Service Engagement and Retention of Participants: Lessons from the Early Childhood Connections Program

Background/Purpose: 

High attrition rates common among home visiting programs create challenges for service providers, families in need, and researchers seeking to build on these prevalent programs. Across various studies of different program models, attrition rates range from 30% to 70%. A growing body of literature has identified several factors linked to initial service engagement such as attitudes toward services, social support, mental health status, and community health indicators. However, it is not known if factors influencing initial engagement remain important to longer-term retention in services. The purpose of this study is to help fill this gap in understanding which factors relate to both initial engagement and long term retention in a home visitation study partnered with Parents as Teachers.

Methods:

Participants in Early Childhood Connections were referred by child welfare and invited to participate in the Parents as Teachers program. A total of 64 families consented to the study and home visitation. Various family characteristics were explored to understand initial engagement and retention, including social support, social contacts, partner communication, depression (clinical cutoff for the CESD), stressors, a home supporting child development (HOME items), prior maltreatment reports, and prior foster care placement. Survival analyses were conducted to examine retention for at least three months (initial engagement) compared to retention for at least nine months (retention). For ease of presentation we examined two thresholds. A high threshold examined factors associated with an 80% retained rate at 3 and 9 months and then the criterion was relaxed the criterion to 60% to correspond to the average rate found in prior studies.

Results:

Overall, ECC successfully engaged 86% of participating families for at least three months and retained 75% for at least nine months. Using the 80% threshold, initial engagement was not achieved for caregivers characterized by poor partner communication (n=15), non-Black (n=17), and prior foster care placement (n=15). Over nine months, some factors remained important to retention (Black caregivers) but new factors also emerged such as high social contact, meeting clinical criteria for depression and home environment lacking books, toys, etc. When the criterion for successful engagement/retention was relaxed from 80% to 60%, the program was successful at achieving this for all families for at least three months. After that, non-Black caregivers and those reporting poor partner communication had the highest attrition.

Conclusions and Implications:

A hypothesized benefit of home visitation is improved social support, but program retention was higher for caregivers reporting high levels of social contact at baseline.  Retention was also related to risk factors for maltreatment (depression and lack of positive child development environment in the home). However, other risks such as poor partner communication and prior foster care history predicted attrition. Our findings highlight the need for strategies that can engage more socially isolated families and those with lower quality partner communication. As high levels of depression predicted retention, this suggests the import of screening for and developing means to address this issue as part of usual care home visitation.