2003, Vol. 52, No. 3 271

Multi-Level Determinants of Mothers’ Engagement in HomeVisitation Services*

William M. McGuigan,** Aphra R. Katzev, and Clara C. Pratt

A two-level hierarchical linear model was used to investigate the impact of poor community health and maternal isolation on mothers’active engagement in a home-visiting family support program. Data came from 4,057 mothers with firstborn infants who enrolled inthe Oregon Healthy Start (OHS) home-visiting program from 1995 through 1998. At the time of this study OHS operated in 15 Oregoncounties. Results showed that if the mother was living in a county that displayed poor community health, or if the mother was isolatedfrom immediate family and friendship networks, the likelihood of actively engaging in home visits was significantly reduced. Implicationsfor programming and study limitations are discussed.

National surveys report parents generally approve of theidea of home-visiting family support programs (Taffee-Young, Davis, & Schoen, 1996). Visiting families at

home allows families to receive support services in the conve-nience of their own home, eliminating potential barriers such asthe need for child care and transportation costs. Still, many eli-gible parents do not participate in these voluntary services (Daro& Gelles, 1992). Reaching and enrolling target families in ser-vices is a common problem for programs designed to supportchildren and families (McCurdy, Hurvis, & Clark, 1996), espe-cially for those serving high-risk populations (Larner, Halpern,& Harkavy, 1992). A number of studies report that up to 25%of eligible parents decline to enroll in home-visiting family sup-port programs (Gomby, Culross, & Behrman, 1999; NationalCommittee to Prevent Child Abuse [NCPCA], 1996; Olds, Hen-derson, Tatelbaum, & Chamberlin, 1986).

Even when parents enroll in home visitation programs, thereis no guarantee that they will engage in services (Daro & Har-ding, 1999). A survey by Healthy Families America (HFA)found that most home-visiting programs considered parents en-rolled if they agreed to participate when services were initiallyoffered (D. Daro, personal communication, September 1997).Agreeing to participate in a program is different from activelyengaging in services (Herzog, Cherniss, & Menzel, 1986). Forexample, evaluation of Hawaii’s Healthy Start program, a home-visiting program for at-risk parents with newborns, found that,beyond the 15% of ‘‘initial refusals,’’ there was an additional15% of ‘‘secondary refusals’’ (Hawaii Department of Health,1992; NCPCA, 1996)—those who initially enrolled in services,but who dropped from the program after receiving few, if any,home visits during 3 months of intensive outreach efforts. Otherstudies confirm that a substantial portion of parents drop out ofhome-visiting programs within the first few weeks after enroll-ment (Marcenko & Spence, 1994; Myers-Walls, Elicker, & Ban-dyck, 1997). Conceptually, parents who never actively engagein home visitation services after initial enrollment are a uniquegroup that requires further research. The purpose of this studyis to examine the community- and maternal-level factors that

*Data for this study were provided by the Oregon Healthy Start Evaluation (97–59),awarded to Oregon State University Family Policy Program by the Oregon Commission onChildren and Families.

**Penn State Shenango, 309D Sharon Hall, 147 Shenango Avenue, Sharon, PA 16146(wmm11@psu.edu).

Key Words: community, home visitation, infants, mothers.

(Family Relations, 2003, 52, 271–278)

contribute to the decision to actively engage in home visitationservices.

Previous Research

We agree with Duggan and colleagues (2000) that ‘‘it isimportant to understand which at-risk families programs reachand engage’’ (p. 256). We propose that past research on partic-ipation in home-visiting programs has not sufficiently examineddistinct degrees of participation. Studies have not differentiateddegrees of participation by separating nonengaging families fromengaging families. Instead, studies of program participation havecombined families who enrolled but were dropped or withdrewafter receiving few, if any, home visits (nonengaging families)with other families who received ongoing home visits butdropped out at some point before program completion (Clark &Winje, 1998; Halpern, 1992). In fact, most studies of attritionfrom therapeutic treatment programs struggled with defining whoto include and how to differentiate degrees of participation (Har-ris, 1998). This might be because most studies focus on factorsthat contribute to overall attrition or any premature departurefrom services (McCurdy & Daro, 2001) and have not lookedspecifically at program engagement.

By focusing almost exclusively on why parents leave pro-grams, researchers ignore an equally fundamental question: Whydo some eligible parents who enroll in home visitation programsnever fully engage in services? More specifically, what factorsin the community and in the family influence the decision toengage in services? Because many evaluations of home-visitingprograms have small samples (see Daro & Harding, 1999; Gom-by, 1999), analyses that control statistically for factors specifi-cally affecting engagement were not possible. As a result, it isunknown whether factors that predict overall program attritionalso predict why some parents who enroll never go on to activelyengage in services.

We also agree with McCurdy and Daro (2001) that pastresearch has ‘‘suffered from a restrictive conceptual framework. . . in terms of the areas explored’’ (p. 113). The vast majorityof researchers limit their scope to one or two potential deter-minants of program participation (primarily participant and pro-vider characteristics), rather than acknowledging that participantsand providers live in communities. Focusing strictly on partici-pant and provider characteristics ignores the potential influencethat community factors might have on families’ involvement inhome-visiting programs (McCurdy & Daro).

We add to the discussion of engagement in home-visitingprograms that past research is restricted in the methods of anal-ysis. Researchers understand that individual factors (e.g., in-

272 Family Relations

come, age, ethnicity) and community factors (e.g., communityhealth characteristics) can influence where parents live. However,individual and community factors also are likely to influencewhich services a parent seeks out and uses. The ‘‘nested’’ struc-ture of these levels of influence (individuals within communities)requires recognition of the interdependence of these causalagents and movement from a reliance on conventional linear ormain effect models.

Community Level Factors

Evaluators of home-visiting prevention programs are chal-lenged to design models that identify and explain community-level factors that influence program participation (McCurdy &Daro, 2001). Researchers suspected that community factors like-ly influence mother’s commitment to engage in home visitationservices (McCurdy et al., 1996). Yet to date, we could find noresearch that has addressed specifically which community factorsaffect mother’s engagement in home visitation services.

Studies examining the general effect of community on fam-ilies have used compilations of community health factors, suchas infant death rate, teen suicide rate, and the rate of low birthweight infants (Coulton, 1995; Coulton, Korbin, Su, & Chow,1995; Korbin & Coulton, 1996). These health outcomes may beproxies for reflecting overall community wellness. Examiningcommunity health factors exemplifies an ‘‘outcome orientation’’(see Coulton) that communities can affect families positively ornegatively, and this effect can be measured in higher or lowerrates of positive outcomes for the population living in the area.Thus, comparisons across community areas on established healthoutcomes can be valuable in understanding differences in theeffectiveness and practices of programs within the communities.

Individual Level Factors

The overall scarcity of consistent findings regarding pro-gram participation was highlighted in a meta-analysis (Wierz-bicki & Pekarik, 1993) and review of past studies (Harris, 1998).Many past studies of recruitment and retention did not directlyexamine home-visiting programs but did involve family supportservices (i.e., parenting support, therapeutic intervention). Re-tention issues may be different for various kinds of services andmay vary by level of family risk. Inconsistent findings existabout the role such factors as maternal isolation, age, and eth-nicity play in program participation. Early studies of participa-tion in home-visiting programs found that after initial enrollmentmothers who were raising their children without a supportivenetwork of family and friends perceived greater benefits andfewer costs of program involvement than did mothers with ex-tensive support networks (Birkel & Repucci, 1983; Powell,1984). In contrast, later studies of home-visiting programs foundthat family and friendship networks had the opposite effect onprogram engagement. Luker and Chalmers (1990) reported thatafter an initial decision to enroll in home visitation, mothers witha limited network of maternal support were more likely to with-draw from the program early. Likewise, if teenage mothers hada conflictive and nonsupportive family, they were less likely toengage fully in a home-visiting parenting program (Herzog etal., 1986). Clearly, these mixed findings on how isolation frommaternal supports affect engagement in home-visiting programspoint to a need for additional investigation.

Furthermore, mother’s ethnicity did not affect retention inone home-visiting parenting program (Herzog et al., 1986),

whereas another study found recruitment and retention rates weresignificantly higher for Hispanic parents (Dumka, Garza, Roosa,& Stoerzinger, 1997). Some studies reported that younger moth-ers tended to engage and remain in parenting services (Herzoget al.; Olds & Kitzman, 1993), and other studies found that youn-ger mothers presented a higher risk for dropping out (Birkel &Reppucci, 1983; Josten, Mullett, Savik, Campbell, & Vincent,1995). Researchers and practitioners agree that successfully re-solving these contradictory issues is critical, if home visitationprograms are to be effective (Olds & Kitzman, 1993), becauseprograms provide little help to families who never fully engagein services (Larner et al., 1992).

Other individual-level factors show more consistency intheir effects on program participation. Studies report higher ratesof engagement in family support programs among motherswhose infants displayed health risks at birth (Josten et al., 1995;Olds & Kitzman, 1993). Lower rates of engagement in homevisitation services are reported for mothers who experiencedfamily conflict or family problems (Herzog et al., 1986; Jostenet al.). High-risk pregnant women who abused substances (Na-vaie-Waliser et al., 2000) and mothers who knew they wouldsoon be moving to another house or neighborhood also werefound to be less likely to engage in home-visiting services(NCPCA, 1996; Olds et al., 1986).

Hypotheses

We used a multilevel framework, recognizing that familiesare nested within communities. Although the term communityusually suggests a social rather than geographical unit, this studyfocused on communities that were bounded spatially, politically,and by shared institutions (i.e., county units). Because countyunits remained constant over time, yearly data on health out-comes are available. County units were also appropriate becauseeach county in this study maintained local control of their home-visiting family support program, and most programs were housedin county offices, including county health departments.

We proposed that the overall health of the community wouldinfluence the decision of mothers with newborns to engage inhome visitation services. Although there are many possible pathsof influence, one plausible explanation is that in areas of highcommunity health, mothers may see supports for healthy familyconditions as common. We concur with McCurdy and Daro’s(2001) speculation that in communities where the dominantethos views healthy families as an asset, mothers may be morelikely to engage in services. In contrast, mothers raising theirnewborns in areas with poor community health may be morewary and less likely to expect positive results from a social ser-vice program. These mothers may see the family deficits presentin their community (i.e., high infant death rate, high number oflow birth weight infants) as normal conditions families shouldexpect to endure alone.

Here we examined the effect of community health on moth-ers’ engagement in a home-visiting family support programwhile simultaneously considering the effect of maternal isolation.We used a statistical method that has received little attention, butone that most accurately represented the fact that mothers mayvary as individuals but share the experience of living in the samecounty. This was a multilevel model (see Figure 1) with a hi-erarchical structure (Raudenbush, Bryk, Cheong, & Congdon,2000). An adequately large sample allowed us to control statis-tically for several factors related empirically to participation in

2003, Vol. 52, No. 3 273

Figure 1. Two-level model predicting engagement in home visits for 4,057 mothers residing in 15 counties.

home-visiting programs while testing the following two hypoth-eses:

Hypothesis 1: After initial enrollment, mothers raising theirnewborn infants in areas with poorer community health are lesslikely to actively engage in home-visiting family support servic-es.

Hypothesis 2: After initial enrollment, mothers experiencinggreater maternal isolation are less likely to actively engage inhome-visiting family support services.

Methods

Context of the ResearchData for this study came from Oregon Healthy Start (OHS),

a voluntary, home-visiting family support program designed toassist families in giving their newborn children a ‘‘healthy start’’in life. Oregon Healthy Start is modeled after HFA, a nationalinitiative adopted in 1992 by the National Committee to PreventChild Abuse (1996), now known as Prevent Child Abuse Amer-ica. At the time of this study, OHS was operating in 15 Oregoncounties and was overseen by the Oregon Commission on Chil-dren and Families. Variations in program effects are minimizedby the fact that one governing body oversees OHS, and eachprogram operates under the same set of administrative rules, pol-icies, and procedures. Although some program level effects like-ly remain, for this study we chose to examine community effects,because we believed that the community context of health wouldprovide more variability across the sites and might be a betterpredictor of program engagement.

One of the mandates from the Oregon legislature is thatOHS seeks to improve health outcomes for the families it serves,such as ensuring access to preventative health care and improv-ing immunization rates for children. Public health departmentsare active collaborators in the OHS programs. In many countiesthe OHS program is physically housed within the public healthbuilding. Thus, whereas other community factors such as socialcohesion and social disorganization can have an impact on fam-ilies, community health factors are particularly important to theOHS home-visiting program.

To improve the health and welfare of Oregon families, OHSoffers regular home visits to high-risk families during the first 5years of raising their firstborn child. Home visits are scheduledbased on the family’s needs, beginning with weekly visits andgraduating to monthly visits. Home visitors offer parenting ed-ucation, support, and referrals to any needed services such asmental health services, alcohol and drug treatment programs,child care, food, housing, and transportation. All OHS home vis-

itors receive at least 96 hours of initial training, and more thanhalf (53%) have college degrees, some with degrees in nursing.

ParticipantsData were obtained from 4,057 families enrolled in OHS

from January 1, 1995, to December 31, 1998, all of whom wereidentified as high risk. To identify high-risk families, OHS usesan extensive screening and assessment process. Screening isdone in the hospital shortly before or after the child’s birth, usingthe 15-item Hawaii Risk Indicator (HRI) checklist (Hawaii Fam-ily Stress Center, 1994). Oregon Healthy Start was able to con-tact and screen 80% of the first births in the 15 counties it serves.Risks on the HRI include being unmarried, having less than ahigh school education, and having an inadequate income. Moth-ers who are single, had no or inadequate prenatal care, or whoshow any two other risk characteristics are further assessed usingthe Kempe Family Stress Inventory (KFSI).

The KFSI is an in-depth interview that assesses 10 psycho-social factors related to the risk of child abuse. The KFSI hasestablished criterion and predictive validity (McGuigan & Pratt,2001). According to a recent review (Korfmacher, 2000), a well-controlled reliability study of the KFSI (Katzev, Henderson, &Pratt, 1997) was conducted on 115 families. Independent ratersreviewed notes from KFSI interviews, and high reliability wasfound for classifying the parent as low, medium, or high risk forchild maltreatment (r 5 .93).

In the present study, Healthy Start family assessment work-ers conducted KFSI interviews after having received extensivetraining in the interview protocols. Interviews were conductedin the hospital or in the home shortly after the child’s birth aspart of a ‘‘welcome baby’’ visit. In addition, all families receiveda list of community resources and a packet of child developmentinformation. From January 1, 1995, to December 31, 1998,4,341 families were assessed as high risk and offered regularhome visitation services. Of these, 284 (7%) refused any furtherservice. The remaining 4,057 (93%) mothers gave their writtenconsent to participate in home visitation and were consideredenrolled in the OHS program. These mothers made up the studysample (N 5 4,057). There were no significant differences inrisk or assessment scores between those who refused and thosewho initially accepted OHS services.

Mothers in the study sample resided in semirural or smallmetropolitan areas and were predominantly single (78%). Morethan half had low incomes (58% with gross monthly family in-comes , $1,000) and less than a high school education (54%).The sample was predominantly White (77%) with 23% minori-ties (18% Hispanic, 5% African American, Native American,Asian, or other). On average, mothers were 20.6 years old (SD

274 Family Relations

Table 1Means (SDs) or Percentages of All Variables by Engagement Status

Variables

Engaged

(n 5 3,312)

Never Engaged

(n 5 745)

Poor community health indexMaternal isolation indexMother’s age (years)Mother White (%)No infant health risks at birth (%)Marital or family problems (%)History of substance abuse (%)Unstable housing (%)

.63 (.88)1.53 (.82)

20.63 (4.97)8192473225

.86 (.75)1.78 (.93)

20.46 (4.93)8894543129

5 5.0) when their child was born, and most did not work outsidethe home (82%). More than half of the mothers (58%) lived withtheir husband or boyfriend; one third (33%) lived with parents,relatives, or friends; and the remaining 9% lived only with theirnewborn child.

Defining Program EngagementThe OHS program followed HFA guidelines when dealing

with families who had accepted the program but were reluctantto engage fully in services or difficult to contact. For the first 3months after enrollment, OHS workers used ‘‘creative outreach’’techniques to connect with families. These included repeatedmailings; telephone calls to home, work, and message numbers;and drop-by visits to the home. After 3 months of intensive out-reach efforts, families were discharged from the program if (a)home visitors were not able to schedule a visit, (b) families wereconsistently absent after scheduling home visits, or (c) the fam-ilies said they no longer wanted to participate.

Based on these guidelines and the fact that OHS was de-signed to provide 5 years of supportive services, involvement inthe program beyond 3 months was accepted as a legitimate def-inition of program engagement. Engagement was coded as 0 5received services more than 90 days and 1 5 received servicesfor 90 days or less. Thus, the dependent variable was nonen-gagement in home visitation services. Of the 4,057 families whoinitially accepted services, 745 (18.4%) remained enrolled in theprogram from 1 to 90 days, for an average of 34 days (SD 531). The number of home visits completed by these 745 familiesranged from 0 visits (61%) to 4 visits, with an average of 0.48home visits (SD 5 0.72). Because OHS provided an assessmentinterview, a list of community resources, and a packet of childdevelopment information during the initial ‘‘welcome baby’’ vis-it, all of these families received some level of OHS service.Nevertheless, adhering to HFA standards and the definition ofengagement explained above, we considered these 745 familiesas never actively engaging in the OHS home visiting program.

Poor Community HealthSimilar to the community health and safety indicators out-

lined by Coulton (1995), six county-level health outcomes werecombined as an index of poor community health. Indices of poorcommunity health included the counties’ infant death rate, lowbirth weight rate, attempted teen suicide rate, suicide rate, al-coholism-related death rate, and accidental death rate (includingdrug overdoses). All rates reflected frequency of occurrence per1,000 in the county population.

When examining ‘‘rare events, multiple years need to beaveraged and rather large community areas must be used foranalysis’’ (Coulton, 1995, p. 181). We used county-level vitalstatistics (Oregon Department of Health and Human Resources,1997, 1998, 1999, 2000) for each of the 15 counties participatingin OHS. First, we averaged the 1995–1998 rates of each indexitem. After taking the 4-year average of each item, individualitem scores were standardized to a mean of zero and standarddeviation of 1.0. This was necessary because there was extensivevariation in rates across items. For example, the infant death ratewas much lower than the rate of low birth weight infants. Next,the six standardized items were summed to produce the index ofpoor community health. Each county’s total score on the indexof poor community health was then standardized to simplify in-terpretation. Standardization resulted in an approximate 4-pointrange with 1 unit representing 1 standard deviation. Scores for

the index of poor community health ranged from 21.95 to11.67, with higher scores representing poorer communityhealth.

Maternal IsolationOne item assessed during the KFSI interview was ‘‘mother

is isolated with few lifelines, low self-esteem, or depression.’’This combination of few lifelines, low self-esteem, or depressionalways has been part of the KFSI (Orkow, 1985). It is a globalmeasure that reflects the mother’s standing on two psychosocialcomponents of maternal isolation: being socially isolated fromothers through a lack of lifelines and being personally isolatedfrom immediate others due to low self-esteem and depression.Trained family assessment workers rated this item as not an issuefor this mother, somewhat of an issue, or a significant issue. Forthis study, ratings were dichotomized as 0 5 not at all an issuefor this mother and 1 5 at least somewhat of an issue for thismother.

Four self-report items gathered at or near the time of thechild’s birth were combined with the isolation item from theKFSI to form a 5-item index representing maternal isolation.Separate x2 analyses showed that each of the self-reported iso-lation items were significantly associated with the isolation itemfrom the KFSI. Self-report items included ‘‘single, no spouse orpartner’’; ‘‘inadequate or no emergency contact person’’; ‘‘notelephone’’; and ‘‘living only with the newborn child and noother adults in the home.’’ Each self-report item was scored 05 not true or 1 5 true. Responses to the four self-report itemsand the isolation item from the KFSI were summed to create a6-point index that ranged from 0 to 5. Higher scores indicatedgreater maternal isolation and a smaller network of immediatesupport. Overall, mothers did not report high levels of maternalisolation; however, there was variation between engaging andnonengaging mothers at the lower levels of the isolation index(see Table 1).

Control VariablesBased on prior research, six additional variables were in-

cluded in the analysis as statistical controls. This was done toincrease model precision and isolate the effects of our predictorvariables on program engagement. To control for the relationshipbetween mother’s age and engagement, the mother’s age in yearswas included. Mother’s ethnicity was included in the analysis as0 5 Hispanic and 1 5 other ethnicity. Infant health status wasassessed using information from birth records, that indicatedwhether the child was premature (gestation , 37 weeks), lowbirth weight (# 2,500 g), or had any other medical risks at birth.Of the 4,057 newborns in the study families, 320 (7.9%) dis-

2003, Vol. 52, No. 3 275

Table 2Community- and Family-Level Factors Contributing to Nonengagement (N 54,057)

VariablesCoeffi-cient t-Ratio Odds-Ratio

Poor community health indexMaternal isolation indexMother’s age (years)Mother WhiteNo infant health risks at birthMarital or family problemsHistory of substance abuseUnstable housing

.31

.33

.01

.60

.24

.07

.10

.10

2.866.63.04

4.711.40.85

1.111.01

1.36*1.39**1.011.82**1.271.071.101.10

*p # .01. **p # .001.

played at least one of these three health concerns at birth. Infanthealth status was included in the analysis as 0 5 at least onehealth concern present at birth and 1 5 no health concernspresent at birth. As previously mentioned (see Individual LevelFactors) current marital or family problems, maternal history ofsubstance abuse, and living in unstable housing may affect re-tention. These three items were collected during the initial hos-pital screening shortly after the child’s birth and were includedas additional control variables. Items were coded as 0 5 not anissue for this family and 1 5 an issue for this family.

Statistical AnalysesFamilies in the same community were not differentiated on

the measure of community health, so standard logistic regressionwould have introduced the possibility of bias by violating theassumption of independence. Families were not randomly as-signed to family support programs, nor were families or pro-grams randomly assigned to communities. This lack of indepen-dence required a statistical method that could estimate nonin-dependent community and individual level effects. Our outcomevariable had a Bernoulli distribution (engaged: yes or no), so weused the hierarchical general linear model (HGLM) for the non-linear analysis of binary outcomes (Raudenbush et al., 2000).The HGLM Bernoulli model was used to estimate the uniqueeffect of poor community health and the unique effect of ma-ternal isolation on mothers’ engagement in the OHS program,while holding constant the effect of the six control variables.This model allowed for the examination of all possible moder-ator effects within and across individual and community levels.Tolerance tests indicated no multicollinearity.

The HGLM Bernoulli model calculates the probability of abinary outcome by generating logit coefficients. These modelshave been found to be highly robust and produce smaller stan-dard errors than traditional logit analysis (Rodriguez & Gold-man, 1995). In our HGLM analysis, each Level 1 case corre-sponded to an individual mother with a single binary outcomefor each mother (engaged: yes or no). In this analysis, 4,057mothers at Level 1 were nested within 15 counties at Level 2(see Figure 1). The model was specified to predict the probabilityof engagement for individual mother i in county j.

Results

Logit coefficients generated by the two-level Bernoulli mod-el were converted to odds ratios (OR) for ease of interpretation(Table 2). Results of the multilevel analysis provided support forour first hypothesis. Mothers living in counties with poorer com-

munity health were significantly less likely to engage in homevisitation services. The odds of engaging in services decreasedby 36% with every 1 SD increase in the index of poor com-munity health (OR 5 1.36, p , .05). The multilevel analysisalso provided support for our second hypothesis: isolated moth-ers were less likely to engage. For every 1-unit increase in thematernal isolation index the odds of engaging in home visitationservices decreased by 39% (OR 5 1.39, p , .001).

Furthermore, the multilevel model revealed that non-His-panic mothers (95% of whom were White) were 82% less likelyto engage in home visitation services than were Hispanic moth-ers (OR 5 1.82, p , .001). When controlling for the significanteffects of community health, maternal isolation and mother’s eth-nicity, program engagement was not significantly related to anyof the other variables: mother’s age, history of substance abuse,unstable housing, family problems, or infant health.

The multilevel model also was used to test for all possibletwo-way interaction effects. There were no significant interac-tions between any of the variables. This includes no moderatoreffects between any of the control variables and the primaryexogenous variables. Because some research has found teenagedmothers more likely to remain in home visiting programs (Dug-gan et al., 2000), we further tested the model with mother’s agedichotomized as teen (,17) and nonteen and obtained the sameresults as when age was a continuous variable. In addition, modelparameters were unchanged when we included family income asa statistical control. Unfortunately, missing data on the familyincome variable (35% missing) prohibited its inclusion in thefinal model.

In the multilevel analysis (see Table 2), the sizes of the oddsratios were modest, but it is understood that without collinearitythe additive log odds of significant predictors are multiplicative.This means that the addition of each risk factor ‘‘multiplies’’ thelikelihood of nonengagement. Consequently, a White mother(OR 5 1.82), who lived in a county that scored 1 SD above theaverage on the index of poor community health (OR 5 1.36),was 2.47 times (1.82 3 1.36 5 2.47) less likely to engage inservices. If this mother had any one of the five indices of ma-ternal isolation (OR 5 1.39), she was 3.44 times (1.82 3 1.363 1.39 5 3.44) less likely to engage in visitation services thanmothers with none of these characteristics.

Discussion

This study sought to deepen our understanding of how com-munity- and individual-level factors influence engagement inhome-visiting family support programs. The study sought to ad-vance engagement research in at least three ways. First, using amultilevel causal model to explain engagement in a voluntaryhome-visitation program is an approach that has received littleattention. Second, by including both community- and individual-level factors, this study responded to the call for evaluation re-searchers to consider macro- and microlevel predictors of en-gagement (McCurdy & Daro, 2001; McCurdy et al., 1996).Third, this study had a sample sufficiently large to test multiplepredictors using a statistically rigorous design.

We found support for our hypothesis that mothers living inareas of poorer community health were less likely to engage ina home visitation program. This suggests that program engage-ment is just as much a function of the community context as itis a function of individual characteristics of the family. Themechanism for this relationship may lie in the way that the

276 Family Relations

overall health of the community affects mothers’ perceptionsof community services. When communities are unhealthy plac-es to live, with high rates of low birth weight babies, infantmortality, suicides, and alcoholism-related deaths, mothers mayview these as normal conditions that simply must be endured.They may see services designed to ameliorate these conditionsas largely ineffective. These mothers may be less likely to seebenefits for either themselves or their children from getting in-volved with a community agency and opening their home to avisitor. On the other hand, mothers who live in healthier com-munities may have a more positive outlook and may see ser-vices as being beneficial. It also could be that communities withbetter health outcomes simply have better health services. Al-though these are plausible explanations, further research isneeded to clarify the relationship between engagement andoverall community health.

We also found support for our hypothesis that mothers fac-ing the challenge of first-time parenting in isolation (and withlow self-esteem or depression) or mothers with few immediatesupports are less likely to engage in home visitation services.Despite being without the guidance traditionally offered by im-mediate support network such as family and friends, isolatedmothers were significantly less likely to engage in home visits.One possible interpretation is that certain parents choose to beisolated to keep deviant activities private. Yet even after con-trolling for substance abuse and marital or family problems,mothers who were isolated remained less likely to engage inservices.

Identification of the exact psychological processes that linkmaternal isolation with mothers’ decisions not to engage in homevisits is beyond the scope of this study. We have no doubt thatchildrearing is a demanding life process, especially the birth ofthe first child, a process that can be enhanced by a mother’simmediate network of supportive family and friends. Family andfriends provide interpersonal resources from which support andadvice may be anticipated—abundant and accessible for some,and rare and unapproachable for others (Thompson, 1995). Im-mediate maternal supports, such as partners, parents, and friends,may need to reach a certain level of both quantity and qualityto facilitate the acceptance of nonfamilial change agents likehome visitors.

Conversely, it could be that mothers who lack a supportivenetwork of family and friends simply have little confidence inthe ability of all others, whether family, friends, or professionalexperts, to help with parenting. Research on help-seeking be-havior shows that isolated individuals not only seek less sup-port but also are less supportable. A lack of confidence in othersleads them to misinterpret and reject even sincere attempts atsupport (for a comprehensive review see Albrecht & Adelman,1987).

Implications for PracticeThe identification of poor community health and maternal

isolation as factors contributing to mother’s failure to engage inhome visitation services provides a basis for the development ofstrategies to increase engagement in home-visiting family sup-port programs. Program practitioners will find this informationdirectly applicable.

In communities with poor health outcomes, practitionersmay need to make special efforts to market their home-visitingprogram as being effective in helping families achieve betterhealth outcomes for their children. Human service practitioners

are increasingly focusing on marketing approaches to reach andengage their target audiences. To be successful, practitionersneed to know what services families need and want. Becausemost parents set high value on their children’s health, emphasiz-ing the benefits for children can be an effective approach. Al-though home visitors typically are not health care providers, theyprovide important health care information and support familiesto access the health care system successfully.

Even with an effective marketing approach, families livingin communities with poor health outcomes still may not engagewithin a 3-month period. Three months of outreach simply maynot be adequate in these communities. Practitioners must thenweigh the potential benefits of using staff time to extend outreachefforts against the cost of being unable to offer services to newand equally needy families.

This study also found that mothers who are socially isolatedare the most difficult to engage in home visitation, especially ifthey live in areas characterized by poor community health. Con-centrated efforts are necessary to reach these parents. Both thefrequency and duration of outreach efforts must increase wheninitial information indicates that maternal isolation may be anissue. Isolated mothers may not have strong enough social skillsto know how to function with a home visitor (or establish asupport system). For these mothers, home visitors may need toincorporate basic social skills training into their initial outreachstrategies. In addition, isolated mothers may have had past ex-periences with individuals or agencies that did not deliver ontheir promises. Home visitors face a major challenge in over-coming this kind of history. These families need special reas-surance that the home visitor is committed to helping them, re-gardless of whether they miss a scheduled visit. Other effectivestrategies for working with isolated parents include patience, fol-lowing through on any commitments, and delivering to familiesthe things they ask for, even if it is little.

Providing transportation to parent support groups to aug-ment home visits can also maximize engagement among isolatedmothers. Parents enjoy hearing from other parents who are ex-periencing similar challenges and gain support and self-confi-dence by participating. To engage isolated mothers in home vis-its, practitioners may need to develop strategies that involve fam-ily and friends more effectively. It is true that a lack of supportfrom family and friends often is the very problem the programis seeking to address, yet special efforts to reach and educatefamily members as to the program’s objectives may increasetheir involvement in the program and increase their support forthe mother. Special invitations to grandparenting classes may beone technique. Certainly increasing the quantity and quality ofthe mothers support network is an implicit, if not direct, goal ofall home-visiting family support programs.

Finally, it must be acknowledged that home visiting maynot be the most effective method of program delivery for somefamilies. Home visitation is not a panacea for all family prob-lems. When necessary, home visitors can refer families to otherprograms or treatment protocols that may be more conducive tothe family’s needs.

Study LimitationsOne limitation is the lack of data or supporting literature to

explain or support our finding that mother’s ethnicity effects pro-gram engagement. Most of the Hispanic mothers in this samplewere Mexican immigrants who were matched with Hispanichome visitors. Perhaps Hispanic mothers allied with their bilin-

2003, Vol. 52, No. 3 277

gual home visitors out of the necessity to access basic services(i.e., interpreting rent contracts, utility bills, and medical forms).Another plausible explanation may lie in the empathy of theHispanic home visitors toward the families they served. In per-sonal discussions with the lead author, many of the Hispanichome visitors disclosed that they were only recently acculturatedthemselves (first and second generation). Hispanic mothers mayhave bonded quickly to their home visitors because the Hispanicvisitors were empathetic to the needs of recent immigrants. Fu-ture studies should examine the relationship between programparticipation and home visitors’ empathy, ethnicity, and level ofacculturation.

Another limitation of our study concerns the generalizabilityof the findings to other populations. Participants were predomi-nantly White (77%) and Hispanic (18%) and lived in semiruralor small metropolitan areas. Although this sample parallels thedemographic characteristics of many young Oregon families, itis unclear to what extent these findings reflect those in morediverse or urban populations.

Another limitation was statistical power. Having only 15communities limited the analyses to only one county-level pre-dictor. Aggregate county-level indicators may mask differenceswithin the county. This is less of an issue in our study becausecounties were somewhat homogeneous in overall ethnic and eco-nomic diversity. However, the data do not allow us to investigatewhether families who never engaged in services lived in thespecific areas within their county that had the poorest communityhealth. Although counties were a meaningful focus for this study,future studies may wish to narrow their focus to attributes at thezip code, school district, or census block level. Having morecommunity-level units of analysis would allow other communityfactors, such as social cohesion (McCurdy & Daro, 2001) andsocial disorganization, to be included in the analyses. Further-more, future studies that include qualitative interviews or casestudies in different neighborhoods are warranted in order to pro-vide a more rigorous investigation of how community healthinfluences mothers’ decisions to engage in home-visiting servic-es.

Despite these limitations, this study adds to the research onprogram engagement. Although research on home visitationcould benefit from statistical methods that accurately representthe grouping of clients within communities, more studies withlarge samples linking macro- and microlevel influences wouldbe particularly informative. This study illustrates the utility ofconsidering both family and community contexts when devel-oping strategies for engaging mothers in home-visiting familysupport programs. Such strategies could be advanced by quan-titative and qualitative research methodologies that illuminate thedifferent contexts that influence participants moving from intentto actual program engagement.

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