Introduction

Today I am going to tell you about the NSW Parent-Child Health and Wellbeing Project. This research project was funded for 3 years by the Commonwealth Department of Family and Community Services and the Aging and Disability Department. The aim of the project was to evaluate the effectiveness of a home learning program designed to teach parents with special learning needs about child health and home safety.

By "special learning needs" we mean parents who have intellectual disabilities or have been otherwise identified by service organisations as not responding to traditional teaching methods due to some cognitive limitation.

I will first give you a brief background to the project and tell you a little bit about the home learning program itself. I will then explain how we went about evaluating the program, and give a profile of the people who participated in the trial. Lastly, I’ll talk about the results of the trial and discuss the implications of these results.

Research has shown that parents who have special learning needs, are disproportionately represented in child protection services (Seagull & Sheurer, 1986; Taylor, Norman, Murphy, Jellinek, Quinn, Poitrast & Goshko, 1991; Tymchuk & Andron, 1990)

Their children are regarded as being at higher than average risk for both injury from accidents and serious illness caused by ineffectively met health care needs.

Many parents in the community need some assistance in learning to take care of the health and safety needs of their children. Resources are available to help them, however these are aimed at the general population and usually do not cater for parents with special needs. Programs tend to be conducted in groups, at community venues. They usually rely on reasonably complex verbal instructions and written material and require quite a bit of initiative on the parent’s part. International research suggests that these traditional methods are not effective with parents with special learning needs (Feldman, 1994). Recent research has also shown that with support and education matched to their learning needs, these parents can learn to provide effective health and safety care for their children.

In studies by Llewellyn and her colleagues, generic and specialist service providers in NSW voiced their concerns about the limitations of programs currently available for parents with special learning needs and talked about the lack of resources specifically designed for these parents.

The home learning program we trialled was developed and tested by Professor Alexander Tymchuk at the University of California Los Angeles and is the cumulation of 20-odd years of empirical research in the area. It is based on teaching principles which have been shown to be effective with people with special learning needs. These include that it is structured, it is taught on a one-to-one basis in the environment in which the skills will be used, it is practical, it has the flexibility to cater to individuals’ different needs and learning styles, it uses a variety of teaching modalities, provides opportunities for practice, and uses behavioural principles such as verbal and natural reinforcement.

The HLP is designed to be delivered weekly over 10 weeks by a trained parent educator in the parent’s home.

The UCLA program was modified for the NSWPCH&W project to eliminate language and cultural differences, to ensure consistency with Australian best practice, and to further reduce reliance on literacy by inclusion of more pictures.

Some lessons were far too long so we also modified lessons to reduce the time taken and to ensure that the most essential material was covered first.

Materials were prioritised based on the prevalence of problems in the area and the seriousness of the consequences of these problems. For example poison dangers are statistically common and potentially fatal and were therefore given high priority. Consideration was also given to the length of time needed for particular sections and how well parents had so far responded to the material.

To give you a brief idea of the contents of the home learning program: there are basically 2 sections, the first is on recognising symptoms of illness, knowing what to do about them, and how to prevent and deal with life threatening emergencies. The second section is about safety in and around the home and goes through common dangers to small children and how to prevent injury caused by these dangers.

The research project

The home learning program was trialled with 45 parents with special learning needs. These parents were randomly divided into 3 groups. Each group received the home learning program, but at different times. Parents were assessed approximately every 3 months. The research design allowed us to compare the results of the home learning program to three conditions —

1. No intervention from us— parents continued to receive any services they were currently receiving.
2. Non-program home visits — parents received a weekly home visit, but no teaching of the home learning program was provided.
3. Provision of program materials without face to face teaching — so every week parents would receive a workbook with the same information and pictures as used in the home learning program.

45 parents participated in the study from 40 families. The 5 fathers who participated were the partners of mothers who were also participating. Over half (57.5%) of families were 2 parent families and the average number of children per family was just over 2. All participants spoke fluent English.

Although three quarters of families were identified on referral as being known to child care and protection services, just a little over a quarter had actually had children removed at some time prior to the project (27.5%). Nearly half (45.5%) of these removed children had been subsequently restored prior to the project. In three-quarters (75%) of families all their children were currently living at home.

All families lived in the Sydney metropolitan area, the majority spread throughout the western suburbs.

Most families were residing in Department of Housing accommodation (57.5%) with a further 15% in some other non-market accommodation, such as in the home of a family member or in supported accommodation .

More than half (55%) of families relied entirely on social security payments for their income and all families who answered the question received some government allowances. Most participants described themselves as homemakers (86.7%).

The average IQ score in the group was tested at 72.6, with 71% of parents having an IQ of less than 80. 60% of parents had received some form of special education , most having been in a special class. The average reading age was less than 11 years.

Results

A variety of curriculum based measures were used to determine whether parents had acquired and maintained knowledge and skills.

1. Home dangers & precautions interview & observation

This is a checkist which is done partly by interviewing the parent, and partly by observation of the home environment. It gives a total number of precautions reported or observed to be implemented around the home. While some precautions are observable by the assessor, such as "scissors stored out of child’s reach", others rely on parent report and therefore represent a measure of knowledge rather than implementation of precautions. (eg "always supervises child in bath").

2. Home safety illustrations

Parents were asked to look at illustrations of different areas of the home (kitchen, bathroom, living room, bedroom, stairs and yard) and to identify all the dangers that they could see in the pictures. For each danger they identified they were asked what precautions could be taken for that danger. So there are 2 measures for this assessment — total dangers identified and total precautions.

3. Health measures

There were a number of health measures which were grouped together into 5 subgroups for analysis.

1. General knowledge: Understanding of health related words and body parts
2. Illness and symptom recognition: Knowledge about the symptoms of illness and common child health problems.
3. Going to the doctor: Knowledge about when to go to the doctor, what to tell and ask the doctor.
4. Using medicine: Knowledge about safe use of medicine
5. Life threatening emergencies: Knowledge about the different types of life threatening emergencies, their causes and ways to prevent them.

The data was analysed on 2 levels. Firstly, the groups were pooled and examined together. This demonstrated whether or not the program was effective overall (without providing between group comparisons).

Four scores were examined for each measure, which I’ll explain using the data from one measure.

Precautions identified

1. Baseline score — The score at the initial assessment, regardless of group.
2. Pre-HLP score — The score immediately prior to implementation of the home learning program (so depending on what group a parents were in, this could have been the initial assessment score or it could have been the score for the assessment performed 3 or 6 months later.
3. Post-HLP score — The score immediately after completion of the home learning program.
4. Follow-up score — The score 3 months after completion of the hlp (if possible — 17 participants)

This graph is of the scores for precautions identified or observed in the parent’s home in the Home dangers & precautions interview & observation checklist.

This line between the baseline and pre-HLP scores represents the increase in score that occurred prior to the home learning program for the people in groups 2 & 3. During this time, group 2 received the non-program home visits and group 3 received first nothing at all, then the program materials only. As you can see, there was a slight increase in scores prior to the home learning program. This was the only measure in which the change prior to HLP was, in fact, found to be significant using a repeated measures analysis of variance. It is obvious from this chart however, the increase after the HLP was considerably greater. Our hypothesis is that the increase in precautions prior to HLP may have been partly due to an assessment effect — so having been asked all sorts of questions about precautions they take in the home might have, in itself, increased parents’ knowledge and perhaps even stimulated them to take more precautions. You can see that there is a slight drop off in precautions scores at 3 month follow up, however this was not significant.

Using the same analysis on the other measures yielded similar results but without the significant pre-HLP difference. For all the other measures the only significant change occurred when the home learning program was implemented.

The second type of analysis we did on our data was a more sophisticated analysis to compare the 3 groups. For this we used a multiple analysis of variance with planned orthogonal contrasts and Bonferoni adjustment — (An adjusted significance level from .05 to .017 because we had to repeat the test 3 times to get all the contrasts we wanted).

This looks at the differences between the way the 3 groups changed over time. We could see just from looking at our data that when the home learning program was implemented for each group, there was an improvement in scores on all our measures. We could also see that these improvements were greater than any improvements that occurred for the groups who had not received the HLP yet but had been subject to the other conditions (non-program home visits, program materials or no intervention). The statistical measure we used was to let us see whether the difference between change due to the home learning program and the changes due to other conditions, was actually statistically significant.

So without going into too much detail, for each measure (eg precautions identified, life threatening emergencies etc), we compared the change that occurred after a group received the home learning program, to the changes that occurred for the other groups, after home visiting, materials only and no intervention.

Unfortunately the statistical power of our analysis was not great. Statistical power is the ability of an analysis to detect significant differences and is determined by the sample size and the sensitivity of the measure. Our sample size was small — only 45 - which meant that any differences had to be very large to be found to be statistically significant.

Despite this, a number of significant differences were found.

Basically there were 3 different patterns.

Between groups

Pattern 1 —

There were significant differences between HLP and each of the other 3 conditions.

This pattern was seen in 4 of the 8 measures.

Pattern 2 —

There were significant difference between HLP and home visiting and between the HLP and no intervention, but no significant difference between HLP and project materials.

This pattern was seen in 2 of the 8 measures.

Pattern 3 —

A significant difference was found between HLP and project materials only and not when HLP was compared to home visiting or no intervention.

This pattern was also seen in 2 of the 8 measures.

As I said, rather than being discouraged by the non-significant results, we were extremely pleased that so many of the comparisons did yield significant results given the small size of our groups.

Overall, the results from the trial of the home learning program were extremely positive and certainly suggest that we have a useful tool for helping parents with special learning needs to learn to take care of the health and safety needs of their children. Along with our statistical data, we also collected a lot of qualitative data from parents and parent educators and this has been used to further improve the program. Improvements include such things as more pictures, reduced basic lesson time, greater flexibility to cater for parents’ different circumstances and learning needs, and development of different levels of difficulty for some materials to accommodate a greater range of abilities.

We are also currently developing a program for potential parent educators. This will provide training in implementation of the home learning program as well as background knowledge and skills. Negotiations with the Department of Aging and Disability will hopefully result in the home learning program and associated parent educator training being made available to service providers in the near future.