The Evidence Portal

Hawaii Healthy Start Program - Enhanced with Cognitive Appraisal

About the program

The Hawaii Healthy Start program (Enhanced with Cognitive Appraisal) (HSP-Enhanced) is a home visitation program designed to promote the well-being of children by providing services to parents and parents-to-be at risk of child abuse. The program is an enhanced version of the original Hawaii Healthy Start program, which is designed to improve family functioning, prevent child abuse and promote child health development.

HSP-Enhanced includes the original HSP components plus an additional cognitive appraisal component.

HSP-Enhanced is designed specifically to assist parents in becoming competent and independent problem solvers, a skill that is underdeveloped among abusive parents and that may be expected to endure following participation in the program. The goal of the enhanced program is to give parents repeated experience in finding new ways (directed away from self- or child-blame) of explaining problems and in finding new ways of resolving those problems.

Who does it work for?

HSP-Enhanced is designed for all families expecting the birth of a child (or having recently given birth to a child) who are identified as at moderate risk to become abusive.

The program has only been evaluated in the USA (Bugental et al. 2002; Bugental & Schwartz 2009).

One randomised control trial was conducted with 73 people (the numbers of people in the intervention group and control group was not reported). On average, parents were 25 years old. Most parents were Latino and 50% had been physically abused as children (Bugental et al. 2002).

Another randomised control trial was conducted with 102 people (45 people were in the intervention group and 57 people were in the control group). On average, parents were 27 years old and most were Latino (Bugental & Schwartz 2009).

The program has not been tested in Australia or with Aboriginal Australians.

What outcomes does it contribute to?

Positive outcomes:

  • Harsh parenting:
    • parents who received HSP-Enhanced report less use of physically abusive discipline tactics (Bugental et al. 2002).
    • parents who received HSP-Enhanced use less corporal punishment, e.g. slapping/spanking (Bugental et al. 2002; Bugental & Schwartz 2009).
  • Parenting attitude: parents who received HSP-Enhanced have improved beliefs about power and control in a parent-child relationship (Bugental et al. 2002).
  • Parent’s mental health: parents who received HSP-Enhanced report larger improvements in depression scores (Bugental et al. 2002).
  • Neglectful parenting: parents who received HSP-Enhanced report less safety neglect, such as fewer injuries and higher amounts of home safety precautions (Bugental & Schwartz 2009).

No effects:

  • Parent’s social support: the program has no effect on an increase in a parent’s social supports (Bugental et al. 2002).

Negative outcomes:

  • No negative effects were found.

How effective is it?

Overall, HSP-Enhanced has a positive effect on client outcomes.

How strong is the evidence?

Supported research outcomes:

  • At least two high-quality randomised controlled trial (RCT) studies report statistically significant positive effects for at least one outcome, AND
  • Fewer RCT studies of similar size and quality show no observed effects than show statistically significant positive effects for the same outcome(s), AND
  • No RCT studies show statistically significant adverse effects.

How is it implemented?

The HSP-enhanced program consists of a series of home visitations.

The visits last for one year, with about 17-20 visits in total.

The original HSP provided regular home visits to assist with:

  • setting and reaching family goals
  • parenting education and modelling effective parent-child interaction
  • ensuring that the child has a medical home
  • accessing needed services, such as income and nutritional assistance, education, and services to address risks such as domestic violence, parental substance abuse, and poor mental health.

HSP-Enhanced combined all features of the original program, but also includes an additional cognitive appraisal component. This consists of:

  1. Causal appraisal of reasons for a caregiving difficulty - At-risk parents are assisted in acquiring skills in reading children’s cues to distress and in countering mis-attributional processes (e.g., countering the view that infants or very young children can read parents’ minds, are behaving with negative intent, or are challenging parental power).
  2. Problem-focused coping - At-risk parents are provided with problem-solving training in which they define the problem, brainstorm possible solutions, evaluate possible consequences, develop an action plan, and observe and evaluate the success of their efforts.

At the start of each visit, parents are asked for examples of recent caregiving problems. They are then asked about

(a) the potential causes of those problems (with repeated inquiry until a benign or non–blame-oriented cause was generated by the parent)

(b) potential ways of solving problems (to be tried out during the next period and discussed at the following visit).

How much does it cost?

Not reported    

Where does the evidence come from?

Two RCTs:

  • One conducted in the USA with 73 participants (Bugental et al. 2002).
  • One conducted in the USA with 102 participants (Bugental & Schwartz 2009).

Further resources

Bugental et al. (2002), A cognitive approach to child abuse prevention. Journal of Family Psychology, Vol. 16, No. 3, pp. 243-258.

Bugental & Schwartz (2009), A cognitive approach to child mistreatment prevention among medically at-risk infants. Developmental Psychology, Vol. 45, No. 1, pp. 284-288.

Last updated:

16 Feb 2023

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