Client Satisfaction with the Early Start Service

David M. Fergusson ¹
Hildegard Grant
L. John Horwood
Elizabeth M. Ridder

Abstract

Early Start, funded under the Government’s Family Start initiative, is a home visitation service provided by trained family support workers designed to support, empower and assist families to address issues relating to child-rearing, parenting and family functioning. This paper examines a series of issues relating to client satisfaction with Early Start. A randomised field trial of programme efficacy involved a series of families receiving the Early Start service and a comparison series of families not receiving the service. At 36 months following trial entry, families who had received Early Start (n = 163) were asked about their satisfaction with the service. Client families reported generally high levels of satisfaction, similar for Māori and non-Māori. Higher levels of satisfaction were associated with increasing service duration and having fewer family support workers involved with the family.

Introduction

There has been growing interest and investment in home visitation programmes for families facing stress and difficulties. Typically these programmes are targeted at families facing severe stress or difficulty, are provided by home visitors with small case loads and are of lengthy duration (for a review of the literature see Gomby et al. 1999). The aim of these programmes is to form collaborative partnerships with families to encourage positive outcomes for children and their families. In New Zealand a number of home visitation models have been developed and evaluated. The models include Parents as First Teachers (Boyd 1997, Campbell and Silva 1997, Livingstone 1998) and the Family Start programme (Evaluation Management Group 2003). Evaluations of these programmes have produced mixed results, which suggest both limitations in programme success and issues relating to programme delivery (Evaluation Management Group 2003, Farquhar 2003, Livingstone 1998).

An approach to home visitation that has recently been subject to a rigorous evaluation is the Early Start programme, developed in Christchurch by a consortium of local providers, Māori and researchers. The evaluation of the Early Start programme used a randomised design in which 220 families enrolled in the Early Start programme were contrasted with 223 families not enrolled in Early Start, with both groups being studied over a 36-month follow-up period. Funding for the service provision component of the randomised trial was provided under the Government’s Family Start initiative; funding for the evaluation component of the trial was provided by the Health Research Council of New Zealand.

Analyses of the trial results led to four major conclusions about the effectiveness of the Early Start programme.

• The programme was associated with small but pervasive benefits in the areas of child health, pre-school education, parenting, child abuse and neglect, and childhood behavioural adjustment (Fergusson, Grant et al. 2005; Fergusson, Horwood et al. 2005).
• The programme did not lead to detectable changes in parental and family outcomes, including maternal health, family socio-economic conditions, family stability, family violence and family stress (Fergusson et al. 2006; Fergusson, Horwood et al. 2005).
• Programme benefits were similar for Māori and non-Māori but, if anything, Māori clients received slightly greater benefits from the programme.
  In comparison to other international and local randomised trials of home visitation programmes, the results from the Early Start evaluation were as good as – if not better than – those reported in the literature (Fergusson, Horwood et al. 2005).

While these results clearly suggest that Early Start was an effective home visitation model, which produced benefits for client children, the randomised trial provides only one perspective on this service by examining the extent to which the service led to beneficial outcomes. An equally important issue concerns the ways in which the client families perceived the service and the extent to which they saw the service as meeting their needs. These issues are important for at least three reasons.

• There has been a growing recognition in the areas of health and social services of the need for service providers to take account of the views and perspectives of the client population.
• In the areas of home visitation and family support, there have been ongoing debates and suggestions that such programmes may have harmful effects by exposing client families to stigmatisation or through the imposition of intrusive or inappropriate programmes (Sanders 1999).
• These concerns have been underwritten in New Zealand by broader concerns about the need for health and social programmes to be delivered in a way that is culturally appropriate and acceptable to Māori (Fanslow et al. 2000, Ministry of Health 1998, Voyle and Simmons 1999).

For all three reasons it is important to supplement data from the outcome evaluation of Early Start with a parallel evaluation of the service from the client’s perspective.

Against this background, this paper reports on the results of a client satisfaction survey conducted at the 36-month follow-up with families enrolled in the Early Start programme.

The aims of this analysis are threefold:

• to examine overall levels of client satisfaction/dissatisfaction with the Early Start service in terms of three general domains:
  • the extent to which the service assisted the family in achieving specific goals and outcomes
  • the nature of the relationship between the family and the family support worker
  • the client’s overall assessment of the service in terms of cultural appropriateness and effectiveness
• to compare levels of client satisfaction between Māori and non-Māori (specifically, the results of the randomised trial suggested that, if anything, Early Start was slightly more effective with Māori clients than with non-Māori clients, and an important question raised by this result is whether similar results were evident for levels of client satisfaction)
• to identify client and service-related factors associated with the variation in service satisfaction.

Methods

Client Recruitment

Clients for the trial were recruited using a population-based screening procedure. In this procedure, Plunket community nurses in the Christchurch urban region screened all new clients using an 11-point screening measure based on the measure used in the Hawaii Healthy Start Program. This screening measure covers several areas of parent and family functioning, including age of parents, social support, planning of pregnancy, parental substance use, family financial situation and family violence. Plunket Nurses were asked to refer any family where two or more risk factors were present. In addition, Plunket nurses were asked to refer any family in which there were serious concerns about the family’s capacity to care for the child.

Over the 19-month recruitment period (January 2000 through July 2001), Plunket nurses saw 4,523 families, with 588 of these families being eligible for the trial. Of those eligible for the trial, 443 (75%) agreed to participate in the study. The evaluation of the Early Start programme used a randomised controlled design in which the outcomes of 220 families enrolled in the programme were compared with the outcomes of 223 control families. Sample size was determined by the availability of funding for the service. The present study of client satisfaction involves the 220 families who entered the Early Start service. In all cases, signed consent was obtained at the point of study referral. The study design had the ethical approval of the Canterbury Ethics Committee.

Service Delivery

Early Start uses a social learning model approach to home visitation. The critical elements of this model include:

• assessment of family needs, issues, challenges, strengths and resources
• development of a positive partnership between the family support worker (FSW) and client
• collaborative problem solving to devise solutions to family challenges t
• the provision of support, mentoring and advice to assist client families to mobilise their strengths and resources
• involvement with the family throughout the child’s pre-school years.
  

This model aims to strike a balance between deficits-based approaches that focus solely on family limitations, and an exclusively strengths-based approach that may fail to attend to family deficits. Details of the programme, including programme delivery and programme goals, have been given in a previous paper (Fergusson, Grant et al. 2005).

Research Assessments

At baseline and 36 months following trial enrolment, client families were assessed on a structured interview administered in the clients’ homes by a trained survey interviewer who was independent of the programme. Interviews typically lasted 45–60 minutes. At 36 months, families were also asked a series of questions related to their satisfaction with the Early Start service. These questions examined three dimensions of client satisfaction.

The first dimension of client satisfaction was the extent to which the parent found that the service was able to meet the specific needs of the family; for example, “To what extent has Early Start helped you to understand your child(ren)’s needs?” These questions were scored on a three-point scale whereby the parent could answer “not at all”, “a little” or “a lot” to each question. The full list of items relating to specific family needs is given in Table 1.

The second dimension of client satisfaction was the parent’s satisfaction with their relationship with their FSW; for example “Do you feel that you have (had) a good relationship with your family support worker?” These questions were scored on a three-point scale, with endorsements ranging from “not at all” to “yes, somewhat” to “yes, definitely”. Parents were also questioned about problems or difficulties experienced with the FSW and whether they had ever made a complaint to the Early Start Service about their FSW or the programme.

Overall satisfaction with the service was assessed using three questions. The first question, “Overall, would you say that Early Start has treated you and your family in a way that is culturally appropriate and sensitive?” was scored on a three-point scale ranging from “not at all” to “yes, somewhat” to “yes, definitely.” The second question, “Overall, how helpful do you feel the Early Start service has been in assisting you to address the needs of your family?” was scored on a four-point scale, with two positive endorsements (very helpful, helpful) and two negative endorsements (not helpful, very unhelpful). The third question, “Overall, how satisfied are you with the service provided by Early Start?” was also scored on a four-point scale, with two positive endorsements (very satisfied, satisfied) and two negative endorsements (unsatisfied, very unsatisfied).

Sample Size

Of the 220 clients who entered the trial, 184 (84%) were interviewed at the 36-month follow-up. Of those interviewed, in 10 cases the reference child had been removed from the client family and placed with foster parents or other family members who were not in receipt of Early Start. A further 11 families had either declined entry into Early Start or had been lost to the service in the early stages of service delivery and were unable to respond to questions about service satisfaction. This left a total of 163 clients who provided information regarding satisfaction with the Early Start service.

To examine the extent to which losses from the survey were systematic, the 163 clients completing the satisfaction questions were compared with the 57 clients not responding to these questions on a wide range of measures describing client characteristics at baseline. These comparisons included measures of:

• demographic characteristics of the family
• maternal childhood disadvantage
• current maternal health
• family financial circumstances
• family stability, family relationships and family violence
• characteristics of the mother’s current partner
• pregnancy characteristics and pregnancy outcomes.
  

Of the 40 comparisons conducted, in four cases there was a significant (p < .05) association with loss from the survey. Clients not participating in the survey were less likely to be depressed at baseline (p < .001); were less likely to smoke cigarettes during pregnancy (p < .05); were less likely to report interparental violence during childhood (p < .05); and had infants of slightly lower birthweight (p < .05) than those who participated. However, given the large number of comparisons conducted, it was possible that some of these associations may have been significant by chance as a result of multiple significance testing. To adjust for this possibility, a Bonferroni correction (Grove and Andreasen 1982) was applied. The Bonferroni corrected p-value in this instance was .00125 (.05/40). Using this p-value, only one comparison remained statistically significant (maternal depression at baseline).

Results

Levels of Client Satisfaction

Table 1 summarises levels of client satisfaction reported by the 163 clients interviewed at 36 months who reported that they were ever enrolled in Early Start and had received the Early Start service. These measures covered helping clients meet goals, the mother’s relationship with her FSW, and overall satisfaction.

Families reported on the extent to which Early Start had assisted them in achieving various goals relating to parenting, family needs and use of community services. Table 1 shows generally high levels of positive responses to these items, with 26–80% (median 51%) reporting that Early Start had been of some help and 10–48% (median 28%) reporting that Early Start had helped a lot. The items with the highest levels of positive response were that the programme had:

• made the mother feel at ease in asking for help (80%)
• helped the mother to feel more confident as a parent (75%)
• assisted the mother to set personal goals (70%)
• assisted the mother to better understand the child’s needs (70%).
• At the other extreme only a minority of mothers reported that the programme had assisted them to manage family finances (26%).

The second set of measures related to the mother’s relationship with her FSW(s). Overall, clients reported high satisfaction with FSWs, with over 90% reporting that:

• they had a good relationship with their FSW
• their FSW had a good understanding of the family’s needs
• the FSW was generally helpful and supportive
• the FSW treated the family in a culturally appropriate way.

Nonetheless, approximately one in six clients reported experiencing some difficulties with their FSW or the Early Start service, and 5% had made complaints about their FSW to the Early Start service. Of the 28 mothers who reported difficulties with Early Start or their FSW:

• seven mothers reported that the FSW was unreliable and lacked punctuality
• seven mothers reported that their FSW was unhelpful and did not help the mother follow through on goals
• seven mothers felt that the FSW was too pushy or intrusive
• four mothers reported that they did not have a good relationship with the FSW
• three mothers reported that the FSW had betrayed their confidence.

In addition, nine mothers had made complaints to Early Start about their FSW:

• two complaints were related to FSW unreliability
• two complaints were made because mothers found the FSW unhelpful
• three complaints were laid concerning the FSW being overly bossy or pushy
• one complaint was made regarding a betrayal of confidence by the FSW
• one complaint related to an inappropriate comment made by the FSW.

Overall ratings of satisfaction were in keeping with the findings reported above: the great majority of clients saw the service as culturally appropriate, helpful and supportive, and satisfactory.

The overall impression conveyed by these results is that the great majority of clients saw the Early Start service as being useful and supportive, but there was a minority who were dissatisfied with the service.

Assessments of Māori and Non-Māori

The trial data were examined to determine whether there were differences between Māori and non-Māori in overall levels of service satisfaction. Table 2 compares Māori and non-Māori families on the measures reported in Table 1, and Māori families were defined as those families in which either parent reported that they were of Māori ethnicity using the New Zealand census definitions. To simplify presentation of the table, only the positive responses to each item are reported. Each comparison is tested for statistical significance using the chi-squared test.

Table 2 shows that overall levels of satisfaction were very similar for Māori and non-Māori families, with both groups reporting generally high levels of satisfaction. Closer inspection also reveals a small but pervasive tendency for Māori families to be more likely than non-Māori families to report that Early Start had helped “a lot” in meeting specific family needs. Although these differences are not significant in most comparisons, the higher levels of satisfaction among Māori families are reflected in statistically significant differences on the items of helping mother to enjoy playing with her child (p < .05), assistance with managing family finances (p < .05), assistance with personal/family problems (p < .05), and a marginally significant difference in assistance with crises/emergencies (p = .07). These results suggest that satisfaction with Early Start was at least as high among Māori as among non-Māori. It is notable that over 95% of the Māori mothers found the service was responsive to, and respectful of, the cultural values of Māori families.

Measurement of Service Satisfaction

To devise an overall measure of service satisfaction, a simple points score was constructed by summing up for each respondent the number of positive reports made about Early Start using the items in Table 1. This sum ranged from 0 for the clients who reported no satisfaction with the service, to 21 for the clients who endorsed all items as satisfactory, with a mean of 14.8 and standard deviation of 4.3. The resulting measure was then reduced to a five-point ordinal measure by dividing the scale scores into 20% groups (quintiles) on the basis of the satisfaction score.

Table 2 Comparison of Item Endorsement Rates (%) Between Māori and Non-Māori Clients

Note: To simplify presentation of results only positive item responses are presented in this table.

Table 3 Item Endorsement Rates (%) by Early Start Satisfaction Score Quintile

Table 3 shows the profile of positive item endorsements for each quintile of the satisfaction score. Each association is tested for significance using the Mantel-Haenszel chi-squared test of linearity. Inspection of the table shows that those in the highest quintile of the overall satisfaction score reported almost universal satisfaction on all items. In contrast, the group reporting the lowest overall satisfaction had relatively low rates of satisfaction on most items. More generally, for all items there was a clear trend for reported levels of satisfaction to increase with increasing overall satisfaction. This suggests that the overall satisfaction score provided a useful summary of overall client satisfaction with Early Start.

Factors Associated with Service Satisfaction

To identify the factors that predicted greater satisfaction with Early Start, analyses were conducted to examine the associations between the overall satisfaction score and a range of measures of client characteristics and service delivery factors. Exploration of a large number of factors showed that levels of satisfaction with Early Start did not vary with a large number of client characteristics assessed at baseline. These characteristics included:

• demographic characteristics of the family, including parental age, parental ethnicity, parental educational qualifications, family type and family size
• maternal childhood disadvantage, including childhood abuse, impoverished
• family circumstances, problems with alcohol and drugs, and running away from home
• current maternal health, including alcohol use, cannabis use and depression
• family financial circumstances, including welfare dependence, debt, and inadequacy of income
• family stability, partner relationships and family violence
• characteristics of the mother’s current partner, including alcohol and drug problems, problems with aggression, and troubles with the law
• pregnancy characteristics and pregnancy outcomes, including breastfeeding.
  

Only two factors were found to predict satisfaction. These factors were duration of service provision and number of FSWs. Table 4 summarises the results of a regression model in which these factors were analysed using multiple regression to predict the overall satisfaction score described above. Table 4 reports the mean satisfaction score for levels of each predictor after adjustment for the other factors in the model.

Table 4 Adjusted associations between measures of service provision and overall satisfaction score

R² = .16 (p <. 0001)

Examination of the table shows that increasing client satisfaction was associated with increasing duration of service provision (p < .0001). The small minority of clients who received less than 18 months’ service provision had adjusted mean scores that were more than one standard deviation lower than the scores for those receiving more than 30 months’ service.

Decreasing client satisfaction was associated with having a greater number of FSWs (p < .01). Around one-third of families had experienced three or more FSWs, and these families had adjusted mean satisfaction scores that were approximately half a standard deviation lower than for families with only one FSW.

The level of prediction from these factors, however, was relatively weak (R² = .16), implying that only 16% of the variation in client satisfaction was explained by these factors. Furthermore, it is unclear whether duration of service provision is a predictor or consequence of client satisfaction, a point discussed below.

Discussion

In this paper we have examined measures of client satisfaction, with the Early Start programme of home visitation. This analysis led to conclusions regarding overall client satisfaction, ethnic similarities and factors influencing client satisfaction, which are summarised below.

Overall Client Satisfaction

The findings in Table 1 suggest a relatively high level of overall satisfaction with over 90% of clients reporting satisfaction with the services provided by Early Start. Of particular note was the high frequency with which mothers endorsed items relating to personal support, empowerment and assistance with child rearing tasks. Collectively, these findings provide a profile that suggests that the Early Start service was well received by mothers and seen in a positive light. Nonetheless, in the region of one in six clients ventured some negative comments about the service.

Analysis of client reports of difficulties with their FSW identified three major sources of complaint. The first concerned instances in which the mother felt that their FSW was too “pushy” or “intrusive” in aspects of family functioning. These complaints probably reflect the inevitable tensions that will arise in home visitation with families facing stress and difficulty. On the one hand, such services will have a commitment to parental support and empowerment, but on the other hand they also have a commitment to child protection and maximising child health and wellbeing. This dual loyalty to the needs of both the parents and the children is likely to lead to situations in which well-meaning actions of FSWs to promote child health and wellbeing are seen as an intrusion into family life. However, these incidents appear to be comparatively uncommon.

The second major source of complaint concerned worker reliability and punctuality. These complaints were made by only seven of those enrolled in Early Start but they highlight the fact that to preserve credibility, family support services need to demonstrate a strong commitment to worker reliability and punctuality. Seven mothers also reported that the FSW was unhelpful, did not follow through on promises to help or did not help the mother follow through on goals set by Early Start.

A further class of complaint concerned the development of a specific conflict between the FSW and family. This conflict arose most commonly in instances in which FSWs referred families to the Department of Child, Youth and Family Services (now Child, Youth and Family) for suspected child abuse or neglect. In these circumstances parents sometimes felt that the referral was a betrayal of trust. Again, this issue highlights the potential tensions that arise in the delivery of a family support service that addresses the needs of both parents and children, but which attaches priority to the child’s needs.

Ethnic Similarities

An important issue raised in the evaluation of Early Start concerns the extent to which the service provides similar outcomes for Māori and non-Māori families. In particular, there have been repeated claims that mainstream services are unable to meet the needs of Māori families and that such needs are better met by Māori service providers (Fanslow et al. 2000, Ministry of Health 1998, Voyle and Simmons 1999). The evaluation of Early Start does not support this viewpoint. In particular, the outcome evaluation of the programme showed no significant differences in the levels of benefit received by Māori and non-Māori families (in fact, Māori families received slightly greater benefits than non-Māori families) (Fergusson, Horwood et al. 2005).

The results of the client satisfaction survey were in line with the outcome evaluation. Overall levels of satisfaction among Māori and non-Māori families were similar, but Māori clients reported slightly greater satisfaction. For example, a significantly greater proportion of the Māori participants felt that Early Start had assisted them in the areas of helping mother to enjoy playing with her child, assistance with managing family finances, and managing personal/family problems.

The principal conclusion that may be drawn from these findings is that client ethnicity was not a significant factor that influenced either the effectiveness of the Early Start programme in achieving positive outcomes for client families (Fergusson, Horwood et al. 2005) or the programme’s acceptability to the client population. These results show that it is possible to deliver a mainstream family support programme such as Early Start to Māori and non-Māori, and to produce similar (positive) outcomes in terms of both programme outcomes and client satisfaction.

It is difficult to identify the factors that led the Early Start programme to have similar levels of effectiveness and acceptability for Māori and non-Māori. However, it is likely that a major contributor to this result was the process by which Early Start was developed, which involved consultation with Māori and the active engagement of Māori on the Board of Early Start. For most of the period over which this study was conducted, the Board of Early Start comprised eight members, with four of these members being Māori women. The involvement of Māori in Early Start led to an organisational structure where issues relating to Māori were incorporated into organisation culture. In this environment, a family support model was developed that drew upon a common set of principles and methods, but was delivered in a way that was respectful of and sensitive to the cultural values of Māori families. The results of the present study suggest that what is likely to determine whether or not organisations are effective in addressing the needs of Māori clientele may have little do with the “ownership” of services and more to do with an organisational philosophy that recognises diversity and unites diverse viewpoints in a commitment to produce good outcomes for families.

Factors Influencing Client Satisfaction

Client satisfaction with a service is likely to act as an important determinant of both engagement with the service and service retention. In other words, those families who remain in the service do so because they are satisfied with what the service offers. Examining the factors that influence levels of client satisfaction led to the following conclusions regarding client characteristics, duration of service and number of FSWs.

The literature on client satisfaction suggests that client characteristics may play an important role in determining the acceptability of a service and levels of satisfaction (Gomby 2000). However, examination of a wide range of client factors – spanning demographic characteristics of the family; maternal childhood disadvantage; current maternal health; family financial circumstances; family stability, family relationships and family violence; characteristics of the mother’s current partner; pregnancy characteristics and pregnancy outcomes – failed to show that the characteristics of client families at the point of enrolment predicted later client satisfaction. Levels of satisfaction did not vary with socio-demographic background, maternal characteristics, family economic circumstances or measures of family functioning.

Only two factors were identified as predicting client satisfaction. The first was that increasing duration in Early Start was associated with increased satisfaction. However, the interpretation of this result is not straightforward. On the one hand it could be that increasing exposure to the service led to greater commitment, engagement and satisfaction. On the other hand it may be that the time spent in the service was a reflection of the extent of client satisfaction, so that those who were least satisfied with the service tended to drop out of the service earlier.

The second factor was the number of FSWs that had been involved with the family, with more FSWs resulting in reduced levels of satisfaction. These findings are consistent with the views of the management of Early Start, who have noted on many occasions that changes in FSWs lead to reduced engagement and satisfaction with the service. These results point to the importance of putting in place structures that increase the stability of the family support workforce and/or act to mitigate the adverse effects of staff changes.

Concluding Comments

Overall, the results of this client satisfaction study were very positive in that there was evidence of high levels of satisfaction among the Early Start clientele. The study also suggests directions for increasing satisfaction and engagement with the service. First, the analysis of client complaints suggested that three areas were sources of potential conflict in the process of the service: perceptions by some families that the service was too intrusive; concerns expressed by a minority of families about the punctuality and reliability of their FSWs; and cases in which there were specific conflicts between FSWs and their clients. Because of the complexities of delivering family support to families facing often complex problems and issues, it is doubtful whether such concerns can be entirely eliminated.

Nevertheless, the results point to the likely value of increased efforts to ensure client engagement and buy-in to the service to minimise risks of conflicts between FSWs and families over service objectives and goals. Further, quality control and quality assurance processes could be put in place to ensure that the service is delivered to clients in a reliable and punctual way. Also, consideration could be given to mechanisms for mediation in cases where conflicts develop between FSWs and their clients. The findings of the regression model suggest that the major route for addressing these issues may be through increasing the stability of contact between FSWs and families, which in turn raises organisational issues about incentives and structures to encourage staff retention and commitment.

References

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Campbell, K. and P.A. Silva (1997) Parents as First Teachers Pilot Project Evaluation: Age Three Assessments: Final Report to the Ministry of Education on the Dunedin and Gisborne/East Coast Areas, Dunedin Multidisciplinary Health and Development Research Unit, Dunedin.

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Footnotes

1 Acknowledgement
The development and evaluation of the Early Start service has been critically dependent on the support of a series of funding bodies. These bodies include: the Health Research Council of New Zealand; the New Zealand Lottery Grants Board; Trustbank Community Trust; the Family Start Fund; Canterbury District Health Board; Ministry of Health; the Department of Child, Youth and Family Services; Christchurch City Council; the Southern Regional Health Authority; the Community Funding Agency; JM Ferrier Trust; Lion Foundation; Rotary Linwood; Hyman Marks Trust; and Rotary Riccarton.
Correspondence
Correspondence should be addressed to Professor David Fergusson, Christchurch Health and Development Study, Christchurch School of Medicine and Health Sciences, PO Box 4345, Christchurch, New Zealand. Telephone: +64 3 372 0406, fax: +64 3 372 0405, email: david.fergusson@chmeds.ac.nz

Hildegard Grant, A.D.N. is a Registered Social Worker with the Early Start Service. L. John Horwood, MSc, and Elizabeth M. Ridder, MSc, are with the Christchurch Health and Development Study, Christchurch School of Medicine and Health Sciences.