

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Lessons learned

The study reported a few implementation lessons. First, the authors discussed factors that might have contributed to overall program outcomes, such as using professional staff and investing in mechanisms to ensure program fidelity. Authors also discussed factors that might have contributed to outcomes among Māori. They suggested that ongoing efforts to create an organizational environment sensitive to Māori participants contributed to the program benefits this group experienced. Those efforts included having an initial consultation with Māori about the program design and directions, establishing a board in which half the members were Māori, holding a cultural training for all workers, and employing Māori staff.

Finally, study authors suggested that the program’s benefits to child-focused outcomes and a lack of benefits in maternal or family functioning could reflect Early Start’s emphasis on child welfare and treating the child as the primary client. It could also indicate that families have greater potential for change when it comes to areas of new learning, such as parenting practices, rather than in areas involving long-standing personal, social, and economic difficulties. The study concluded that lack of benefits in maternal or family functioning indicated that the program should be viewed as one component of an integrated approach to assisting high-need families.

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