CHALLENGES FACED BY HOME VISITING PROGRAMS
The workshop participants identified several critical challenges that face virtually all home visiting programs. They include family engagement, staffing, cultural and linguistic diversity, and conditions, such as maternal depression, that are experienced by many of the participating families.
The engagement of families in home visitation programs includes the combined challenges of getting families to enroll, keeping them in the program, and sustaining their interest and commitment during and between visits. Parental engagement is essential to the effectiveness of programs and to the validity of research efforts. For example, ongoing reanalyses conducted by Margaret Burchinal, of the University of North Carolina at Chapel Hill, Jeanne Brooks-Gunn, of Columbia University’s Teachers College, and Michael Lopez, of the Administration on Children, Youth, and Families, of data from the Comprehensive Child Development Program revealed that families at two sites that successfully provided more home visits per participating family showed significant effects on child cognitive outcomes compared with control group families; families at sites that offered less home visiting were significantly below the control group in child outcomes. As noted in the Spring/Summer 1999 issue of The Future of Children, programs “rely to some extent upon changes in parental behavior to generate changes in children’s health and development. If parent involvement flags between visits, then changes in children’s behavior will be much harder to achieve” (Gomby et al., 1999). This general conclusion was repeated throughout the workshop by both practitioners and researchers.
Mildred Winter, of the Parents as Teachers National Center, Inc., cited one of the main barriers to the success of home visiting programs to be the lack of motivation of parents to commit to the program. Many others acknowledged that home visiting is a relatively invasive procedure that entails a huge commitment of time and energy on behalf of parents, primarily mothers. It is therefore not surprising that The Future of Children review indicated that families typically received only half the number of visits prescribed. “The consistency with which this occurs across the models suggests that this is a real phenomenon in implementation of home visiting programs” (Gomby et al., 1999). Even when motivated and eager to participate, as noted by workshop participants, families miss visits because of difficulties associated with rescheduling, given busy families and home visitors with large caseloads.
Workshop participants were in agreement that one of the keys to keeping the family engaged throughout the duration of the program is a good relationship between the home visitor and the family. In the Infant Health and Development Program, home visitors’ ratings of parental engagement in the visits were highly predictive of program effects. As noted by Janet Dean, of the Community Infant Program in Boulder, Colorado, “Home visitors need to create a good relationship -- a safe context -- with the family before they can help the family. ” Although some programs target children directly, most home visiting programs are premised on the belief that parents are effective mediators of change in their children, and therefore target the parents directly. Despite the positive findings of some evaluations (such as the reanalysis of data from the Comprehensive Child Development Program), Brooks-Gunn noted that, in general, there is
not much evidence to back up the belief in this premise, nor is there a good appreciation for the difficulty of creating sufficient behavioral change in parents to actually improve child functioning. Workshop participants were in agreement that what is needed is better measurement and understanding of the relationship between the home visitor and the mother.
Attrition is endemic to home visitation. Many families not only miss visits, but also leave the program altogether before it is scheduled to end. For example, of the programs reviewed in Spring/Summer 1999 issue of The Future of Children, attrition rates ranged from 20 to 67 percent. Anne Duggan, of Johns Hopkins University’s School of Medicine, reported that the program ’s approach to retention can affect attrition rates. The three Hawaii Healthy Start programs that she studied had highly variable attrition rates (from 38 to 64 percent over one year). The program with the lowest attrition rate actively and repeatedly tracked down families that tried to drop out, whereas the program with the highest attrition rate assumed that if the parent did not want to be involved, it was not the program’s responsibility to push her.
What can programs do to increase engagement? Olds surmised that enrolling mothers into the Nurse Home Visiting Programs while they were still pregnant with their first child and therefore highly motivated to learn about effective parenting strategies improved retention rates. Another strategy, which was mentioned by many at the workshop, is to make parents part of the program planning process. This may help parents “buy into” the program from the beginning, in addition to ensuring that the program really addresses the needs of the families it intends to serve. Parents need to believe that the home visiting services will help them accomplish goals that they have set for themselves and that warrant an extensive commitment. Answering the question of how to improve engagement is still a big challenge and an issue that needs much more systematic examination as part of implementation studies.
Virtually every speaker at the workshop commented that the home visitor ’s role is critical. As noted by Melmed, “Any service program is only as good as the people who staff it.” In the case of home visiting, the demands on the staff are diverse and often stressful. They must have “the personal skills to establish rapport with families, the organizational skills to deliver the home visiting curriculum while still responding to family crises that may arise, the problem-solving skills to be able to address issues that families present in the moment when they are presented, and the cognitive skills to do the paperwork that is required” (Gomby et al., 1999). Workshop participants identified challenges associated with finding appropriate staff, retaining staff, offering the necessary training and supervision, and matching staff to families with differing needs and predilections, some of which are culturally based and others that are not.
Program designers differ in their views about appropriate staff. Some programs, such as the Nurse Home Visitation Program, rely heavily on professionals (people with degrees in fields relevant to home visiting, such as nursing), but the majority of home visiting programs use paraprofessionals who often come from the community being served and typically have less formal education or training than professional staff beyond that provided by the program. There is an active debate in home visiting over which type of staff is most effective at delivering the curriculum and achieving results. The Nurse Home Visitation Program is based on the premise
that nurses are more effective home visitors than paraprofessionals. An evaluation of the Nurse Home Visitation Program in Denver, Colorado, found that families visited by nurses have a lower rate of attrition and complete more visits than families visited by paraprofessionals, even though the paraprofessionals worked just as hard as the nurses to retain families. Olds speculated that the families conferred greater authority upon the nurses and that the nurses were better equipped to respond to the mothers’ needs and feelings of vulnerability. As a result, the mothers may have complied more willingly with the nurses ’ guidance.
Others see paraprofessionals as better than professionals at creating the essential relationship with the family, because there is less social distance between paraprofessionals and the families they serve. Pilar Baca, of the Kempe Prevention Research Center for Family and Child Health and a trainer of staff for the Nurse Home Visitation Program, noted that the choice of staff is really a question of “for whom, for what?” She argued for the development of “robust paraprofessional models” as an alternative to assuming that professionals will be the preferred or even feasible option for all circumstances.
Regardless of the prior background of the visitors, they invariably face extremely complex issues when working with families and require appropriate preparation, ongoing information, and constant feedback to perform their jobs well. Many at the workshop commented on the need for more extensive and higher-level staff training, both before the home visitor begins working with families as well as during the course of their employment. Two aspects of training were mentioned often at the workshop. The first pertained to ensuring that the home visitors are well versed and accepting of the desired objectives and the philosophy of the particular home visiting program that they are responsible for implementing. The second had to do with the relatively poor ability of some home visitors to recognize conditions such as maternal depression, substance abuse, and domestic violence that interfere with program implementation, family engagement, and effectiveness.
Staff turnover is a significant problem for many programs. For example, the Nurse Home Visitation Program in Memphis had a 50 percent turnover rate in nurses due to a nursing shortage in the community. Other programs relying more on paraprofessionals reported even higher turnover rates. The Nurse Home Visitation Program in Denver, for example, had no turnover among the nurses who were providing home visits, but substantial turnover among the paraprofessionals. The specific impact of turnover on the effectiveness of programs is unknown, but it is likely to present a real problem since the quality of the home visitor/mother relationship is so predictive of program efficacy.
In this area, home visiting may be able to learn from the experiences of the child care field, since both have similar levels of turnover. In the child care field, turnover has been linked to the low wages earned by child care workers as well as to the quality of care received by children and families. Home visiting positions are also typically low-paying and stressful, and it makes sense that many staff will leave if they find a better-paying opportunity. Other keys to staff retention discussed at the workshop include good supervision and good morale. Providing home-based services can be isolating for the home visitor and, as such, requires a higher, more intense level of supervision. At the same time, because supervisors do not typically accompany staff on home visits and therefore do not observe home visitors performing the intervention, it
can be difficult for them to help the home visitor reflect on and learn from their experiences. Despite these difficulties, home visitors need supervision that goes beyond “did you do your job or not” to include elements of social and emotional support, teamwork, and recognition of staff effort. Terry Carrilio, of the Policy Institute at the San Diego State University School of Social Work, aptly observed that the “process needs to reflect what you are trying to do. If a program does not treat its staffwell, how can we expect the staff to deliver a supportive service? ”
Cultural and Linguistic Diversity
Cultural and linguistic considerations are also involved in the decision of who can best deliver home visiting services, but they encompass many other complex issues as well. Home visiting programs deal with fundamental beliefs about how a parent interacts with a child. These beliefs, which are heavily imbued with cultural meaning, provide the foundation for the design and implementation of any program. As noted by Baca, for example, it is likely to be more difficult for a home visitor from a culture different from that of the family to distinguish between practices and beliefs that are culturally different and those that are culturally dysfunctional. This applies as well to evaluators. Linda Espinosa, of the Department of Curriculum and Instruction at the University of Missouri, cautioned that there are possible ripple effects when “we start changing highly personal, highly culturally embedded ways of interacting and socializing children within the family unit. We hope the effects are positive, but we cannot ignore the possibility that they could be negative.” In this context, Espinosa specifically mentioned the potential for programs to upset “the fragile balance of power within the family.”
Decisions about using bicultural and bilingual home visitors are often determined by forces beyond the control of the program. For example, the Family Focus for School Success program in Redwood City, California, chose to hire paraprofessionals because, as Espinosa described, “there were no certificated or B.A.-level people who were bilingual and bicultural and who were floating around in the community waiting to be hired.” Program developers made the decision that having bilingual and bicultural staff was more important than having professional staff. This issue creates certain challenges when programs are expanded since it may not be possible to find enough people willing to be home visitors with the necessary qualifications. The basic question, as for all interventions, is: “Do our goals and outcomes align with the hopes, dreams, and aspirations of the families we serve?”
Domestic Violence, Maternal Depression, and Substance Abuse
Three conditions that can significantly impede the capacity of a home visiting program to benefit families were identified and discussed at the workshop: domestic violence, maternal depression, and substance abuse. Home visiting programs generally set goals that are preventive in nature: to prevent child abuse and neglect, to improve the nutrition and health practices of the mother, to reduce the number of babies born with low birthweight, and to promote school readiness and prevent school failure. However, the families that are targeted by home visiting programs often experience other problems, such as maternal depression, substance abuse, and domestic violence, that need to be addressed before the prevention goals of the program can be achieved.