Multi-level determinants of retention in a home-visiting child abuse prevention program

Child Abuse & Neglect 27 (2003) 363–380

Multi-level determinants of retention in a home-visitingchild abuse prevention program�

William M. McGuigana,∗, Aphra R. Katzevb, Clara C. Prattb

aDepartment of Human Development and Family Studies, Pennsylvania State University, Shenango Campus,Sharon Hall 309D, 147 Shenango Avenue, Sharon, PA 16146, USA

bDepartment of Health and Human Sciences, Oregon State University, Corvallis, OR, USA

Received 16 October 2001; received in revised form 29 July 2002; accepted 11 August 2002

Abstract

Objective: This exploratory study investigated how attributes from multiple domains influence retentionin a voluntary home-visiting child abuse prevention program.Method: A sample of 1093 “at-risk” families participated in a home-visiting child abuse preventionprogram. A total of 71 Family Support Workers (FSWs) provided home visitation services in 12 differentcommunities. Hierarchical general linear modeling (HGLM) was used to examine the community, homevisitor, and maternal attributes that predicted retention in the program beyond 1 year.Results: Multi-level analyses (HGLM) revealed significant community, home visitor, and maternallevel effects. Families were less likely to remain in a home-visiting child abuse prevention programfor at least 1 year if they lived in an area with high community violence. Families were more likelyto remain when the home visitor received more hours of direct supervision. Older mothers were morelikely to remain for at least 1 year than were younger mothers. Hispanic mothers were more likely toremain than were White non-Hispanic mothers.Conclusions: These findings demonstrate the utility of looking across multiple levels of influencewhen examining retention in home-visiting child abuse prevention programs. To increase retention rateshome visitors will need to be adaptable to fit the needs of families in violent communities. Supervisorscan influence retention rates by providing more hours of direct supervision. Other strategies that maycontribute to program retention include meeting the scheduling needs of younger mothers and involvingthe families of younger mothers more effectively.© 2003 Elsevier Science Ltd. All rights reserved.

Keywords:Child maltreatment; Home-visiting; Retention

� Data for this study was provided by the Oregon Healthy Start Evaluation (97–59), awarded to Oregon StateUniversity Family Policy Program by the Oregon Commission on Children and Families.

∗ Corresponding author.

0145-2134/03/$ – see front matter © 2003 Elsevier Science Ltd. All rights reserved.doi:10.1016/S0145-2134(03)00024-3

364 W.M. McGuigan et al. / Child Abuse & Neglect 27 (2003) 363–380

Introduction

Home-visiting has received widespread endorsement as a strategy to support families andprevent poor child and family outcomes, including child maltreatment (Duggan et al., 1999,2000; Gomby, Larson, Lewit, & Behrman, 1993; Guterman, 2000; Leventhal, 2001). How-ever, a summary of the home-visiting literature (Gomby, Culross, & Behrman, 1999) showedthat most home-visiting programs reported only moderate success in changing parental riskbehaviors. When success is reliant upon parental involvement a lack of participation mayundermine program effectiveness. While no studies have been conducted to demonstrate theexact number of visits or exact time in a home-visiting program necessary to create change,there is evidence that families who participate more show greater benefits (Olds et al., 1999;Wagner & Clayton, 1999).

For example, home-visiting programs that deliver at least reasonably intensive services(bi-weekly or weekly home visits) over a sufficient period of time have been shown to be ef-fective in reducing the risk of child maltreatment (Caruso, 1989; National Committee to PreventChild Abuse, 1996; Olds, Henderson, & Kitzman, 1994). Many home-visiting programs havebeen unable to provide this optimal level of service intensity, or duration of service, due tolow rates of program retention. Increasing retention rates is therefore an important strategy toincrease the effectiveness of home-visiting programs.

In a review of six home-visiting programs between 20 and 67% of families left before theprogram was scheduled to end (Gomby et al., 1999). Another review of home-visiting programs(Guterman, 2001) found that 8–51% of families leave home-visiting programs within 12months of service. The specific factors that contribute to these low rates of program retentionremain unclear, but it is suspected that multiple levels of influence have some bearing onretention rates (McCurdy & Daro, 2001).

Despite growing interest in understanding how multiple domains influence participation inhome-visiting child abuse prevention programs, past studies have limited their focus to twopotential determinants: attributes of families, particularly attributes of mothers, and attributesof programs, including characteristics of home visitors (McCurdy, Hurvis, & Clark, 1996).While retention rates have varied across community sites within the same program (Dugganet al., 1999), the potential of community attributes to influence retention rates has largely beenignored (Duggan et al., 2000; Harris, 1998; McCurdy & Daro, 2001).

This study examined the association between retention in a voluntary home-visiting childabuse prevention program, and (1) the attributes of the communities in which the programwas offered; (2) attributes of the home visitors; and (3) maternal attributes. Previous studieshave been unable to estimate these multiple effects within the same statistical model, due tothe violation of independence. Mothers who receive visits from the same home visitor are notstatistically independent of each other, nor are visitors working within the same community.

This lack of independence required a statistical method that could simultaneously esti-mate “non-independent” community, visitor, and maternal level effects, while considering allpossible interactions. It is only in the past decade that such robust statistical methods have be-come available. Hierarchical General Linear Modeling (HGLM) (Raudenbush, Bryk, Cheong,& Congdon, 2000) is one such statistical technique, appropriate for this type of multi-levelanalysis. This study used HGLM to obtain an accurate assessment of the unique roles that

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community, visitor, and maternal level attributes play in retaining families in a voluntaryhome-visiting child abuse prevention program.

Past studies of community attributes

Community level attributes, such as community violence, contribute to the overall qualityof family and community life and may have an impact on program retention. Communityviolence has a negative effect on children’s healthy growth and development (Vig, 1996)and has been associated with increased family violence (Osofsky, 1995) and increased childmaltreatment (Lynch & Cicchetti, 1998). An extensive body of research also shows that highlevels of community violence contribute to a “toxic environment” detrimental to both familiesand the community as a whole (Garbarino, Dubrow, Kostelny, & Pardo, 1992; Osofsky, 1995).Garbarino and Kostelny (1992)found that in the most socially toxic communities, residentsreported less family involvement, fewer positive interactions with neighbors, and a lowerquality of life. In contrast, residents in less toxic communities were more hopeful, reportedmore available services, and were more likely to participate in both formal and informal familysupport services.

Further, in their cardinal study assessing the effects of community on child maltreatment,Garbarino and Sherman (1980)compared the help-seeking behavior of mothers living in highrisk, lower quality of life communities to mothers living in low risk, higher quality of lifecommunities. They reported that mothers living in high risk communities were less likelyto rely upon experienced helpers for support, and when they did so, they were more likelyto demonstrate an “incomplete” use of support services. These studies suggest that familiesraising children in violent communities may be difficult to retain in a voluntary home-visitingchild abuse prevention program.

Past studies of home visitor attributes

There are limited accounts of how retention rates are influenced by the home visitor’s age(Josten, Reckenger, Frederickson, Savik, & Cross, 1997), education and training (Korfmacher,O’Brien, Hiatt, & Olds, 1999; Olds & Kitzman, 1993; Wasik, 1993). A recent study (Korfmacheret al., 1999) found higher rates of program retention for nurse home visitors than for non-collegedegreed paraprofessional home visitors. However, it remains unclear how home visitors withother educational degrees, such as Master of Social Work, Master of Public Health, or Bach-elors degrees in social sciences, might influence retention rates.

Lacking any standardized credentials or licensing, home visitors are often hired basedon personal attributes thought to contribute to an effective helping relationship (Wallach &Lister, 1995). In a national survey of home visitation programs, staff identified maturity,warmth, empathy, and a non-judgmental orientation as essential home visitor attributes (Wasik,1993). However, it remains unclear which, if any, of these attributes affect program retention.An important home visitor attribute notably absent from previous studies is the amount ofsupervision the home visitor receives (Duggan et al., 2000). Supervision is especially importantfor home visitors serving at-risk families that experience chaotic lifestyles, multiple stresses,and difficulty in maintaining active service (Wallach & Lister, 1995).


The few studies that examined the interactions between home visitor and maternal attributesidentified some promising influences on retention. These included matching home visitors andparticipating mothers on ethnicity (Barth, Ash, & Hacking, 1986); establishing mutual per-spective taking (Luker & Chalmers, 1990); and developing an empathetic helping relationship(Wallach & Lister, 1995). However, these findings have yet to be sufficiently replicated acrossstudies (Harris, 1998).

Past studies of maternal attributes

Previous studies of intervention programs identified several notable maternal attributes thatinfluenced program retention, but with little agreement about the direction of influence. Whilesome studies reported that younger mothers tended to engage and remain in parenting pro-grams (Herzog, Cherniss, & Menzel, 1986; Olds & Kitzman, 1993), other studies reportedyounger mothers were more likely to drop out (Birkel & Reppucci, 1983; Josten, Mullett,Savik, Campbell, & Vincent, 1995). Still another study reported that teens that had not fin-ished high school were most likely to remain in home-visiting services (Duggan et al., 2000).Married mothers were more likely to remain in a parent training intervention (Dumka, Garza,Roosa, & Stoerzinger, 1997) while single mothers were more likely to engage in a statewidehome visitation program (Myers-Walls, Elicker, & Bandyk, 1997). Ethnicity had no signifi-cant effect on retention in one home-visiting parenting program (Herzog et al., 1986), whileother studies found significantly higher retention rates for Hispanic (Dumka et al., 1997) andAfrican American parents (Navaie-Waliser et al., 2000). Several studies have found mothersof low birth weight pre-term infants were more likely to remain in home-visiting programsthan mothers whose full term infants had no special health care needs (Duggan et al., 2000;Josten et al., 1995; Olds & Kitzman, 1993).

Research statements

Using an ecological framework (Bronfenbrenner, 1979) this study investigated the effects ofcommunity, visitor, and maternal attributes on retention in a voluntary home-visiting program.Mothers were nested within home visitors, and both were nested within communities (seeFigures 1 and 2). A review of the literature indicated that attributes from each of these threelevels could influence program retention. Accordingly, analyses were conducted to:

Examine the effect of community violence on program retention;Examine key home visitor attributes that influence program retention;Examine key maternal attributes that influence program retention;Examine all possible interactions within and across these three levels.Exploratory techniques were warranted, as this study was part of an ongoing program

evaluation. The immediate intent was to inform program funding agents, administrators, andproviders of the distinct attributes at each of these levels that may impact retention in voluntaryhome-visiting child abuse prevention programs. As outlined in the introduction, the underlyingempirical rationale for this study is that program retention is linked to program efficacy. Byknowing what factors influence program retention strategies may be developed to increaseretention rates and, thereby, increase program effectiveness.


Figure 1. Diagram of the multi-level structure of one community’s home-visiting program.

Figure 2. Ecological model of mothers, nested within home visitors, nested within communities.

Methods

Context of the research

Since 1994, Oregon State University’s Family Policy Program has conducted annual eval-uations of the Oregon Healthy Start (OHS) program. Oregon Healthy Start is a voluntaryhome-visiting family support program designed to prevent poor child outcomes, includingchild maltreatment. The OHS program is modeled after Healthy Families America (HFA),a national child abuse prevention initiative ofPrevent Child Abuse America (1999). OregonHealthy Start is designed to provide regular home visits to at-risk families during the first 5years of child rearing.


Since 1994, OHS has screened approximately 80% of all new mothers in participatingOregon counties using the 15-item Hawaii Risk Indicators (HRI) Checklist (Hawaii FamilyStress Center, 1994). Mothers were screened at or near the time of their first child’s birth.Screening items included known risks for child maltreatment, such as a mother who has notcompleted high school, is unmarried, and who received late or no prenatal care. All familieswho were screened received one “welcome baby” home visit, a list of community services,and various free baby supplies (diapers, baby blanket). Approximately one half of all mothersscreened showed two or more risks on the HRI checklist. Two or more risks qualified thesemothers for further assessment using the Kempe Family Stress Inventory (KFSI). The KFSIis an in depth interview that assessed 10 psychosocial factors related to child maltreatmentincluding history of childhood abuse, and history of substance abuse. Unfortunately, budgetlimitations only allowed for approximately one half of the families who scored high on theHRI to be assessed with the KFSI.

Healthy Start Family Assessment Workers (FAWs) conducted the KFSI interviews afterreceiving extensive training in the KFSI interview protocols. Scores on the KFSI can rangefrom 0 to 100 with scores above 25 considered at risk for poor child outcomes. Approximately75% of all families assessed with the KFSI scored above 25 and were offered weekly homevisits and extensive family support services by trained Family Support Workers (FSWs). Eachyear over 92% of the families who were assessed as high risk on the KFSI accepted regularhome visits and were considered enrolled in the Healthy Start Program.

Family Support Workers, most with Bachelors degrees, receive 96 hours of training beforeproviding home visits to higher risk families with firstborns, as they begin parenting. Nursesand multidisciplinary teams of professionals supervised FSWs. Participation in all screenings,assessments and home visitations were voluntary and each family signed a confidentialityagreement. Oregon State University’s Institutional Review Board reviews the evaluation an-nually. This study was part of that ongoing evaluation and represents families who receivedhome visits between February 1, 2000 and February 1, 2001.

Defining retention

Research has shown the first year families begin parenting to be especially stressful (Belsky& Rovine, 1990). National statistics show the highest percentage of child abuse fatalitiesoccur during the child’s first year (US Department of Health and Human Services, 2000).Accordingly, OHS begins services either during the prenatal period or immediately after thefirst child’s birth, starting with weekly home visits. Home visitors work with parents to setservice-plan goals and refer parents to needed services (i.e., health care, counseling). Duringthe first year, children in OHS families are linked to a primary health care provider, beginthe immunization sequence, are screened for developmental delays, and are referred to earlyintervention or other necessary services (Katzev, Pratt, & McGuigan, 2001). As families makeprogress toward service goals, they graduate to a lower intensity of service and less frequentvisits throughout the first 5 years of child rearing.

Because families drop out at varying times, the challenge for program evaluators is to definea level of retention that is meaningful to the specific program under review. A program relevantcutoff point may be the most meaningful measure of retention when participation falls short of


program completion. Such a measure could be the completion of a major element of the pro-gram, or participation beyond a significant intervention milestone. This study used the crucialfirst year time point as a meaningful measure of retention in the OHS home-visiting program.This 1-year time point closely parallels the mean number of months (M = 13.7) all OHSfamilies received services during the 1999–2000 fiscal year (Katzev et al., 2001). Retentionwas dichotomized as “families who received services at least 1 year” (1), and “families whostopped receiving services, for any reason, prior to 1 year” (0).

Defining community

As of February 1, 2000, OHS was operating in 14 geographically defined sites, representing16 counties within the state of Oregon. All 14 sites represented one program, operated under theguidance of the Oregon Commission on Children and Families. Twelve of the sites served fami-lies in single counties and two sites served families in dual counties. The populations of the dualcounty sites were similar, and families in these counties often received services from sharedinstitutions (i.e., the same hospital, social service office, and school district). One OHS site wasundergoing an administrative transition and was not selected to participate in the study. Anothersite provided incomplete data (no visitor ID numbers), precluding its inclusion in the study.The remaining 12 sites, representing 14 Oregon counties, were included in the present study.

The term community may suggest a social or geographical area. This study focused on ge-ographical communities that were bounded by shared social and political institutions: specif-ically, the 12 OHS sites. These sites were large in geographic area but each site was more orless homogeneous in ethnic and economic diversity. The 12 OHS sites were the appropriateunits of analysis at the community level given the assumptions and purpose of this study, andsince each OHS site maintained local control of their home-visiting program.

Community attributes

The community attributes included in this study were four indices of community violence:“the number of homicides, assaults, and forcible rapes known to police” and “the numberof domestic violence arrests.” The most reliable data available on the number of homicides,assaults, and forcible rapes known to police in each county were obtained from theBureau ofthe Census (1999). Data on the number of domestic violence arrests in each county wereobtained from theOregon Department of Human Resources (1999). Because of the lag in timebefore crime reports are validated and released, all four indices of community violence werebased on 1995 rates per 1000 adults in each county’s population. Rates were calculated forthe two sites composed of dual counties. The rates of these four violent crimes were summed toform an index of community violence for each OHS site. The combined number of these violentcrimes per 1000 adults in the population ranged from 3.1 to 11.3 across the 12 OHS sites.

Home visitor attributes

On February 1, 2000, a Staff Questionnaire was mailed to all OHS site administrators, whomade the questionnaire available to home visitors. The questionnaire included a cover page


explaining that participation was voluntary. The questionnaire did not ask for home visitors’names, but did require home visitor ID numbers to match visitors with the families theyserved. Of the 73 home visitors employed across the 12 OHS sites, 71 (97%) completed thequestionnaire.

The Staff Questionnaire contained demographic questions including age, race, gender (allhome visitors were female), and educational attainment. Job specific questions were alsoincluded, such as prior experience conducting home visits and hours of individual supervisionreceived per month. In addition, the questionnaire included two scales from the InterpersonalReactivity Index (IRI) (Davis, 1980, 1983).

The IRI is a self-report measure of empathy consisting of four 7-item scales. The StaffQuestionnaire included the 7-item Perspective Taking scale, that assessed the tendency toadopt the point of view of others, and the 7-item Empathic Concern scale that assessed feelingsand concern for others. Questions on the Perspective Taking scale included “I believe thereare two sides to every question and try to look at them both.” A typical question from theEmpathic Concern scale was “I am often quite touched by things I see happen.” Responseswere on a 5-point scale indicating level of agreement. Both scales had high internal reliabilities(Cronbach’s alphas of .70 and .77, respectively) and established convergent and discriminantvalidity (Davis, 1983).

The Perspective Taking and Empathic Concern scales were included in exploratory analyseswith five other home visitor attributes thought to effect program retention. Visitor’s age wasmeasured in years. Visitor’s ethnicity was included as “Hispanic” (1) and “other ethnicity”(0). Education was recorded as “Bachelors degree or higher” (1) and “less than a Bachelorsdegree” (0). Experience conducting home visits prior to employment with OHS was measuredas “prior home-visiting experience” (1), “no prior home-visiting experience” (0). While thesame service program employed the home visitors working in each community, workers in agiven program could experience very different hours of supervision. The final home visitorattribute included in analyses was the “hours of individual supervision received per month.”

Maternal attributes

Only those mothers who initially began receiving OHS services from 1 of the 71 homevisitors who completed the Staff Questionnaire were included in the study. In addition, onlymothers who began receiving OHS services before February 1, 2000 were included in thisstudy. Data indicated whether any of these families had left the program at any time prior toFebruary 1, 2001. Therefore, all mothers had the opportunity to remain in the OHS programfor at least 1 year.

Based on previous research, five maternal attributes were included in initial exploratoryanalyses. Mother’s age was measured in years. The ethnic distribution of families in the sam-ple mirrored the ethnicity of Oregon families, with 77% of families being White non-Hispanic,19.5% Hispanic, and 3.5% African American, Asian American, or Native American. Sinceresearch has found Hispanic families more likely to remain in home-visiting programs (Dumkaet al., 1997) ethnicity was coded as “Hispanic” (1) and “other ethnicity” (0). Mother’s educa-tion was included as “high school graduate/GED” (1) and “less than a high school education”(0). Marital status was included as “currently married” (1) or “other marital status” (0).


Table 1Means and standard deviations or percentages of all attributes

M SD %

Community level (n = 12)Community violence index 7.85 2.22

Home visitor level (n = 71)Visitor is Hispanic 18.3Bachelors degree or higher 53.5Prior experience conducting home visits 41.0Visitor’s age in years 39.25 9.54Hours of supervision received each month 1.75 .70Perspective taking scale 3.10 .38Empathic concern scale 3.00 .51

Maternal level (n = 1093)Mother is Hispanic 19.5Mother has HS diploma or GED 43.0Mother is currently married 20.0Infant health risks at birth

Not premature, but low birth weight 4.0Premature and low birth weight 8.5No health risks at birth 87.5

Mother’s age in years 20.35 4.43

Experiencing an infant health risk at childbirth was categorized as “not premature, but low birthweight” (=2500 g) (2), “born premature” (gestation<37 weeks) (1), or “no health concerns atbirth” (0). Infants with more serious health concerns were not admitted into the OHS program.Instead, they were referred to a separate program that targets medically high risk/crises infants.Table 1lists the attributes included in preliminary analyses.

Statistical analyses

Separate bivariate analyses usingχ2- or t-tests identified which attributes of the mothersand home visitors were significantly associated with program retention. All attributes withp values less than .10 were retained for inclusion in an initial HGLM analysis. To isolatesignificant predictors of retention, only attributes that were significantly related to retentionat p ≤ .10 in the initial HGLM analysis went on to be included in the final HGLM analysis.This eliminated variables that did not result in a significant reduction in model deviance.

Since the predictor variables were from multiple levels, and the outcome variable had aBernoulli distribution, HGLM was the preferred methodology for multivariate analyses (seeRaudenbush et al., 2000). The HGLM Bernoulli model calculates the probability of a binaryoutcome by generating logit coefficients. These models have been found to be highly robust,and produce smaller standard errors than traditional logit analysis (Rodriguez & Goldman,1995). In the HGLM analyses, each level-1 case corresponded to an individual mother, witha single binary outcome for each mother (remained in service at least 1 year: yes/no). In this


model, 1093 mothers at level-1 were nested within 71 home visitors at level-2, who werenested within 12 communities at level-3 (seeFigure 2). The model was specified to predictthe probability of at least 1 year participation in OHS for individual motheri, receiving homevisits from visitorj, while living in communityk (seeFigure 1).

Results

Of the 1093 mothers in the study sample, 497 (45%) exited prior to 1 year and 596 (55%)remained at least 1 year. Similar retention rates have been reported since OHS began (Katzevet al., 2001). Based on bivariate analyses (χ2- or t-test) four maternal attributes were signif-icantly associated with program retention. Compared to mothers who left the OHS programprior to 1 year, mothers who remained were significantly more likely to be older, Hispanic,married, and to have given birth prematurely. These four maternal attributes were includedas level-1 predictors in the initial HGLM multivariate analysis. Since having a high schooldiploma/GED was not significantly related to retention in bivariate analysis it was not enteredin the subsequent multivariate analysis.

Next, bivariate analyses were used to identify home visitor attributes to include in themultivariate analysis. Mothers were significantly more likely to remain in the program for atleast 1 year if their home visitor was Hispanic, had less than a Bachelors degree, and receivedmore hours of monthly supervision. These three home visitor attributes were included as level-2predictors in the initial HGLM multivariate analysis. Bivariate analyses showed that remainingin the OHS home-visiting program at least 1 year was not significantly related to the homevisitors age, prior home-visiting experience, or scores on the Perspective Taking or EmpathicConcern scales. These home visitor attributes were excluded from the multivariate analysis.

Table 2shows the results of the initial HGLM multivariate analysis that included the fourmaternal attributes and three home visitor attributes significantly associated with program

Table 2Initial HGLM analysis of all attributes significantly related to program retention in bivariate analyses

Coefficient t-ratio Odds-ratioa p-value

Community level (n = 12)Community violence index −.15 −2.93 .86 .02

Home visitor level (n = 71)Visitor is Hispanic .33 1.29 .20Bachelors degree or higher −.20 −1.26 .21Monthly hours of supervision .58 5.07 1.79 <.001

Maternal level (n = 1093)Mother is Hispanic .32 1.58 1.38 .10Mother is currently married .23 1.43 .15Infant health risks at birth −.06 −.58 .56Mother’s age in years .04 2.84 1.04 .01

aOdds ratios are only reported for attributes withp ≤ .10.


retention in bivariate analyses, as well as the index of community violence. For this initialmodel, significance was considered at the exploratory criterion ofp ≤ .10. Logit coefficientswere converted to odds-ratios for ease of interpretation. Results indicated a significant commu-nity level effect on program retention. With every one-unit increase in the index of communityviolence mothers were 14% less likely to remain in home-visiting services at least 1 year(OR = .86,p = .02).

This initial HGLM multivariate analysis also revealed a significant provider level effect onprogram retention. The odds of remaining in the OHS program for at least 1 year increased by79% (OR= 1.79,p < .001) with every 1-hour increase in the amount of monthly supervisionthe home visitor received. In this multivariate analysis, remaining in home-visiting servicesfor at least 1 year was not significantly related to the home visitor’s ethnicity, or whether thevisitor had a college degree.

On the maternal level, this initial HGLM analysis revealed that Hispanic mothers were 38%more likely to remain in the OHS program for at least 1 year, than non-Hispanic mothers(OR = 1.38,p = .10). With every year of age, mothers were 4% more likely to remain in theOHS program (OR= 1.04,p = .01). After considering the significant effects of communityviolence, home visitor supervision, mother’s age and ethnicity, results of the multi-level anal-ysis showed that mother’s marital status and infant health risks were not significantly relatedto remaining in home-visiting services for 1 year or more. This initial model was used toexamine all possible interactions within and across the three levels. There were no significantinteractions.

A statistical concern was the number of non-significant predictors in the initial HGLManalysis. Hierarchical general linear models are sensitive to the unique effects of all predic-tors. Parsimony often increases model precision. To identify more accurately the significantpredictors of retention, only attributes significant at thep ≤ .10 level in the initial multi-levelmodel went on to be included in the final HGLM analysis.

The final HGLM analysis (Table 3) validated significant community, visitor, and maternallevel effects on retention in home-visiting services. In this final model, every one-unit increasein the community violence index reduced the likelihood of mothers remaining in home visi-tation services for 1 year by 13% (OR= .87,p = .02). Every 1-hour of monthly supervisionthe home visitor received, increased the mothers odds of remaining in the OHS program for

Table 3Final HGLM analysis of attributes effecting retention in a home-visiting program

Coefficient t-ratio Odds-ratio p-value

Community level (n = 12)Community violence index −.14 −2.70 .87 .02

Home visitor level (n = 71)Monthly hours of supervision .64 5.79 1.89 <.001

Maternal level (n = 1093)Mother is Hispanic .39 2.50 1.48 <.01Mother’s age in years .04 2.76 1.04 <.01


1 year by 89% (OR= 1.89, p < .001). Hispanic mothers were 48% more likely to remainin home-visiting services for 1 year or more than were non-Hispanic mothers (OR= 1.48,p < .01). Mothers were 4% more likely to remain in the OHS program with every year of age(OR = 1.04,p < .01).

Discussion

The purpose of this study was to use the statistical rigor of HGLM to obtain a more precisedescription of the community, home visitor, and maternal attributes associated with reten-tion in a voluntary, home-visiting child abuse prevention program. Applying an ecologicalperspective, this study makes clear the importance of assessing attributes from multiple lev-els. Program retention was significantly affected by community, visitor, and maternal levelattributes.

Community violence operated independently and in addition to home visitor and maternalattributes, significantly reducing the likelihood of mothers remaining in a home-visiting childabuse prevention program. These findings parallel those ofGarbarino and Sherman (1980)who found that parents living in “high risk” communities were more likely to demonstrate an“incomplete” use of family support services.

Even when receiving support services, parenting remains a complex process that can be filledwith difficulties for at-risk parents. Violence in the community only adds to these difficulties.Community violence has resulted in increased stress for parents, reducing their ability toparent, and instilling feelings of hopelessness (Osofsky, 1995), and distrust of others (Coulton,Korbin, Su, & Chow, 1995). An additional outcome of living in a violent community is greaterprivacy concerns, often resulting in social isolation (Vig, 1996). Isolation deprives parentsof social support and information from others about parenting and increases resistance to anoutsider’s involvement in family affairs. It may be that when hopelessness, distrust, and thefear of violence reach a critical level, a family’s desire for privacy causes them to terminateinteractions with outsiders, including home visitors.

After considering community and maternal level effects, the only home visitor attributesignificantly associated with program retention was the average hours of supervision thatthe home visitor received each month. Supervision is essential, as families with multiplerisks often require services beyond the home visitor’s expertise. For example, a depressedmother living with a violent mate, while struggling to meet the needs of her developmentallydelayed child, will need more than weekly home visits. By working with supervisors, homevisitors can develop service plans that incorporate other skilled service providers from a rangeof disciplinary perspectives. When these breadths of services can be delivered it will likelyincrease program retention.

In addition, because most home visitors sincerely want to help families, some parents willtest the limits of the home visitor’s role. Supervision reduces the ambiguity in the homevisitor’s functions and reminds visitors that their role is one of mobilizing parents to act ontheir own behalf (Wallach & Lister, 1995). Supervisors may also inform home visitors ofsuccessful retention strategies used by other visitors who served similar families. Still, homevisitors sometime assume personal responsibility for an inability to retain families in the


program. Here supervisors can be invaluable by reminding visitors to remain objective andallow families to exercise self-determination.

On the maternal level, Hispanic mothers were significantly more likely to remain in home-visiting services. Most of the Hispanic mothers in this sample were recently arrived Mexicanimmigrants. Hispanic mothers were matched with Hispanic or Spanish speaking home visitorswhenever possible. Hispanic mothers may have allied with their bilingual home visitors outof the necessity to access basic services (i.e., interpreting rent contracts, utility bills, and med-ical forms). However, this explanation was not supported by additional analyses that showedneither ethnic nor language matches between mothers and home visitors were significant pre-dictors of program retention. Hispanic families stayed longer regardless of these home visitorcharacteristics.

A more plausible explanation may be that in the Hispanic culture, extended family members,such as the grandmother and the “comadre” (Godmother), are valued participants in childrearing. Home visitors, regardless of ethnicity or language, may have served in this role forthe recently arrived Hispanic mothers who may have had no, or only a small number of familymembers and friends nearby. As stated byWasik (1993)the key consideration may not be thathome visitors be of the same ethnicity as client families. What may be more important is thatthe visitor understands and respects the values and beliefs of other cultures and can respondin a culturally appropriate manner.

An additional maternal attribute that contributed to remaining in home-visiting serviceswas the mother’s age. With every additional year of age, mothers were 1.04 times more likelyto remain in the program. As a result, a 26-year-old mother was 40% more likely to remainin home-visiting services for 1 year than was a 16-year-old mother. Compared to youngermothers, older mothers may be somewhat more stable in their place of residence and place ofemployment. Of course, younger teen mothers would be more likely to return to school thanwould older mothers. Research has shown that moving, securing new employment, or returningto school, are all frequent reasons mothers give for terminating home-visiting services (Dugganet al., 1999; Katzev et al., 2001).

Implications for practice

Identifying community, visitor, and maternal attributes that contribute to program reten-tion provides a basis for developing strategies to retain families in home-visiting child abuseprevention programs. However, home visitation programs cannot be expected to cure all com-munity ills. Certainly, reducing the rate of community violence is beyond the expected tasks ofhome visitation programs. Reduction of community violence will require the concerted effortsof community residents, police, district attorneys, social service providers, and policy makers.

Nonetheless, home-visiting programs will need to be adaptable to fit the needs and chal-lenges of specific communities (Leventhal, 2001). In violent communities, home visitors mayneed to encourage community safety in order to build trust with the families and communitiesthey serve. One strategy would be for home visitors to encourage families to become involvedin neighborhood safety organizations, such as Neighborhood Watch. Neighborhood Watch isa national crime prevention program that forges bonds among community residents and localpolice. Taking action for the community good increases social cohesion, builds “collective


efficacy” and reduces rates of violence (Sampson, Raudenbush, & Earls, 1997). Involvementin any block organization that promotes the reduction of violent crime could increase com-munity safety, reduce isolation, enhance family social supports, and promote natural helpingnetworks within the community.

Supervisors could increase program retention by providing on-going individual supervisionto home visitors. Supervisors should periodically shadow home visitors and provide visitorswith regular opportunities to discuss difficult cases. Regular supervision and on-going stafftraining could provide home visitors with support and a sense of value, reducing the likelihoodof burnout (McCurdy & Daro, 2001). Another approach to ensure quality service deliveryand supervision is underway by HFA. This organization is currently attempting to credentialhome-visiting sites throughout the county.

Maternal attributes affecting retention demonstrate the need for home-visiting child abuseprevention programs to intensify efforts to retain younger mothers. Perhaps programs couldincrease retention rates by meeting the scheduling demands of younger mothers who returnto high school. This may require evening, or weekend visits. Since younger mothers are morelikely to live with their family, programs may need to involve the families of younger mothersmore effectively. Importantly, there needs to be increased efforts to educate fathers in theircare-taking role (Leventhal, 2001). Involving both parents in family support services wouldlikely reduce early program withdrawal.

Study limitations and recommendations

As with all research, this study has limitations. The findings are based on White non-Hispanic(77%) and Hispanic (19.5%) families who received home visits in semi-rural and smallmetropolitan areas. Although this sample parallels the characteristics of many young Ore-gon families, future studies may wish to examine these relationships in a more ethnicallydiverse urban sample.

Aside from the hours of supervision, none of the significant predictor variables had largeodds ratios. This suggests that the model may not have particularly strong predictive capac-ity. More importantly, this model informs future researchers that other factors that were notincluded in the present analyses may be important contributors to program retention.

For example, it was interesting that home visitor’s scores on the Perspective Taking andEmpathic Concern scales were not significantly related to program retention. All visitors ratedthemselves high on both constructs. A more useful measure may be how program participantsviewed their home visitors in terms of these and other dimensions. Future studies may wishto examine the family’s view of their home visitor. It may be more important to know howfamilies view their workers than how workers view themselves.

This study was also limited by the restrictions of statistical power. Having only 12 com-munities limited the HGLM analyses to only one level-3 predictor. Aggregate county levelindicators can mask differences within the county. This is less of an issue in the current studysince counties were more or less homogeneous in overall ethnic and economic diversity. How-ever, the data does not allow us to investigate whether families who left prior to 1 year livedin the specific areas within their county that had the highest rates of violence. Although coun-ties were a meaningful focus for this study, future studies may wish to narrow their focus to


attributes at the zip code, school district, or census block level. This would provide a morerigorous investigation of how community violence influences retention rates and allow mul-tiple community factors, such as social integration (Garbarino & Kostelny, 1992) and socialcohesion (McCurdy & Daro, 2001) to be included in the analyses.

Despite these limitations, this study illustrated the utility of considering community, homevisitor, and maternal attributes when developing strategies for retaining families in home-visiting child abuse prevention programs. Through a series of exploratory analyses this studydemonstrated a statistical methodology that produces greater model specification, a method-ology that could improve future research on retention in home-visiting child abuse preventionprograms. By identifying attributes across multiple levels that were associated with retention ina home-visiting child abuse prevention program, it is our hope that a number of new directionsfor future research, practice, and policy will emerge.

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Résumé

Objectif: Cette étude préliminaire porte sur les causes multiples qui peuvent influencer la poursuited’un programme volontaire de visites à domicile pour la prévention de mauvais traitements aux enfants.Méthode: Un échantillon de 1093 familles dites “à risque” a participé à un programme de visitesà domicile pour la prévention des mauvais traitements aux enfants. Un total de 71 intervenants ensoutien familial ont effectué des visites à domicile dans 12 ensembles communautaires différents.On a eu recours à un modèle hiérarchique linéaire général (HGLM) pour examiner la communauté,l’intervenant à domicile et les caractéristiques maternelles qui pouvaient prédire le maintien dans leprogramme au-delà d’un an.Résultats: Les analyses à plusieurs niveaux (HGLM) ont révélé des effets significatifs pour les com-munautés, les intervenants et le niveau maternel. Les familles qui étaient les moins susceptibles decontinuer à suivre pendant au moins un an un programme de visites à domicile pour la prévention desmauvais traitements étaient celles qui habitaient dans une zone communautaire violente. Les famillescontinuaient plus volontiers quand l’intervenant recevait un plus grand nombre d’heures de supervisiondirecte. Les mères les plusagées restaient plus facilement au moins une année que les mères les plusjeunes. Les mères latino-américaines restaient plus que les mères blanches non latino-américaines.Conclusions: Ces résultats montrent l’utilité de considérer de multiples niveaux de causalité lorsquel’on examine la poursuite de la participation à un programme de visites à domicile pour la préventiondes mauvais traitements aux enfants. Pour augmenter la poursuite du programme les intervenants àdomicile devront s’adapter aux besoins des familles des communautés violentes. Les superviseurspeuvent améliorer le taux de participation en donnant un plus grand nombre d’heures de supervisiondirecte. D’autres stratégies peuvent contribuer à la poursuite du programme comme de tenir compte desexigences d’horaires des plus jeunes mères et de recourir aux familles de ces jeunes mères d’une façonplus efficace.

Resumen

Objetivo: Este estudio exploratorio investigó como los atributos de varios aspectos influyen la retenciónen un programa de visitas al hogr sobre prevención del abuso a los niños.


Método: Una muestra de 1093 familias “en riesgo” participaron en un programa de visitas al hogar sobreprevención del abuso a los niños. Un total de 71 trabajadores de apoyo familiar ofrecieron servicios devisitas al hogar en 12 comunidades diferentes. Se utilizó un modelamiento general jerárquico (HGLM)para examinar la comunidad, el visitador familiar, y los atributos maternos que predecıan la retenciónen el programa después de 1 año.Resultados: Los análisis multidimensionales (HGLM) revelaron los efectos significativos en la comu-nidad, el visitador familiar y el nivel maternal. Las familias tenıan menos probabilidad de permaneceren un programa de visitas al hogar sobre prevención del abuso a los niños por lo menos 1 año, si vivıanen un área con mucha violencia comunitaria. Las familias tenıan mayor probabilidad de permanecercuando el visitador familiar recibıa más horas de supervisión directa. Las madres de mayor edad tenıanmayor probabilidad de permanecer en el programa por lo menos por más de un año que las madres másjóvenes. Las madres hispanas tenıan mayor probabilidad de permanecer en el programa que las madresblancas no hispanas.Conclusiones: Estos hallazgos demuestran la utilidad de tomar en cuenta múltiples dimensiones deinfluencia cuando se examina la retención en un programa de prevención del abuso a los niños convisitas al hogar. Para aumentar la retención los visitadores familiares deberán adaptarse para respondera las necesidades de las familias en comunidades violentas. Los supervisores pueden aumentar las tasasde retención aumentando las horas de supervisión directa. Otras estrategias que pueden contribuir conlos programas de retención pueden ser el responder a las necesidades de horario de las madres másjóvenes e integrando las familias de madres jóvenes con mayor efectividad.