"We're the Constant": Navigating Resource Scarcity and Relational Depth in Rural and Urban Home Visiting Programs

Background
Home visiting is a widely endorsed prevention strategy for reducing child maltreatment by addressing familial needs ranging from parenting skills to housing (Avellar & Supplee, 2013; Dodge et al., 2014). Yet, home visitors often work within systems that are under-resourced, rigid, or culturally misaligned with the lived realities of the families they serve (Shaw et al., 2018; Sama-Miller et al., 2017). This qualitative study investigates how home visitors from child maltreatment prevention agencies in Iowa perceive their roles, navigate geographic and systemic barriers (e.g., "service deserts" in rural areas; Breidenbach et al., 2022), and tailor services to meet families’ needs. Focusing on how home visitors adapt provision across rural and urban contexts—where disparities in resource allocation and service accessibility are well-documented (Donelan & Singh, 2022; Edwards et al., 2021)—this study surfaces the relational, structural, and contextual tensions that shape everyday decision-making in practice.

Methods
Data were drawn from four focus group interviews with home visitors (N ≈ 20) across urban and rural regions of Iowa in Fall 2018. The interviews explored family demographics, client needs, organizational constraints, and resource distribution strategies. A semi-structured guide probed themes related to program structure, parenting and material supports, systemic barriers, and ideal service enhancements. Transcripts were coded inductively and thematically after collaboratively refining a coding framework. There were five themes and subthemes: Program Information (Clients & Structure), Context (Client, Organization, Systemic, Desired Services), Supports (Parenting, Material, Social), Parental Reactions, and Visionary Improvements.

Results

Home visitors consistently described families facing multilayered adversities, including poverty, trauma, and housing instability. These challenges were amplified in rural settings where, as one participant noted, “we use all of our resources that we have and then we go to the churches” due to a lack of formal supports. Across sites, visitors emphasized the emotional labor of showing up consistently: “Sometimes we work harder than the family does, just to let them know we’re sincere.” They described their roles as both relational anchors and system navigators, helping families build confidence, access hard-to-reach services, and parent through intergenerational trauma. Participants highlighted systemic gaps—particularly around childcare, transportation, and dual-diagnosis treatment—and discussed how these affect service delivery and family progress. While all participants described adapting services to fit each family’s goals, several expressed concern that program metrics or state contracts often do not reflect the realities or timelines of trauma-informed work.

Conclusions
This study underscores the critical, relational work that home visitors do to buffer families from systemic harm and disconnection—particularly in high-risk, under-resourced contexts. Findings suggest that home visiting outcomes hinge on family risk profiles and the flexibility, cultural responsiveness, and resource access of home visitors themselves. To improve outcomes, policymakers and funders should expand definitions of success to include relational continuity and trust-building, especially for trauma-impacted families. Investing in sustained training, team-based supports, and flexible funding for material goods (e.g., gas cards, diapers) may enhance both worker capacity and family stability. Ultimately, as one participant put it, “sometimes just being there for them—that’s the service.”