The Board of Health submits the report (September 3, 1997) from the Medical Officer of Health:
Origin: Medical Officer of Health, August 27, 1997 (p:\1997\ug\cms\hld\hl970076.hld)
1. That this report be adopted by the Board of Health and forwarded to the Toronto Transition Team, the Board of Health of the new City of Toronto, and the new City of Toronto Council with the recommendation that the Parents Helping Parents program be continued and expanded to other communities with similar needs within the new City of Toronto;
2. That this report be distributed to all health units in Ontario and the Ministry of Health..
3. That this report be forwarded to the Metropolitan Toronto Community Services Department and to Caroline DiGiovanni, Chair, Metro Task Force on Services forYoung Children and Families.
4. That periodic needs assessments be undertaken to determine the changing needs of ethno-cultural communities at risk in the new Toronto and ensure their access to the program.
5. That planning for the Parents Helping Parents program be closely coordinated with development of the new Healthy Babies, Healthy Children Program.
Toronto Public Health's Parents Helping Parents (PHP) program is an innovative primary prevention program intended to promote the development of healthy children by delivering necessary information and support to families who are at risk of providing inadequate parenting skills due to socio-economic stresses and/or language/cultural barriers. In operation since 1983, the program is offered to clients in their homes. It employs experienced mothers of the community as Home Visitors, pairing clients with Home Visitors on the basis of ethno-linguistic background. At present, the program serves Aboriginal, Tamil, Vietnamese, Portuguese, Spanish, Chinese, South Asian, Somali and West Indian communities. Home Visitors receive training, direction and support from Public Health Nurses.
A quasi-experimental design was employed to test the impact of the PHP program, utilizing the Home Observation for Measurement of the Environment (HOME) inventory, and the Everyday Stressors Index (ESI) as outcome measures. Pre- and post-intervention scores obtained on these measures from an ethnically diverse group of PHP mothers were statistically compared. Post-intervention results of these PHP mothers were also compared to scores obtained from a comparison group of mothers recruited through Community Health Centres who had not participated in the PHP program. In general, results suggest that PHP does make a difference.
The current PHP program promotes improved parent-child interaction and enables parents to more easily cope with the day-to-day stresses in their lives. In turn, these improvements to the family's psycho-social environment are enabling to the healthy development of the whole child.
Toronto Public Health's Parents Helping Parents (PHP) program is an innovative primary prevention program intended to promote the development of healthy children by delivering necessary information and support to families who may be isolated and at risk of demonstrating inadequate parenting skills due to socio-economic stresses and/or language/cultural barriers. During 1994-95, an evaluation of PHP was undertaken in an attempt to assess the impact of the program on selected outcomes. Several aspects of the evaluation, including a qualitative component, were exploratory in nature. This report presents results obtained from one aspect of the evaluation: a quasi-experimental investigation into the impact of PHP on mothers' perceptions of stress, and on the capacity of the home environment to support the development of healthy children.
Following is a brief introduction to the PHP program. A review of related literature and a detailed description of the PHP program then precede the presentation of results from the research investigation.
The PHP program was implemented in 1983 in response to a number of converging factors: the belief on the part of a City of Toronto Public Health psychologist that many of the behavioural, cognitive, language and physical problems that were in abundant evidence in Toronto's daycare centres were preventable; the identification of parent-child health as a program priority at Toronto Public Health; and, the growing numbers of non-English speaking immigrants, representing diverse cultural backgrounds, residing in Toronto (City of Toronto, 1987).
PHP is offered to clients in their homes by visiting paraprofessionals who are themselves mothers in the community. These Home Visitors provide parents with information and training regarding age-appropriate activities for their child, as well as information on nutrition, safety, health care, dental care, and family planning. They also offer social support and assist families in accessing community resources. Clients are paired with Home Visitors on the basis of ethno-linguistic background. At present, the program serves Aboriginal, Tamil, Vietnamese, Portuguese, Spanish, Chinese, South Asian, Somali and West Indian communities. Public Health Nurses direct the work of the Home Visitors, and provide them with ongoing training, advice and support.
Historically, Parents Helping Parents was the first program of its kind in Ontario. In recent years, home visiting by paraprofessionals, utilizing the Parents Helping Parents delivery model, has proliferated as a prenatal and/or postnatal intervention. Babies Best Start, initiated in Scarborough in 1991, is a primary prevention program delivered by community mothers from a variety of ethnocultural groups who are trained in child development and child management. At the same time, Parents for Better Beginnings in the Regent Park/Moss Park area in Toronto secured funding to begin their program. The City of Toronto, Department of Public Health was involved in the development and continues to play an on-going supportive role in this program.
In April 1997, the provincial government announced a $10 million Healthy Babies, Healthy Children Program, to be led jointly by the Ministries of Health and Community and Social Services. Boards of Health will work in partnerships with the Ministry of Community and Social Services and community partners to develop a coordinated system of early identification, assessment and referral services for children to age two.
The City of Toronto Parents Helping Parents program has served as the model for this recently announced provincial initiative but it is a separate and complementary program which provides a higher level of intervention for those at highest risk.
Background to Early Childhood Interventions
Early intervention programs aimed at preventing abnormal child development during infancy and early childhood evolved during the 1960s, following the lead of Hunt (1961) and Bloom (1964), who both stressed the importance of environmental circumstances and events during the early years as being crucial to a child's capacity for intellectual development (Shonkoff & Meisels, 1990). In the U.S., The Head Start programs grew directly out of this perspective, and were based on findings of a high incidence of developmental delays, at the time of school entry, among children living in poverty. Thus, Head Start programs targeted low-income children, providing them with extra support to develop and enhance their cognitive and social abilities (Murphy, 1990). In general, programs initiated during the 1960s represented postnatal interventions and focussed on parent training or direct teaching of infants and toddlers. Measured outcomes tended to focus on developmental and/or intelligence quotients (DQ/IQ), with some long term follow-up of school achievement (Halpern, 1984).
Starting in the 1970s and carrying through into the 1980s, the focus of early intervention programs expanded to include such issues as preventive mental health (especially related to child abuse and neglect), and maternal and child health. Some of the programs in the 1970s broadened the intervention focus to include the family environment and the nature of the mother-infant interaction as targets for positive change. Accordingly, the types of outcome measures expanded to include, for example, the conduciveness of the home environment to healthy developmental outcomes, and parent-infant attachment (Caldwell & Bradley, 1979).
Now, in the 1990s, the evidence linking socio-economic status at birth to social, educational and health-related outcomes throughout childhood and adulthood is well established (Roberts, 1997). Thus, early childhood interventions designed to improve developmental outcomes, to some extent, are actually determinants of outcomes in adulthood. This long range trajectory can be described as a pathways model, which takes into account "the cumulative effect of life events along developmental trajectories" (Power & Hertzman, 1997, p. 211). Thus, "the focus on cognitive and social-emotional functioning is relevant because of its connection to school readiness. School readiness, in turn, is important because the complex web of early academic failure and early school misbehaviour is associated with lack of school readiness and in turn, strongly predictive of school failure, employability, criminality, and psychological morbidity in young adulthood" (Power, et al., 1997, p. 217). Based on a review of research, these authors conclude that while early intervention programs cannot fully overcome conditions associated with socio-economic disadvantage, evidence suggests that well-designed early intervention programs with sufficient intensity, duration and parental involvement can be successful at improving childrens' opportunities for later success in life.
Models of Intervention
PHP is premised on a combination of theory and practice from both the field of early childhood intervention and the parent support movement. Respectively, these traditions are embodied by the professional perspective provided by the PHN, and the grassroots empowerment offered by the peer Home Visitor. During the 1970s, both of these traditions experienced a shift from a child-oriented perspective to one rooted in the ecology of the family and the community with concomitant changes in service delivery from child-centred program models to those with a child/ family/ community orientation (Weissbourd & Kagan, 1989; Zigler, 1990; Zigler & Black, 1989).
The ecological model assumes a systems approach to the child within the family within the community. "On a practical level, (it) leads the home visitor to examine simultaneously maternal personal resources, social support, and stresses in the home, family, and community that can facilitate or interfere with optimal health-related behaviours during pregnancy and subsequent care of the child" (Olds & Kitzman, 1990, p. 109). Programs based on an ecological model recognize the need to offer both education and social support as part of an encompassing and meaningful intervention that aims to impact on the context and content of parent-child interactions. PHP is one such program.
Findings from Home Visiting Research
In general, the belief that appropriate early interventions can prevent developmental delays and promote optimal child development outcomes is well-established. But, while pre- and postnatal interventions that employ a home visiting component have become widely accepted in practice, evidence of their efficacy has been somewhat equivocal (Olds & Kitzman, 1993). This has been, at least in part, due to the fact that home visiting programs tend to represent a range of target populations, program details and outcomes which then prohibit direct comparisons and confuse the interpretation of results. Also, achieving adequate integrity of research design in field settings (i.e. randomized controlled trials) is not always possible, and adequate control of possible confounding variables is not always exercised (for a discussion of methodological issues see, for example, Douglas & Wade, 1997).
However, despite methodological issues, several recent (overlapping) reviews of home visiting research find support for the effectiveness of postnatal home visiting programs (Ciliska, et al., 1994; Olds, et al., 1993; Olds, et al., 1990). Ciliska et al. (1994), in a systematic review of the literature on home visiting as a delivery strategy for public health programs, concluded that: "...the studies have demonstrated a positive impact of home visiting on physical health, mental health and development, social health, health habits, knowledge and service utilization" (p. 20). In terms of specific factors related to program effectiveness, the authors identified: intensity of intervention, risk status of client, and the apparent additive nature of intervention impacts. Olds et al. (1990), concluded that programs with the greatest chances of success share three major characteristics: they are based on an ecological model of the family; they encourage the development of a "therapeutic alliance" (p. 113) between the client and the home visitor through frequency and duration of home visits pre- and postnatally; and, they are targeted "on families at greater risk for maternal and child health problems by virtue of their poverty and lack of personal and social resources" (p. 114).
Typically, the effects of the use of paraprofessionals as home visitors have not been isolated for study. However, it would seem that the use of paraprofessionals often coincides with both a narrow program focus and a subsequent lack of program effect. While this outcome may be attributed to the use of paraprofessionals, it could be that the program itself is lacking (Olds, et al., 1993). As an exception to this general finding, a Jamaican study of professionally supervised paraprofessional home visitors in a program similar to PHP, found significant effects in terms of improvements in child development outcomes (Powell & Grantham-McGregor, 1989). However, this intervention also included frequent visitations over time, and the target population was more socio-economically deprived than their U.S. counterparts in comparable interventions (Olds, et al., 1990).
A third recent systematic review of literature focussed specifically on the use of paraprofessionals as home visitors in promoting positive maternal and child health outcomes (Douglas, et al., 1997). The authors conclude that programs utilizing paraprofessionals can be successful, and they summarize the significant aspects of successful programs as follows: intensive long term home visiting; extensive training for home visitors; ongoing supervision of home visitors by professionals; and, individualized curriculum based on clients' needs.
Parents Helping Parents - Program Description
In addition to representing an ecological approach to intervention, PHP comprises many of the other elements identified as typifying successful intervention programs:
1. It is home-based, providing the opportunity for one-to-one interaction between the client and the Home Visitor in the client's own environment. This choice of venue also allows the Home Visitor to gain an appreciation of the client's day-to-day life in its lived context.
2. It is ethnically and linguistically diverse. Both clients and Home Visitors are recruited from a range of ethno-cultural groups. Visits are conducted in the client's language of origin by Home Visitors who share the client's cultural background. Currently, the program serves the following ethno-cultural groups: Aboriginal, Tamil, Vietnamese, Portuguese, Spanish, Chinese, South Asian, Somali and West Indian.
3. PHP families are considered to be at high risk. Eligible families experience a number of socio-economic stresses and/or ethno-linguistic barriers which may interfere with normal parenting and result in developmental delays for the child.
4. Home Visitors are experienced mothers selected from the target ethnic communities. They receive training in child development and parenting techniques from Public Health Nurses.
5. Home Visitors serve as peer instructors and advocates. These lay visitors receive training in child development and parenting techniques in order to provide information and skills to PHP mothers. They also provide social support, and information and assistance pertaining to the access of community resources.
6. PHP clients are actively involved, willing participants in the program. The mothers are taught infant stimulation exercises which they are encouraged to practice with the child between visits.
7. Infant stimulation is a key activity of the program. The child receives appropriate stimulation both during the home visits and from the mother between visits.
8. Public Health Nurses provide advice and support to the Home Visitors in the areas of case management and program implementation.
Several of the above key program elements are reflected in the client eligibility criteria. That is, potential clients must demonstrate a willingness to participate in the program; they must represent one of the ethno-cultural groups served by the program; and, they must be considered to be at increased risk due to socio-economic stresses and/or ethno-linguistic barriers. In addition, clients must be City of Toronto residents with an infant under 9 months of age. They cannot currently be involved in other infant/child stimulation programs; and, they must lack parental skills and knowledge about infant/child developmental needs. Finally, parents should not be in a 'crisis' situation that would prevent them from participating in program activities. (City of Toronto, 1995). Clients can remain in the program until their child reaches three years of age.
At present, there are eight full-time Home Visitors employed by the City. They receive 15 days of initial training, and continue to receive on-the-job training and support through a Public Health Nurse/Home Visitor 'buddy' system. Each Home Visitor has a caseload of 15 to 20 families from her own ethno-cultural community. In general, families are visited once weekly during the first year; bi-weekly during the second year; and monthly during the third and final year of participation. Each visit lasts between 45 minutes and one hour. This schedule is open to modification based on a family's particular needs. On average, 150 to 200 families per year have participated in the PHP program in recent years.
Role of the Public Health Nurse
Public Health Nurses are members of the PHP Coordinating Committee, and participate in activities such as case discussions; revising and updating of policies, procedures and forms; orientation of new staff; the promotion of the program in the community; and data collection. At the program level, they provide direction and support to the Home Visitors, including review of client referrals; periodic visiting with clients; regular consulting with Home Visitors regarding cases and program planning; assessment and monitoring of parent and child progress.
The program employs a number of widely used client assessment tools including the Everyday Stressors Index (ESI) and the Home Observation for Measurement of the Environment (HOME) inventory. The Everyday Stressors Index (ESI) covers such problems as financial concerns, role overload, parenting worries, employment problems, and interpersonal conflict (Hall, 1983). The Home Observation for Measurement of the Environment (HOME) inventory (Caldwell & Bradley, 1979) measures the conduciveness of the home environment to healthy child development in cognitive, emotional, physical and social realms. It includes items which measure mother-infant attachment. It was introduced into the protocol of the PHP program in 1986 in an attempt "to gain some impression of parental competence in providing for the learning needs of children" (City of Toronto, 1987, p. 11). Both the ESI and HOME inventory are typically administered pre-, mid-, and post-intervention to PHP clients. Home visitors administer the ESI, while PHNs are responsible for collecting HOME data.
PHP - Related Results from an Earlier Evaluation
A 1987 evaluation of the PHP program compared HOME scores of clients at the beginning, mid-point and end of the program within a PHP group, and between this group and a comparison group. Results indicated a gradual increase on HOME scores the longer clients were in the program. Also, the scores of PHP participants at the beginning of the program were identical to those of the comparison group with 17% of each group scoring low enough to be considered at risk of developmental delays. By the end of the program, none of the PHP clients were at risk on the basis of HOME scores (City of Toronto, 1987).
PHP - The Current Investigation
Unfortunately, an analysis of long term child development outcomes was beyond the scope of this investigation. Thus, the specific questions of interest were :
1. Does participation in the PHP program enable families to better cope with daily stressors?
2. Does the PHP program support the development of a home environment that is conducive to positive parent-child relationships and healthy child development outcomes?
A quasi-experimental research design was employed. Investigation of the potential impact of PHP on the ability to cope with daily stressors proceeded by means of a comparison of pre- and post-intervention ESI scores among PHP participants. To address the second question, program participants' pre- and post-intervention HOME scores were compared. Additionally, the post-intervention HOME scores of PHP participants were compared to HOME scores of a comparison group (CG) of non-participants.
Sample Eligibility and Selection
While the PHP program is offered to both men and women, women are the primary focus of the program, thus, only mothers were recruited for this study. Further, only mothers whose child was neither of low birth weight (less than 2500 grams),nor had a congenital defect, was admitted into the study.
Criteria for the selection of the PHP sample included membership in one of the ethno-cultural minority groups served by the PHP program. CG participants were recruited from Community Health Centres (CHCs) that serve high risk, low-income, multi-cultural clientele residing within the City of Toronto. In an effort to control for the potential effect of ethnicity, the attempt was made to recruit a CG with proportionately similar levels of ethnic representation as the intervention (PHP) group. Also, in keeping with the PHP program eligibility requirements,
CG participants could not be involved in programs pertaining to infant stimulation or parenting skills; nor could they be involved with child protection service agencies. As a further measure to create comparable groups, both PHP clients and CG participants were chosen from the same health areas of the City.
Finally, all children who participated in this study were required to be between the ages of 18 months and three years. Given that families are accepted into the PHP program up until the time their child is 9 months of age, the decision to set a minimum age requirement of 18 months would ensure that at least 9 months had passed between the administration of pre- and post-intervention measures and thus increase the likelihood of detecting a treatment effect. Also, in terms of accessing comparison group participants, 18 months of age is the time at which children would be attending their local CHC for a booster shot, and two years of age is the recommended age for a medical check-up. Thus, access to CG participants would be improved.
All current PHP clients who met the eligibility criteria were approached by their HV to participate in this study. CG participants were chosen from CHCs' patient rosters according to the eligibility criteria established for the study.
Data Collection Instruments
Everyday Stressors Index (ESI)
The ESI (Hall, 1983) was developed to assess the extent to which day-to-day problems that are common to low-income mothers with young children are experienced as sources of stress. It consists of 20 items that utilize a 4 point Likert-type scale with score range of 0 to 3 per item, and total scale score range from 0 to 60. Items refer to possible stressors in environmental (basics), interpersonal, personal and health-related contexts. Examples include: 'Problems with housing' (environmental); 'Problems with friends and neighbours' (interpersonal); 'Having too many responsibilities' (personal); and, 'Concerns about your children's health' (health). Respondents are asked to indicate verbally the extent to which these issues bother them, and responses are recorded by the interviewer. High scores indicate high levels of stress.
Home Observation of the Environment (HOME) Inventory
The HOME inventory is a behavioural checklist that consists of 45 statements, and 6 subscales, that describe various aspects of family life and the home environment. The statements require simple agreement or
disagreement, and are scored as 1 ('yes') or 0 ('no'), for a possible total score range of 0 to 45. Items are
positively keyed with high scores indicating an environment supportive of child development. Interviewers complete the HOME inventory outside of the presence of the client, following a sufficient number of visits to gather the requisite information through a combination of direct observation and client interview.
The content areas of the subscales are as follows: emotional and verbal responsivity of mother, avoidance of restriction and punishment, organization of environment, provision of appropriate play materials, maternal involvement with the child, and opportunities for variety in daily routine. Item examples, corresponding to the preceding order of subscales, include: 'Mother caresses or kisses child at least once during visit'; Mother does not shout at child during visit'; 'Child's play environment appears safe and free from hazards'; 'Child has a manipulative toy'; 'Mother "talks" to child while doing her work'; and, 'Father provides some caregiving'.
The scoring key provides five interpretive categories for scores obtained, ranging from 'at-risk' (total score up to 24) through to 'excellent' (score 37 to 45). Low total scores have been predictive of poor academic performance (Stevens and Baheman, 1985). The HOME inventory has been shown to predict language development, intellectual performance and academic achievement in the early school years (Bee, et al., 1982; Gottfried, 1984). HOME scores for children at 24 months of age correlate (+.70) with the 36 month Stanford Binet Intelligence Test (Caldwell, et al., 1979).
While the validity of the ESI and HOME was established by their respective developers with samples similar to the population of interest in some of its features, a focus group conducted with past and present PHP staff helped to confirm the scales' apparent appropriateness (i.e., face validity) for use with the PHP population. As well, a questionnaire was designed to collect demographic information from all study participants.
Since the ESI and HOME Inventory are measures used for the assessment at entry of PHP clients, these original scores were used as the pre-intervention, or baseline measures for the PHP group. The post-intervention phase of data collection occurred over a 12 month period beginning in March 1994. During this time, ESI and HOME inventory data were collected from both the PHP group and the CG by trained interviewers. Interviewers were blind to the participant's group designation.
A total of seven interviewers participated in the collection of data; one interviewer was assigned to each ethno-cultural group. The interviewers were women who had experience as home visitors in programs similar to PHP, who spoke the language of their ethno-cultural community, and who were not relatives or friends of the PHP's home visiting staff. Interviewers attended two training sessions conducted by the Toronto Public Health program evaluation committee.
Study participants were each interviewed in their homes on three different occasions at, approximately, one week intervals. The first meeting provided an opportunity for the interviewer and participant to become acquainted, and for the participant to provide her informed consent. During the second interview, the ESI and the demographic questionnaire were completed.
Information for the HOME Inventory was collected during all three visits. Since this inventory requires numerous observations of the mother's interactions with the child and of the child's home environment, three visits were considered necessary to gather this information, according to the PHP planning committee, based on their experience with PHP clients. Recording of the HOME data occurred after the interviews, since it is designed to be completed in the absence of the client.
An honorarium of $10 and a gift of baby products were given to both the PHP and comparison group participants in an attempt to encourage participation and reduce attrition.
The main threats to the integrity of the results from this study are those that are inherent to quasi-experimental design, including the effects of history and maturation. Attempts to counter such problems included group matching efforts at the recruitment stage, and the enlistment of additional statistical procedures to further control for group differences. But without randomization and/or pre-test results for the CG, it is possible that important differences between the groups remain. As well, statistical data to support the use of the ESI and HOME scales with multi-ethnic populations are lacking.
In total, the study was comprised of 29 PHP participants and 43 CG participants. A larger sample would provide greater assurance that any statistically significant effects observed represent true treatment effects. The mean ages of PHP and CG mothers were 31.2 and 32.1 years, respectively. The infants' mean ages at the time of this study were 26.8 (PHP) and 28.4 (CG) months.
While PHP and CG participants were similar on most demographic and socioeconomic indicators, there were some differences of note. In particular, the PHP clients had fewer children than CG participants (means, 1.6 vs. 2.7). Fewer PHP clients had experience raising children of their own or others (41% PHP vs. 77% CG) and fewer had attended a prenatal program (21% vs. 44%). Also, PHP clients indicated lower levels of confidence in their parenting. And though attempts were made to include each ethnicity in equal proportion in the two groups, this balance was not achieved.
Analysis of Research Questions
1. Does participation in the PHP program enable families to better cope with daily stressors?
A paired t-test was used to compare the difference between pre- and post-intervention scores on the ESI for PHP participants. The decrease in scores was statistically significant (p<.02) with an average difference in mean scores of 5.13 (total score range 0 to 60). This finding suggests that participation in PHP may help to moderate mothers' feelings of distress regarding day-to-day problems.
2. Does the PHP program support the development of a home environment that is conducive to positive parent-child relationships and healthy child development outcomes?
Paired t-tests, which controlled for the effects of maturation, were used to determine the magnitude and direction of within-group (i.e., PHP) differences on the HOME inventory (full scale and subscales), pre- and post-intervention. The increase in the full scale score (4.7 points, total score range 0 to 45) was statistically significant (p<.01), as were increases in scores on four subscales. It would appear that scores did not exhibit significant change on the 'emotional responsivity of mother' subscale because the original scores were already relatively high (11 point subscale, unadjusted mean = 8.5).
An examination of changes to 1st quartile and median total scale scores of the PHP group is also revealing. The pre-intervention 1st quartile score was 21 (i.e., 'at risk'), with a median of 26.5. At post-test, these scores had increased to 31 and 36, respectively. Given that the PHP group was not a true 'end of program' (i.e., three year) group, but rather a group representing variable lengths of time in the program, one would assume that this change, while substantial, is itself diluted relative to an end of program measure.
In the case of the subscale, 'avoidance of restriction', an unexpected decrease in scores was statistically significant (diff = -1.06, p<.01). This means that the likelihood of a parent resorting to restriction or punishment was greater at the time of post-test. However, perhaps this finding should not be unexpected, given that the conditions under which a parent might restrict or punish a child are likely to arise with greater frequency as a child grows and becomes more active.
Post-intervention full scale HOME scores of PHP participants were also compared to CG HOME scores through the use of a multiple linear regression model, controlling for the effects of confounding variables. The mean HOME score of PHP participants was higher than that of the CG by 3.80 points and approached statistical significance (p=.057).
These findings, regarding a general increase in HOME scores for PHP participants, suggest that PHP makes a positive difference to parent-child interactions and the family life environment as measured by the HOME inventory.
Methodological limitations notwithstanding, the results from the preceding analyses of ESI and HOME scores provide evidence to support the ability of PHP to help parents cope with the stresses of daily life and create a psycho-social family environment that is conducive to healthy child development. The findings from the HOME inventory scores are in keeping with those reported by Ashem & Kurz (City of Toronto, 1987).
The PHP program, in large part, comprises the program components observed in the more successful early childhood home visitation programs. These include the adoption of an ecological perspective toward program development and implementation; the targeting of families at increased risk due to limited economic, personal and social resources, the development of a therapeutic alliance between the Home Visitor and the client based on high frequency and duration of visits (Olds, et al., 1990); and, well-trained paraprofessional Home Visitors who are supervised by Public Health Nurses (Douglas, et al., 1997).
This successful innovative primary prevention program which has been in operation since 1983 was the first program of its kind in Ontario. Since then similar programs have been initiated utilizing the Parents Helping Parents delivery model. In April 1997, the provincial government announced a $10 million Healthy Babies, Healthy Children Program, in which Boards of Health will work in partnerships with the Ministry of Community and Social Services and community partners to develop a coordinated system of early identification, assessment and referral services for children to age two. However, it is acknowledged that this is insufficient financing for this target group. The City of Toronto Parents Helping Parents program has served as a model for this recently announced provincial initiative, but it is a separate and complementary program which provides a higher level of intervention for those most at risk. The Parents Helping Parents program should continue and be expanded to other communities in need in the new City of Toronto.
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