"Sometimes things don't work out": Barriers and Facilitators of Service Use

Purpose: One challenge for voluntary prevention and early intervention programs is engaging families in services long enough to obtain expected benefits from services. Quantitative analyses indicate considerable variability in service use among our sample of low-income families and that these service patterns were associated with families' demographic characteristics, health, social support, maternal functioning, and previous service use. Mothers who used more services were more likely to have been born in the United States, be unemployed, have more children, have at child with special needs, and received more services in the Healthy Beginnings system. However, these characteristics explained only some of the variations in service use. We employed qualitative analyses to further understand how barriers and facilitators of service use were related to these variations.

Methods: We analyzed six waves of qualitative data on a subsample of families. We looked at barriers and facilitators to service use within and across families and within and across service areas (e.g., health care, income supplements, social services, and child care.) Guided by an ecocultural framework, we categorized the factors emerging from the qualitative data as one of four different but interconnected levels—the individual, the provider, the program, and the neighborhood level—and looked for changes in these factors over time.

Results: Families' decisions to apply for and use services were shaped by a host of factors, including individual characteristics (language, transportation, attitudes, social networks, economic stability, and past program experiences), program characteristics (intake, waiting time), provider characteristics (behavior, cultural competency, communication style), and neighborhood characteristics (transportation, social networks, safety). The importance of these factors varied from one service area to another. For example, mothers' decisions to use or not use child care were shaped by parenting beliefs as well as need for child care and the choices available to them, while use of health care or food programs was influenced more by need than by personal beliefs or ease of application. The role of individual characteristics in accessing services was especially evident in the experiences of immigrants who experienced problems with transportation and child care, lost wages when taking time from work to apply for services, and limited English and literacy skills. We also found that social workers and other providers in the Healthy Beginnings system played an important role in helping mothers connect to economic support programs and other services.

Implications: To be effective, program policies and practices need to be grounded in the circumstances of the low-income families they are intended to serve and consider the other services and systems with which they may have contact. The importance of social workers for connecting mothers to economic support and other services suggests that expanding care coordination services or providing more community-based staff to assist mothers with reading, writing, and translation would go a long way towards helping mothers who don't require ongoing care coordination but who need assistance in maintaining their access to services.