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March 15, 2012 Service is Everything: How Home Visiting Service Delivery Impacts Family Outcomes Anne Duggan

FINE Newsletter, Volume IV, Issue 1
Issue Topic: New Developments in Early Childhood Education

Voices from the Field

Anne Duggan, ScD, is Professor of Pediatrics and Professor of Health Policy and Management at Johns Hopkins University. In this Voices from the Field, Dr. Duggan reflects on what she has learned from nearly 20 years of evaluative research on home visiting.

Home visiting programs offer a range of services to expectant parents and families with young children. Home visiting can play a crucial role for these families, providing direct educational and support services to promote healthy family functioning and positive parenting. Equally important, home visiting can link families to needed health, education, and social services and can coordinate with these services to reinforce one another’s work.

Each family who enrolls in home visiting is unique. Each has its own history, its own set of strengths and needs, and its own reasons for enrolling. The challenge is to understand and respond to this diversity, and to build on each family’s strengths while advancing the goals of the agency.

MY WORK EVALUATING HOME VISITING PROGRAMS

My colleagues and I have studied home visiting for 19 years. Many years ago, we were struck by the fact that home visiting often had only modest impacts on family outcomes, how challenging it was to engage families in service, and by the enormous variation in how services were delivered, even among sites that had adopted the same home visiting model.

At the time, most published studies of home visiting focused on outcomes rather than looking at actual service delivery, which can strongly impact family outcomes. In contrast, our work looks at how services are delivered to families, and the possible reasons for unintended variation in service delivery. We do this by using 1) an implementation science¹ conceptual model—that is, a roadmap leading from the program’s service model to its desired family outcomes—that considers both organization- and individual-level factors, and 2) behavioral theories, such as attachment theory, to better understand how services are delivered.

A ROAD MAP TO SERVICE DELIVERY

Figure 1 shows our conceptual model of a home visiting program. For each program, influential organizations (e.g., funders and the home visiting agency) define the service model and implementation system. The service model is how a home visiting intervention looks on paper; it describes the outcomes that the program expects to achieve, the families it wants to target, and the services that families will receive. When a service model is clear and coherent, each intended outcome is explicitly identified, the pathway to each outcome is defined, and the pathways fit together in a way that makes sense.

A program’s implementation system is the set of resources that "brings the service model to life."  This can include the curriculum and training models that programs use to prepare home visitors for their work, and also the program’s processes for supervising home visitors.

When the program’s implementation system is strong, staff have the motivation, knowledge and skills to carry out each aspect of their roles effectively, they receive positive reinforcement to do so, and they work in an environment that makes it easy for them to perform expected behaviors.

Just as with the service model, a clear coherent system is needed for each intended outcome: an implementation system can be strong for achieving one outcome, but inadequate for achieving another.

THEORIES OF BEHAVIOR

The second part of our approach is to test theories of behavior to explain service delivery. Attachment theory is one such theory. It holds that a person’s experiences with his or her early caregivers influence how he or she views relationships as an adult. We can think of individuals as falling into four main attachment style groups:

• those who are secure and comfortable trusting others
• those who are anxious about and overly needy of close relationships
• those who feel discomfort with close relationships
• those who are fearful and/or preoccupied with a need for close relationships yet also feel discomfort with closeness

Many home visiting programs are attachment-based. This means that the programs aim to promote consistent, empathic caregiving by the parent so that the child develops a secure attachment, and that programs aim for home visitors to provide services in a consistent, empathic way to earn the parent’s trust. We have studied both mothers’ and home visitors’ attachment anxiety and discomfort with closeness. Our findings suggest some important ways that attachment styles influence service delivery and outcomes.

• Maternal attachment style affects family engagement and outcomes. We have found that mothers with relationship anxiety were more likely than non-anxious mothers to remain enrolled in home visiting, possibly because the home visitor helped meet the mothers’ need for close relationships. Mothers who scored high on attachment anxiety but not on discomfort with closeness were the group most likely to show improved outcomes. For mothers who were fearful, we did not see improved outcomes. These findings illustrate the need to design our service models and implementation systems to be more effective in engaging with and improving outcomes for mothers who feel discomfort with close relationships.
• Home visitors’ attachment anxiety influences how they deliver services. Programs rely on home visitors to develop a trusting relationship with the families they serve. For this reason, we have studied how the home visitor’s attachment style influences service delivery. We found that highly anxious home visitors were less likely to recognize and respond to poor maternal mental health and intimate partner violence. Highly anxious home visitors were also more likely to suffer from job burnout.
• Maternal and home visitor attachment anxiety combined have a large impact on the development of a trusting relationship. We found that maternal ratings of trust in the home visitor were significantly poorer when both the mother and the home visitor scored high for attachment anxiety.

APPLYING THIS RESEARCH TO HOME VISITING PROGRAMS

The above findings underscore the importance of considering attachment security in how we design home visiting programs.

• Use a tailored approach to parent training. Increasingly we are seeing parent training models that include a component to raise the mother’s awareness of her thoughts and feelings in how she relates and responds to her child. We are seeing success in this approach and is one that I think has great promise. But we need to be sure that our service models define the approach clearly, and that our implementation systems are up to the task of preparing and supporting staff to carry out tailored parent training competently.
• Provide tailored professional development to address home visitors’ attachment styles. In addition to tailoring the program for families, our home visiting implementation systems can and should be tailored for home visitors. Supervisors can use reflective approaches with home visitors to help them identify their own attachment styles and understand how this relates to their relationships with families.
• Use individualized family support plans. Many home visiting programs use an individualized family support plan (IFSP) to help families set goals and develop plans to achieve them. Home visitors receive training in how to introduce the IFSP to families and how to help families articulate their goals. The IFSP becomes an integral part of the home visits.
• Collaborate with other service providers. In addition to these individualized approaches, service coordination is essential. It would be a wonderful thing, for example, if home visitors not only linked families with needed services, but also reinforced those services by giving concordant messages and by helping families carry out the recommendations of other providers, such as mental health service providers and the child’s primary care provider. Coordination takes work because providers often work for different organizations, but programs can and must develop ways to improve coordination.

CONCLUSION

We have reached an exciting new era, with an unprecedented increase in national funding for home visiting programs. But expectations are high. If we are to realize home visiting’s potential to improve the lives of young children and their families, influential organizations and program staff must work together to create clear, coherent service models and strong implementation systems. Children and their families can’t wait. 

1. Implementation science is the study of the process of implementing programs and services.
2. Duggan, A. (2012, February). Multi-level research on home visiting. Presented at The National Summit on Quality in Home Visiting Programs, Washington, DC.

This resource is part of the March 2012 FINE Newsletter. The FINE Newsletter shares the newest and best family involvement research and resources from Harvard Family Research Project and other field leaders. To access our archive of past issues, visit www.hfrp.org/FINENewsletter.