1. Enrollment and Retention in Voluntary Home Visiting Programs Deborah Daro

2. Main Points Challenges in attracting and retaining families in voluntary prevention programs is long standing. As policy interests shift to achieving measurable population level change in critical outcome areas, greater emphasis is being placed on successfully engaging a broader segment of the at-risk population. Research on the issue has identified a number of participant, provider and contextual characteristics that impact enrollment and retention. Programs need intentional strategies to improve performance in this area.

3. Understanding Engagement and Enrollment

4. The Enrollment/Engagement Problem Roughly one-third of participants drop out of voluntary home visiting services. Poor retention rates limit a program’s overall impacts and compromise their ability to “go to scale”. Research often does not adequately consider the multiple decision points in determining a participant’s service levels. Research does not fully examine the unique impacts of related factors operating at different conceptual levels.

5. Daro McCurdy Research Approach Built an integrated theory of parent enrollment in voluntary support services. Tested this theory against a retrospective sample to confirm factors associated with duration and dosage. Tested the theory against a prospective sample to confirm factors associated with intent, actual enrollment and retention. Applied statistical methods (HLM) to detect unique impacts of individual, provider, program and community characteristics on enrollment and retention decisions.

6. Daro McCurdy Assumptions Intent is a function of readiness to change, attitude toward seeking help, and prior service experience. Intent is the strongest predictor of enrollment. Retention is influenced by many factors and multiple levels: – Participant objective experiences – Participant subjective experiences – Provider characteristics – Program characteristics – Community characteristics

7. An Integrated Theory of Family Engagement

8. The Enrollment Decision Process INTENT ENROLL REMAIN ENROLLED I want it.I’ll try it.I’ll stick with it.

9. Model Predictors Participant Factors – Demographic characteristics; initial concerns; service attitudes and prior experiences; community context. Provider Factors – Demographics; job credentials; service delivery style; work environment. Program/Agency Factors – Connection to community; staff-participant matching.

10. Integrated Theory of Parent Engagement INTENT ENROLL REMAIN ENROLLED Program Factors Auspice Provider Factors Cultural humility Service delivery style Individual Factors Service attitudes Cost-benefit perceptions Readiness to change Subjective norms Past experiences Individual Factors Subjective Norms Individual Factors Objective experiences Subjective experiences Program Factors Duration between acceptance and first contact Neighborhood Factors Informal social control Social cohesion Concrete resources Program Factors Funding Supervision Incentives Provider Factors Caseloads Competence Neighborhood Factors Social Disorganization Social Capital

11. What Does the Research Suggest?

12. What draws parents to these programs? Few new parents actively reject services (< 5%) and 8% of those initially interested do not enroll. Maternal perception of infant risk – those worried about their baby or who had given birth to a low weight baby are more likely to seek out services. In some cases, interest in services is higher during pregnancy than at birth. Parents can articulate possible program benefits. Parents see a need to focus on parental capacity – they are open to learning.

13. What factors contribute to retention? Participant level – Perception that program changed them. – Involvement with other service programs. – Residing in high risk communities. Provider level – Cultural awareness/humility – Job experience – More personal service delivery style which balancing responsiveness with mission.

14. What factors account for more visits? Participant factors predicting more visits – Several studies suggest Hispanics are most open to program. – Infant risk – higher the risk the more visits accepted. – Support for program among informal network. – Strong relationship with home visitor. – Residing in a high risk community. – Not working and/or not in school. Provider Factors – Prior work experience/not simply educational qualifications – Relationship with family

15. General Findings Enrollment and retention decisions are influenced by multiple factors occurring at multiple levels. New parents enroll to help their infant but remain to help themselves. High risk families living in distressed communities can be successfully enrolled and retained. Service delivery style and work experience are strong predictors of retention and dosage success. Service duration and dosage, while correlated, represent different aspects of “engagement”.

16. Strategies to Improve Enrollment

17. Targets of Opportunity Re-frame the outreach message – Present the program as serving child and parent. – Stress “good care” is more than meeting an infant’s physical needs. Broaden the benefits to parents – Establish linkages to other providers as child develops and parent matures. Embed program in trusted community organizations – “Normalize” the service as something of benefit to all parents.

18. Targets of Opportunity Take culture seriously – Train staff on cultural sensitivity and humility. – Evaluate race-matching participants and providers. – Ensure outreach message demonstrates respects for diversity. Focus on the “fit” – Hire for openness and empathy; train and supervisor to insure competence and quality. – Seek a balance between respect for participant and delivering the program message.