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March 15, 2012
Service is Everything: How Home Visiting Service Delivery Impacts Family Outcomes
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 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.
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.
FIGURE 1. Conceptual Model2 * For both families and staff, key attributes include Demographics; Psychosocial Well-Being; Cognitive Capacity; and Attitudes, Perceived Norms, Personal Agency, Knowledge, and Skills regarding Expected Behaviors.
**This diagram illustrates the model for a program that improves outcomes for the child indirectly, through direct benefits for parents. The diagram could also be altered to show direct benefits for the child (e.g., to represent an early intervention program that provides direct services to the child).
FIGURE 1. Conceptual Model2
* For both families and staff, key attributes include Demographics; Psychosocial Well-Being; Cognitive Capacity; and Attitudes, Perceived Norms, Personal Agency, Knowledge, and Skills regarding Expected Behaviors.
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.
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:
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.
The above findings underscore the importance of considering attachment security in how we design home visiting programs.
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.