Enrollment and Retention in Voluntary Home Visiting Programs

1. Enrollment and Retention in Voluntary Home Visiting Programs Deborah Daro

2. Challenges in attracting and retaining families in voluntary prevention programs is long standing. As policy interests shift to achieving measurable population level change in critical outcome areas, greater emphasis is being placed on successfully engaging a broader segment of the at-risk population. Research on the issue has identified a number of participant, provider and contextual characteristics that impact enrollment and retention. Programs need intentional strategies to improve performance in this area. Main Points

3. Understanding Engagement and Enrollment

4. Roughly one-third of participants drop out of voluntary home visiting services. Poor retention rates limit a program’s overall impacts and compromise their ability to “go to scale”. Research often does not adequately consider the multiple decision points in determining a participant’s service levels. Research does not fully examine the unique impacts of related factors operating at different conceptual levels. The Enrollment/Engagement Problem

5. Built an integrated theory of parent enrollment in voluntary support services. Tested this theory against a retrospective sample to confirm factors associated with duration and dosage. Tested the theory against a prospective sample to confirm factors associated with intent, actual enrollment and retention. Applied statistical methods (HLM) to detect unique impacts of individual, provider, program and community characteristics on enrollment and retention decisions. Daro McCurdy Research Approach

6. Intent is a function of readiness to change, attitude toward seeking help, and prior service experience. Intent is the strongest predictor of enrollment. Retention is influenced by many factors and multiple levels: Participant objective experiences Participant subjective experiences Provider characteristics Program characteristics Community characteristics Daro McCurdy Assumptions

7. An Integrated Theory of Family Engagement

8. The Enrollment Decision Process REMAIN ENROLLED ENROLL INTENT I want it. I’ll try it. I’ll stick with it.

9. Participant Factors Demographic characteristics; initial concerns; service attitudes and prior experiences; community context. Provider Factors Demographics; job credentials; service delivery style; work environment. Program/Agency Factors Connection to community; staff-participant matching. Model Predictors

10. Integrated Theory of Parent Engagement Individual Factors Service attitudes Cost-benefit perceptions Readiness to change Subjective norms Past experiences Individual Factors Objective experiences Subjective experiences Individual Factors Subjective Norms ENROLL REMAIN ENROLLED INTENT Program Factors Funding Supervision Incentives Provider Factors Caseloads Competence Program Factors Duration between acceptance and first contact Neighborhood Factors Informal social control Social cohesion Concrete resources Program Factors Auspice Provider Factors Cultural humility Service delivery style Neighborhood Factors Social Disorganization Social Capital

11. What Does the Research Suggest?

12. Few new parents actively reject services (< 5%) and 8% of those initially interested do not enroll. Maternal perception of infant risk – those worried about their baby or who had given birth to a low weight baby are more likely to seek out services. In some cases, interest in services is higher during pregnancy than at birth. Parents can articulate possible program benefits. Parents see a need to focus on parental capacity – they are open to learning. What draws parents to these programs?

13. Participant level Perception that program changed them. Involvement with other service programs. Residing in high risk communities. Provider level Cultural awareness/humility Job experience More personal service delivery style which balancing responsiveness with mission. What factors contribute to retention?

14. Participant factors predicting more visits Several studies suggest Hispanics are most open to program. Infant risk – higher the risk the more visits accepted. Support for program among informal network. Strong relationship with home visitor. Residing in a high risk community. Not working and/or not in school. Provider Factors Prior work experience/not simply educational qualifications Relationship with family What factors account for more visits?

15. Enrollment and retention decisions are influenced by multiple factors occurring at multiple levels. New parents enroll to help their infant but remain to help themselves. High risk families living in distressed communities can be successfully enrolled and retained. Service delivery style and work experience are strong predictors of retention and dosage success. Service duration and dosage, while correlated, represent different aspects of “engagement”. General Findings

16. Strategies to Improve Enrollment

17. Re-frame the outreach message Present the program as serving child and parent. Stress “good care” is more than meeting an infant’s physical needs. Broaden the benefits to parents Establish linkages to other providers as child develops and parent matures. Embed program in trusted community organizations “Normalize” the service as something of benefit to all parents. Targets of Opportunity

18. Take culture seriously Train staff on cultural sensitivity and humility. Evaluate race-matching participants and providers. Ensure outreach message demonstrates respects for diversity. Focus on the “fit” Hire for openness and empathy; train and supervisor to insure competence and quality. Seek a balance between respect for participant and delivering the program message. Targets of Opportunity