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Duggan, A., Caldera, D., Rodriguez, K., Burrell, L., Rohde, C., & Crowne, S. S. (2007). Impact of a statewide home visiting program to prevent child abuse. Child Abuse & Neglect, 31(8), 801–827.

Model(s) Reviewed: Healthy Families America (HFA)®
Manuscript screening details
Screening decision Screening conclusion
Passes screens Eligible for review
Study design details
Rating Design Attrition Baseline equivalence Reassignment Confounding factors
High Randomized controlled trial Low Established on race and SES. Baseline equivalence on outcomes not feasible. None None
Notes:

footnote76

Submitted by user on Fri, 03/15/2019 - 14:29

High rating applies to the following outcomes: child maltreatment, mother relinquished role, child hospitalized for <abbr title=” Ambulatory care sensitive conditions “>ACSC</abbr>, and child seen in the emergency room. A moderate rating applies to all other outcomes in the study’s Table 3, as well as the partner violence and substance use outcomes in the study’s Table 4, because of high attrition and equivalence on race and <abbr tilte="social economic status">SES<abbr>. Mental health outcomes in Table 4 receive a low rating because of high attrition and statistically significant baseline differences by race or <abbr tilte="social economic status">SES<abbr>.

Study characteristics
Study participants Between January 2000 and July 2001, 388 families who screened positive on a Healthy Families Alaska (HFAK) protocol for risk factors associated with poor health and social outcomes and received scores of 25 or higher on the Kempe’s Family Stress Checklist were recruited during pregnancy or at the time of birth (Duggan et al., 2007). Of these families, 364 consented to participate and were randomly assigned to the program group (n = 179) or the comparison group (n = 185). 325 families completed a baseline interview. The sample was 22% Alaska native, 55% Caucasian, 8% multiracial, and 15% other race. 58% of families were below poverty level, 58% of mothers had graduated from high school, and 73% had worked in the year prior to enrollment (Johns Hopkins University, 2005). The average age of mothers at baseline was 23.5 years. This study reports the second-year follow-up results of the HFA K evaluation, with a sample size of 138 program group primary caregivers and 140 comparison group primary caregivers. Most of the analyses are limited to families in which the biological mothers had custody of the index child at follow-up (249 families), with additional outcomes obtained from medical records (268 families). The outcomes included in this study were also described in an earlier report (Johns Hopkins University, 2005).
Setting This study included six Healthy Families Alaska sites, two in Anchorage and one each in Wasilla, Fairbanks, Juneau, and Kenai.
Intervention services Families in the program group were assigned to receive visits monthly until their child’s birth and weekly thereafter. By design, families receive gradually less frequent visits as they reach critical milestones, ranging to quarterly visits at the highest level of functioning. Families were enrolled in the program until they functioned sufficiently to “graduate” or until their child turned 2. In practice, home visits were less frequent than intended, with only 4% of families receiving 75% or more of their designated frequency of visits and completing the full two years. Home visits were intended to emphasize preparing for child growth, development, and critical milestones; screening and referral for developmental delays; promoting a safe environment; positive parent-child interactions; establishing a “medical home” for the child; and supporting the family during crises. The program also emphasized the development of an Individual Family Support Plan (IFSP) or setting and monitoring progress toward individual family goals.
Comparison conditions Families assigned to the comparison condition received referrals to other community services.
Staff characteristics and training Guidelines suggest paraprofessional staff have a high school diploma at a minimum and that program managers have a master’s degree in a relevant field. In five of the six sites included in the evaluation, home visits were conducted by paraprofessionals. The remaining site combined nurse-visiting and paraprofessional-visiting models. Staff members were required to complete a one-week training geared directly to their role and a community-based training. Training for staff who conducted home visits or administered the Kempe Family Stress Checklist was conducted by certified instructors. All staff also had to complete 100 hours of training covering “child development, parent-child interaction, family dynamics, child safety, the dynamics of child abuse and neglect, crisis intervention and problem solving, communication skills, domestic violence, substance abuse, infant mental health and other related topics.” Continuous training varied by program. Training was initially administered by the Hawaii Family Stress Center and later by Great Kid’s Inc.
Funding sources Alaska Mental Health Trust Authority and Alaska State Department of Health and Social Services.
Author affiliation None of the study authors are developers of this model.

Findings details

Child health
Rating Outcome measure Effect Sample Timing of follow-up Sample size Intervention group Comparison group Group difference Effect size Statistical significance Notes
High Child hospitalized for ambulatory care sensitive conditions (ACSC)
FavorableUnfavorable or ambiguousNo Effect
Families with complete medical record data, Alaska trial Years 1 and 2 268 families % (adjusted) = 9.00 Adjusted mean % = 9.00 OR = 1.09 HomeVEE calculated = 0.00 Not statistically significant, p ≥ 0.05

footnote54

Submitted by user on Fri, 03/15/2019 - 14:29

Ambulatory care sensitive conditions include: asthma, pneumonia, other upper airway conditions, gastroenteritis, dehydration, cellulitis, and seizures.

High Child seen in emergency department for ACSC
FavorableUnfavorable or ambiguousNo Effect
Families with complete medical record data, Alaska trial Years 1 and 2 268 families % (adjusted) = 81.00 Adjusted mean % = 78.00 OR = 1.23 HomeVEE calculated = 0.11 Not statistically significant, p ≥ 0.05
High Number of times hospitalized for ACSC
FavorableUnfavorable or ambiguousNo Effect
Families with complete medical record data, Alaska trial Years 1 and 2 268 families Adjusted mean = 0.11 Adjusted mean = 0.12 Mean difference = -0.01 Not available Not statistically significant, p ≥ 0.05
High Number of times seen in emergency department for ACSC
FavorableUnfavorable or ambiguousNo Effect
Families with complete medical record data, Alaska trial Years 1 and 2 268 families Adjusted mean = 3.13 Adjusted mean = 4.09 Mean difference = -0.96 Not available Not statistically significant, p ≥ 0.05
Maternal health
Rating Outcome measure Effect Sample Timing of follow-up Sample size Intervention group Comparison group Group difference Effect size Statistical significance Notes
High Alcohol or drug use
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at interview, Alaska trial Year 2 249 mothers % = 28.00 % = 33.00 OR = 0.80 HomeVEE calculated = -0.14 Not statistically significant, p ≥ 0.05
High Any illicit drug use
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at interview, Alaska trial Year 2 249 mothers % = 21.00 % = 18.00 OR = 1.23 HomeVEE calculated = 0.12 Not statistically significant, p ≥ 0.05
High Problem alcohol use
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at interview, Alaska trial Year 2 249 mothers % = 13.00 % = 22.00 OR = 0.52 HomeVEE calculated = -0.39 Not statistically significant, p ≥ 0.05
Positive parenting practices
Rating Outcome measure Effect Sample Timing of follow-up Sample size Intervention group Comparison group Group difference Effect size Statistical significance Notes
High Mother relinquished role (child lived separately from mother for one month or more)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Alaska trial Years 1 and 2 322 families % = 18.00 % = 16.00 OR = 1.19 HomeVEE calculated = 0.09 Not statistically significant, p ≥ 0.05
Moderate Attitudes toward corporal punishment (AAPI)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers Adjusted mean = 20.50 Adjusted mean = 10.10 Mean difference = 0.38 Not available Not statistically significant, p ≥ 0.05
Moderate Poor caregiver interaction, (NCAST score = 35)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers % = 17.00 % = 21.00 OR = 0.79 HomeVEE calculated = -0.16 Not statistically significant, p ≥ 0.05
Moderate Poor quality home environment (HOME score = 33)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers % = 20.00 % = 31.00 OR = 0.51 HomeVEE calculated = -0.36 Statistically significant,
p < 0.05
Moderate Total AAPI score
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers Adjusted mean = 130.00 Adjusted mean = 125.60 Mean difference = 4.47 Not available Not Statistically significant,
p >: 0.05
Reductions in child maltreatment
Rating Outcome measure Effect Sample Timing of follow-up Sample size Intervention group Comparison group Group difference Effect size Statistical significance Notes
High Common corporal punishment (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers % = 91.00 % = 92.00 OR = 0.80 HomeVEE calculated = -0.08 Not statistically significant, p ≥ 0.05
High Common corporal punishment (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers Adjusted mean = 19.48 Adjusted mean = 24.17 Mean difference = -4.69 Not available Statistically significant,
p < 0.05
High Corporal/verbal punishment (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers % = 66.00 % = 68.00 OR = 0.92 HomeVEE calculated = -0.05 Not statistically significant, p ≥ 0.05
High Corporal/verbal punishment Frequency (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers Adjusted mean = 4.02 Adjusted mean = 4.57 Mean difference = -0.55 Not available Not statistically significant, p ≥ 0.05
High Extreme physical punishment (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers % = 2.00 % = 3.00 OR = 0.75 HomeVEE calculated = -0.25 Not statistically significant, p ≥ 0.05
High Extreme physical punishment Frequency (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers Adjusted mean = 0.19 Adjusted mean = 0.04 Mean difference = 0.15 Not available Not statistically significant, p ≥ 0.05
High Hit with object (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers % = 10.00 % = 5.00 OR = 2.40 HomeVEE calculated = 0.45 Not statistically significant, p ≥ 0.05
High Hit with object Frequency (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers Adjusted mean = 0.33 Adjusted mean = 0.46 Mean difference = -0.13 Not available Not statistically significant, p ≥ 0.05
High Mild physical assault (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers % = 80.00 % = 85.00 OR = 0.70 HomeVEE calculated = -0.21 Not statistically significant, p ≥ 0.05
High Mild physical assault Frequency (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers Adjusted mean = 9.56 Adjusted mean = 11.93 Mean difference = -2.38 Not available Statistically significant,
p < 0.05
High Neglectful behavior (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers % = 19.00 % = 22.00 OR = 0.81 HomeVEE calculated = -0.11 Not statistically significant, p ≥ 0.05
High Neglectful behavior Frequency (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers Adjusted mean = 0.92 Adjusted mean = 0.75 Mean difference = 0.16 Not available Not statistically significant, p ≥ 0.05
High Neglectful behavior revised (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers % = 18.00 % = 18.00 OR = 0.97 HomeVEE calculated = 0.00 Not statistically significant, p ≥ 0.05
High Neglectful behavior revised Frequency (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers Adjusted mean = 0.65 Adjusted mean = 0.66 Mean difference = -0.01 Not available Not statistically significant, p ≥ 0.05
High Psychological aggression (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers % = 84.00 % = 83.00 OR = 1.10 HomeVEE calculated = 0.04 Not statistically significant, p ≥ 0.05
High Psychological aggression Frequency (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers Adjusted mean = 11.17 Adjusted mean = 13.09 Mean difference = -1.92 Not available Statistically significant,
p < 0.05
High Severe assault Frequency (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers Adjusted mean = 0.41 Adjusted mean = 0.30 Mean difference = 0.10 Not available Not statistically significant, p ≥ 0.05
High Severe assault (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers % = 9.00 % = 7.00 OR = 1.28 HomeVEE calculated = 0.17 Not statistically significant, p ≥ 0.05
High Threat to esteem (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers % = 24.00 % = 22.00 OR = 1.17 HomeVEE calculated = 0.07 Not statistically significant, p ≥ 0.05
High Threat to esteem Frequency (CTS-PC)
FavorableUnfavorable or ambiguousNo Effect
Biological mothers with custody of index child at follow-up, Alaska trial Year 2 246 mothers Adjusted mean = 0.95 Adjusted mean = 0.64 Mean difference = 0.31 Not available Not statistically significant, p ≥ 0.05
High Substantiated CPS reports, all types
FavorableUnfavorable or ambiguousNo Effect
Full sample, Alaska trial Child age 1 309 families % = 12.00 % = 10.00 = 2.00 HomeVEE calculated = 0.12 Not statistically significant, p ≥ 0.05
High Substantiated CPS reports, all types
FavorableUnfavorable or ambiguousNo Effect
Full sample, Alaska trial Child age 2 297 families % = 9.00 % = 9.00 = 0.00 HomeVEE calculated = 0.00 Not statistically significant, p ≥ 0.05
High Substantiated CPS reports, neglect
FavorableUnfavorable or ambiguousNo Effect
Full sample, Alaska trial Child age 1 309 families % = 10.00 % = 6.00 = 4.00 HomeVEE calculated = 0.34 Not statistically significant, p ≥ 0.05
High Substantiated CPS reports, neglect
FavorableUnfavorable or ambiguousNo Effect
Full sample, Alaska trial Child age 2 297 families % = 6.00 % = 7.00 = -1.00 HomeVEE calculated = -0.10 Not statistically significant, p ≥ 0.05

Outcome measure summary

Child health
Outcome measure Description of measure Data collection method Properties of measure

Child hospitalized forACSCChild seen in emergency department for ACSCNumber of timeshospitalized for ACSCNumber of timesseen in emergency department for ACSC

The researchersused the Parker& Schoendorf (2000) definitionof ACSC to examine hospitalizations that might have been avoided with adequate primary care. The list of conditions includes asthma, pneumonia, other upper airway conditions, gastroenteritis, dehydration, cellulitis, and seizures. The percentage of children hospitalized for ACSC, the percentage of children that were seen in the emergency department for ACSC, the number of times the child was seen in the emergency department for ACSC, and the number of times the child was hospitalized for ACSC were analyzed. Parent/caregiver report and review of medical records

Not applicable

Maternal health
Outcome measure Description of measure Data collection method Properties of measure

Alcohol or drug use

Percentage of parents with a positive CAGE score and who drank in the past year or who had any illicit drug use in 2 years prior to baseline interview Parent/caregiver report

Not applicable

Any illicit drug use

Percentage of parents who engaged in illicit drug use, defined as a report of any illegal drug use in the past 2 years Parent/caregiver report

Not applicable

Problem alcohol use

Percentage of parents with problem alcohol use, defined as a report of alcohol use in the year prior to pregnancy and a CAGE score greater than or equal to 2 Parent/caregiver report

Not reported by author

Positive parenting practices
Outcome measure Description of measure Data collection method Properties of measure

Mother relinquished role

Percentage of families in which the child lived separately from the mother for one month or more. Research staff determined whether separation cases were a relinquishment of parenting responsibilities, or a necessary separation to meet professional or family responsibilities. Parent/caregiver report and review of records

Not applicable

NCAST: Poor caregiver interaction

The NCAST assesses the quality of teaching interaction between caregivers and young children. The researchers define poor caregiver interaction as a composite NCAST caregiver score below or equal to 35. Observation

Not reported by author

AAPI: Attitudes toward corporal punishment  AAPI: Total score

The AAPI assesses parenting and childrearing attitudes. The researchers examined both the AAPI total score and a subscale of the Discipline Questionnaire that measured attitudes about the effectiveness of physical punishment. Parent/caregiver report

Not reported by author

HOME: Poor-quality HOME environment (HOME score = 33)

The HOME assesses parenting practices and aspects of the home environment. The researchers defined poor-quality home environment as a HOME total score below or equal to 33. Parent/caregiver interview and observational assessment

Not reported by author

Reductions in child maltreatment
Outcome measure Description of measure Data collection method Properties of measure

Conflict Tactics Scale-Parent Child (CTS-PC):

  • Psychological aggression
  • Mild physical assault
  • Severe assault
  • Traditional neglect
  • Common corporal punishment
  • Threat to esteem
  • Hit with object
  • Extreme physical punishment
  • Revised neglect
  • Corporal/verbal punishment
The CTS-PC assesses neglectful, psychologically aggressive, and abusive parenting behaviors and acts. The assessment is divided into six subscales: (1) nonviolent discipline, (2) psychological aggression, (3) minor physical assault, (4) severe physical assault, (5) very severe physical assault, and (6) neglect. The researchers conducted factor analysis to determine whether a different set of subscales may be more applicable to the sample. This process produced five revised subscales: (1) common corporal and verbal punishment, (2) assault on child’s self-esteem, (3) hitting with an object, (4) extreme physical violence, and (5) neglect. They assessed program impact for both the traditional and revised subscales. The researchers examined both the prevalence and frequency of these behaviors. Parent/caregiver report

Not reported by author

Substantiated CPS reports, all types

Percentage of families who had a substantiated report across all child abuse or neglect classifications Review of CPS records

Not applicable

Substantiated CPS reports, neglect

Percentage of families who had a substantiated report for child neglect Review of CPS records

Not applicable