Pilot Evaluation of a Home Visit Parent Training Program in Disadvantaged Families

Abstract

Objectives:

The study reported the pilot evaluation of the Healthy Start Home Visit Program for disadvantaged Chinese parents with preschool children, delivered by trained parent assistants. Home visiting was used to make services more accessible to disadvantaged families.

Method:

The participants included 21 parent–child dyads. Outcome measures included parent report, teacher report, and direct assessment of children.

Results:

Paired samples t-test results indicated significant increase in child cognitive measures, child school readiness, child oral health practices; decreases in child sedentary activities, child home injury, and hospital visits; decreases in parenting stress and child behavior problems and increases in social support. The parent assistants delivering the program reported significant decreases in child behavior problems and parenting stress from pretraining to posttraining and completion of home visits.

Conclusion:

There was promising evidence that the Healthy Start Home Visit Program was effective in addressing the needs of disadvantaged families with preschool children.

Keywords

child behavior child learning parenting Chinese home visit

According to the World Health Organization (WHO, 1948, p. 100), health is “a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity”. Programs on early child development should thus target healthy development in physical, cognitive, and psychosocial aspects.

Importance of Early Intervention

Many adolescent and adult health problems have their roots in the early years and this is why it is important to intervene during the early years (Webster-Stratton & Taylor, 2001). For example, in areas of physical health, the first 5 years of life is a period of rapid growth and change, and it is during this time that healthy lifestyles such as eating habits are established (Lytle, Seifert, Greenstein, & McGovern, 2000). Childhood obesity is associated with a higher risk of adult obesity (Singh, Mulder, Twisk, van Mechelen, & Chinapaw, 2008). Unintentional injury is among the leading causes of death for children aged 1–14 in Hong Kong, but it is also one of the most preventable childhood conditions (Department of Health, 1998). In terms of learning, children at risk of reading difficulties were found to become poor readers over time (Morgan, Farkas, & Hibel, 2008), and it is important that help is given to children before a sense of failure sets in (Nelson, Westhues, & MacLeod, 2003). Early intervention may help prevent or overcome other problems that might affect learning, such as conduct problems (Webster-Stratton & Taylor, 2001). For psychosocial health, it is also well known that adolescent mental health problems are associated with childhood conduct problems (Webster-Stratton & Taylor, 2001). Early intervention could also help to prevent a downward spiral among at-risk families (MacLeod & Nelson, 2000). There are many successful examples of early intervention programs overseas, such as Family–Nurse Partnership, High/Scope Perry Preschool Program, and Head Start, with positive outcomes on child physical, cognitive, and psychosocial development (Lee, Brooks-Gunn, Schnur, & Liaw, 1990; Olds, 1988, 1990; Schweinhart & Weikart, 1990). However, these programs were conducted in Western societies and there are few studies on early intervention programs in Chinese societies.

Importance of Family Involvement

According to the ecological theory (Bronfenbrenner, 1979), children’s development is shaped by the interaction of nature and nurture, including their biogenetic makeup, experiences, and relationships with the micro, mezzo, and macro systems, such as the family, the school, and the wider social environment. Therefore, development of early intervention programs should consider both family and social contexts, and be in step with children’s development. For preschool children, their parents play an important role in their development.

In line with the ecological framework, in physical health, parental involvement is essential for nutrition programs to be effective (Swadener, 1994). Similarly, many injury prevention programs for preschool children involve parents (Towner & Dowswell, 2002). For learning, shared book reading and language activities involving parents and children, parent aspirations and family learning resources are important influences on children’s learning (Brooks-Gunn & Markman, 2005; Erion, 2006; Marjoribanks, 1984). In terms of psychosocial health, evidence from parenting programs also indicates positive parent and child outcomes such as decrease in child behavior problems, as well as improvement in parent competence and parenting (e.g., Webster-Stratton & Taylor, 2001). All these studies point to the importance of parent involvement in programs to promote child development. However, there is little or no evidence on the effectiveness of parent involvement in promoting child development in physical, cognitive, and psychosocial areas in Chinese societies.

Families That Might Need Extra Support

Though the importance of parent influence on child development is well recognized, some groups of parents might need more support in their parenting, such as parents with low education level or new immigrants. For example, parents’ educational level was found to be positively associated with their nutrition knowledge (Räsänen et al., 2003), while high body mass index was associated with low socioeconomic status (O’Dea & Wilson, 2006). Many injury prevention programs were also targeted at disadvantaged families. It is also noted that children from new immigrant families experienced difficulties in school work (Education and Manpower Bureau, 2006), and their parents reported higher parenting stress and were more troubled by their children’s behavioral problems than nonimmigrant families (Leung, Leung, & Chan, 2007). These results suggest that particular groups of families may need more support in terms of early intervention programs to promote all aspects of child development.

Again, there is limited evidence on the effectiveness of early intervention programs for disadvantaged families in Chinese societies. One of the available studies is the Hands-On Parent Empowerment program in Hong Kong (Leung, Tsang, & Dean, 2011), which has demonstrated decrease in child behavior problems and parenting stress among the participants, but this study only focused on new immigrant mothers. It is not clear whether the program is effective with other disadvantaged families such as low-income families.

Home Visit Programs

Home visit is a strategy for service delivery (Sweet & Appelbaum, 2004) and is based on ecological theory (Nievar, Angela, van Egeren, & Pollard, 2010). A recent meta-analysis of home visit programs found that such programs were effective in improving maternal behavior in low-income or at-risk families (Nievar et al., 2010). Specifically, for cognitive and psychosocial areas, various home visit programs for parents of preschool children, such as Family–Nurse Partnership (Olds, 1988, 1990), New Parents as Teachers (Pfannenstiel, 1989), and Home Instruction for Parents of Preschool Youngsters (Bradley & Gilkey, 2002) have been found to be effective in promoting child learning, behavior, and development, as well as improving parent–child interaction. In terms of physical health areas, home visit programs have also been found to be effective in reducing childhood injuries and abuse and health encounters (Hong Kong Childhood Injury Prevention and Research Association, 2002; Roberts, Kramer, & Suissa, 1996; Towner & Dowswell, 2002). Home visit program has the advantages of convenience for parents with young children in terms of child care, transportation, and work arrangements. These are important elements to make services more accessible to disadvantaged families who might face difficulties in terms of cost of child care or transportation to attend center-based programs. For disadvantaged families with insecure jobs, they might be less willing to make alternative work arrangements to attend center-based programs during office hours for fear of jeopardizing their jobs. Home visits may also enhance whole family involvement. It can make services more individualized and enable rapport building. These qualities are essential in increasing program retention rates (Puckering, 2009; Sweet & Appelbaum, 2004).

In terms of program design, it was found that the more intensive (higher frequency and more number of visits) the home visit program, the greater the effect size (MacLeod & Nelson, 2000). Programs with three visits per month were more effective than programs with less frequent visits (Nievar, Angela, van Egeren, and Pollard, 2010). The findings on type of staff were inconsistent. In their recent meta-analysis, Nievar et al. (2010) found that paraprofessionals were as effective as professionals in producing positive outcomes. Sweet and Appelbaum (2004) found larger effect size for child cognitive outcomes among professionals than nonprofessionals, but paraprofessionals achieved higher effect sizes for potential child abuse cases.

The Healthy Start Home Visit Program

Despite exciting findings from the above studies, there is an absence of similar systematic and evidence-based programs for Chinese families. The Healthy Start Home Visit Program was an initiative to test the effectiveness of home visit programs in Hong Kong. The program aimed to enhance parents’ competence and confidence in promoting their children’s development in physical, cognitive, and psychosocial aspects. The home visits were delivered by paraprofessionals (parent assistants) who were parents in the local community who had successfully completed the relevant training provided by the project team.

The program was developed following the principles of effective program development outlined by Dusenbury (2000), Nation et al. (2003), Puckering (2009), and Small, Cooney, and O’Connor (2009). These principles include structured curriculum, comprehensive coverage, relationship enhancement strategies, potent dosage and duration, use of role-play during sessions, homework between sessions, and well-trained staff.

The current program consisted of a carefully designed curriculum including 20 sessions with structured lesson plans. In each visit, the parent assistants first explained the session content to the parents, with the aid of an illustration booklet. They then used role-play to coach the parents on the homework activities. The program was comprehensive and covered child physical, cognitive, and psychosocial development. Strategies for enhancement of parent–child relationship, increasing desirable behavior, management of difficult behavior, learning of preschool concepts, oral health, nutrition, home safety, and physical exercises were also included. For dosage and duration, each participating parent enjoyed 20 weekly home visits, each lasting about 1–2 hour and delivered by a pair of parent assistants. Role-play was used during sessions to enable the parent participants to master the micro parenting skills. The parent participants in the program had to complete homework activities 5 days a week with their children, so as to put the parenting skills into practice. The details of the program are shown in Table 1.

Table 1.

Healthy Start Home Visit Program.

Psychosocial		Learning		Physical
L1	Building parent–child relationship: Talking with children (1)	L4	Reading: Building up reading habits	L6	Oral health
L2	Building parent–child relationship: Talking with children (2)	L5	Reading: Paired reading skills	L7	Home safety
L3	Praise skills	L8	Reading: Asking open questions and question skills	L15	Healthy diet and meal time routines
L10	Children’s behaviors	L9	Learning through play	L16	Physical exercises
L11	Management: Ignoring and family rules	L13	Preschool concepts: Quantity and numbers
L12	Management: Effective commands	L14	Preschool concepts: Shapes and matching
L18	Management: Quiet area and time out	L17	Preschool concepts: Comparing and categories
L19	Management: Dealing with problem situations
L20	Conclusion

The program was developed by the project team, which consisted of psychologists and social workers, with input from health professionals such as medical practitioners, dentists, nutritionists, physiotherapists, and dental therapists. A package (including a manual for parent assistants with detailed instructions and notes for each home visit session, an illustration booklet to be used in home visit sessions, and notes and homework sheets for parents) was produced by the project team in light of parent assistants’ feedback.

The program was delivered by parent assistants under the supervision of the project coordinator, a registered social worker with over 5 years of parent education experience. The parent assistants attended 25 two hour training sessions on the topics to be covered in the home visit sessions. The training was conducted by the project team, together with guest speakers including pediatricians, nurses, dental therapists, physiotherapists, and nutritionists. To evaluate the effectiveness of training of the parent assistants and to ensure their adequacies in delivering the program content to the parent participants, the parent assistants had to pass a written examination on knowledge and a live skill demonstration of home visit skills before they started the home visits. The details of the training program are in Table 2. During the home visit stage, the project coordinator conducted monthly group meetings with the parent assistants to provide supervision and support.

Table 2.

Parent Assistants’ Training Program.

Lesson	Topic	Trainer
L1	Building parent–child relationship: Talking with children (1)	Project team
L2	Building parent–child relationship: Talking with children (2)	Project team
Advanced level	Home visit skills training	Psychologist
L3	Praise skills	Project team
L4	Reading: Building up reading habit	Project team
L5	Reading: Paired reading skills	Project team
Advanced level	Oral health	Dental therapist
L6	Oral health	Project team
Advanced level	Home safety	Pediatrician and Nurse
L7	Home safety	Project team
L8	Reading: Asking open questions and question skills	Project team
L9	Learning through play	Project team
L10	Children’s behaviors	Project team
L11	Management: Ignoring and family rules	Project team
L12	Management: Effective commands	Project team
L13	Preschool concepts: Quantity and numbers	Project team
L14	Preschool concepts: Shapes and matching	Project team
Advanced level	Healthy diet and meal time routines	Nutritionist
L15	Healthy diet and meal time routines	Project team
Advanced level	Physical exercises	Physiotherapist
L16	Physical exercises	Project team
L17	Preschool concepts: Comparing and categories	Project team
L18	Management: Quiet area and time out	Project team
L19	Management: Dealing with problem situations	Project team
L20	Conclusion	Project team

The Present Study

The present study aimed to examine the effectiveness of the pilot trial of the Healthy Start Home Visit Program for disadvantaged parents in Hong Kong. Findings on the training outcomes of parent assistants and the child and parent outcomes of families receiving home visits would be reported.

Method

Home Visit Program Recipients

Participants

The target participants were parents of preschool children from socially disadvantaged backgrounds. They included new immigrants, single parents, and low-income families (those in the government’s half/full textbook assistance scheme or those on social welfare benefits) in Tuen Mun, an outlying residential area in Hong Kong. The participants in the present pilot study included 21 mothers with children aged 2.5–5.5 years old, all of whom were attending preschools at the time of the study. There were 15 new immigrant mothers (in Hong Kong less than 7 years) in the sample. All but one family had monthly household income below HK$20,000^1,2 and two families were on social welfare benefits. The mother of the family whose income was above HK$20,000 was a new immigrant. The details are in Table 3.

Table 3.

Demographic Characteristics of Home Visit Program Participants (N = 21).

	Number	Percentage
Sex of target child—male	11	52.4
Sex of target child—female	10	47.6
Target child born in Hong Kong	17	81.0
Relationship of participant to target child—mother	21	100
Mother’s education—junior secondary or below	12	57.1
Father’s education—junior secondary or below	10	47.6
Father’s employment—employed	18	85.7
Mother’s employment—employed	0	0
Mother as new immigrant	16	76.2
Father as new immigrant	1	4.8
Family status—nuclear	17	81.0
Family status—extended	2	9.5
Family status—reconstituted	2	9.5
Marital status—married	20	95.2
Marital status—separated	1	4.8
Monthly household income—below HK$20,000	19	90.5
On social welfare benefits	2	9.50
	M	SD	Minimum to maximum
Age of target child (in years)	3.91	0.80	2.5–5.5
Age of mother (in years)	33.76	4.02	27.0–42.0
Age of father (in years)	40.15	8.14	29.0–60.0
Length of residence in Hong Kong of target child (in years)	3.23	1.36	0.6–5.5
Length of residence in Hong Kong of mother (in years)	8.63	12.68	0.66–39.0
Length of residence in Hong Kong of father (in years)	37.09	12.26	0.66–60.0
Number of children at home	1.86	0.91	1–4

Measures

Triangulation of data was adopted to optimize the information collected from this study for future program refinement. Data source included parent report, teacher report, and direct assessment of children. The measures used were designed to measure the achievement of outcomes in child physical, learning, and psychosocial areas.

Measures of Children’s Outcomes

To measure outcome achievement in the psychosocial area, a measure of child behavior problems was used. Measure of child behavior problems is a very frequently used child outcome measure in the evaluation of parent training programs (e.g., Piquero, Farrington, Welsh, Tremblay, & Jennings, 2008). For learning outcomes on learning motivation and preschool concepts, measures on the learning of preschool concepts, academic competent behavior, learning motivation, and school readiness were included. For physical development, a series of questions on physical exercise, oral health practices, nutrition, and home injury prevention were included. The child outcome measures included:

Eyberg Child Behaviour Inventory (ECBI; Eyberg & Ross, 1978)—this is a 36-item multidimensional measure of parental perception of disruptive behavior in children, to be completed by the parent. It consists of two scales. The intensity scale is a measure of the frequency of problem behavior, which parents rate on a 7-point scale. The problem scale is a measure of the extent to which parents are troubled by the problem behaviors, with responses 1 = yes and 0 = no. The Chinese version of the inventory has been validated by Leung, Chan, Pang, and Cheng (2003).

Academic competence (Leung, Lo, & Leung, 2012)—this is based on the Behavior Rating scale for Presented Academic Self-Esteem in Young Children (Fuchs-Beauchamp, 1996). It consists of 15 questions on sense of competence, persistence, initiative, and coping, and it has a parent version and a teacher version. Teachers and parents rate their students/children on each statement on a 4-point scale (1 = never, 2 = seldom, 3 = sometimes, and 4 = always). It correlates with child cognitive development and child behavior, and it differentiates children with developmental disabilities from children with typical development (Leung et al., 2012).

Effort and task motivation (Leung & Lo, 2013)—this is based on the Inventory of School Motivation (McInerney & Ali, 2006). The Effort subscale measures effort attribution and effort-focused motivation. The Task subscale measures task orientation and involvement. Teachers and parents rate their students/children on each statement on a 4-point scale (1 = never, 2 = seldom, 3 = sometimes, and 4 = always). It correlates with child cognitive development and child behavior, and it differentiates children with developmental disabilities from children with typical development (Leung & Lo, 2013).

School readiness (Gumpel, 1999)—this is based on the Gumpel School Readiness scale. It consists of 6 items. Teachers and parents rate their students/children on each statement on a 4-point scale (1 = never, 2 = seldom, 3 = sometimes, and 4 = always). A Chinese version was developed and validated. It correlates with child cognitive development and child behavior, and it differentiates children with developmental disabilities from children with typical development, as well as children of different age groups (Ho, 2011).

The cognitive domain of the Preschool Developmental Assessment scale (PDAS; Leung, Mak, Lau, Cheung, & Lam, 2010)—this scale is developed for Hong Kong children aged 3–6 years and covers preschool concepts such as color, shape, categorization, and verbal comprehension. It consists of 40 items and is individually administered to children. It can differentiate children with developmental disabilities from children with typical development, as well as children of different age groups (Leung et al., 2010).

Health status—this consists of children’s height and weight compared with weight-for-height standards as supplied by Department of Health (Department of Health, 2012), number of physical activities and sedentary activities, and number of injuries (home accidents and hospital visits).

Oral health—this is based on a questionnaire developed by the Oral Health Education Unit of the Department of Health, Hong Kong SAR Government. There are three questions on teeth brushing, and parents rate each item on a 5-point scale. A higher score indicates more frequent teeth brushing.

Measures of Parents’ Outcomes

It was expected that with the acquisition of effective parenting skills, there would be a decrease in parenting stress and increase in general self-efficacy among the parent participants. These are frequently used maternal outcomes in evaluation of parent training programs (Barlow, Coren, & Stewart Brown, 2005). It was also expected that the support of the parent assistants would enhance the social support network of the parent participants, which is another commonly used maternal outcome measures in parent training programs (Barlow et al., 2005). The parent outcome measures included:

The Parenting Stress Index (PSI; Lam, 1999)—this is a 36-item questionnaire on parental stress. The Chinese version of the scale has been validated by Lam (1999).

The General Self-Efficacy scale (Schwarzer, 1993)—this scale consists of 10 items measured on a 4-point Likert-type scale ranging from not at all true (1) to exactly true (4) and is used as a measure of parent confidence. A validated Chinese version is available (Zhang & Schwarzer, 1995).

The Duke-UNC Functional Social Support Questionnaire (Broadhead, Gehlbach, de Gruy, & Kaplan, 1988)—this is an 8-item questionnaire on perceived social support in various areas, and it is used as a measure of parent support network. The Chinese version of the questionnaire has been used among Hong Kong new immigrant parents with preschool children with satisfactory reliability (.79 and above; Leung et al., 2011).

Demographic information—parents are also requested to supply basic demographic information such as age, length of residence in Hong Kong, education level, occupation, income, social welfare status, family type, and marital status.

Procedures

The participants were recruited by a Tuen Mun social service center through the center’s brochure, leaflets specially designed for the Healthy Start Program, and promotion of the program by the coordinator in other social service centers. Upon securing their consent to participate, participants completed the preintervention measures. Upon completion of the home visit program, participants completed the postintervention measures. The teachers of the participants’ children were also requested to complete preintervention and postintervention measures on children’s motivation, school readiness, and academic competence. The children were assessed individually by trained research assistants on their cognitive development before and after their parents’ participation in the home visit program. This study was approved by the ethics committee of The Hong Kong Polytechnic University.

The Parent Assistants

Participants

There were 11 parent assistants, all of them mothers not in the workforce. Four of them were new immigrants (in Hong Kong less than 7 years). None of these families were on social welfare benefits, and the majority had completed senior secondary education or above. The demographic details are in Table 4.

Table 4.

Demographic Characteristics of Parent Assistants (N = 11).

	Number	Percentage
Education of parent assistant—senior secondary or above	9	81.8
Spouse’s education—senior secondary or above	9	81.8
Employment status of parent assistant—employed	0	0
Spouse’s employment status—employed	11	100
Parent assistant as new immigrant (less than 7 years)	4	36.4
Spouse as new immigrant (less than 7 years)	0	0
Family status—nuclear	9	81.8
Family status—extended	2	18.2
Marital status—married	11	100
Monthly household income—below HK$20,000	6	54.5
On social welfare benefits	0	0
	M	SD	Minimum to maximum
Age of parent assistant (in years)	36.27	4.20	29–43
Age of spouse (in years)	43.36	5.46	33–52
Length of residence in Hong Kong of parent assistant (in years)	20.27	17.50	3–43
Length of residence in Hong Kong of spouse (in years)	41.27	6.80	28–52
Number of children at home	1.73	0.79	1–3

Measures

Parent assistants were requested to complete the ECBI (Eyberg & Ross, 1978), PSI (Lam, 1999), and General Self-Efficacy scale (Schwarzer, 1993) before and after training, and also after completion of home visits. The details of these measures are described above in the measures section on the home visit program recipients.

Upon completion of the training program, parent assistants were required to sit for a written multiple-choice test on child development and on topics covered in the home visit sessions. They were also required to participate in a live skills demonstration, pairing up with another parent assistant and demonstrating two home visit sessions (talking with children and another one of their own choice) using role-play.

Procedures

The parent assistants were recruited by a Tuen Mun social service center through the center’s brochure, leaflets specially designed for the Healthy Start Program, and promotion of the program by the coordinator in other social service centers. Parent assistants completed the questionnaires before (pretraining) and after the training course (posttraining). They also sat for a written test and participated in a live skills demonstration at the end of the training course. Upon completion of the home visit program, they completed the above-mentioned measures (posthome visit) again.

Results

Home Visit Program Recipients

Of the 21 participants, 19 participants completed the program. Two participants dropped out from the program due to family issues (returning to mainland China to look after sick family members) and employment. All participants (N = 21) completed preintervention and postintervention measures.

The reliability estimates (Cronbach’s α) of the scales were above .70, except for postintervention parent measures of school readiness (.66) and preintervention teacher measures of school readiness (.63). Paired samples t-tests were used to compare the preintervention and postintervention scores of participants on various measures. The details are in Table 5.

Table 5.

Preintervention and Postintervention Measures and Reliability Estimates (Cronbach’s α) for Home Visit Program Participants (N = 21).

	Preintervention	α	Postintervention	α	Significance
Cognitive domain of PDAS	15.38 (8.08)	.91	22.19 (8.69)	.92	t(20) = 7.15, p < .001
ECBI intensity	113.14 (18.50)	.85	87.52 (20.61)	.93	t(20) = 4.66, p < .001
ECBI problem	15.24 (8.96)	.92	4.33 (5.28)	.89	t(20) = 6.03, p < .001
Parent-reported school readiness	12.48 (3.08)	.76	14.43 (2.11)	.66	t(20) = 2.94, p = .008
Parent-reported academic competence	32.19 (6.89)	.89	34.90 (5.10)	.82	t(20) = 1.46, p = .160
Parent-reported task motivation	9.33 (2.44)	.86	10.14 (1.80)	.82	t(20) = 1.30, p = .209
Parent-reported effort motivation	15.67 (3.41)	.87	16.67 (3.60)	.88	t(20) = 0.88, p = .389
Oral health practice (brushing teeth)	8.10 (3.43)	79	10.00 (2.72)	.88	t(20) = 3.66, p = .002
Sedentary activities	23.14 (5.72)	na	20.29 (5.43)	na	t(20) = 2.42, p = .025
Outdoor activities—weekday	3.00 (0.95)	na	2.33 (1.39)	na	t(20) = 1.78, p = .090
Outdoor activities—weekend	3.43 (0.98)	na	3.14 (1.35)	na	t(20) = 0.86, p = .400
Home accidental injuries	1.29 (0.46)	na	1.00 (0.00)	na	t(20) = 2.83, p = .010
Visits to hospital	0.29 (0.46)	na	0.00 (0.00)	na	t(20) = 2.83, p = .010
Body mass index	15.27 (1.54)	na	15.37 (1.10)	na	t(20) = 0.43, p = .674
Teacher-reported school readiness	13.05 (2.80)	.63	13.33 (3.12)	.79	t(20) = 0.63, p = .536
Teacher-reported academic competence	30.95 (9.04)	.93	32.00 (7.04)	.79	t(20) = 0.91, p = .372
Teacher-reported task motivation	9.14 (3.12)	.91	9.71 (2.76)	.89	t(20) = 1.15, p = .262
Teacher-reported effort motivation	16.14 (3.64)	.90	16.67 (3.04)	.85	t(20) = 0.72, p = .479
PSI total scores	106.33 (11.42)	.79	89.00 (18.07)	.94	t(20) = 4.81, p < .001
Social support	24.48 (7.17)	.94	29.48 (5.33)	.89	t(20) = 2.93, p = .008
Self-efficacy	24.29 (3.61)	.72	25.76 (5.87)	.91	t(20) = 1.07, p = .299

Note. ECBI = Eyberg Child Behavior Inventory; PDAS = Preschool Developmental Assessment scale; PSI = Parenting Stress Index.

For parent measures, paired samples t-test results indicated significant improvements in parenting stress (PSI total scores; d = 1.10) and social support (d = 0.79), but there was no significant difference in self-efficacy. Participants reported a decrease in parenting stress and an increase in perceived social support postintervention.

For children’s measures, paired samples t-test results indicated significant changes in ECBI-intensity (d = 1.31), ECBI-problem (d = 1.42), parent-reported school readiness, (d = 0.73), cognitive domain of the PDAS (d = 0.80), sedentary activities (d = 0.51), number of accidental injuries at home, number of hospital visits,³ and oral health practice (brushing teeth; d = 0.59). Parents reported lower child behavior problems, fewer accidental injuries and hospital visits, fewer sedentary activities and higher scores on school readiness, and more frequent teeth brushing at postintervention. Children at postintervention also scored higher on PDAS cognitive domain. However, there were no significant differences in parent measures of academic competence and task/effort motivation. McNemar test indicated no significant change in children’s weight status.

For teacher evaluation of children’s learning, paired samples t-test results indicated no significant changes in school readiness, academic competence, or task/effort motivation. The details are in Table 5.

The Parent Assistants

The average mark for the multiple-choice test on knowledge was 42.5 out of a total score of 45 (range: 41–45). The passing rate for the live skills demonstration was 100%.

The reliability estimates (Cronbach’s α) of the scales were above .70, except for pretraining and posttraining PSI. Repeated measures analysis of variance (ANOVA) was used to compare the pretraining, posttraining, and posthome visit scores of participants on various measures. The details are in Table 6.

Table 6.

Pretraining, Posttraining, and Posthome Visit Scores and Reliability Estimates (Cronbach’s α) for Parent Assistants (N = 11).

	Pretraining	α	Posttraining	α	Posthome visit	α
ECBI intensity	118.09 (21.38)	.89	100.00 (17.94)^a	.90	81.36 (22.20)^a,b	.96
ECBI problem	7.09 (8.37)	.94	2.36 (6.25)^a	.97	2.00 (3.32)	.86
PSI total scores	96.00 (2.58)	.68	90.82 (1.91)	.60	82.00 (4.69)^a	.92
Self-efficacy	25.18 (2.89)	.73	24.00 (2.83)	.72	26.73 (4.67)	.89

Note. ECBI = Eyberg Child Behavior Inventory; PSI = Parenting Stress Index.

^aSignificantly different from pretraining.

^bSignificantly different from posttraining.

For ECBI intensity, repeated measures ANOVA results indicated significant overall change, F(2, 20) = 26.42, p < .001, partial η² = .73. Participants reported a decrease in ECBI intensity from pretraining to posttraining, and from posttraining to posthome visit. For ECBI problem, repeated measures ANOVA results indicated significant overall change, F(2, 20) = 6.40, p = .007, partial η² = .39. Participants reported an overall decrease in ECBI problem. Posttraining scores were significantly different from pretraining scores, but there was no significant difference between posttraining and posthome visit scores, or between pretraining and posthome visit scores.

For parenting stress, repeated measures ANOVA results indicated significant change in PSI total scores over time, F(2, 20) = 7.52, p = .004, partial η² = .43. Participants reported an overall decrease in PSI total scores. Posthome visit scores were significantly different from pretraining scores, but there was no significant difference between pretraining and posttraining scores, or between posttraining and posthome visit scores.

With regard to self-efficacy, repeated measures ANOVA results were not significant, F(2, 20) = 2.07, p = .152, partial η² = .17. There was no significant difference in self-efficacy across the three time points.

Discussion

The results provided encouraging support for the Healthy Start Home Visit Program. In terms of parent outcomes, parent participants reported lower parenting stress and increased social support after program participation. For children’s outcomes, in the psychosocial area, the results indicated a decrease in parent-reported child behavior problems. For learning, the results indicated an increase in parent-reported school readiness. Individual assessment of children also indicated an increase in cognitive scores. For physical health, the results indicated a decrease in parent-reported home injuries and sedentary activities, and an increase in frequency of teeth brushing. Changes were observed in psychosocial, learning, and physical health areas. The results are consistent with the literature on the effectiveness of home visit programs in both improving parent–child outcomes and in reducing home injuries (e.g., Bradley & Gilkey, 2002; Olds, 1988, 1990; Towner & Dowswell, 2002).

In the present study, the attrition rate was 9.5% (2/21), which was comparatively lower than the 19.5% reported in other center-based parent training programs (e.g., Nowak & Heinrichs, 2008). This provides some evidence on home visit as an effective strategy in improving program retention rates. The program results also indicated changes in child learning, parenting stress, and home injury, which were difficulties found among disadvantaged families (e.g., Education and Manpower Bureau, 2006; Leung et al., 2007; O’Dea & Wilson, 2006). This suggests that the program could address the needs of disadvantaged families.

On the other hand, there were no significant changes in teachers’ reports of children’s learning. One possible explanation was that children might behave differently in different contexts. At home, children might have responded positively to their parents’ strategies in supporting their learning in a one-to-one situation, but these behaviors might not generalize to the school setting. In home visit programs, the operating principle is that parents are trained to interact positively with their children, and parents mediate changes for their children (Sweet & Appelbaum, 2004). Given that there was no direct input into the school system, the effect on child changes in the school context needs further investigation, like measuring changes in psychosocial behavior in addition to learning outcomes.

The results for the parent assistants were also encouraging. Not only did they achieve good passes in terms of knowledge and skills mastery, they also reported decreases in child behavior problems and parenting stress. These changes were also significant for pretraining and posthome visit comparisons. The results suggested that it was not only the training program but also the actual experience of applying the knowledge and skills learnt in supporting other parents, which contributed to the reinforced improvements in their own parenting.

In line with the guidelines on effective parent training programs (Dusenbury, 2000; Nation et al., 2003; Puckering, 2009; Small, Cooney, & O’Connor, 2009) emphasizing structured content, trained facilitators, relationship enhancement strategies, potent dosage and duration, role-play, and homework, the project team emphasized structured input in the home visit sessions and tailored equipment and empowerment of the parent assistants. A very detailed manual with teaching aids, role-play activities, and home work sheets was produced, and there was significant input from health professionals, psychologists, and social workers, both in terms of development of the home visit program content and the training of the parent assistants. Ongoing support for the parent assistants, as individuals and as a team, was provided by the project coordinator. The results provided encouraging evidence that the program benefited not only the parents receiving home visits but also the parent assistants delivering the program.

Limitations

First, the current study, as a pilot study, involved only premeasures and postmeasures; and the changes could be due to practice effect, regression to the mean or maturation. Research using a more rigorous design, such as randomized controlled trial design, is needed to provide support for the efficacy of the Healthy Start Home Visit Program. However, the present results provided encouraging support for further evaluation of the program with rigorous designs. Second, some participants’ children’s ages were outside (younger) the age range designed for the cognitive domain of the PDAS. The results, however, were still significant with the younger children excluded. Third, the participants included only a small group of self-selected parents in one suburb of Hong Kong. The effectiveness of the Healthy Start Program among parents in other areas, or among parents with different socioeconomic backgrounds, needs to be further investigated. Fourth, the present pilot study did not involve preschools in which the target children were studying, except completion of preintervention and postintervention questionnaires. Involvement of the preschools might promote home–school cooperation and facilitate the generalization of program effects to the school setting. Fifth, only quantitative data were collected. Qualitative data would provide more insight into the process. Finally, only mothers were involved in the enhancement of parenting. The role and impact of fathers and other significant caregivers should also be identified.

Discussion and Applications to Social Work

The initial evidence of success in a structured parenting program with professional input has positive implications for social work practice. The program is locally developed, theory-driven, and clearly documented in a culturally friendly manner. It is a handy resource, as social service providers will be able to replicate the program to serve families with similar backgrounds. The systematic and structured nature of the program also enables motivated but less experienced service providers to focus on improving their micro skills in working with the parent assistants as a team or as individuals whenever needed. Such focused learning promises better skills mastery and can empower beginning workers to assume the competence to become expert parent-intervention professionals. The fact that the parent assistants reported less parenting stress and fewer perceived child behavior problems after providing home visit services showed both their smooth transition from the role of service consumers to that of service providers and their clear acceptance of structured programs with systematic input and demands on their performance. This new and positive horizon in their identity is very important in the building of critical masses of positive social capital to enhance social cohesion to benefit community development. For instance, Hudson, Phillips, Ray, and Barnes (2007) claimed that social cohesion should not only help to erode disparities, inequalities, and social exclusion. It should also encourage positive relationships between different groups in a community to nurture the social infrastructure of neighborhoods, social relations, interactions, and ties to achieve positive social changes. These theorists tend to treat social cohesion as an end, and indices were devised to assess social cohesiveness and to quantify social capital (Tsang & Chu, 2010).

The initial evidence also highlights the importance of structured input, as advocated by Dusenbury (2000), Nation et al. (2003), Puckering (2009), and Small et al. (2009). There was a structured session plan for each home visit session, and the content was aligned with the objectives and the intended outcome of the program. There was intense training as well as close monitoring and support for the parent assistants delivering the home visits. The structured program, the intense training, and the monitoring served to ensure that the intended program content and the activities were delivered at the planned dosage and intensity. These measures also served to facilitate parent assistants’ smooth and effective delivery of the program. This successful experience empowered the parent assistants and advanced their roles from service recipients to effective change agents. This also reduced the professional costs of the program and greatly enhanced the chances of replicating and sustaining the program in other communities.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is supported by The Quality Education Fund, Education Bureau, Hong Kong SAR Government.

Notes

References

Barlow

Coren

Stewart-Brown

(2005). Parent-training programmes for improving maternal psychosocial health. Campbell Systematic Reviews, 9, 3. doi:10.4073/csr.2005.3

Bradley

R. H.

Gilkey

(2002). The impact of the home instructional program for preschool youngsters (HIPPY) on school performance in 3rd and 6th grades. Early Education & Development, 13, 302–311.

Broadhead

W. E.

Gehlbach

S. H.

de Gruy

F. V.

Kaplan

B. H.

(1988). The Duke-UNC functional social support questionnaire: Measurement of social support in family medicine patients. Medical Care, 26, 709–723.

Bronfenbrenner

(1979). The ecology of human development. Cambridge, MA: Harvard University Press.

Brooks-Gunn

Markman

L. B.

(2005). The contribution of parenting to ethnic and racial gaps in school readiness. The Future of Children, 15, 139–168.

Census and Statistics Department. (2012). Monthly domestic household income/rent/mortgage payment and loan repayment, median rent to income ratio and mortgage payment and loan repayment to income ratio by district council district, 2011 (E201). Hong Kong, People’s Republic of China: Author. Retrieved from http://www.census2011.gov.hk/en/main-table/E201.html

Department of Health. (1998). Public health report no.3: Viral hepatitis & liver cancer and unintentional injuries in children. Hong Kong SAR, People’s Republic of China: Author.

Department of Health. (2012). Growth and nutrition. Retrieved from http://www.fhs.gov.hk/english/health_info/class_life/child/child_tsy_nutrition.html

Dusenbury

(2000). Family-based drug abuse prevention programs: A review. The Journal of Primary Prevention, 20, 337–353.

10.

Education and Manpower Bureau. (2006). Education and support service for newly-arrived children. Retrieved from http://www.emb.gov.hk/index.aspx?nodeID=236&langno=1

11.

Erion

(2006). Parent tutoring: A meta-analysis. Education and Treatment of Children, 29, 79–106.

12.

Eyberg

S. M.

Ross

A. W.

(1978). Assessment of child behaviour problems: The validation of a new inventory. Journal of Clinical Psychology, 16, 113–116.

13.

Fuchs-Beauchamp

(1996). Preschoolers’ inferred self-esteem: The behaviour rating scale of presented self-esteem in young children. The Journal of Genetic Psychology, 157, 204–210.

14.

Gumpel

(1999). Use of item-response theory to develop a measure of first-grade readiness. Psychology in the Schools, 36, 285–293.

15.

(2011). Validation of the Gumpel readiness inventory for preschool children in Hong Kong (Unpublished Master of Educational and Child Psychology thesis). The Hong Kong Polytechnic University, Hong Kong.

16.

Hong Kong Childhood Injury Prevention and Research Association. (2002). Promoting a safer household environment: A volunteer-based home visit program. Hong Kong Childhood Injury Prevention and Research Association. Retrieved from http://www.childinjury.org.hk/home_frame.html

17.

Hudson

Phillips

Ray

Barnes

(2007). Social cohesion in diverse communities. York, England: Joseph Rowntree Foundation.

18.

Lam

(1999). Parenting stress and anger: The Hong Kong experience. Child and Family Social Work, 4, 337–346.

19.

Lee

Brooks-Gunn

Schnur

Liaw

F. R.

(1990). Are head start effects sustained? A longitudinal follow-up comparison of disadvantaged children attending Headstart, No preschool and other preschool programmes. Child Development, 61, 495–507.

20.

Leung

S. K.

(2013). Validation of a questionnaire to measure mastery motivation among Chinese preschool children. Research in Developmental Disabilities, 34, 234–245.

21.

Leung

S. K.

Leung

S. S. L.

(2012). Validation of a questionnaire on academic competence behaviour among Chinese preschool children. Research in Developmental Disabilities, 33, 1581–1593.

22.

Leung

Mak

Lau

Cheung

Lam

(2010). Development of a preschool development of a preschool developmental assessment scale for assessment of developmental disabilities. Research in Developmental Disabilities, 31, 1358–1365.

23.

Leung

Tsang

Dean

(2011). Outcome evaluation of the hands-on parent empowerment (HOPE) program. Research on Social Work Practice, 21, 549–561.

24.

Leung

C. M.

Chan

S. C. M.

Pang

R. C. Y.

Cheng

W. K. C.

(2003). Validation of the Chinese version of the Eyberg child behaviour inventory for use in Hong Kong. Wanchai, Hong Kong: Education and Manpower Bureau.

25.

Leung

S. S. L.

Leung

Chan

(2007). Perceived child behaviour problems, parenting stress and marital satisfaction: A comparison between new arrival and local parents of preschool children in Hong Kong. Hong Kong Medical Journal, 13, 364–371.

26.

Lytle

L. A.

Seifert

Greenstein

McGovern

(2000). How do children’s eating patterns and food choices change over time? Results from a cohort study. American Journal of Health Promotion, 14, 222–228.

27.

MacLeod

Nelson

(2000). Programs for the promotion of family wellness and the prevention of child maltreatment: A meta-analytic review. Child Abuse & Neglect, 24, 1127–1149.

28.

Marjoribanks

(1984). Ethnicity, family environment and adolescents’ aspirations: A follow up study. Journal of Educational Research, 77, 166–171.

29.

McInerney

D. M.

Ali

(2006). Multidimensional and hierarchical assessment of school motivation: Cross-cultural validation. Educational Psychology, 26, 717–734.

30.

Morgan

P. L.

Farkas

Hibel

(2008). Matthew effects for whom? Learning Disability Quarterly, 31, 187–198.

31.

Nation

Crusto

Wandersman

Kumpfer

K. L.

Seybolt

Morrissey-Kane

Davino

(2003). What works in prevention: Principles of effective prevention programs. American Psychologist. Special Issue: Prevention that Works for Children and Youth, 58, 449–456.

32.

Nelson

Westhues

MacLeod

(2003). A meta-analysis of longitudinal research on preschool prevention programs for children. Prevention & Treatment, 6, article 31.

33.

Nievar

Angela

N. M.

van Egeren

L. A.

Pollard

(2010). A meta-analysis of home visiting programs: Moderators of improvements in maternal behavior. Infant Mental Health Journal, 31, 499–520.

34.

Nowak

Heinrichs

(2008). A comprehensive meta-analysis of triple P-positive parenting program using hierarchical linear modeling: Effectiveness and moderating variables. Clinical Child and Family Psychology Review, 11, 114–144.

35.

O’Dea

J. A.

Wilson

(2006). Socio-cognitive and nutritional factors associated with body mass index in children and adolescents: Possibilities for childhood obesity prevention. Health Education Research, 21, 796–805.

36.

Olds

D. L.

(1988). The prenatal/early infancy project. In Price

R. H.

Cowen

E. L.

Lorion

R. P.

Ramos-McKay

(Eds.), 14 ounces of prevention: A casebook for practitioners (pp. 9–23). Washington, DC: American Psychological Association.

37.

Olds

D. L.

(1990). The prenatal/early infancy project: A strategy for responding to the needs of high-risk mothers and their children. In Lorion

R. P.

(Ed), Protecting the children: Strategies for optimizing emotional and behavioral development (pp. 59–87). New York, NY: The Haworth Press.

38.

Pfannenstiel

J. C.

(1989). New parents as teachers: Evaluation of an early parent education program. Early Childhood Research Quarterly, 4, 1–18.

39.

Piquero

A. R.

Farrington

D. P.

Welsh

B. C.

Tremblay

Jennings

W. G.

(2008). Effects of early parent/family training programs on antisocial behaviour and delinquency. Campbell Systematic Reviews, 4, 11. doi:10.4073/csr.2008.11

40.

Puckering

(2009). NICE guidelines on parenting programmes for children with conduct disorder. Child and Adolescent Mental Health, 14, 58–61.

41.

Räsänen

Niinikoski

Keskinen

Helenius

Talvia

Rönnemaa

… Simell

(2003). Parental nutrition knowledge and nutrient intake in an atherosclerosis prevention project: The impact of child-targeted nutrition counselling. Appetite, 41, 69–77.

42.

Roberts

Kramer

M. S.

Suissa

(1996). Does home visiting prevent childhood injury? A systematic review of randomized controlled trials. British Medical Journal, 312, 29–33.

43.

Schwarzer

(1993). Measurement of perceived self-efficacy: Psychometric scales for cross-cultural research. Berlin, Germany: Zentrale Universitats Druckerei der FU Berlin.

44.

Schweinhart

L. J.

Weikart

D. B.

(1990). The high/scope Perry preschool study: Implications for early childhood care and education. In Lorion

R. P.

(Ed.), Protecting the children: Strategies for optimizing emotional and behavioral development (pp. 109–132). New York, NY: The Haworth Press.

45.

Singh

A. S.

Mulder

Twisk

J. W. R

van Mechelen

Chinapaw

M. J. M.

(2008). Tracking of childhood overweight into adulthood: A systematic review of the literature. Obesity Reviews, 9, 474–488.

46.

Small

S. A.

Cooney

S. M.

O’Connor

(2009). Evidence-informed program improvement: Using principles of effectiveness to enhance the quality and impact of family-based prevention programs. Family Relations, 58, 1–13.

47.

Swadener

S. S.

(1994). Nutrition education for preschool age children: A review of research. U.S. Department of Agriculture. Retrieved from http://www.nal.usda.gov/fnic/usda/preschoolne.html

48.

Sweet

M. A.

Applebaum

M. I.

(2004). Is home visiting an effective strategy? A meta-analytic review of home visiting programs for families with young children. Child Development, 75, 1435–1456.

49.

Towner

Dowswell

(2002). Community-based childhood injury prevention interventions: What works? Health Promotion International, 17, 273–284.

50.

Tsang

S. K. M.

Chu

Y. K.

(2010). Social cohesive efforts to meet youth development needs in Tin Shui Wai in Hong Kong. In Mok

K. H.

(Ed.), Social cohesion in greater China: Challenges for social policy and government (pp. 43–68). London, England: Imperial College Press and World Scientific Publishing.

51.

Webster-Stratton

Taylor

(2001). Nipping early risk factors in the bud: Preventing substance abuse, delinquency, and violence in adolescence through interventions targeted at young children. Prevention Science, 2, 165–192.

52.

World Health Organization. (1948). Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, NY, June 19–22, 1946; signed on July 22, 1946 by the representatives of 61 states (official records of the World Health Organization, no. 2, p. 100) and entered into force on April 7, 1948.

53.

Zhang

J. X.

Schwarzer

(1995). Measuring optimistic self-beliefs: A Chinese adaptation of the general self-efficacy scale. Psychologia, 38, 174–181.