Starting early for families: an early intervention programme for at-risk families in Christchurch is making a difference in the daily lives of children and their parents.
Subject: Nurses (Practice)
Child welfare (Management)
Family (Health aspects)
Family (Management)
Authors: Egan, Jan
Yarwood, Judy
Pub Date: 07/01/2010
Publication: Name: Kai Tiaki: Nursing New Zealand Publisher: New Zealand Nurses' Organisation Audience: Trade Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2010 New Zealand Nurses' Organisation ISSN: 1173-2032
Issue: Date: July, 2010 Source Volume: 16 Source Issue: 6
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Product: Product Code: 8043100 Nurses NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 233291252

A challenge issued more than a decade ago for nurses to pay more attention to the lives of vulnerable families and children remains as salient and, one could argue, even more urgent today. (1) Much has been written about the vulnerability of young families in today's increasingly diverse and fragmented society--a society frequently portrayed in a negative light by a steady stream of media headlines proclaiming the results of endemic violence and misuse of alcohol and drugs. Despite numerous inquiries and reports searching for answers to address these concerns, little appears to have changed, as New Zealand's shocking child abuse and neglect statistics continue to rise. Far from being the best place to raise children, New Zealand is fast becoming a country with an unenviable track record in regards to child health and well-being. Being ranked 23 out of 26 for child poverty and 24 out of 27 for child deaths as a result of maltreatment, in the Organisation for Economic Co-operation and Development countries (2) should be enough to galvanise government and health professionals into action. Perhaps the latest in a long line of reports, Every child counts, (3) commissioned by several non-government agencies, including Plunket, Barnados and Unicef, may provide the turning point to address child welfare concerns in this country. Four key components identified in this report offer a blueprint for action:

* children and family at the centre of policy and planning;

* ensuring all children get a good start in the early years;

* reducing child abuse and neglect; and

* ending child poverty.

The reason we believe action may be forthcoming from this particular report is its focus on the imperative driving most government action today--economics. Apparently the cost of child abuse in New Zealand is about $2 billion a year. (4) Just imagine what could be achieved if even half this amount was spent on preventing neglect and abuse rather than picking up the pieces from fractured families and damaged children. Investing in the health of children is after all about investing in the health of a nation. (5)

Despite a multitude of social and health services being available to children and families in need, many, for a range of reasons, are unable or unwilling to access these services. Some families only come to the attention of health professionals when they are in distressing or dire circumstances, while behind the headlines thousands of other families and children struggle to make sense of their worlds. Who or what informs and guides these young families as they strive to do the very best they can for their family members? In this article we describe a Canterbury health visiting service aiming to do just that, the Early Start Project. This project aims to guide and support families as they build their health, educational and social capabilities in a variety of ways. We begin by exploring briefly the diverse needs facing young and, at times, troubled families with children living in contemporary society.

Families, however defined, structured or functioning, underpin society and, as such, are contexts in which we are all, for better or worse, embedded. (6) Many authors have identified the crucial role families play in health and well-being, not only for each family member, but also for that of communities and societies. (7,8,9) It is in families health beliefs, values and behaviours are learned and embedded, supporting Helman's contention that family is "the real site of primary health care". (10)

The Kiwi Nest, the Families Commission's recent report, highlights significant family changes over the last 60 years. (9) Solo, teen parenting, and absent fathers are identified as three family structures that create stress and anxiety. Families, finding themselves in such situations, are often unable to afford adequate housing, and have insufficient income to cover constantly rising living and food costs, utility services, and health care, all of which can have detrimental effects on family health and well-being. The effects of poverty, and its pervasive health-related sequelae, commonly manifest in poor child health and development. Neglecting children's health, educational and social needs can blight early child development and future life opportunities. And yet often children fail to receive these necessities because of impaired parenting practices and limited family resources and supports. (2,11) Parental influence on children's opportunities in life, within the context of poverty, is one of many complexities (12) that confront those working to ameliorate risk factors children may experience.

Health and social services

Home visitation (HV) services, more recently known as early intervention programmes, (6) have, since the 19th century and before, (13) offered health and social services, as part of the health and social fabric of many Western countries. Nurses, by their very mandate of providing human and social services, are often involved with family care in institutional and community settings.

In England, registered nurses (RNs) as home visitors is commonplace in nursing practice. (14) However in New Zealand, home-visiting, while not named as such, is more aligned with public health nurses' (PHN) work. School-aged children with health concerns, which often manifest as behavioural issues, are referred to the PHN with responsibility for that school. Home visiting per se occurs through social and health agencies, rather than explicitly within nursing practice. And yet, paradoxically, long-term home visiting goals have a broad health and well-being focus. (15,16) Health visiting programmes tend to cover health surveillance, education and promotion in the peri-natal period, and the first five years of life. Disease prevention, including childhood immunisation, maternal support, improving parenting skills, and prevention of child neglect and maltreatment all aim to improve family and child health and life course. (17) One such service is Early Start, a Canterbury early intervention programme.

Early Start Project

Early Start (ES) was developed in Christchurch by a consortium of heath care providers in 1995 and then, in 1997, funded as a joint venture by the then Regional Health Authority and Child Youth and Family (CYF). Now funded by the Ministry of Social Development under the Family Start initiative, the ES project uses a social learning approach to provide free, intensive home-based support to vulnerable at-risk families with children, from the antenatal period or birth of a baby up to five years of age. (18) Early Start evolved in response to a growing recognition by social services of the number of children in the Canterbury region living in families with behavioural concerns, drug and abuse issues and poor mental health. Many children were living in an impoverished "disadvantaged, dysfunctional and chaotic home environments". (18)


Recruitment to the programme

Initially, recruitment to the ES programme was undertaken by Plunket nurses, whose mandate to visit families in the Canterbury region soon after the birth of each child, positioned these nurses well to identify families at risk. On enrolment to the service the child is the primary client. However, the fundamental and critical role families play in child development, health, and wellness is recognised by ES. (8,18,19) Currently, families are referred for ES assessment from a wide range of community services including well child providers, midwives, hospitals, medical practices and self referrals.

Underpinning the ES service is an imperative to build supportive, encouraging and trusting relationships between families and family support workers (FSWs), most of whom are RNs, social workers, and teachers. Such relationships are key to producing positive change in families. With their ability to develop and build strong, effective and insightful relationships, RNs play a critical role in achieving success with families and children.

Registered nurses working in the Early Start project are skilled practitioners who use their nursing competencies in a holistic and contemporary way, in partnership with individuals, families, whanau and community.

When first enrolled with ES, families meet their allocated FSW. Some "matching" of FSW to family is applied; this may be in relation to a specific request from the family regarding the ethnicity or age or experience of the FSW. It is on a case-by-case basis and is also dependent on the availability of FSWs. A six-week assessment period follows, where the FSW and family have space and time to assess if the family is willing to participate in the ES programme. Following the assessment period, the FSW builds on this to plan, in partnership with the family, interventions that will meet the family's goals of becoming confident in family self management.

Interventions occur during weekly visits, usually in the family home and will focus on healthy lifestyle, which involves an interactive health promotion and/or education session. Topics or sessions include family values, how the family will take responsibility for promoting health and well-being, while reducing risks and vulnerability.

Ongoing assessment of identified family issues, eg family violence, occurs with the FSW being broker or advocate to ensure the family can make full use of available community services, and Learn how to manage future crises. FSWs enable families to connect with well child, pre-school education and oral health services, and other community facilities, thus providing the family with opportunities to fully participate in society and improve health and social outcomes. Be they generic or targeted interventions, eg parent/child interaction, all work to enhance family cohesion, build family resilience and increase parenting capacity, which, in turn, promotes healthy child development.

Early Start has six essential components, not dissimilar to the four identified in Every child counts: (3)

* improving child health;

* reducing child abuse;

* improving parenting skills;

* supporting parental, particularly maternal physical and mental health and well-being;

* encouraging family economic and day to day material functioning and well-being; and

* encouraging stable positive and supportive relationships. (18)

Under the umbrella of these six key components are 13 health-promoting criteria by which success with each family can be measured: immunisation; primary health care provider visits--GP/well child care; well child provider core scheduled contacts; breastfeeding; oral health; smoke free environment; early childhood education; child safety--child abuse/neglect and health and safety awareness; family nutrition; positive parent child interaction/attitude; parental health and well-being; family economic circumstances; and law-breaking behaviours. (20)

Programmes and strategies employed to achieve these outcomes are dependent on family needs and embrace many concerns ranging from Low socio-economic circumstances and insufficient family resilience, to Limited educational, financial and health Literacy.

Programme evaluation, determining the value of home visiting family services and programmes generally, both in New Zealand and abroad, has been fraught. (21,6) Although an increasing number of families warrant intervention, health, social and other professionals remain perplexed about just what interventions work, and why. One of the many strengths of the ES project has been its ability to be reflective and responsive to ongoing external evaluation and internal benchmarking outcomes, a practice to be encouraged. (22)

Evaluation of ES, using randomised controlled trials, (18) demonstrated an uptake of child health services and improved child behaviours, as well as decreasing numbers of accidents Leading to hospital admission. A reduction in harsh parenting practices and child assaults was accompanied by more encouraging and affirming parenting practices. (18)

When families were asked how satisfied they were with the ES service, most families reported being well satisfied, with more 90 of families experiencing a good relationship with their FSW. Comparisons between Maori and non-Maori families found Levels of satisfaction to be similar, although for Maori families, the service was particularly helpful in meeting their needs. Maori mothers appreciated the manner in which FSW responded to and respected their cultural heritage. Ongoing evaluation of ES services is focused on individual and collective outcomes measured against benchmarks.

Child poverty, child maltreatment and child deaths have no place in New Zealand. Attention is given to the plight of vulnerable children and their families in many diverse areas of health care, including home visitation services such as ES. Notwithstanding the somewhat problematic and equivocal nature of early intervention evaluations, (23) the imperative remains that New Zealand children and families in need and often at risk deserve and must have support, encouragement and assistance to increase their resilience and ability to promote their own family health and well-being.


(1) Taylor, C. (1995) Social threats to family health: redefining nursing's roles. Journal of Family Nursing; 1: 30, 30-40.

(2) Hoare, K. J., & Wilson, D. L. (2007) The place for children's centres for New Zealand children. Australian Health Review; 31: 1, 123-132.

(3) Every child counts (2009). Retrieved 106/12/09.

(4) Armstrong, G. (2009) New report reveals hidden costs, Retrieved 06/10/09.

(5) Marmot, M. & Wilkinson, R.G. (Eds.) (2006) Social determinants of health. (2nd ed.) Oxford: Oxford University Press.

(6) Ministry of Social Development. (2005) Outcome/impact evaluation of Family start: Final report. Wellington: Author

(7) McMurray, A. (2007) Community health and wellness: A socio-ecological approach. Marrickville, NSW: Elsevier.

(8) Denham, S. (2003) Family health: A framework for nursing. Philadelphia: F.A. Davis Publishers.

(9) The Families Commission. (2008) The kiwi nest: 60 years of change in New Zealand families. Wellington: Author.

(10) Helman, C.G. (2003) Culture, health and illness. (4th ed.) Oxford: Butterworth-Heinemann.

(11) Stirling, P. (2008) Guns and roses. The New Zealand Listener; June 28, 3.

(12) Kalil, A. (2003) Family resilience and good child outcomes: A review of the literature. Wellington: Ministry of Social Development.

(13) Weiss, H. (2003) Home visits: Necessary but not sufficient. The Future of Children; 3: 3, 113-127.

(14) McHugh, G. & Luker, K. (2002) Users' perception of the health visiting service. Community Practitioner; 75: 2, 57-61.

(15) Kearney, M.H., York, R. & Deatrick, J. A. (2000). Effects of home visits to vulnerable young families. Journal of Nursing Scholarship; 32: 4, 369-376.

(16) Olds, D. & Kitzman, H.J. (1993) Review of research on home visiting for pregnant women and parents of young children. The Future of children; 3: 3, 53-92.

(17) Boyle, M., Gafni, A., Jamieson, E., Macmillian, H.L., Shannon, H., Thomas, B.H., et al. (2005) Effectiveness of home visitation by public health nurses in prevention of the recurrence of child abuse and neglect: A randomized controlled trial. The Lancet; 365: 9473, 1786-1794.

(18) Fergusson, D., Horwood, 3., Ridder, E. & Grant, H. (2005) Early Start Evaluation Report. Christchurch: Early Start Project Ltd.

(19) Olds, D., Henderson, C.R., Kitzman, H.J., Eckenrode, J.J., Cole, R.E., & Tatelbaum, R.C. (1999) Prenatal and infancy home visitation by nurses: Recent findings. The Future of Children, 9: 1, 44-65.

(20) Early Start Project. (2008) Early Start project benchmarking. Christchurch. Author.

(21) Gray, A. (2001) Family support programmes: A literature review. Wellington: Gray Matter Research Ltd.

(22) Bromley, M. National Coordinator, Family Start, Personal communication, December 2009.

(23) Bruner, C. (2006) Developing an outcome evaluation framework for use by family support programs. In P. Dolan, J. Canavan & J. Pinkerton (Eds.) Family support as reflective practice (pp.237-249) London: Jessica Kingsley Publishers.

This article was reveiwed by Kai Tiaki Nursing New Zealand's practice article review committee in April this year.

Judy Yarwood, RN, MA (Hons), Tchg Dip (tertiary), is a principal Lecturer at Christchurch Polytechnic Institute of Technology's School of Nursing and Human Services.

Jan Egan, RN, BN, Plunket Cert, is the clinical manager of the Early Start Project in Christchurch.
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