Key findings from The Impact of the Family Start Home Visiting Programme on Outcomes for Mothers and Children: A Quasi-Experimental Study

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About Family Start

Family Start is one of the Government’s principal early intervention services aimed at helping support vulnerable families to achieve better outcomes. It was developed in the late 1990s, informed by the pilot of the Early Start programme which operates in Christchurch, and has been enhanced and expanded since that time.

Family Start is currently available in close to half of district and city council areas around New Zealand, and is delivered by contracted local providers with the aim of ensuring services are provided in a manner that is responsive to each community.

Children are generally enrolled either before birth or in their first year, and can remain in the programme until the family “graduates” or the child reaches school age. Family Start workers make regular home visits and, using a structured program, seek to improve parenting capability and practice.

Workers also actively work to promote breastfeeding, reduce home hazards, connect infants to immunisation and primary health services, promote children’s participation in early childhood education, and connect families to services that might help address any challenges they face.

The Study

There have been a number of studies and reviews of Family Start. These have tended to find that families value the programme. But in contrast to Early Start which has been evaluated in a randomised controlled trial, no study of Family Start to date has been able to establish the effectiveness of the programme in improving outcomes.

The Ministry of Social Development commissioned a quasi-experimental impact study of Family Start with the aim of filling this gap. The study was a collaborative effort involving, at different times, researchers from AUT, the University of Auckland, the Ministry of Social Development and George Washington University in the United States. It used newly available linked research data from across health and other social services to estimate the difference that Family Start made to outcomes for children and mothers.

Key findings

What this study tells us:

the enhanced Family Start programme phased in to new areas between 2005 and 2007 had positive impacts on use of some health services and children’s participation in Early Childhood Education
mortality rates in the first 2 years of life were significantly reduced for children who participated in Family Start, with reductions in injury death and SUDI
Family Start children were more likely to come to the early attention of CYF and more likely to have substantiated findings of maltreatment, but no more likely to be hospitalised for injuries coded as maltreatment related or considered markers for maltreatment.

What this study doesn’t tell us:

whether all providers generated positive impacts
the mechanisms by which positive impacts were achieved
whether Family Start children were more likely to have contact with CYF in the longer term (or whether the programme simply brought forward contact that would have occurred in any case), and whether increased early contact was preventive in that concerning behaviours and circumstances were identified and addressed early
whether impacts estimated, which relate to the programme as it was for children born prior to 2012, would be similar to those delivered by the programme in its current form – changes intended to make Family Start more effective and to more tightly target the programme to families facing the greatest number of challenges introduced in 2011-12 may mean that Family Start is now more effective, but this study can’t say
whether outcomes less readily measured using administrative data were impacted (eg. inter partner conflict and violence, parents’ discipline practices, and child cognition)
what parents and caregivers thought of the effectiveness of Family Start
whether the programme benefits outweighed the costs – whether Family Start was “cost effective” for the cohort studied.

How the study will be used:

the study will help inform the on-going development of intensive home visiting services in New Zealand.

In Detail

The enhanced Family Start programme that was phased in to new areas between 2005 and 2007 was associated with some small but statistically significant positive impacts for Family Start children overall, and for Māori and Pacific children who participated in the programme.

Reduced Child Mortality

The most striking finding from the study is evidence that Family Start reduced post-neonatal mortality. The evidence of a programme impact was strongest and most persuasive in the case of Sudden Unexplained Deaths in Infancy (SUDI) and injury deaths.

Mortality results are very promising and consistent with emerging evidence from studies of home visiting programmes in the United States. They are of particular interest in the New Zealand context because infant mortality rates are high in this country compared with other OECD countries, with particularly high rates for Māori infants.

Positive Impacts on Use of some Health Services and Early Childhood Education

Like the Early Start randomised controlled trial, findings indicate positive impacts on connection to some health services and to early childhood education. Compared to a matched control group who had similar characteristics but lived in areas where Family Start was not available, children who received Family Start:

had a higher likelihood of being fully immunised at one or more milestone in their first 2 years
had a higher rate of participation in early childhood education at age 4..

In addition, there was some indication that mothers had a higher rate of use of community-based mental health services in the first year post-birth as a result of Family Start. Mothers of Māori children appeared more likely to use community-based addiction services as a result of Family Start.

Other Findings

The study found no significant impact on participation in the B4School Check, the last of the Well Child/Tamariki Ora health checks. By the time the B4School Check was due, most children would no longer be participating in Family Start. Data on participation in earlier Well Child/Tamariki Ora checks were not available for study.

A concerning finding was that Family Start children were less likely to be enrolled with a primary health organisation (PHO) at age 1 than the matched control group. This was seen in overall results and for Māori children, and may reflect an unintended programme effect. By age 2 there was no evidence of a negative impact on PHO enrolment in overall results, and Māori children who received Family Start were in fact more likely to be enrolled with a PHO than children in the matched control group.

The study looked at whether Family Start had an impact on hospital admissions that were coded as being for a maltreatment-related injury, or were for injuries in infancy that are considered “markers” for maltreatment.

There was no evidence of an impact, positive or negative, on such admissions. There is some ambiguity in interpretation of an absence of a reduction in these measures. Underlying injury rates may have been reduced, but rates of hospitalisation might have appeared unchanged as a result of more families seeking treatment for children’s injuries as a result of Family Start.

Finally, the study found children who received Family Start were more likely to come to the early attention of Child Youth and Family (CYF) compared to the matched control group. Results suggested that an increased rate of notification to CYF was likely to have also led to increases in the proportion of children with substantiated findings of maltreatment.

The magnitude of this effect was difficult to establish: while the matched control group was similar to the children who received Family Start on most characteristics, they were more likely to be in a family where older children had previously come to the attention of CYF and this, rather than participation in Family Start, might explain some of the estimated difference in early contact with CYF; in addition, some children entered Family Start as a result of earlier CYF involvement resulting in “reverse causality” inflating some of the estimated effects.

These results suggest that the presence of the Family Start worker in the home, and increased contact with other services as a result of Family Start, made it more likely that concerning behaviours and circumstances were identified and brought to the early attention of CYF.

Studies of other home visiting programmes have also suggested these sorts of effects. The study highlights the difficulty in using administratively sourced measures to capture whether maltreatment is reduced as a result of home visiting programmes.