The Hawaii Healthy Start Program

Healthy Start engages families who face multiple stresses right from the start, when a child is expected or born.  Supportive Healthy Start home visits focus on strengthening the family, reducing risk factors and  enhancing  protective factors, such as promoting parent infant attachment, the parent’s understanding of normal stages of child development. Staff seek to promote  healthy growth and development of the child.


Services include:

  • Program staff visit families either before birth or in the hospital after delivery, to screen families to determine  needs and risk levels,  and engage families in need of services into the home visiting program in their community.
  • Families receive social-emotional support, assistance in identifying and planning to reach family goals, obtaining material supplies such as food, clothing, household furnishing as needed, support in bonding and interacting with their infant, information on what to expect related to phases of early childhood development, mentoring in parenting skills and life coping skills, assistance with housing and employment and a listening ear when needed.
  • The family support worker assists the family in finding a “medical home” for the infant, encourages immunizations, and conducts periodic developmental screening with referrals for any developmental delays. A clinical specialist is available to work with the family on issues related to problems in parent-child attachment, domestic violence, substance abuse and mental health problems.
  • The family is supported in becoming more self-reliant and able to provide a safe, nurturing home environment for their children.


  • The Hawaii State legislature funded a Healthy Start pilot project in the Ewa community in Leeward Oahu from 1985-1988; there were no cases of abuse and only 4 cases of mild medical neglect among 241 families served during this period.
  • Based on this outcome, the program was incrementally expanded through funding appropriated by the Hawaii State Legislature, beginning with highest risk communities and finally statewide in 2000, under the mandate of the Felix Consent Decree for children’s mental health services.
  • The program has been conducted through a public-private partnership involving the Department of Health, Maternal Child Health Branch and six private agencies (DOH program status report, 2009).
  • Since major cuts to the program in 2008-2009, the new state administration has worked to re-establish a home visiting program involving several home visiting models, and the Governor has verbally committed to re-establishing Healthy Start.  Advocates  see  re-instatement of Healthy Start as most critical for families at highest levels of risk and need state-wide , within a network of home visiting services to meet other levels of family need.
  • The Department of Health received a highly competitive federal Evidence Based Quality Improvement grant, which has resulted in additional improvements to the program to ensure alignment with current evidence based practice.
  • The Department has also received around $7 million in home visiting funds under the Affordable Health Care Act, which are being used to re-build a home visiting network comprised of several models of home visiting services which will now accept referrals through the hospital screening process at birth.
  • The Department is re-establishing the hospital based screening services in several communities, and there are hopes of re-establishing Healthy Start services in most communities with capacity to serve those most in need of support.

Evaluation Summary

  • Program data has consistently shown no confirmed abuse or neglect for over 99% of families over the years. This compares very favorably with confirmed reports for low-income families nationwide. According to the Federal Inter-agency Forum on Child and Family Statistics (“America’s Children: Key National Indicators of Well Being”, (1997): the confirmed maltreatment rate for families with incomes $15,000-30,000 was 20/1000 or 2.0%. For families with incomes of <$15,000, rates were 47/1000 or 4.7% of families. Most Healthy Start families have incomes of under $30,000, and many earn less than $15,000. Comparing a 1% abuse rate for Healthy Start served families with 2%  to 4.7% for low income families suggests significant success for Healthy Start.
  • In 2009, of the 1% of abuse cases that were confirmed among families served for at least 12 months, most were found to have been confirmed for threatened harm rather than actual abuse/neglect. The few actual maltreatment cases identified were not severe abuse or neglect. This indicates that Healthy Start was quite successful in averting abuse, especially serious abuse and neglect.
  • A  study was conducted at Kapiolani Medical Center (1991-1994), which cross-referenced data on families who had been screened for risk of child abuse and neglect with data on children hospitalized for abuse and neglect.  The rate of hospitalization for high risk families not served was 4 times the rate for high risk families served.

Randomized Control Trial

Johns Hopkins University conducted a 10 year longitudinal study of Hawaii Healthy Start.  Results in Year I and II are quoted from “Evaluation of Hawaii’s Healthy Start” (PDF) (  The initial results at 1-2 years did show some significant differences between served and control group  families:

  •  Confirmed abuse reports for  HS families was 1%; control group was 2%. Many of these reports were for threatened harm; apparently no abuse;
  • Healthy Start mothers showed greater use of non-violent discipline;
  • Healthy Start mothers showed less psychological aggression;
  • The incidence rate for domestic violence was 28% versus 56% for control families;
  • Healthy Start mothers had significantly less depression.
  • H.S. violent fathers spent less time with children than non-violent fathers;
  • While the dropout rate was higher than expected, very high risk families tended to stay in service for at least 12 visits;  they were not the most likely to drop out.

The 10 year outcomes revealed substantial benefits for a key subset of targeted families, as shared with Healthy Start providers in a memo by Johns Hopkins evaluators. These benefits became evident when organizing family data by the attachment category for the mother and infant, which included securely attached, anxiously attached and avoidant-attached pairs. Quoting from  the Johns Hopkins report, the greatest benefits were for anxiously attached pairs:

  • “Benefits extended to both mothers and children.
  • Benefits were sustained years after families had been in the Healthy Start program.
  • Benefits extended across a range of health, parenting and child developmental outcomes. These benefits translate to cost savings for health, welfare and special education services.  For example, in this subset of the served families:
    • Fewer mothers were depressed: Only 31% of HSP mothers compared with 68% of control group mothers were depressed.
    • Healthy Start children experienced less abuse and neglect. Only 9% of HSP families vs. 20% of control group families had a substantiated report of abuse or neglect by 3rdgrade.
    • Healthy Start children performed better in school: 32% of HSP children vs. 54% of control children scored below norms for academic achievement.”

The Johns Hopkins study also showed that occurrence of domestic violence was 50% lower for Healthy Start families than for control group families after several years of service.

These findings are very significant, particularly as the results were long lasting ,compared with the results of nationally acclaimed Head Start programs. Those programs had excellent outcomes; however, the results faded a few years after program completion. The difference could be in that Healthy Start interventions occurred earlier, during the time period when the brain and emotional systems are being initially structured.

These findings are also of great relevance for future program development and research. The Johns Hopkins researchers concluded that despite other risk factors, the securely attached mothers and infants did fairly well without intensive services. The avoidant attached pairs did not respond well to the program, which suggests the need for further demonstration on interventions to develop strategies to engage and work more successfully with these families.  The fact that most gains were in the category of anxiously attached pairs suggests a need to ensure enrollment of these families.

Current Program

As already noted, the former state administration did not release legislatively appropriated funding for the programs in 2009, thus eliminating the hospital-based screening program and leaving only programs in Ewa/Leeward Oahu and Hilo/Puna, Hawaii.

As also noted, the Hawaii Department of Health was awarded a highly competitive Evidence Based Home Visiting grant award over 5 years to participate with other grantees to explore and implement evidence based program improvements. Staff have focused on model fidelity, reflective supervision and  manualizing the Nurturing Program to promote positive parent child relationships.  The program will participate in a nationwide evaluation utilizing the recently published Federal Benchmarks for home visiting services. as previously noted, Hawaii is participating in the national level MIECHV home visiting initiative, funded through the Affordable Health CAr Act.  The state has successfully sought and been awarded a total of about $7  million in federal funds for program development. This work is focused primarily on training, re-establishing the hospital based screening and integrating other home visiting services into a new statewide network as well as re-establishing Healthy Start services in Kalihi and some capacity on Kauai.


Hilo Healthy Start is conducted by the Hawaii Island YWCA, Family Support Services

Program Director: Andy Kahili


Ewa Healthy Start: services are provided by Child and Family Service

Agency Director: Howard Garval,

Program Director: Jodi Aiu,


For further information, contact

Cindy Hirai, DOH Program Manager 733-9042,

Gail Breakey, Executive Director, Hawaii Family Support Institute,

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