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Duggan, A. K., McFarlane, E. C., Windham, A. M., Rohde, C. A., Salkever, D. S., Fuddy, L., et al. (1999). Evaluation of Hawaii’s Healthy Start program. Future of Children, 9(1), 66–90; discussion 177–178.

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:

footnote80

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

High rating applies to outcomes in the study’s Tables 4 and 6. Outcomes in Tables 5 and 7 are excluded because they overlap with analyses reported in other reports.

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 families 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).
Funding sources From 1991 to 1994, this evaluation received funding from: the Robert Wood Johnson Foundation; the Annie E . Casey Foundation; The David and Lucile Packard Foundation; the Maternal and Child Health Bureau of the U.S. Department of Health and Human Services; the Hawaii Department of Health; and the Hawaii Medical Association committed office space and an administrative home for fieldwork staff.
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 Ever hospitalized for any reason
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Years 1 and 2 534 children % = 19.00 % = 22.00 = 3.00 HomeVEE calculated = -0.11 Not statistically significant, p ≥ 0.05
High Ever hospitalized for any reason
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 children % = 17.00 % = 18.00 = -1.00 HomeVEE calculated = -0.04 Not statistically significant, p ≥ 0.05
High Ever used emergency department
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Years 1 and 2 534 children % = 58.00 % = 60.00 = -2.00 HomeVEE calculated = -0.05 Not statistically significant, p ≥ 0.05
High Ever used emergency department
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 children % = 40.00 % = 44.00 = -4.00 HomeVEE calculated = -0.10 Not statistically significant, p ≥ 0.05
High Has a PCP who handles most health care needs
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 children % = 93.00 % = 90.00 = 3.00 HomeVEE calculated = 0.24 Not statistically significant, p ≥ 0.05
High Has a PCP who handles most health care needs
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 567 children % = 89.00 % = 84.00 = 5.00 HomeVEE calculated = 0.26 Not statistically significant, p ≥ 0.05
High Has a PCP who knows all aspects of child’s care
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 children % = 84.00 % = 79.00 = 5.00 HomeVEE calculated = 0.20 Not statistically significant, p ≥ 0.05
High Has a PCP who knows all aspects of child’s care
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 567 children % = 80.00 % = 75.00 = 5.00 HomeVEE calculated = 0.17 Not statistically significant, p ≥ 0.05
High Has a PCP who knows family’s concerns about child
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 children % = 45.00 % = 48.00 = 3.00 HomeVEE calculated = -0.07 Not statistically significant, p ≥ 0.05
High Has a PCP who knows family’s concerns about child
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 567 children % = 50.00 % = 39.00 = 11.00 HomeVEE calculated = 0.27 Statistically significant,
p < 0.05
High Has a primary care provider (PCP)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 567 children % = 91.00 % = 86.00 = 5.00 HomeVEE calculated = 0.30 Not statistically significant, p ≥ 0.05
High Has a primary care provider (PCP)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 children % = 94.00 % = 90.00 = 4.00 HomeVEE calculated = 0.34 Not statistically significant, p ≥ 0.05
High Immunizations up-to-date
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 567 children % = 87.00 % = 85.00 = 2.00 HomeVEE calculated = 0.10 Not statistically significant, p ≥ 0.05
High Immunizations up-to-date
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 children % = 82.00 % = 82.00 = 0.00 HomeVEE calculated = 0.00 Not statistically significant, p ≥ 0.05
Family economic self-sufficiency
Rating Outcome measure Effect Sample Timing of follow-up Sample size Intervention group Comparison group Group difference Effect size Statistical significance Notes
High Mother earned HS degree or in school
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 mothers % = 81.00 % = 80.00 = 1.00 HomeVEE calculated = 0.04 Not statistically significant, p ≥ 0.05
High Mother earned HS degree or in school
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 567 mothers % = 82.00 % = 81.00 = 1.00 HomeVEE calculated = 0.04 Not statistically significant, p ≥ 0.05
High Someone in household worked
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 mothers % = 68.00 % = 70.00 = -2.00 HomeVEE calculated = -0.06 Not statistically significant, p ≥ 0.05
High Someone in household worked
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 567 mothers % = 77.00 % = 75.00 = 2.00 HomeVEE calculated = 0.07 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 Confidence in adult relations
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 mothers Mean = 34.30 Mean = 33.80 Mean difference = 0.50 Not available Not statistically significant, p ≥ 0.05
High Confidence in adult relations
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 567 mothers Mean = 34.40 Mean = 33.70 Mean difference = 0.70 Not available Not statistically significant, p ≥ 0.05
High Maternal life skills (CLSS)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 567 mothers Mean = 23.90 Mean = 23.90 Mean difference = 0.00 Not available Not statistically significant, p ≥ 0.05
High Maternal life skills (CLSS)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 mothers Mean = 24.20 Mean = 24.30 Mean difference = -0.10 Not available Not statistically significant, p ≥ 0.05
High Maternal social support (MSSI)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 mothers Mean = 21.50 Mean = 21.90 Mean difference = -0.40 Not available Not statistically significant, p ≥ 0.05
High Maternal social support (MSSI)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 567 mothers Mean = 21.40 Mean = 21.70 Mean difference = -0.30 Not available 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 Learning environment (HOME)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 567 mothers Mean = 34.60 Mean = 34.10 Mean difference = 0.50 Not available Not statistically significant, p ≥ 0.05
High Learning environment (HOME)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 mothers Mean = 35.20 Mean = 35.20 Mean difference = 0.00 Not available Not statistically significant, p ≥ 0.05
High Mother-child interaction, Caregiver total score (NCAST)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 567 mothers Mean = 15.00 Mean = 14.60 Mean difference = 0.40 Not available Not statistically significant, p ≥ 0.05
High Mother-child interaction, Caregiver total score (NCAST)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 mothers Mean = 12.80 Mean = 12.70 Mean difference = 0.10 Not available Not statistically significant, p ≥ 0.05
High Mother-child interaction, Child total score (NCAST)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 567 mothers Mean = 7.20 Mean = 7.20 Mean difference = 0.00 Not available Not statistically significant, p ≥ 0.05
High Mother-child interaction, Child total score (NCAST)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 mothers Mean = 6.80 Mean = 6.50 Mean difference = 0.30 Not available Not statistically significant, p ≥ 0.05
High Parenting efficacy (PSOC)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 mothers Mean = 75.20 Mean = 74.40 Mean difference = 0.80 Not available Not statistically significant, p ≥ 0.05
High Parenting efficacy (PSOC)
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 2 567 mothers Mean = 76.10 Mean = 74.10 Not Reported Not available 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 Ever had injury needing medical care
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Year 1 564 children % = 9.00 % = 11.00 = -2.00 HomeVEE calculated = -0.14 Not statistically significant, p ≥ 0.05
High Ever had injury needing medical care
FavorableUnfavorable or ambiguousNo Effect
Full sample, Hawaii trial Years 1 and 2 534 children % = 22.00 % = 24.00 = -2.00 HomeVEE calculated = -0.07 Not statistically significant, p ≥ 0.05

Outcome measure summary

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

Ever hospitalized for any reason

Percentage of children who had ever been hospitalized for any reason Parent/caregiver report

Not applicable

Ever used emergency department

Percentage of children who had ever used the emergency department Parent/caregiver report

Not applicable

Has a PCP

Percentage of children who had a PCP Parent/caregiver report

Not applicable

Has a PCP who handles most health care needs

Percentage of children who had a PCP who handled most health care needs Parent/caregiver report

Not applicable

Has a PCP who knows all aspects of child’s care

Percentage of children who had a PCP who knew about all aspects of the child’s care Parent/caregiver report

Not applicable

Has a PCP who knows family’s concerns about child

Percentage of children who had a PCP who understood the family’s concerns about child Parent/caregiver report

Not applicable

Immunizations up-to-date

Percentage of children who were up-to-date on the appropriate immunizations for the child’s age Parent/caregiver report

Not applicable

Family economic self-sufficiency
Outcome measure Description of measure Data collection method Properties of measure

Mother earned high school degree or in school

Percentage of mothers who had earned a high school degree or who were currently enrolled in school Parent/caregiver report

Not applicable

Someone in household worked

Percentage of families in which a household member was employed Parent/caregiver report

Not applicable

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

CLSS: Maternal life skills

The CLSS assesses a person’s transportation, budgeting, support service, support-involvement, interests-hobbies, regularity/organization routines, practices, and resources. Parent/caregiver report

Not reported by author

MSSI: Maternal social support

The MSSI assesses caregiver social support with regard to the division of household tasks and responsibilities for child rearing, access to transportation, interaction with other adults, and community involvement. Parent/caregiver report

Not reported by author

Confidence in adult relations

No description provided by author Parent/caregiver report

Not reported by author

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

NCAST: Caregiver total score  NCAST: Child total score

The NCAST assesses the quality of teaching interaction between caregivers and young children. The researchers examined separate composite scores for both children and parents. Observation

Not reported by author

PSOC

The PSOC measures parent attitudes and self-efficacy. Parent/caregiver report

Not reported by author

HOME: Learning environment

The HOME assesses parenting practices and aspects of the home environment. 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

Ever had injury needing medical care

Percentage of children who had ever had an injury that required medical care Parent/caregiver report

Not applicable