The effect of Alaska's home visitation program for high-risk families on trends in abuse and neglect
Introduction
During 1995, the State of Alaska implemented Healthy Families Alaska, a home visitation program designed to decrease child abuse and neglect and improve other child health outcomes. This decision was based on the Healthy Families America initiative promoted by the National Committee to Prevent Child Abuse (now Prevent Child Abuse America), which in turn was based on initial promising results from other sites (Olds, Henderson, Chamberlin, & Tatelbaum, 1986; Olds & Kitzman, 1990). After several years of implementation, the Alaska State legislature required an evaluation of the home visitation approach and, from 2000 to 2004, a randomized trial of the Healthy Families Alaska program at six sites was conducted. This study has now been completed and results reported (Duggan, Caldera, Rodriguez, Burrell, & Shea, 2004).
Since the initial promising results, several studies from other areas have found that home visitation programs could decrease the risk of child abuse and neglect under some circumstances (Eckenrode et al., 2000, Olds et al., 1997), prompting the US Centers for Disease Control and Prevention to recommend these programs for child abuse prevention (Centers for Disease Control and Prevention, 2003). However, similar to most studies, including those conducted more recently (Duggan, McFarlane, et al., 2004; Sweet & Appelbaum, 2004), no or minimal impact on child abuse was found in Alaska (Duggan, Caldera, et al., 2004).
The primary goal of Healthy Families Alaska was to decrease the occurrence of abuse and neglect among high-risk families, and specifically that 95% of target children would have no substantiated child abuse or neglect. However, the randomized program evaluation found that Healthy Families Alaska “did not prevent child maltreatment, reduce malleable parent risks for maltreatment, or improve child health.” Sixteen percent of enrolled children compared to 17% of unenrolled children experienced substantiated neglect or abuse during the first 2 years of life, and both groups had similar rates of abuse when stratified by age.
Negative results could have occurred because of specific program implementation problems. Even at the best performing sites, service delivery fell short of program standards. The highest site specific retention was 45% at 2 years and the highest visitation rate averaged once per 2 weeks versus a goal of once a week. Almost half of families had no individualized family support plan. Home visitors usually did not address the risk factors for child maltreatment that led to program enrollment, namely poor mental health, domestic violence, and substance abuse. Finally, while in theory program delivery guidelines were codified, substantial changes occurred in service delivery over time. A full description of the Healthy Families Alaska program, including its implementation and results of the randomized trial, is available at http://hss.state.ak.us/ocs/Publications/JohnsHopkins_HealthyFamilies.pdf (last accessed 10 April 2007).
In addition to implementation issues, program design and analysis issues may have unfairly biased results toward the null. All randomized home visitation evaluations conducted to date, including Alaska's, have been by necessity nonblinded. Because of this, program staff may have delivered services to control families beyond those that they would have received in the absence of the study. This problem was augmented in Alaska where the study was designed to provide enhanced community resources referral immediately before randomization to children in both the intervention and control arms. Consequently, no true control population existed. Additionally, Healthy Families Alaska may have decreased true episodes of child maltreatment but this effect could have been masked if home visitors identified and reported additional cases of maltreatment. Presumably, as home visitor competency increased over time, this effect should have diminished and rates of decline in maltreatment outcomes should have been higher among enrolled than control families. However, the published analysis of Healthy Families Alaska did not evaluate changes in maltreatment outcomes over time.
To address these latter methodological limitations, the current study was conducted to determine if all children enrolled in Healthy Families Alaska throughout the state (including those in the intervention arm of the study) experienced a greater decrease in child abuse over time than that documented among all and high-risk unenrolled children living in Healthy Families Alaska communities (the majority of whom had received no change in services during the evaluation period). By linking Healthy Families Alaska enrollment status to Child Protective Services records and birth certificates, it became possible to use as controls the general population of children in the Healthy Families Alaska communities and children identified as high-risk based on birth certificate characteristics. This approach thus reduced the potential bias caused by provision of enhanced resources either before or after study enrollment to all children enrolled in Healthy Families Alaska.
Section snippets
Healthy Families Alaska background
Healthy Families Alaska began serving clients during 1995 in Juneau and the Central Kenai Peninsula (Kenai, Soldotna, Sterling, Clam Gulch, Cohoe, Funny River, Kasilof, Nikiski, Ninilchik, Salamatof, and Ridgeway) followed in 1996 by Anchorage, Dillingham, Fairbanks, and the Matanuska-Susitna Borough (Palmer, Sutton, Wasilla, Willow, Talkeetna, and Houston). The program in Dillingham ceased at the end of 2003 while that serving the Central Kenai Peninsula ceased mid-2005. Anchorage had two
Background
There were 40,099 children born during 1996–2002 to residents of Healthy Families Alaska communities; 23,929 (60%) children were born to Anchorage residents. During the 9-year period of follow-up for abuse and neglect outcomes and among all 40,099 children, 3909 (9.7%) were referred to Child Protective Services during the first 2 years of life with a total of 7138 referrals (range, 1–15 per child); 2839 (7.1%) were referred for neglect (total referrals, 4589; range, 1–11 per child) and 1356
Program effectiveness
Healthy Families Alaska screening criteria successfully identified families at high risk of experiencing child abuse or neglect. Rates among enrolled children were approximately fourfold higher than among the control population. The screening criteria utilized, however, were no more successful at identifying high-risk children than risk factors easily identifiable from the birth certificate. Moreover, having identified high-risk families, the current evaluation found little evidence that home
Acknowledgments
The author would like to acknowledge Debra Caldera for her assistance with implementation of Healthy Families Alaska and for providing critical review of the current manuscript. The author also would like to acknowledge Phillip Mitchell of the Alaska Bureau of Vital Statistics for preparing birth certificate data and performing data linkage.
References (22)
An experimental evaluation of in-home child abuse prevention services
Child Abuse & Neglect
(1991)- et al.
A prospective study of secondary prevention of child maltreatment
Journal of Pediatrics
(1993) Is it time to rethink Health Start/Healthy Families?
Child Abuse & Neglect
(2004)- et al.
Randomized trial of a statewide home visiting program: Impact in preventing child abuse and neglect
Child Abuse & Neglect
(2004) - et al.
The incidence of infant physical abuse in Alaska
Child Abuse & Neglect
(2004) - et al.
Family support and parenting education in the home: An effective extension of clinic-based preventive health care services for poor children
Journal of Pediatrics
(1989) - et al.
A cognitive approach to child abuse prevention
Journal of Family Psychology
(2002) First reports evaluating the effectiveness of strategies for preventing violence: Early childhood home visitation and firearms laws: Findings from the Task Force on Community Preventive Services
Morbidity and Mortality Weekly Report
(2003)- et al.
Evaluating new vaccines for developing countries. Efficacy or effectiveness?
Journal of the American Medical Association
(1996) - Duggan, A., Caldera, D. L., Rodriguez, K., Burrell, L. D., & Shea, S. K. (2004a). Evaluation of the Healthy Families...