Engaging Families with Newborns in Home Visitation Services

Background and Purpose: The dissemination of home visitation programs nationwide represents a significant investment in improving the early childhood experience. While controlled studies have found long-term benefits across domains including maltreatment and healthy development, research is needed to determine whether the same results will be expected in community applications. Home visiting is typically a voluntary service delivered early, often, and over a long period of time. One major implementation issue across programs is early disengagement from services. The purpose of this study is to examine two key questions that must be addressed to ensure program effectiveness and efficiency. First, what factors are associated with a caregiver’s decision to engage with services? Second, as most evidence has come from a fairly narrow risk population, will families with multiple risk factors engage with services?

Methods: Electronic records from one nurse home visitation agency was used to create a sample of low-income families served between 2009 and 2011 (n=3,620). As part of standard practice, nurses bring laptops to each visit to collect information in areas such as maternal and infant health, service utilization, and family risk factors. Engagement was operationalized as receipt of a second home visit following referral and intake visit. Factors predicting engagement were modeled using multivariate logistic regression. Moderation analysis was used to examine the differential effect of risk factors across four service populations (primary poverty, teen mothers, caregivers with health limitations, and medically-fragile newborns).

Results: Overall, 79% of the families engaged with the program. There was a significant association between service population and engagement (X² = 36.7, p <.0001). Caregivers current enrollment in WIC (OR=3.32) and infants in Medicaid (OR=6.02) were the strongest predictor of engagement. Significant predictors across populations include inadequate prenatal care (OR=1.51), less than 18 months between pregnancies (OR=1.99), caregiver history of abuse (OR=1.81), and caregiver mental illness or disability (OR=1.44). Some predictors were isolated to specific service populations. Families of medically-fragile newborns born at low birth weight were more likely to engage with services (OR=1.71) while engagement was higher for teenage mothers if their child was born premature (OR=1.91). For the families whose primary risk factor was poverty, pregnancy problems (OR=1.84) and infant medical problems (OR=1.58) increased engagement.

Conclusions/Implications: Results indicate that adversity, particularly in risks related to the pregnancy and newborn, is associated with greater engagement in home-visitation preventive services. Caregivers who engaged in services were also more likely to take advantage of other services that benefit their infant such as WIC and Medicaid. Together, these findings suggest that while these caregivers face challenges in their lives and the health of their newborns, they also have strengths in the form of protective help-seeking behaviors. Strategies at the onset of home-visitation services that seek to promote and motivate these behaviors might improve engagement, particularly among families experiencing less adversity related to the pregnancy. As programs are scaled up, this type of research focusing on external validity is needed to help establish benchmarks for engagement and strategies to maximize uptake among diverse service populations.