Mother and Home Visitor Emotional Well-Being and Alignment on Goals for Home Visiting as Factors for Program Engagement

Mother and Home Visitor Emotional Well-Being and Alignment on Goals for Home Visiting as Factors... Objectives Family engagement in home visiting (HV), as indicated by length of enrollment, is a major challenge as most families do not stay enrolled for the intended duration prescribed by HV models. This study examined maternal and visitor emotional well-being as factors for maternal satisfaction with the program in addressing reasons for enrolling in HV and program engagement and the role of their working alliance with the visitor as a mediator of this. Methods Longitudinal data were collected from 148 mothers and 54 visitors in 21 HV programs. Mothers completed surveys shortly after enrolling and 6 months later to assess attributes of the working alliance with their visitor. Visitors completed a survey to assess work-related well-being. HV program data were used to measure engagement. Results Mothers enrolled for multiple, diverse reasons, most often to promote child development and parenting (96%). Mothers’ satisfaction with program efforts to address reasons for enrollment was highest for parenting (79%) and lowest for jobs and education (30%). Results of the mediational path model indicated that ratings of the visitor on goal alignment were positively associated with engagement. Maternal emo- tional availability and visitor work-related emotional exhaustion were negatively associated with engagement. Exploratory analyses suggested that ratings of the visitor on goal alignment were a stronger predictor of engagement for mothers with low emotional availability compared to other mothers. Conclusions for Practice Visitor alignment with mothers on goals and responsiveness to reasons for enrolling appear to be effective in promoting engagement. Individualizing services to reflect maternal goals and emotional capacity may be important strategies to address engagement challenges. Keywords Home visiting · Maternal satisfaction · Engagement · Emotional well-being Significance Introduction Family engagement continues to be an important issue fac- Family engagement, most commonly defined as the length of ing home visiting field; studies find that most families do not enrollment or the frequency of home visits, has been a major receive the intended amount of services. Previous studies challenge for home visiting (MIECHV TACC, 2015). Most have documented attributes of visitors and families that are evidence-based home visiting models intend to serve fami- associated with HV engagement. This study extends pre- lies for 2–3 years with intensive visit schedules and research vious investigations into attributes of mothers and visitors suggests that engagement rates fall well below expectations. associated with HV engagement by considering mothers’ In fact, typically 40–50% of families leave within 1 year reasons for enrolling and their visitors’ alignment with and (Boller et al. 2014; Duggan et al. 2007). Because engage- attention to these reasons. ment remains a challenge, research to promote it is a national priority (Duggan et al. 2013). Studies have documented attributes of visitors and fami- * L. Burrell lies that are associated with engagement (Cho et al. 2017; lburrell@jhu.edu Latimore et al. 2017; O’Brien et al. 2012). For example, Department of Population, Family and Reproductive Health, Latimore et al. (2017) found that visitor morale was asso- Johns Hopkins Bloomberg School of Public Health, 615 N. ciated with receiving a high dose of services. Maternal Wolfe Street, Baltimore, MD 21205, USA age, race, and pregnancy status are commonly associated Dartmouth Geisel School of Medicine, 1 Rope Ferry Road, with engagement (Daro et al. 2003; McGuigan et al. 2003; Hanover, NH 03755-1404, USA Vol.:(0123456789) 1 3 S44 Maternal and Child Health Journal (2018) 22 (Suppl 1):S43–S51 O’Brien et al. 2012). Other maternal characteristics, includ- Methods ing depression and relationship security, may influence engagement (Girvin et al. 2007; Sharp et al. 2003). Rela- Setting and Participants tionship security is the extent to which an adult provides and receives support in relationships, including one formed With State and Federal MIECHV funding, the New Jersey between a mother and visitor. McFarlane et al. (2010) found Departments of Health and Children and Families are col- that mothers with anxious relationship styles were more laborating to build the state’s home visiting program (NJ- likely to receive a high dose of service, suggesting that they HV). The evaluation of NJ-HV incorporates mixed methods may be particularly open to developing a close relationship to inform strategies to improve engagement and outcomes with the visitor. Mikulincer and Nachshon (1991) found by strengthening the implementation system. This paper associations between relationship avoidance and a lack of uses data from a longitudinal study of a purposive sample self-disclosure, which may make it harder for a visitor to of mothers newly enrolling in home visiting. The research identify the mother’s needs. was conducted in accord with prevailing ethical principles Home visiting values a strong alliance between visitors and approved by the Johns Hopkins School of Medicine and and mothers to help mothers reach their goals. Mothers state Institutional Review Boards. Study participants pro- choose to enroll for many reasons, such as wanting infor- vided written informed consent and were remunerated for mation about job training, child development, and tangible data collection. assistance (Stevens et al. 2005; Tandon et al. 2008). Visi- In 2012, NJ-HV funded 33 home visiting program sites tors respond to these reasons in varied ways. For instance, statewide. Each site used one of three evidence-based mod- Tandon et al. (2008) found that visitors were most likely to els: Healthy Families America (HFA), Nurse-Family Part- meet the needs that were more proximal to program goals nership (NFP), and Parents as Teachers (PAT). Sites were such as parenting information. eligible for this study if they had operated for at least 2 The nature of the mother’s working alliance with the visi- years and had at least three visitors who had completed a tor is predictive of family engagement. Studies have shown web-based survey. Visitors were eligible if they had com- that mothers with better relationships with their visitors were pleted core training and were able to visit families indepen- more likely to have higher levels of program involvement dently. In total, 95 visitors in 21 program sites were eligible and complete the program (Girvin et al. 2007; Korfmacher for this study (27 visitors across 13 HFA sites, 27 visitors et al. 2007). Evidence suggests that this working alliance across 7 NFP sites, 3 visitors from 1 PAT site). may be impacted by characteristics of the mother and the A maximum of three mothers per eligible visitor were visitor. For example, mothers with both severe depression recruited between June 2012 and March 2013. Researchers and discomfort with trusting others had lower ratings of trust trained visitors to identify eligible mothers and introduce the in their visitor (Cluxton-Keller et al. 2014). study within the first three visits. A mother was eligible for The Maternal, Infant, and Early Childhood Home Visit- the study if she: (a) was pregnant or had an infant less than ing (MIECHV) Program was established in 2010 to expand 3 months old; (b) received services in English or Spanish; evidence-based home visiting and to carry out research to and (c) was assigned to a visitor who had not recruited three study its implementation and effectiveness. The current families. study aims to: (a) describe mothers’ reasons for enrolling, During recruitment, 730 mothers enrolled in services. (b) examine the associations of maternal and visitor charac- Of those enrolled, 536 were eligible for the study. Of the teristics with mothers’ ratings of their working alliance with 536, researchers received contact information for 205. Pri- their visitors, (c) examine the association of attributes of the mary reasons for not receiving information included mother working alliance with program engagement, and (d) explore declined to participate (47%), the study was not yet intro- the role of the working alliance as a mediator of associa- duced to the mother, but she did not have at least three vis- tions of maternal and visitor characteristics with program its (e.g. family was discharged) (31%), and the study was engagement. not introduced to the mother during the first three visits (16%). Of the 205 mothers who agreed to be contacted by the research team, 177 (86%) consented and completed a baseline survey. 1 2 For more information, see https ://mchb.hrsa.gov/mater nal-child For HFA sites, the site also had to have completed the national -healt h-initi ative s/home-visit ing-overv iew. model’s site accreditation process. 1 3 Maternal and Child Health Journal (2018) 22 (Suppl 1):S43–S51 S45 ing education”) and were asked whether each was applica- Data Sources ble. These reasons were grouped into 10 broad domains. Mothers were counted as enrolling for each domain if they Maternal and Visitor Surveys endorsed any of the items within it. The baseline maternal surveys included questions about demographic characteristics, psychosocial well-being (e.g. Maternal Follow-Up Measures depression and relationship security), and maternal and family functioning. They completed follow-up surveys 6 Rating of  the Visitor on  Goal Alignment The 4-item, goals subscale from the Working Alliance Inventory—Home Visit- months later or, if pregnant at baseline, when the child was 6 months. The follow-up surveys included questions from ing Short Form (Boller et al. 2014; Horvath and Greenberg 1994) was used to assess the mother’s rating of her visitor baseline, but also included measures of child development, parent–child interaction, and ratings of home visiting. regarding goals for home visiting (e.g. “My visitor and I are working toward mutually agreed upon goals”). Items were Visitors completed web-based surveys in early 2012. The survey captured demographic information, ratings of work- summed to yield overall scores ranging from 4 to 28 with high scores indicating greater alignment. place culture, training, supervision, and psychosocial aspects of work (e.g. emotional exhaustion and morale). Rating of Satisfaction with the Program’s Eor ff ts to Address Program Management Information Systems (MIS) Reasons for  Enrolling For each endorsed reason, moth- ers were asked how satisfied they were with the program’s NJ HFA and PAT sites use a web-based, MIS developed by efforts to meet each need. A continuous score (range from 0 to 100) was created that represented the proportion of the the State University of New York and NJ NFP sites use ETO provided by the NFP National Service Office. These systems reasons where the mother indicated being completely or very satisfied. enable sites to document service delivery. Visitor Measures Measurement Perceptions of Organizational Climate Three first-order cli- Maternal Baseline Measures mate subscales of the Organization Social Context Meas- urement System (OSC; Glisson et  al. 2008) were used to Emotional Availability Emotional availability includes depressive symptoms and relationship security as research measure individual-level perceptions of emotional exhaus- tion, personalization, and personal accomplishment. Raw has confirmed a link between them (Roberts et  al. 1996; Strodl and Noller 2003). Each dimension of attachment scores were converted to standardized T-scores with a mean of 50 and standard deviation of 10. High scores on personal- has characteristics that can make one vulnerable to devel- oping depression (Mikulincer and Shaver 2007). To assess ization and personal accomplishment are desirable and low scores are desirable for emotional exhaustion. depressive symptoms, we used the 12-item, Center for Epi- demiologic Studies Depression Scale—Short Form (Ross Morale The OSC also includes an individual-level meas- et  al. 1983). A total score was derived by summing items and scores ≥ 10 indicated moderate to severe symptoms. ure of morale. Raw scores were converted to standardized T-scores with a mean of 50 and standard deviation of 10. Relationship security was measured using the 29-item, Attachment Style Questionnaire-Short Form (Karantzas High scores are desirable. et al. 2010). An exploratory factor analysis identified items loading onto anxiety and avoidance factors. The relationship Program Engagement anxiety subscale included 12 items (α = 0.85) and the rela- tionship avoidance subscale included eight items (α = 0.76). Engagement was defined as the total number of days from program enrollment to last completed home visit. For fami- Items were summed to create relationship anxiety and avoidance scores and then dichotomized such that scores lies still active, total number of days was calculated to the last home visit as of March 31, 2017. above the theoretical median were considered ‘high.’ Moth- ers were considered low on emotional availability if they Analytic Plan scored ‘high’ on relationship avoidance and scored positive for depressive symptoms or high on relationship anxiety. Of the 177 mothers completing a baseline survey, 148 com- Reasons for Enrolling in Home Visiting Mothers were given pleted the follow-up (76 HFA, 70 NFP, and 2 PAT). When possible, analyses included all 148 mothers to maximize a list of 27 reasons for enrolling (e.g. “Want help finish- 1 3 S46 Maternal and Child Health Journal (2018) 22 (Suppl 1):S43–S51 Table 1 Baseline maternal characteristics (n = 148) Table 2 Visitor characteristics (n = 54) Age Maternal age in years (mean (SD)) 22.7 (5.9) Teen mother (< 19 years old) 36%  < 30 21% Enrolled prenatally 71%  30–39 23% Race/ethnicity  40–49 33%  Hispanic/Latina 24%  50+ 23%  Black/African American 39% Race  White, Non-Hispanic 30%  Hispanic/Latina 33%  Other 7%  Black/African American 28% Married/living with partner 28%  White, Non-Hispanic 35% Highest grade completed  Other 4%  < HS 28% Highest level completed in school  HS/GED 32%  HS/GED 14%  > HS, no degree 27%  Some college, no degree 24%  Degree past HS 12%  Associate’s/vocational 12% Currently working 20%  Bachelor’s or higher 51% Receiving TANF/welfare 19% Years in position (mean (SD)) 4.7 (3.9) Low emotional availability 32% Organizational climate (mean (SD))  Emotional exhaustion 50.7 (8.1)  Personalization 49.4 (8.7)  Personal accomplishment 57.8 (7.1) study power to detect meaningful differences. Analyses Morale (mean (SD)) 60.2 (7.6) including visitor characteristics were limited to the 100 mothers whose visitor had completed a survey. These 100 Raw scores converted to standardized T-scores with mean of 50 and mothers were served by 54 unique home visitors (31 HF, SD of 10 21 NFP, and 2 PAT). Mothers with a follow-up survey and mothers with visitor surveys did not differ from those with- out on baseline characteristics. their positions an average of 4.7 years. Visitors reported high Simple linear regression was used for bivariate analy- levels of morale, with the average score > 60. ses. Path analysis was used to simultaneously test the direct effects of maternal and visitor characteristics on engagement Reasons for Enrolling and Satisfaction and the mediating effects of ratings of the visitor and pro- with the Program’s Eor ff ts gram satisfaction. Variables were considered for inclusion in the model if they were significant at the bivariate level Most mothers enrolled for many reasons; 82% endorsed (p < .10). To account for clustering of families within visitor, reasons in four or more of the domains. Nearly all enrolled we used a full information maximum likelihood estimator for child development and parenting and healthy pregnancy with standard errors, parameter estimates, and a Chi square and child health (Table 3). Only a sixth enrolled for mental test statistic robust to nonnormality of the outcome vari- health. Reasons for enrolling varied by select characteristics, able and non-independence of observations (Graham 2009; such as pre- or postnatal enrollment, ethnicity, and emotional Muthen and Muthen 1998–2017). Several measures were availability. For example, compared to other mothers, moth- used to evaluate model fit, including Chi square, RMSEA, ers with low emotional availability enrolled for more rea- SRMR, CFI, and TLI. The path analysis was performed sons (6.6 vs. 5.7, p = .01) and were more likely to enroll for using Mplus v7.4. reasons related to education and employment (77 vs. 53%, p = .01) and other economic needs (58 vs. 40%, p = .04). Overall, mothers rated their visitors favorably on goal Results alignment (Table 3). Scores ranged from 9 to 28, with an average of 23.3 (SD = 4.1). Most mothers reported being Mothers were young and most enrolled prenatally (Table 1). very or completely satisfied with the program’s efforts They were diverse in terms of race. About a third had educa- around child development and parenting (79%). They were tion beyond high school and 20% were working. A third of least satisfied with efforts related to education and employ - mothers had low emotional availability. Half of visitors had ment. On average, mothers were satisfied with program a bachelor’s degree or higher (Table 2). They had been in efforts on 71% of their reasons for enrolling. 1 3 Maternal and Child Health Journal (2018) 22 (Suppl 1):S43–S51 S47 Table 3 Mothers’ reasons for % Mothers enrolling for % Satisfied with enrolling in home visiting and a this reasonprogram efforts satisfaction with program efforts (n = 148) Child development and parenting 96 79 Healthy pregnancy and child health 94 63 Social support 77 57 Education and employment 61 30 Income and benefits 56 50 Primary care and insurance 56 47 Family planning 55 73 Other economic needs 46 31 Other maternal health and wellbeing 38 70 Mental health 16 56 Mothers’ ratings of the visitor and program (mean (SD))  Maternal rating of visitor on goal alignment 23.3 (4.1)  Overall satisfaction with program efforts 71.3 (26.8) Completely or very satisfied with program efforts for each reason noted within the domain Includes independence from TANF and housing Includes healthy adult relationships, help with smoking, and help with alcohol Possible range 4–28 Possible range 0–100 Table 4 Bivariate associations of maternal and visitor characteris- Table 5 Factors for program engagement, bivariate associations tics with mothers’ ratings of the visitor and satisfaction with program Bivariate associations Total days efforts enrolled in home Rating of visitor Overall satis- visiting program on goal alignment faction with B p program efforts  Maternal characteristics B p B p   Age 10.5 .07 Maternal characteristics   Hispanic 133.0 .10  Age 0.12 .04 − 0.12 .74   Enrolled prenatally 67.6 .37  Hispanic − 0.12 .87 − 1.92 .71   Low emotional availability − 174.2 .02  Enrolled prenatally 0.15 .84 13.44 < .01  Visitor characteristics  Low emotional availability − 1.97 < .01 − 7.74 .10   Organizational climate Visitor characteristics    Emotional exhaustion − 13.4 .01  Organizational climate    Personalization 4.6 .33   Emotional exhaustion − 0.09 .08 0.04 .92    Personal accomplishment -0.9 .89   Personalization 0.03 .50 − 0.21 .53   Morale 10.1 .09   Personal accomplishment 0.07 .30 − 0.36 .38  Maternal ratings of the visitor and program  Morale 0.12 < .01 − 0.11 .83   Maternal rating of visitor on goal alignment 24.1 < .01 Limited to mothers with a visitor who completed the web-based staff   Overall satisfaction with program efforts 3.4 .01 survey (n = 100). Models are clustered on visitor Limited to mothers with a visitor who completed the web-based staff survey (n = 100). Models are clustered on visitor Bivariate Associations of Maternal and Visitor Characteristics with Ratings of the Visitor and Satisfaction with Program Eor ff ts contrast, low emotional availability and visitor emotional exhaustion were negatively associated with these ratings. Maternal age and visitor morale were positively associated Prenatally enrolled mothers were more likely to report satisfaction with program efforts to address their reasons with ratings of the visitor on goal alignment (Table 4). In for enrolling; mothers with low emotional availability had lower satisfaction scores. 1 3 S48 Maternal and Child Health Journal (2018) 22 (Suppl 1):S43–S51 Fig. 1 Direct effects of mother and visitor characteristics on days enrolled in the program. Red, solid arrows represent statistically significant direct effects at p < .05. Green, dashed arrows represent direct effects significant at p ≤ .10, and black, dotted arrows represent non-significant direct effects (p > .10). Curved arrows between maternal character- istics represent controlling for confounding effects of ethnicity and age in the model. Signifi- cance levels are not represented in curved arrows. Fit statistics: χ2 (9): 9.232, RMSEA = 0.016, SRMR = 0.054, CFI = 0.995, TLI = 0.991. (Color figure online) emotional exhaustion and length of enrollment (B = − 2.08, Factors for Program Engagement—Bivariate p = .14). Fit statistics for this model all fell within the good Associations to very good range. To further explore these pathways, we repeated these On average, mothers were enrolled for 616 days. Days analyses separately for mothers with low and adequate enrolled increased as maternal age increased, Hispanic emotional availability. Visitor emotional exhaustion was mothers were enrolled longer than non-Hispanic mothers significantly associated with fewer days enrolled, but only and mothers with low emotional availability were enrolled for mothers with adequate emotional availability (not shown; fewer days than other mothers (Table  5). Visitor emo- B = − 13.89, p = .01). Additionally, ratings of goal align- tional exhaustion and morale were significantly related to ment were significantly associated with longer enrollment, engagement. but only for mothers with low emotional availability (not Mothers’ ratings of the visitor on goal alignment and their shown in figure; B = 32.83, p = .01). satisfaction with the program’s effort to address reasons for enrolling were positively associated with engagement. Discussion Factors for Program Engagement—Mediational Path Model This study investigated the associations among mother and visitor psychosocial characteristics, mothers’ ratings In the path model, low maternal emotional availability and of the visitor on goal alignment, and satisfaction with pro- higher visitor emotional exhaustion were significantly asso- gram efforts to address their needs with length of enroll- ciated with fewer days enrolled after controlling for age and ment. Mothers enrolled in home visiting for many reasons, ethnicity (Fig. 1). Ratings of the visitor on goal alignment were most satisfied with program efforts to address reasons were positively associated with number of days enrolled. related to parenting and child development and generally In this model, the total mediational effect of ratings of rated their visitors highly on goal alignment. Mothers who the visitor on goal alignment and program satisfaction on rated their visitor highly on goal alignment stayed in the the relationship between emotional availability and length program longer. Additionally, low emotional availability and of enrollment were not statistically significant (B = − 40.03, visitor emotional exhaustion were both negatively associ- p = .15). Likewise, ratings of the visitor and program did ated with a family’s length of enrollment. Mothers with low not significantly mediate the relationship between visitor 1 3 Maternal and Child Health Journal (2018) 22 (Suppl 1):S43–S51 S49 emotional availability left home visiting about 6 months ear- what works, for whom, in what contexts to achieve specific lier than other mothers. Ratings of the visitor and program outcomes, being led by HRSA, future work should examine did not mediate the association of maternal and visitor char- how these pathways vary across race and ethnic groups. acteristics on program engagement. Exploratory analyses suggested that ratings of the visitor on goal alignment were Methodological Considerations a stronger predictor of engagement for mothers with low emotional availability compared to mothers with adequate Study findings should be interpreted in light of methodo- emotional availability. logical strengths and limitations. One strength is that the These findings are consistent with other work, particu- sample was drawn from a large number of local programs larly Korfmacher et al. (2007), who found that maternal rat- using three home visiting models. While the models vary ings of the relationship with her visitor predicted the amount slightly in who they target for services, all three models are of time spent in the program. The current study extends pre- similar in the intended length and intensity of services and vious research by incorporating maternal and visitor charac- in their primary outcomes for families (Michalopoulos et al. teristics and ratings of their relationship to help explain the 2015). While the current study was not designed with the effect on engagement. intention to test for differences across models, future work Addressing maternal psychosocial risks is a challenge; might consider whether models differ in how visitors work studies have cited mental health concerns as one of the most with families to set goals which align with their reasons common challenging situations facing visitors (Harden et al. for enrolling. Another strength is the use of path analysis. 2010; Tandon et al. 2008). Although only 16% of mothers Since variables can be both independent and dependent, path in this study enrolled for mental health reasons, one-third analysis allows for the simultaneous estimation of all direct of mothers experienced low emotional availability, defined and mediating effects. here as high levels of relationship avoidance combined with On the other hand, visitors played a role in recruiting the depressive symptoms and/or high levels of relationship anxi- sample. This might have introduced bias. Also, sample size ety. This is similar to rates found in other studies (Cluxton- was small, particularly in analyses including visitor data, Keller et al. 2014; McFarlane et al. 2013). These mothers limiting power to detect meaningful associations. A post-hoc were at a substantial risk of leaving the program prematurely power analysis using a Monte Carlo simulation was carried and these findings suggest that this risk may be decreased out on the mediational path model and results indicated a when mothers and visitors are aligned on goals. lack of statistical power which could explain the non-signif- Visitor emotional exhaustion was also negatively associ- icant, mediational effects. ated with engagement. In the path model, emotional exhaus- A final limitation relates to measurement of family tion was associated with a decrease in goal ratings. It is engagement. Duration of enrollment is easily measured, but possible that visitors who are more emotionally exhausted is a simplistic indicator of true engagement. Future research are less responsive to addressing goals of mothers. And in should extend its focus to include measures of parents’ fact, the exploratory results suggest that this is of particu- actual participation in visits as indicated by shared decision- lar concern when serving mothers with adequate emotional making, observational measures of how well the visitor com- availability; when visitors are more exhausted, these mothers municates with mothers to build partnership toward reaching leave the program sooner. This would indicate that the work- goals, and how visitors tailor the content of visits to align related characteristics of visitors are important, particularly with mothers’ goals. when serving mothers with adequate emotional availability. We did not find that satisfaction with program efforts was Implications a predictor of days enrolled in the path model. This is con- sistent with Korfmacher et al.’s (2007) finding that when Family engagement in home visiting is a critical issue for the both ratings of the helping relationship and satisfaction with field. Visitor alignment with mothers on goals and respon- the program were included in models together, ratings of the siveness to reasons for enrolling appear to be effective in program were not as strong of a predictor of engagement as promoting engagement, especially for some mothers. Pro- direct ratings of the visitor. grams should formally identify mothers’ reasons for enroll- In this study, Hispanic mothers endorsed more reasons for ing early on so that family goal plans, a strategy to build a enrolling, were more likely to enroll for reasons related to strong working alliance, reflect the goals that are important primary care, mental health, and maternal health and well- to the family from the start. Implementation systems should being, and stayed enrolled in the program longer than non- be strengthened to support visitors in developing and using Hispanic mothers, which is consistent with other research (McGuigan et  al. 2003; O’Brien et  al. 2012). Given the transition to precision home visiting, the differentiation of For more information, see http://www.hvres earch .org. 1 3 S50 Maternal and Child Health Journal (2018) 22 (Suppl 1):S43–S51 goal plans and with funding through a HRSA Innovation References Award, New Jersey and Maryland are partnering to design Boller, K., Daro, D., Del Grosso, P., Cole, R., Paulsell, D., Hart, B., and test elements of a goal plan strategy (GPS) implemen- 4 … Hargreaves, M. (2014). Making replication work: Building tation system. The purpose is to promote engagement by infrastructure to implement, scale-up, and sustain evidence-based improving visitors’ competence to respond to a family’s rea- early childhood home visiting programs with fidelity. Princeton, sons for enrolling, by making it easier for visitors to do this, NJ: Mathematica Policy Research. Cho, J., Terris, D. D., Glisson, R. E., Bae, D., & Brown, A. (2017). and by reinforcing them in doing so. Studies beyond family demographics, community risk influences Services should be individualized not only to a mother’s maternal engagement in home visiting. Journal of Child and Fam- reasons for enrolling but also to her emotional availability. ily. https ://doi.org/10.1007/s1082 6-017-0803-8. Most programs already screen for depression at enrollment Cluxton-Keller, F., Burrell, L., Crowne, S., McFarlane, E., Tandon, S. D., Leaf, P. J., & Duggan, A. (2014). Maternal relationship inse- or at a time relative to the child’s birth (Michalopoulos et al. curity and depressive symptoms as moderators of home visiting 2015). Based on the current study, as well as our broader impacts on child outcomes. Journal of Child and Family Studies, research, we feel it is important that programs consider rela- 23(8), 1430–1443. tionship security in tailoring services. Work is needed to Daro, D., McCurdy, K., Falconnier, L., & Stojanovic, D. (2003). Sus- taining new parents in home visitation services: Key participant design and test strategies for this. Visitors are in a unique and program factors. Child Abuse & Neglect, 27(10), 1101–1125. position not only to use formal screening tools but also to Duggan, A., Caldera, D., Rodriguez, K., Burrell, L., Rohde, C., & recognize and respond to mothers’ cues regarding their emo- Crowne, S. S. (2007). Impact of a statewide home visiting pro- tional well-being—both depressive symptoms and relation- gram to prevent child abuse. Child Abuse & Neglect, 31(8), 801–827. ship security. If home visiting enrolls mothers with low Duggan, A., Minkovitz, C. S., Chaffin, M., Korfmacher, J., Brooks- emotional availability, we need to adjust our expectations Gunn, J., Crowne, S., … Harwood, R. (2013). Creating a national of their engagement, our visitors’ strategies to personalize home visiting research network. Pediatrics, 132(Supplement 2), communication strategies to promote their engagement, or S82-S89. Girvin, H., DePanfilis, D., & Daining, C. (2007). Predicting program both. The high prevalence of low emotional availability completion among families enrolled in a child neglect preventive underscores the importance of precision home visiting to intervention. Research on Social Work Practice, 17, 674–685. improve on our current service models. Glisson, C., Landsverk, J., Schoenwald, S., Kelleher, K., Hoagwood, K. E., Mayberg, S., & Green, P. (2008). Assessing the organizational Acknowledgements The authors thank the NJ Department of Health social context (OSC) of mental health services: Implications for and the NJ Department of Children and Families, the NJ Home Visit- research and practice. Administration and Policy in Mental Health ing Initiative partners, and local program leadership and staff for their and Mental Health Services Research, 35(1–2), 98–113. ongoing support of evaluation and research and commitment to improv- Graham, J. W. (2009). Missing data analysis: Making it work in the real ing services for families in NJ while advancing the field nationally. We world. Annual Review of Psychology, 60, 549–576. would like to acknowledge support for the statistical analysis from the Harden, B., Denmark, N., & Saul, D. (2010). Understanding the needs National Center for Research Resources and the National Center for of staff in Head Start programs: The characteristics, perceptions, Advancing Translational Sciences (NCATS) of the National Institutes and experiences of visitors. Children and Youth Services Review, of Health through Grant Number 1UL1TR001079. Research activities 3, 371–379. were funded under the following federal support: The US Department Horvath, A. O., & Greenberg, L. S. (Eds.). (1994). The working alli- of Health and Human Services (HHS), Administration for Children and ance: Theory research and practice. New York: Wiley. Families, Children’s Bureau, Office of Child Abuse and Neglect, Sup- Karantzas, G. C., Feeney, J. A., & Wilkinson, R. (2010). Is less more? porting Evidence-Based Home Visiting to Prevent Child Maltreatment Confirmatory factor analysis of the attachment style question- (EBHV) (2008–2011: Contract No. HHS-2008-ACF-ACYF-CA-0130), naires. Thousand Oaks: Sage. https ://doi.or g/10.1177/02654 HHS, Health Resources and Services Administration (HRSA), Mater- 07510 37375 6. nal, Infant, Early Childhood Home Visiting Program (MIECHV) (NJ Korfmacher, J., Green, B., Spellmann, M., & Thornburg, K. R. (2007). 2015 Formula Grant Award X02MC28235; NJ 2015 Competitive Grant The helping relationship and program participation in early Award D89MC28268). childhood home visiting. Infant Mental Health Journal, 28(5), 459–480. Latimore, A. D., Burrell, L., Crowne, S., Ojo, K., Cluxton-Keller, F., Open Access This article is distributed under the terms of the Crea- Gustin, S., … Duggan, A. (2017). Exploring multilevel factors for tive Commons Attribution 4.0 International License (http://creat iveco family engagement in home visiting across two national models. mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- Prevention Science. https ://doi.org/10.1007/s1112 1-017-0767-3. tion, and reproduction in any medium, provided you give appropriate McFarlane, E., Burrell, L., Crowne, S., Cluxton-Keller, F., Fuddy, L., credit to the original author(s) and the source, provide a link to the Leaf, P. J., & Duggan, A. (2013). Maternal relationship security Creative Commons license, and indicate if changes were made. as a moderator of home visiting impacts on maternal psychosocial functioning. Prevention Science, 14(1), 25–39. McFarlane, E., Burrell, L., Fuddy, L., Tandon, S. D., Derauf, C., Leaf, P., & Duggan, A. (2010). Association of visitors’ and mothers’ attachment style with family engagement. Journal of Community Psychology, 38, 541–556. HRSA Award # UH4MC307460100. 1 3 Maternal and Child Health Journal (2018) 22 (Suppl 1):S43–S51 S51 McGuigan, W. M., Katzev, A. R., & Pratt, C. C. (2003). Multi-level dysfunctional attitudes and low self-esteem. Journal of Personal- determinants of retention in a home-visiting child abuse preven- ity and Social Psychology, 70, 310–320. tion program. Child Abuse & Neglect, 27(4), 363–380. Ross, C. E., Mirowsky, J., & Huber, J. (1983). Dividing work, sharing Michalopoulos, C., Lee, H., Duggan, A., Lundquist, E., Tso, A., work, and in-between: Marriage patterns and depression. Ameri- Crowne, S., … Knox, V. (2015). The mother and infant home vis- can Sociological Review, 48, 809–823. iting program evaluation: Early findings on the maternal, infant, Sharp, E. A., Ispa, J. M., Thornburg, K. R., & Lane, V. (2003). Rela- and early childhood home visiting program. OPRE Report 2015- tions among mother and visitor personality, relationship quality, 11. Washington, DC: Office of Planning, Research and Evaluation, and amount of time spent in home visits. Journal of Community Administration for Children and Families, U.S. Department of Psychology, 31(6), 591–606. Health and Human Services. Stevens, J., Ammerman, R. T., Putnam, F. W., Gannon, T., & Van MIECHV Technical Assistance Coordinating Center. (2015). MIECHV Ginkel, J. B. (2005). Facilitators and barriers to engagement in Issue Brief on Family Enrollment and Engagement. Retrieved home visitation: A qualitative analysis of maternal, provider, and from https ://mchb.hrsa.gov/sites /defau lt/files /mchb/Mater nalCh supervisor data. Journal of Aggression, Maltreatment & Trauma, ildHea lthIn itiati ves/ HomeVi siting /tafile s/enroll menta ndeng agem 11(4), 75–93. ent.pdf. Strodl, E., & Noller, P. (2003). The relationship of adult attachment Mikulincer, M., & Nachshon, O. (1991). Attachment styles and patterns dimensions to depression and agoraphobia. Personal Relation- of self-disclosure. Journal of Personality and Social Psychology, ships, 10, 171–185. 61(2), 321–331. Tandon, S. D., Mercer, C. D., Saylor, E. L., & Duggan, A. K. (2008). Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood: Paraprofessional visitors’ perspectives on addressing poor men- Structure, dynamics, and change. New York: Guilford. tal health, substance abuse, and domestic violence: A qualitative Muthén, L. K., & Muthén, B. O. (1998–2017). Mplus user’s guide. study. Early Childhood Research Quarterly, 23(3), 419–428. Eighth Edition. Los Angeles, CA: Muthén & Muthén. Tandon, S. D., Parillo, K., Mercer, C., Keefer, M., & Duggan, A. K. O’Brien, R. A., Moritz, P., Luckey, D. W., McClatchey, M. W., (2008). Engagement in paraprofessional home visitation: Fami- Ingoldsby, E. M., & Olds, D. L. (2012). Mixed methods analysis lies’ reasons for enrollment and program response to identified of participant attrition in the nurse-family partnership. Prevention reasons. Women’s Health Issues, 18(2), 118–129. Science, 13(3), 219–228. Roberts, J. E., Gotlib, I. H., & Kassel, J. D. (1996). Adult attach- ment styles and symptoms of depression: The mediating role of 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Maternal and Child Health Journal Springer Journals

Mother and Home Visitor Emotional Well-Being and Alignment on Goals for Home Visiting as Factors for Program Engagement

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Copyright © 2018 by The Author(s)
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Medicine & Public Health; Public Health; Sociology, general; Population Economics; Pediatrics; Gynecology; Maternal and Child Health
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Abstract

Objectives Family engagement in home visiting (HV), as indicated by length of enrollment, is a major challenge as most families do not stay enrolled for the intended duration prescribed by HV models. This study examined maternal and visitor emotional well-being as factors for maternal satisfaction with the program in addressing reasons for enrolling in HV and program engagement and the role of their working alliance with the visitor as a mediator of this. Methods Longitudinal data were collected from 148 mothers and 54 visitors in 21 HV programs. Mothers completed surveys shortly after enrolling and 6 months later to assess attributes of the working alliance with their visitor. Visitors completed a survey to assess work-related well-being. HV program data were used to measure engagement. Results Mothers enrolled for multiple, diverse reasons, most often to promote child development and parenting (96%). Mothers’ satisfaction with program efforts to address reasons for enrollment was highest for parenting (79%) and lowest for jobs and education (30%). Results of the mediational path model indicated that ratings of the visitor on goal alignment were positively associated with engagement. Maternal emo- tional availability and visitor work-related emotional exhaustion were negatively associated with engagement. Exploratory analyses suggested that ratings of the visitor on goal alignment were a stronger predictor of engagement for mothers with low emotional availability compared to other mothers. Conclusions for Practice Visitor alignment with mothers on goals and responsiveness to reasons for enrolling appear to be effective in promoting engagement. Individualizing services to reflect maternal goals and emotional capacity may be important strategies to address engagement challenges. Keywords Home visiting · Maternal satisfaction · Engagement · Emotional well-being Significance Introduction Family engagement continues to be an important issue fac- Family engagement, most commonly defined as the length of ing home visiting field; studies find that most families do not enrollment or the frequency of home visits, has been a major receive the intended amount of services. Previous studies challenge for home visiting (MIECHV TACC, 2015). Most have documented attributes of visitors and families that are evidence-based home visiting models intend to serve fami- associated with HV engagement. This study extends pre- lies for 2–3 years with intensive visit schedules and research vious investigations into attributes of mothers and visitors suggests that engagement rates fall well below expectations. associated with HV engagement by considering mothers’ In fact, typically 40–50% of families leave within 1 year reasons for enrolling and their visitors’ alignment with and (Boller et al. 2014; Duggan et al. 2007). Because engage- attention to these reasons. ment remains a challenge, research to promote it is a national priority (Duggan et al. 2013). Studies have documented attributes of visitors and fami- * L. Burrell lies that are associated with engagement (Cho et al. 2017; lburrell@jhu.edu Latimore et al. 2017; O’Brien et al. 2012). For example, Department of Population, Family and Reproductive Health, Latimore et al. (2017) found that visitor morale was asso- Johns Hopkins Bloomberg School of Public Health, 615 N. ciated with receiving a high dose of services. Maternal Wolfe Street, Baltimore, MD 21205, USA age, race, and pregnancy status are commonly associated Dartmouth Geisel School of Medicine, 1 Rope Ferry Road, with engagement (Daro et al. 2003; McGuigan et al. 2003; Hanover, NH 03755-1404, USA Vol.:(0123456789) 1 3 S44 Maternal and Child Health Journal (2018) 22 (Suppl 1):S43–S51 O’Brien et al. 2012). Other maternal characteristics, includ- Methods ing depression and relationship security, may influence engagement (Girvin et al. 2007; Sharp et al. 2003). Rela- Setting and Participants tionship security is the extent to which an adult provides and receives support in relationships, including one formed With State and Federal MIECHV funding, the New Jersey between a mother and visitor. McFarlane et al. (2010) found Departments of Health and Children and Families are col- that mothers with anxious relationship styles were more laborating to build the state’s home visiting program (NJ- likely to receive a high dose of service, suggesting that they HV). The evaluation of NJ-HV incorporates mixed methods may be particularly open to developing a close relationship to inform strategies to improve engagement and outcomes with the visitor. Mikulincer and Nachshon (1991) found by strengthening the implementation system. This paper associations between relationship avoidance and a lack of uses data from a longitudinal study of a purposive sample self-disclosure, which may make it harder for a visitor to of mothers newly enrolling in home visiting. The research identify the mother’s needs. was conducted in accord with prevailing ethical principles Home visiting values a strong alliance between visitors and approved by the Johns Hopkins School of Medicine and and mothers to help mothers reach their goals. Mothers state Institutional Review Boards. Study participants pro- choose to enroll for many reasons, such as wanting infor- vided written informed consent and were remunerated for mation about job training, child development, and tangible data collection. assistance (Stevens et al. 2005; Tandon et al. 2008). Visi- In 2012, NJ-HV funded 33 home visiting program sites tors respond to these reasons in varied ways. For instance, statewide. Each site used one of three evidence-based mod- Tandon et al. (2008) found that visitors were most likely to els: Healthy Families America (HFA), Nurse-Family Part- meet the needs that were more proximal to program goals nership (NFP), and Parents as Teachers (PAT). Sites were such as parenting information. eligible for this study if they had operated for at least 2 The nature of the mother’s working alliance with the visi- years and had at least three visitors who had completed a tor is predictive of family engagement. Studies have shown web-based survey. Visitors were eligible if they had com- that mothers with better relationships with their visitors were pleted core training and were able to visit families indepen- more likely to have higher levels of program involvement dently. In total, 95 visitors in 21 program sites were eligible and complete the program (Girvin et al. 2007; Korfmacher for this study (27 visitors across 13 HFA sites, 27 visitors et al. 2007). Evidence suggests that this working alliance across 7 NFP sites, 3 visitors from 1 PAT site). may be impacted by characteristics of the mother and the A maximum of three mothers per eligible visitor were visitor. For example, mothers with both severe depression recruited between June 2012 and March 2013. Researchers and discomfort with trusting others had lower ratings of trust trained visitors to identify eligible mothers and introduce the in their visitor (Cluxton-Keller et al. 2014). study within the first three visits. A mother was eligible for The Maternal, Infant, and Early Childhood Home Visit- the study if she: (a) was pregnant or had an infant less than ing (MIECHV) Program was established in 2010 to expand 3 months old; (b) received services in English or Spanish; evidence-based home visiting and to carry out research to and (c) was assigned to a visitor who had not recruited three study its implementation and effectiveness. The current families. study aims to: (a) describe mothers’ reasons for enrolling, During recruitment, 730 mothers enrolled in services. (b) examine the associations of maternal and visitor charac- Of those enrolled, 536 were eligible for the study. Of the teristics with mothers’ ratings of their working alliance with 536, researchers received contact information for 205. Pri- their visitors, (c) examine the association of attributes of the mary reasons for not receiving information included mother working alliance with program engagement, and (d) explore declined to participate (47%), the study was not yet intro- the role of the working alliance as a mediator of associa- duced to the mother, but she did not have at least three vis- tions of maternal and visitor characteristics with program its (e.g. family was discharged) (31%), and the study was engagement. not introduced to the mother during the first three visits (16%). Of the 205 mothers who agreed to be contacted by the research team, 177 (86%) consented and completed a baseline survey. 1 2 For more information, see https ://mchb.hrsa.gov/mater nal-child For HFA sites, the site also had to have completed the national -healt h-initi ative s/home-visit ing-overv iew. model’s site accreditation process. 1 3 Maternal and Child Health Journal (2018) 22 (Suppl 1):S43–S51 S45 ing education”) and were asked whether each was applica- Data Sources ble. These reasons were grouped into 10 broad domains. Mothers were counted as enrolling for each domain if they Maternal and Visitor Surveys endorsed any of the items within it. The baseline maternal surveys included questions about demographic characteristics, psychosocial well-being (e.g. Maternal Follow-Up Measures depression and relationship security), and maternal and family functioning. They completed follow-up surveys 6 Rating of  the Visitor on  Goal Alignment The 4-item, goals subscale from the Working Alliance Inventory—Home Visit- months later or, if pregnant at baseline, when the child was 6 months. The follow-up surveys included questions from ing Short Form (Boller et al. 2014; Horvath and Greenberg 1994) was used to assess the mother’s rating of her visitor baseline, but also included measures of child development, parent–child interaction, and ratings of home visiting. regarding goals for home visiting (e.g. “My visitor and I are working toward mutually agreed upon goals”). Items were Visitors completed web-based surveys in early 2012. The survey captured demographic information, ratings of work- summed to yield overall scores ranging from 4 to 28 with high scores indicating greater alignment. place culture, training, supervision, and psychosocial aspects of work (e.g. emotional exhaustion and morale). Rating of Satisfaction with the Program’s Eor ff ts to Address Program Management Information Systems (MIS) Reasons for  Enrolling For each endorsed reason, moth- ers were asked how satisfied they were with the program’s NJ HFA and PAT sites use a web-based, MIS developed by efforts to meet each need. A continuous score (range from 0 to 100) was created that represented the proportion of the the State University of New York and NJ NFP sites use ETO provided by the NFP National Service Office. These systems reasons where the mother indicated being completely or very satisfied. enable sites to document service delivery. Visitor Measures Measurement Perceptions of Organizational Climate Three first-order cli- Maternal Baseline Measures mate subscales of the Organization Social Context Meas- urement System (OSC; Glisson et  al. 2008) were used to Emotional Availability Emotional availability includes depressive symptoms and relationship security as research measure individual-level perceptions of emotional exhaus- tion, personalization, and personal accomplishment. Raw has confirmed a link between them (Roberts et  al. 1996; Strodl and Noller 2003). Each dimension of attachment scores were converted to standardized T-scores with a mean of 50 and standard deviation of 10. High scores on personal- has characteristics that can make one vulnerable to devel- oping depression (Mikulincer and Shaver 2007). To assess ization and personal accomplishment are desirable and low scores are desirable for emotional exhaustion. depressive symptoms, we used the 12-item, Center for Epi- demiologic Studies Depression Scale—Short Form (Ross Morale The OSC also includes an individual-level meas- et  al. 1983). A total score was derived by summing items and scores ≥ 10 indicated moderate to severe symptoms. ure of morale. Raw scores were converted to standardized T-scores with a mean of 50 and standard deviation of 10. Relationship security was measured using the 29-item, Attachment Style Questionnaire-Short Form (Karantzas High scores are desirable. et al. 2010). An exploratory factor analysis identified items loading onto anxiety and avoidance factors. The relationship Program Engagement anxiety subscale included 12 items (α = 0.85) and the rela- tionship avoidance subscale included eight items (α = 0.76). Engagement was defined as the total number of days from program enrollment to last completed home visit. For fami- Items were summed to create relationship anxiety and avoidance scores and then dichotomized such that scores lies still active, total number of days was calculated to the last home visit as of March 31, 2017. above the theoretical median were considered ‘high.’ Moth- ers were considered low on emotional availability if they Analytic Plan scored ‘high’ on relationship avoidance and scored positive for depressive symptoms or high on relationship anxiety. Of the 177 mothers completing a baseline survey, 148 com- Reasons for Enrolling in Home Visiting Mothers were given pleted the follow-up (76 HFA, 70 NFP, and 2 PAT). When possible, analyses included all 148 mothers to maximize a list of 27 reasons for enrolling (e.g. “Want help finish- 1 3 S46 Maternal and Child Health Journal (2018) 22 (Suppl 1):S43–S51 Table 1 Baseline maternal characteristics (n = 148) Table 2 Visitor characteristics (n = 54) Age Maternal age in years (mean (SD)) 22.7 (5.9) Teen mother (< 19 years old) 36%  < 30 21% Enrolled prenatally 71%  30–39 23% Race/ethnicity  40–49 33%  Hispanic/Latina 24%  50+ 23%  Black/African American 39% Race  White, Non-Hispanic 30%  Hispanic/Latina 33%  Other 7%  Black/African American 28% Married/living with partner 28%  White, Non-Hispanic 35% Highest grade completed  Other 4%  < HS 28% Highest level completed in school  HS/GED 32%  HS/GED 14%  > HS, no degree 27%  Some college, no degree 24%  Degree past HS 12%  Associate’s/vocational 12% Currently working 20%  Bachelor’s or higher 51% Receiving TANF/welfare 19% Years in position (mean (SD)) 4.7 (3.9) Low emotional availability 32% Organizational climate (mean (SD))  Emotional exhaustion 50.7 (8.1)  Personalization 49.4 (8.7)  Personal accomplishment 57.8 (7.1) study power to detect meaningful differences. Analyses Morale (mean (SD)) 60.2 (7.6) including visitor characteristics were limited to the 100 mothers whose visitor had completed a survey. These 100 Raw scores converted to standardized T-scores with mean of 50 and mothers were served by 54 unique home visitors (31 HF, SD of 10 21 NFP, and 2 PAT). Mothers with a follow-up survey and mothers with visitor surveys did not differ from those with- out on baseline characteristics. their positions an average of 4.7 years. Visitors reported high Simple linear regression was used for bivariate analy- levels of morale, with the average score > 60. ses. Path analysis was used to simultaneously test the direct effects of maternal and visitor characteristics on engagement Reasons for Enrolling and Satisfaction and the mediating effects of ratings of the visitor and pro- with the Program’s Eor ff ts gram satisfaction. Variables were considered for inclusion in the model if they were significant at the bivariate level Most mothers enrolled for many reasons; 82% endorsed (p < .10). To account for clustering of families within visitor, reasons in four or more of the domains. Nearly all enrolled we used a full information maximum likelihood estimator for child development and parenting and healthy pregnancy with standard errors, parameter estimates, and a Chi square and child health (Table 3). Only a sixth enrolled for mental test statistic robust to nonnormality of the outcome vari- health. Reasons for enrolling varied by select characteristics, able and non-independence of observations (Graham 2009; such as pre- or postnatal enrollment, ethnicity, and emotional Muthen and Muthen 1998–2017). Several measures were availability. For example, compared to other mothers, moth- used to evaluate model fit, including Chi square, RMSEA, ers with low emotional availability enrolled for more rea- SRMR, CFI, and TLI. The path analysis was performed sons (6.6 vs. 5.7, p = .01) and were more likely to enroll for using Mplus v7.4. reasons related to education and employment (77 vs. 53%, p = .01) and other economic needs (58 vs. 40%, p = .04). Overall, mothers rated their visitors favorably on goal Results alignment (Table 3). Scores ranged from 9 to 28, with an average of 23.3 (SD = 4.1). Most mothers reported being Mothers were young and most enrolled prenatally (Table 1). very or completely satisfied with the program’s efforts They were diverse in terms of race. About a third had educa- around child development and parenting (79%). They were tion beyond high school and 20% were working. A third of least satisfied with efforts related to education and employ - mothers had low emotional availability. Half of visitors had ment. On average, mothers were satisfied with program a bachelor’s degree or higher (Table 2). They had been in efforts on 71% of their reasons for enrolling. 1 3 Maternal and Child Health Journal (2018) 22 (Suppl 1):S43–S51 S47 Table 3 Mothers’ reasons for % Mothers enrolling for % Satisfied with enrolling in home visiting and a this reasonprogram efforts satisfaction with program efforts (n = 148) Child development and parenting 96 79 Healthy pregnancy and child health 94 63 Social support 77 57 Education and employment 61 30 Income and benefits 56 50 Primary care and insurance 56 47 Family planning 55 73 Other economic needs 46 31 Other maternal health and wellbeing 38 70 Mental health 16 56 Mothers’ ratings of the visitor and program (mean (SD))  Maternal rating of visitor on goal alignment 23.3 (4.1)  Overall satisfaction with program efforts 71.3 (26.8) Completely or very satisfied with program efforts for each reason noted within the domain Includes independence from TANF and housing Includes healthy adult relationships, help with smoking, and help with alcohol Possible range 4–28 Possible range 0–100 Table 4 Bivariate associations of maternal and visitor characteris- Table 5 Factors for program engagement, bivariate associations tics with mothers’ ratings of the visitor and satisfaction with program Bivariate associations Total days efforts enrolled in home Rating of visitor Overall satis- visiting program on goal alignment faction with B p program efforts  Maternal characteristics B p B p   Age 10.5 .07 Maternal characteristics   Hispanic 133.0 .10  Age 0.12 .04 − 0.12 .74   Enrolled prenatally 67.6 .37  Hispanic − 0.12 .87 − 1.92 .71   Low emotional availability − 174.2 .02  Enrolled prenatally 0.15 .84 13.44 < .01  Visitor characteristics  Low emotional availability − 1.97 < .01 − 7.74 .10   Organizational climate Visitor characteristics    Emotional exhaustion − 13.4 .01  Organizational climate    Personalization 4.6 .33   Emotional exhaustion − 0.09 .08 0.04 .92    Personal accomplishment -0.9 .89   Personalization 0.03 .50 − 0.21 .53   Morale 10.1 .09   Personal accomplishment 0.07 .30 − 0.36 .38  Maternal ratings of the visitor and program  Morale 0.12 < .01 − 0.11 .83   Maternal rating of visitor on goal alignment 24.1 < .01 Limited to mothers with a visitor who completed the web-based staff   Overall satisfaction with program efforts 3.4 .01 survey (n = 100). Models are clustered on visitor Limited to mothers with a visitor who completed the web-based staff survey (n = 100). Models are clustered on visitor Bivariate Associations of Maternal and Visitor Characteristics with Ratings of the Visitor and Satisfaction with Program Eor ff ts contrast, low emotional availability and visitor emotional exhaustion were negatively associated with these ratings. Maternal age and visitor morale were positively associated Prenatally enrolled mothers were more likely to report satisfaction with program efforts to address their reasons with ratings of the visitor on goal alignment (Table 4). In for enrolling; mothers with low emotional availability had lower satisfaction scores. 1 3 S48 Maternal and Child Health Journal (2018) 22 (Suppl 1):S43–S51 Fig. 1 Direct effects of mother and visitor characteristics on days enrolled in the program. Red, solid arrows represent statistically significant direct effects at p < .05. Green, dashed arrows represent direct effects significant at p ≤ .10, and black, dotted arrows represent non-significant direct effects (p > .10). Curved arrows between maternal character- istics represent controlling for confounding effects of ethnicity and age in the model. Signifi- cance levels are not represented in curved arrows. Fit statistics: χ2 (9): 9.232, RMSEA = 0.016, SRMR = 0.054, CFI = 0.995, TLI = 0.991. (Color figure online) emotional exhaustion and length of enrollment (B = − 2.08, Factors for Program Engagement—Bivariate p = .14). Fit statistics for this model all fell within the good Associations to very good range. To further explore these pathways, we repeated these On average, mothers were enrolled for 616 days. Days analyses separately for mothers with low and adequate enrolled increased as maternal age increased, Hispanic emotional availability. Visitor emotional exhaustion was mothers were enrolled longer than non-Hispanic mothers significantly associated with fewer days enrolled, but only and mothers with low emotional availability were enrolled for mothers with adequate emotional availability (not shown; fewer days than other mothers (Table  5). Visitor emo- B = − 13.89, p = .01). Additionally, ratings of goal align- tional exhaustion and morale were significantly related to ment were significantly associated with longer enrollment, engagement. but only for mothers with low emotional availability (not Mothers’ ratings of the visitor on goal alignment and their shown in figure; B = 32.83, p = .01). satisfaction with the program’s effort to address reasons for enrolling were positively associated with engagement. Discussion Factors for Program Engagement—Mediational Path Model This study investigated the associations among mother and visitor psychosocial characteristics, mothers’ ratings In the path model, low maternal emotional availability and of the visitor on goal alignment, and satisfaction with pro- higher visitor emotional exhaustion were significantly asso- gram efforts to address their needs with length of enroll- ciated with fewer days enrolled after controlling for age and ment. Mothers enrolled in home visiting for many reasons, ethnicity (Fig. 1). Ratings of the visitor on goal alignment were most satisfied with program efforts to address reasons were positively associated with number of days enrolled. related to parenting and child development and generally In this model, the total mediational effect of ratings of rated their visitors highly on goal alignment. Mothers who the visitor on goal alignment and program satisfaction on rated their visitor highly on goal alignment stayed in the the relationship between emotional availability and length program longer. Additionally, low emotional availability and of enrollment were not statistically significant (B = − 40.03, visitor emotional exhaustion were both negatively associ- p = .15). Likewise, ratings of the visitor and program did ated with a family’s length of enrollment. Mothers with low not significantly mediate the relationship between visitor 1 3 Maternal and Child Health Journal (2018) 22 (Suppl 1):S43–S51 S49 emotional availability left home visiting about 6 months ear- what works, for whom, in what contexts to achieve specific lier than other mothers. Ratings of the visitor and program outcomes, being led by HRSA, future work should examine did not mediate the association of maternal and visitor char- how these pathways vary across race and ethnic groups. acteristics on program engagement. Exploratory analyses suggested that ratings of the visitor on goal alignment were Methodological Considerations a stronger predictor of engagement for mothers with low emotional availability compared to mothers with adequate Study findings should be interpreted in light of methodo- emotional availability. logical strengths and limitations. One strength is that the These findings are consistent with other work, particu- sample was drawn from a large number of local programs larly Korfmacher et al. (2007), who found that maternal rat- using three home visiting models. While the models vary ings of the relationship with her visitor predicted the amount slightly in who they target for services, all three models are of time spent in the program. The current study extends pre- similar in the intended length and intensity of services and vious research by incorporating maternal and visitor charac- in their primary outcomes for families (Michalopoulos et al. teristics and ratings of their relationship to help explain the 2015). While the current study was not designed with the effect on engagement. intention to test for differences across models, future work Addressing maternal psychosocial risks is a challenge; might consider whether models differ in how visitors work studies have cited mental health concerns as one of the most with families to set goals which align with their reasons common challenging situations facing visitors (Harden et al. for enrolling. Another strength is the use of path analysis. 2010; Tandon et al. 2008). Although only 16% of mothers Since variables can be both independent and dependent, path in this study enrolled for mental health reasons, one-third analysis allows for the simultaneous estimation of all direct of mothers experienced low emotional availability, defined and mediating effects. here as high levels of relationship avoidance combined with On the other hand, visitors played a role in recruiting the depressive symptoms and/or high levels of relationship anxi- sample. This might have introduced bias. Also, sample size ety. This is similar to rates found in other studies (Cluxton- was small, particularly in analyses including visitor data, Keller et al. 2014; McFarlane et al. 2013). These mothers limiting power to detect meaningful associations. A post-hoc were at a substantial risk of leaving the program prematurely power analysis using a Monte Carlo simulation was carried and these findings suggest that this risk may be decreased out on the mediational path model and results indicated a when mothers and visitors are aligned on goals. lack of statistical power which could explain the non-signif- Visitor emotional exhaustion was also negatively associ- icant, mediational effects. ated with engagement. In the path model, emotional exhaus- A final limitation relates to measurement of family tion was associated with a decrease in goal ratings. It is engagement. Duration of enrollment is easily measured, but possible that visitors who are more emotionally exhausted is a simplistic indicator of true engagement. Future research are less responsive to addressing goals of mothers. And in should extend its focus to include measures of parents’ fact, the exploratory results suggest that this is of particu- actual participation in visits as indicated by shared decision- lar concern when serving mothers with adequate emotional making, observational measures of how well the visitor com- availability; when visitors are more exhausted, these mothers municates with mothers to build partnership toward reaching leave the program sooner. This would indicate that the work- goals, and how visitors tailor the content of visits to align related characteristics of visitors are important, particularly with mothers’ goals. when serving mothers with adequate emotional availability. We did not find that satisfaction with program efforts was Implications a predictor of days enrolled in the path model. This is con- sistent with Korfmacher et al.’s (2007) finding that when Family engagement in home visiting is a critical issue for the both ratings of the helping relationship and satisfaction with field. Visitor alignment with mothers on goals and respon- the program were included in models together, ratings of the siveness to reasons for enrolling appear to be effective in program were not as strong of a predictor of engagement as promoting engagement, especially for some mothers. Pro- direct ratings of the visitor. grams should formally identify mothers’ reasons for enroll- In this study, Hispanic mothers endorsed more reasons for ing early on so that family goal plans, a strategy to build a enrolling, were more likely to enroll for reasons related to strong working alliance, reflect the goals that are important primary care, mental health, and maternal health and well- to the family from the start. Implementation systems should being, and stayed enrolled in the program longer than non- be strengthened to support visitors in developing and using Hispanic mothers, which is consistent with other research (McGuigan et  al. 2003; O’Brien et  al. 2012). Given the transition to precision home visiting, the differentiation of For more information, see http://www.hvres earch .org. 1 3 S50 Maternal and Child Health Journal (2018) 22 (Suppl 1):S43–S51 goal plans and with funding through a HRSA Innovation References Award, New Jersey and Maryland are partnering to design Boller, K., Daro, D., Del Grosso, P., Cole, R., Paulsell, D., Hart, B., and test elements of a goal plan strategy (GPS) implemen- 4 … Hargreaves, M. (2014). Making replication work: Building tation system. The purpose is to promote engagement by infrastructure to implement, scale-up, and sustain evidence-based improving visitors’ competence to respond to a family’s rea- early childhood home visiting programs with fidelity. Princeton, sons for enrolling, by making it easier for visitors to do this, NJ: Mathematica Policy Research. Cho, J., Terris, D. D., Glisson, R. E., Bae, D., & Brown, A. (2017). and by reinforcing them in doing so. Studies beyond family demographics, community risk influences Services should be individualized not only to a mother’s maternal engagement in home visiting. Journal of Child and Fam- reasons for enrolling but also to her emotional availability. ily. https ://doi.org/10.1007/s1082 6-017-0803-8. Most programs already screen for depression at enrollment Cluxton-Keller, F., Burrell, L., Crowne, S., McFarlane, E., Tandon, S. D., Leaf, P. J., & Duggan, A. (2014). Maternal relationship inse- or at a time relative to the child’s birth (Michalopoulos et al. curity and depressive symptoms as moderators of home visiting 2015). Based on the current study, as well as our broader impacts on child outcomes. Journal of Child and Family Studies, research, we feel it is important that programs consider rela- 23(8), 1430–1443. tionship security in tailoring services. Work is needed to Daro, D., McCurdy, K., Falconnier, L., & Stojanovic, D. (2003). Sus- taining new parents in home visitation services: Key participant design and test strategies for this. Visitors are in a unique and program factors. Child Abuse & Neglect, 27(10), 1101–1125. position not only to use formal screening tools but also to Duggan, A., Caldera, D., Rodriguez, K., Burrell, L., Rohde, C., & recognize and respond to mothers’ cues regarding their emo- Crowne, S. S. (2007). Impact of a statewide home visiting pro- tional well-being—both depressive symptoms and relation- gram to prevent child abuse. Child Abuse & Neglect, 31(8), 801–827. ship security. If home visiting enrolls mothers with low Duggan, A., Minkovitz, C. S., Chaffin, M., Korfmacher, J., Brooks- emotional availability, we need to adjust our expectations Gunn, J., Crowne, S., … Harwood, R. (2013). Creating a national of their engagement, our visitors’ strategies to personalize home visiting research network. Pediatrics, 132(Supplement 2), communication strategies to promote their engagement, or S82-S89. Girvin, H., DePanfilis, D., & Daining, C. (2007). Predicting program both. The high prevalence of low emotional availability completion among families enrolled in a child neglect preventive underscores the importance of precision home visiting to intervention. Research on Social Work Practice, 17, 674–685. improve on our current service models. Glisson, C., Landsverk, J., Schoenwald, S., Kelleher, K., Hoagwood, K. E., Mayberg, S., & Green, P. (2008). Assessing the organizational Acknowledgements The authors thank the NJ Department of Health social context (OSC) of mental health services: Implications for and the NJ Department of Children and Families, the NJ Home Visit- research and practice. Administration and Policy in Mental Health ing Initiative partners, and local program leadership and staff for their and Mental Health Services Research, 35(1–2), 98–113. ongoing support of evaluation and research and commitment to improv- Graham, J. W. (2009). Missing data analysis: Making it work in the real ing services for families in NJ while advancing the field nationally. We world. Annual Review of Psychology, 60, 549–576. would like to acknowledge support for the statistical analysis from the Harden, B., Denmark, N., & Saul, D. (2010). Understanding the needs National Center for Research Resources and the National Center for of staff in Head Start programs: The characteristics, perceptions, Advancing Translational Sciences (NCATS) of the National Institutes and experiences of visitors. Children and Youth Services Review, of Health through Grant Number 1UL1TR001079. Research activities 3, 371–379. were funded under the following federal support: The US Department Horvath, A. O., & Greenberg, L. S. (Eds.). (1994). The working alli- of Health and Human Services (HHS), Administration for Children and ance: Theory research and practice. New York: Wiley. Families, Children’s Bureau, Office of Child Abuse and Neglect, Sup- Karantzas, G. C., Feeney, J. A., & Wilkinson, R. (2010). Is less more? porting Evidence-Based Home Visiting to Prevent Child Maltreatment Confirmatory factor analysis of the attachment style question- (EBHV) (2008–2011: Contract No. HHS-2008-ACF-ACYF-CA-0130), naires. Thousand Oaks: Sage. https ://doi.or g/10.1177/02654 HHS, Health Resources and Services Administration (HRSA), Mater- 07510 37375 6. nal, Infant, Early Childhood Home Visiting Program (MIECHV) (NJ Korfmacher, J., Green, B., Spellmann, M., & Thornburg, K. R. (2007). 2015 Formula Grant Award X02MC28235; NJ 2015 Competitive Grant The helping relationship and program participation in early Award D89MC28268). childhood home visiting. Infant Mental Health Journal, 28(5), 459–480. Latimore, A. D., Burrell, L., Crowne, S., Ojo, K., Cluxton-Keller, F., Open Access This article is distributed under the terms of the Crea- Gustin, S., … Duggan, A. (2017). Exploring multilevel factors for tive Commons Attribution 4.0 International License (http://creat iveco family engagement in home visiting across two national models. mmons.or g/licenses/b y/4.0/), which permits unrestricted use, distribu- Prevention Science. https ://doi.org/10.1007/s1112 1-017-0767-3. tion, and reproduction in any medium, provided you give appropriate McFarlane, E., Burrell, L., Crowne, S., Cluxton-Keller, F., Fuddy, L., credit to the original author(s) and the source, provide a link to the Leaf, P. J., & Duggan, A. (2013). Maternal relationship security Creative Commons license, and indicate if changes were made. as a moderator of home visiting impacts on maternal psychosocial functioning. Prevention Science, 14(1), 25–39. McFarlane, E., Burrell, L., Fuddy, L., Tandon, S. D., Derauf, C., Leaf, P., & Duggan, A. (2010). Association of visitors’ and mothers’ attachment style with family engagement. Journal of Community Psychology, 38, 541–556. HRSA Award # UH4MC307460100. 1 3 Maternal and Child Health Journal (2018) 22 (Suppl 1):S43–S51 S51 McGuigan, W. M., Katzev, A. R., & Pratt, C. C. (2003). Multi-level dysfunctional attitudes and low self-esteem. Journal of Personal- determinants of retention in a home-visiting child abuse preven- ity and Social Psychology, 70, 310–320. tion program. Child Abuse & Neglect, 27(4), 363–380. Ross, C. E., Mirowsky, J., & Huber, J. (1983). Dividing work, sharing Michalopoulos, C., Lee, H., Duggan, A., Lundquist, E., Tso, A., work, and in-between: Marriage patterns and depression. Ameri- Crowne, S., … Knox, V. (2015). The mother and infant home vis- can Sociological Review, 48, 809–823. iting program evaluation: Early findings on the maternal, infant, Sharp, E. A., Ispa, J. M., Thornburg, K. R., & Lane, V. (2003). Rela- and early childhood home visiting program. OPRE Report 2015- tions among mother and visitor personality, relationship quality, 11. Washington, DC: Office of Planning, Research and Evaluation, and amount of time spent in home visits. Journal of Community Administration for Children and Families, U.S. Department of Psychology, 31(6), 591–606. Health and Human Services. Stevens, J., Ammerman, R. T., Putnam, F. W., Gannon, T., & Van MIECHV Technical Assistance Coordinating Center. (2015). MIECHV Ginkel, J. B. (2005). Facilitators and barriers to engagement in Issue Brief on Family Enrollment and Engagement. Retrieved home visitation: A qualitative analysis of maternal, provider, and from https ://mchb.hrsa.gov/sites /defau lt/files /mchb/Mater nalCh supervisor data. Journal of Aggression, Maltreatment & Trauma, ildHea lthIn itiati ves/ HomeVi siting /tafile s/enroll menta ndeng agem 11(4), 75–93. ent.pdf. Strodl, E., & Noller, P. (2003). The relationship of adult attachment Mikulincer, M., & Nachshon, O. (1991). Attachment styles and patterns dimensions to depression and agoraphobia. Personal Relation- of self-disclosure. Journal of Personality and Social Psychology, ships, 10, 171–185. 61(2), 321–331. Tandon, S. D., Mercer, C. D., Saylor, E. L., & Duggan, A. K. (2008). Mikulincer, M., & Shaver, P. R. (2007). Attachment in adulthood: Paraprofessional visitors’ perspectives on addressing poor men- Structure, dynamics, and change. New York: Guilford. tal health, substance abuse, and domestic violence: A qualitative Muthén, L. K., & Muthén, B. O. (1998–2017). Mplus user’s guide. study. Early Childhood Research Quarterly, 23(3), 419–428. Eighth Edition. Los Angeles, CA: Muthén & Muthén. Tandon, S. D., Parillo, K., Mercer, C., Keefer, M., & Duggan, A. K. O’Brien, R. A., Moritz, P., Luckey, D. W., McClatchey, M. W., (2008). Engagement in paraprofessional home visitation: Fami- Ingoldsby, E. M., & Olds, D. L. (2012). Mixed methods analysis lies’ reasons for enrollment and program response to identified of participant attrition in the nurse-family partnership. Prevention reasons. Women’s Health Issues, 18(2), 118–129. Science, 13(3), 219–228. Roberts, J. E., Gotlib, I. H., & Kassel, J. D. (1996). Adult attach- ment styles and symptoms of depression: The mediating role of 1 3

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Maternal and Child Health JournalSpringer Journals

Published: May 31, 2018

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