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Duggan, A., Fuddy, L., Burrell, L., Higman, S. M., McFarlane, E., Windham, A., et al. (2004). Randomized trial of a statewide home visiting program to prevent child abuse: Impact in reducing parental risk factors. Child Abuse & Neglect, 28(6), 623–643.

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 but not SES (e.g., maternal employment). Maternal employment is included as a control. Baseline equivalence on outcomes not feasible. None None
Study characteristics
Study participants Families were recruited to the study between November 1994 and December 1995. Hawaii Healthy Start Program staff screened the medical records of mothers from one of four Oahu communities delivering children at Kapiolani Maternity Hospital for risk factors for child abuse and neglect. Mothers found to be at risk, or those whose records did not contain sufficient information to screen out, were screened further using the Kempe Family Stress Checklist; eligible families were those in which either parent scored 25 or greater (Duggan, 2004a). Of the 897 families who were eligible to participate in the study, 730 (81%) agreed to participate and were randomly assigned to the program group (n = 395), the main comparison group (n = 290), or a testing comparison group (n = 45). 684 families completed a baseline interview (373 families in the program group, 270 families in the main comparison group, and 41 in the testing group comparison). On average, at baseline, mothers were 23.7 years of age (program group) and 23.3 years of age (comparison group). 63% (program group) and 67% (comparison group) of participating families lived below the poverty line. The racial composition of the program group was 34% native Hawaiian or Pacific Islander, 28% Asian or Filipino, 10% Caucasian, and 27% of unknown primary ethnicity. The main comparison group consisted of 33% native Hawaiian or Pacific Islander, 28% Asian or Filipino, 14% Caucasian, and 26% of unknown primary ethnicity. This study reports results from the first two follow-ups of the Hawaii Healthy Start randomized controlled trial. Follow-up interviews were completed for 88% of families in years 1 and 2, and 83% of participating families were included in both follow-ups.
Setting Six Healthy Start Program sites operated by three community-based organizations in Oahu, Hawaii.
Intervention services Home visiting services were designed to provide three to five years of home visiting, with weekly visits for most or all of the child’s first year of life, and visits of gradually decreasing frequency thereafter depending on family need. Home visitors endeavored to establish trusting relationships with families, help them resolve immediate crises, and help them build on existing strengths to improve their ability to function independently. Visitors helped families develop problem-solving skills, connected them to needed services, and aimed to develop an individual service plan with each family every six months and help the family reach six-month goals. The actual frequency of visits, however, was lower than that specified by the model, with families receiving an average of 13 visits in the child’s first year of life, and 51% of families not actively participating in the program by the time the child was 12 months old. Families still active at the end of year 1 received an average of 22 visits in the first year.
Comparison conditions The main comparison group was tested annually to measure outcomes. A second “testing” comparison group was evaluated only at year 3 to ascertain the effect of repeated testing on observed outcomes (Duggan, McFarlane, Fuddy, Burrell, Higman, Windham, et al., 2004).
Staff characteristics and training Trained paraprofessionals were recruited from the community to conduct the home visits (Duggan et al., 1999). The authors report that training for home visitors and supervisors may not have been sufficient, particularly in the areas of parent mental health, substance abuse, and domestic violence and their relationship to child abuse.
Funding sources Maternal and Child Health Bureau (R40 MC 00029 (formerly MCJ 240637) and R40 MC 00123 (formerly MCJ 240838)); The Robert Wood Johnson Foundation (18303); The Annie E. Casey Foundation (94-4041); The David and Lucile Packard Foundation (93-6051, 94-7957, 97-8058, and 98-3448); the Hawaii State Department of Health (99-29-J); and the National Institute of Mental Health, Epidemiological Center for Early Risk Behaviors, P30MH38725.
Author affiliation None of the study authors are developers of this model.

Findings details

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 Illicit drug use
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 556 mothers % = 10.00 % = 11.00 = -1.00 HomeVEE calculated = -0.06 Not statistically significant, p ≥ 0.05
High Illicit drug use
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 mothers % = 9.00 % = 9.00 = 0.00 HomeVEE calculated = 0.00 Not statistically significant, p ≥ 0.05
High Illicit drug use
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 3 548 mothers % = 11.00 % = 9.00 = 2.00 HomeVEE calculated = 0.14 Not statistically significant, p ≥ 0.05
High Illicit drug use
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Years 1-3 564 mothers Not available Not available OR = 1.06 Not available Not statistically significant, p ≥ 0.05
High Mothers with depressive symptoms (CES-D)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 mothers % = 23.00 % = 23.00 = 0.00 HomeVEE calculated = 0.00 Not statistically significant, p ≥ 0.05
High Mothers with depressive symptoms (CES-D)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 3 548 mothers % = 16.00 % = 16.00 = 0.00 HomeVEE calculated = 0.00 Not statistically significant, p ≥ 0.05
High Mothers with depressive symptoms (CES-D)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Years 1-3 564 mothers Not available Not available OR = 0.97 Not available Not statistically significant, p ≥ 0.05

footnote51

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

Adjusted odds ratios are based on the average effect across all follow-up years.

High Mothers with depressive symptoms (CES-D)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 556 mothers % = 16.00 % = 18.00 = -2.00 HomeVEE calculated = -0.09 Not statistically significant, p ≥ 0.05
High Poor general mental health (MHI < 67)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 556 mothers % = 35.00 % = 38.00 = -3.00 HomeVEE calculated = -0.20 Statistically significant, p < 0.05
High Poor general mental health (MHI < 67)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 mothers % = 36.00 % = 46.00 = -10.00 HomeVEE calculated = -0.25 Statistically significant, p < 0.05
High Poor general mental health (MHI < 67)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 3 548 mothers % = 29.00 % = 32.00 = -3.00 HomeVEE calculated = -0.09 Not statistically significant, p ≥ 0.05
High Problem alcohol use (CAGE)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Years 1-3 564 mothers Not available Not available OR = 0.76 Not available Not statistically significant, p ≥ 0.05
High Problem alcohol use (CAGE)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 556 mothers % = 8.00 % = 9.00 = -1.00 HomeVEE calculated = -0.08 Not statistically significant, p ≥ 0.05
High Problem alcohol use (CAGE)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 mothers % = 8.00 % = 10.00 = -2.00 HomeVEE calculated = -0.15 Not statistically significant, p ≥ 0.05
High Problem alcohol use (CAGE)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 3 548 mothers % = 7.00 % = 10.00 = -3.00 HomeVEE calculated = -0.24 Statistically significant, p < 0.05
High Severe parenting stress (PSI)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 mothers % = 11.00 % = 10.00 = 1.00 HomeVEE calculated = 0.06 Not statistically significant, p ≥ 0.05
High Severe parenting stress (PSI)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 3 548 mothers % = 8.00 % = 8.00 = 0.00 HomeVEE calculated = 0.00 Not statistically significant, p ≥ 0.05
High Severe parenting stress (PSI)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Years 1-3 564 mothers Not available Not available OR = 1.04 Not available Not statistically significant, p ≥ 0.05
High Severe parenting stress (PSI)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 556 mothers % = 8.00 % = 9.00 = -1.00 HomeVEE calculated = -0.08 Not statistically significant, p ≥ 0.05
Reductions in juvenile delinquency, family violence, and crime
Rating Outcome measure Effect Sample Timing of follow-up Sample size Intervention group Comparison group Group difference Effect size Statistical significance Notes
High Partner incident resulting in injury (CTS)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 556 mothers % = 14.00 % = 20.00 = -6.00 HomeVEE calculated = -0.26 Statistically significant, p < 0.05
High Partner incident resulting in injury (CTS)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Years 1-3 564 mothers % = 24.00 % = 26.00 OR = 0.81 Not available Not statistically significant, p ≥ 0.05
High Partner incident resulting in injury (CTS)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 3 548 mothers % = 17.00 % = 18.00 = -1.00 HomeVEE calculated = -0.04 Not statistically significant, p ≥ 0.05
High Partner incident resulting in injury (CTS)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 mothers % = 24.00 % = 26.00 = -2.00 HomeVEE calculated = -0.06 Not statistically significant, p ≥ 0.05
High Partner physical abuse (CTS)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 556 mothers % = 26.00 % = 32.00 = -6.00 HomeVEE calculated = -0.18 Statistically significant, p < 0.05
High Partner physical abuse (CTS)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Years 1-3 564 mothers % = 37.00 % = 42.00 OR = 0.83 Not available Not statistically significant, p ≥ 0.05
High Partner physical abuse (CTS)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 3 548 mothers % = 29.00 % = 30.00 = -1.00 HomeVEE calculated = -0.03 Not statistically significant, p ≥ 0.05
High Partner physical abuse (CTS)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 mothers % = 37.00 % = 42.00 = -5.00 HomeVEE calculated = -0.13 Not statistically significant, p ≥ 0.05
High Partner psychological abuse (CTS)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Years 1-3 564 mothers % = 49.00 % = 49.00 OR = 1.05 Not available Not statistically significant, p ≥ 0.05

footnote51

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

Adjusted odds ratios are based on the average effect across all follow-up years.

High Partner psychological abuse (CTS)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 3 548 mothers % = 42.00 % = 38.00 = -4.00 HomeVEE calculated = 0.10 Not statistically significant, p ≥ 0.05
High Partner psychological abuse (CTS)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 mothers % = 49.00 % = 49.00 = 0.00 HomeVEE calculated = 0.00 Not statistically significant, p ≥ 0.05
High Partner psychological abuse (CTS)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 556 mothers % = 42.00 % = 42.00 = 0.00 HomeVEE calculated = 0.00 Not statistically significant, p ≥ 0.05

Outcome measure summary

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

CES-D: Depressive symptoms

The CES-D is a 20-item assessment of depressive symptoms. A binary variable was formed from the total score where parents with scores greater than or equal to 24 were said to have probable cases of depression. Parent/caregiver report

Not reported by author

MHI: Poor general mental health

The MHI assesses levels of anxiety and depressive symptoms. The researchers created a binary variable where those with MHI scores less than 67 were considered to have poor mental health. Parent/caregiver report

Not reported by author

PSI: Severe parenting stress

The PSI assesses stress in the parent-child relationship arising from child temperament, parental depression, and negatively reinforcing parent-child interactions. A mother was considered positive for severe parenting stress if she scored positive for personal adjustment problems, child abuse potential, or high child abuse potential as defined by Abidin. Parent/caregiver report

Not reported by author

Illicit drug use

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

Not reported by author

Problem alcohol use (CAGE)

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

Reductions in juvenile delinquency, family violence, and crime
Outcome measure Description of measure Data collection method Properties of measure

CTS:

  • Partner psychological abuse
  • Partner physical abuse
  • Partner incident resulting in injury
The CTS assesses victimization and perpetration related to intimate partner violence and maltreatment. The researchers examined the prevalence of psychological abuse, physical abuse, and an incident of injury. The father was considered to be physically violent if he had committed three or more incidents of physical violence toward the mother in the year prior to the baseline interview and was psychologically aggressive if he had committed acts of psychological aggression more than 35 times in the year prior to the interview. Parent/caregiver report

Not reported by author