Factors Influencing Mothers’ Abilities to Engage in a Comprehensive Parenting Intervention Program

Abstract

Objective

This research identified the possible factors influencing the ability of mothers perceived to be at the highest risk for child maltreatment to engage in a home visitation program. This study holds significance to public health nursing since home visitation is an integral component of public health nursing practice, with engagement being essential for human interaction and thus nursing care to occur.

Design and Sample

A qualitative descriptive design was used to offer a thematic summary of the experiences of program engagement from the perspective of 4 home visitation coach interventionists from health-related fields and a small sample of purposefully selected mothers involved in a longitudinal prevention study.

Results

Qualitative content analysis revealed 3 major themes related to engagement: (1) mothers struggle to meet the emotional needs of the self and the child; (2) mothers lack support in navigating complicated and stressful life events; and (3) mothers’ consistency with program engagement is mediated through a trusting and caring relationship with coaches.

Conclusions

Home visitation coaches in this study demonstrated a continuous process of engagement by supporting mothers to explore and discover self-care strategies and ways to navigate life struggles. Over time, a foundation of trust and caring was developed, which in turn increased relationship building and program engagement.

Background

Home visitation programs designed to enhance parenting can only prove beneficial if families are engaged and actively participating in program interventions (Katz et al., 2001; Peterson, Luze, Eshbaugh, Jeon, & Kantz, 2007; Spieker, Solchany, McKenna, DeKlyen, & Barnard, 2000). In a study of families enrolled in an Early Head Start Program that offered comprehensive child development and family support services to low-income families, researchers found that approximately one third of the mothers were extremely difficult to engage or did not engage in program interventions or activities (Spieker et al., 2000). The home visitors experienced these mothers as often not being available for scheduled visits, limiting the amount of time spent during visits, or appearing distant or distracted during the discussions.

Engagement of families in these intervention programs can be crucial to the development of the child. Research suggests that enhanced parenting can mitigate or buffer the adverse effects of poverty on early childhood development (Duncan & Brooks-Gunn, 2000; Olds et al., 2004). Katz et al. (2001) had an attrition rate of 41% in a multicomponent parenting intervention even though multiple retention strategies were included. They found that those families that dropped out early from the program were less likely to provide developmentally appropriate home environments for their child.

Spieker et al. (2000) found that difficult-to-engage mothers in a home nurse visitation program had attachment disruptions in their own early childhood relationships and proposed that this could be a primary factor in the mother’s struggle to engage in a child development and family support intervention program. Factors placing mothers at a higher risk for child maltreatment include a maternal history of poverty, intergenerational family violence, chronic situational stressors, low self-esteem, and depressive symptomatology (Lutenbacher, 2002).

Research in public health nursing in the area of home visitation programs has focused either on outcomes (Kaiser, Kaiser, & Barry, 2009; Ogbuanu et al., 2009) or on the experiences of program participants and nurses (DeMay, 2003; Wager, Lee, Bradford, Jones, & Kilpatrick, 2004). However, the nursing literature has continued to identify engagement as essential to any human interaction (Kaiser et al., 2009). Falk-Rafael (2000) noted that it is fundamental for nurses to create environments that support participation of the patient/family in the caring process, thus creating self-empowerment and trust. Even with this emphasis on relationship building, there is little research on factors influencing the engagement of vulnerable families in home visitation programs.

The purpose of this study was to identify the possible factors influencing the ability of mothers to engage in a home visitation program. Therefore, we examined the differences in engagement between those mothers perceived by home visitation coaches to be at the highest risk for child abuse and neglect and other mothers in their caseloads. Selection of mothers at the highest risk was based on the coach’s personal working experiences with the mother and child (Spieker et al., 2000), and on the mother’s association with one or more criteria for child maltreatment as documented in the research literature. Engagement was defined by coach impressions of the mother’s level of interest and interaction with both the coaches and the intervention materials during individual sessions. Engagement was also reflected in the degree to which mothers kept appointments.

Research questions

The research questions were: (1) What are the home visitation coaches’ perceptions and experiences of working with mothers determined to be at the highest risk for child abuse and neglect as compared with other mothers in their caseload? (2) What additional factors associated with child maltreatment in the research literature are present for these mothers? (3) What are the perceived differences in the levels of engagement of these mothers as compared with other mothers in their caseloads?

Methods

Design and sample

A qualitative descriptive design (Sandelowski, 2000) offered a thematic summary of coach interventionist perceptions of the ability of mothers determined to be at the highest risk for child maltreatment to be engaged in the program. These perceptions and experiences were constructed within the interactions and worlds of both coaches and mothers.

Home visitation sessions occurred in a large Midwestern city where mothers and their children living in the urban core encounter issues of safety, transportation, and poor economic development. The participants for this study were four family coach interventionists and a small sample of purposefully selected mothers from one of four, “My Baby and Me” sites of a longitudinal, randomized, prevention study (Borkowski et al., 2001). The goals of this study were to help support parents to be more sensitive and responsive (antithesis of neglect and abuse) and to be aware of the importance of stimulating in-home enrichments and the critical roles they play in supporting their children to achieve crucial developmental milestones.

Participants in the “My Baby and Me” multisite intervention study were teen mothers (15–18) and adult mothers (22–35) without a high school diploma who were randomly assigned to one of two groups. A high-intensity intervention group received all in-home interventions (weekly/biweekly home visits in years 1 and 2 with monthly visits in year 3) along with referral services. A minimal intervention control group received referral services but with no in-home interventions. Home visitation coaches began home visits with the high-intensity intervention mothers during late pregnancy and followed them through the child’s 3rd year of life. The specific focus of these sessions was to promote responsive parenting through a skills-based coaching approach that incorporated decision making, play, and child health, and home safety promotion. All coaches were trained and certified in the delivery of the intervention curriculum.

Home visitation coaches.

All coaches (n = 4) actively involved from one site of the primary intervention study were asked to identify mothers within their high-intensity caseloads who were at the highest risk for child maltreatment. All coaches were female; three were Caucasian and one was African American. One coach was in her late 20s and the other three were middle-aged adults.

Mothers at the highest risk.

A purposive sample of 9 mothers from a caseload of 45 mothers in the high-intensity group was identified by coaches as being at the highest risk for child maltreatment. As stated above, mothers were selected based on the coaches’ personal working experiences with the mother and her child, along with one or more of the following criteria associated with child maltreatment in the research literature: a history of previous reports of child neglect or abuse with other children; current behaviors by mothers that indicated problems with anger management; documented involvement with alcohol and/or street drugs; inadequate family and/or poor social supports resulting in the mother being involved in child protection programs; and a history of domestic violence and/or psychological trauma.

Eight mothers identified themselves as African American, and one identified herself as a mixture of African American and Caucasian. There were six teenagers, two women in their early 30s, and one in her late 30s. None of the mothers had completed high school. All the infants lived with their mothers after hospital discharge. Two mothers lived with the fathers of the babies immediately after delivery, and one of these mothers returned to live with her own mother 6 months after delivery. Two older mothers lived in apartments with other children and the other five mothers lived with family members. One teen mother lived with a foster family. All participants in the “My Baby and Me Project” signed consent forms that encompassed all research activities related to the intervention study.

Data collection.

After written consent was obtained, the four coaches participated in a one-time formal tape-recorded interview. Intrviews were strictly voluntary, and coaches were assured that the interview could be stopped at any time. As part of this interview, coaches were asked to describe their experiences with each of their selected mothers and speak specifically about why they believed each mother was potentially at the highest risk for present or future abuse and neglect of her child as compared with other mothers in their caseloads. Coaches were also asked to describe the degree and quality of engagement of these mothers during the intervention sessions. The primary researcher completed formal tape-recorded interviews with only coaches and did not interview the mothers because they were involved in the intensive intervention study at that time.

The primary researcher, a nurse and cultural anthropologist, along with analyzing formal tape-recorded interviews with coaches, observed home visits, documented field notes of coach-mother interactions and mothers’ levels of engagement with family coaches and program materials, and reviewed scheduled quantitative descriptive assessment data collected on the nine mothers and their children. This researcher, completing a postdoctorate with the multisite intervention study, was introduced to mothers as part of the research team and was an observer during the home intervention sessions. It was not unusual for coaches to be accompanied by a person from the research project for safety-related reasons. The primary researcher observed an average of five coach intervention sessions with each of the mothers. Home visit intervention sessions lasted from 1 to 3 hr, with most sessions being 90 min. Observations of coach-mother interactions and other activities for this qualitative study occurred during the first 1.5 years of a 3-year intervention program.

The quantitative measures selected as part of the data collection included two literacy subtests (Letter-Word Identification and Word Attack) from the Wood-cock-Johnson III (Woodcock, McGrew, & Mather, 2001) administered to all mothers during the prenatal assessment. The Postpartum Depression Screening Scale (PDSS) (Beck & Gable, 2002) and an Adult Attachment Style Questionnaire (AASQ) (Hazan & Shaver, 1987) were administered to all mothers approximately 1 month after delivery. Psychometric properties for all the tests used in the multisite intervention program were identified as reliable.

Analytic strategy

Qualitative content analysis of all observational field notes and transcribed coach interview data occurred through a reflexive and iterative process. All data were coded line by line using words and phrases to decontextualize the data and identify units of meaning. Similar units of meaning or patterns were placed together to form descriptive categories. Categories were then collapsed and placed under three major themes with descriptions that recontextualized the data (Coffey & Atkinson, 1996). The three quantitative descriptive measures used in the parent study provided case-bound descriptions of the mothers that were integrated and reported in the overarching themes.

The credibility of the research was supported by the use of multiple triangulation methods consisting of 40 home visits by the primary researcher with coaches and selected mothers over a 12-month period, formal audio-taped interviews with coach interventionists, a review of family history and assessment data on both the mother and the child, and descriptive quantitative data from the parent study. Peer debriefing throughout the research process included bimonthly project team meetings and scheduled meetings with two coinvestigators of the parent study. A close working relationship with the coaches and their review of the data analysis (member checks) ensured their voices in the findings of the study. The use of analytic process notes and reflective journaling provided additional direction and support for decision making and were incorporated into the emergent themes of the study.

Results

Three themes were identified relevant to coaches’ perceptions and experiences with program engagement among vulnerable mothers for abuse and neglect. These themes reflect the coaches’ perceptions of the fragile state of these mothers’ and children’s lives and the multiple life distractions affecting the mother’s ability to engage in program interventions.

Mothers struggle to meet the emotional needs of the self and the child

Coaches perceived mothers at the highest risk as having difficulty in understanding how their psychological processes, such as depression, anxiety, or fear of new situations, influenced their ability to meet their own emotional needs and those of their child. This theme consisted of three categories.

Difficulty in identifying emotional needs.

These difficulties were often mirrored in the mother-child relationship. Coaches stated that since mothers were not emotionally cared for, they in turn had difficulty in recognizing how their own emotional wellbeing impacted their child’s emotional and behavioral state and how a child’s symptoms could be a direct result of the mother’s emotional state. Canuso (2007) referred to this phenomenon as the “dance of the dyads.”

One coach, describing an unemployed and isolated 30-year-old mother with an infant daughter and a 2-year-old son, stated “... if the two-year-old is acting out... and not really doing what she wants him to do, it’s his fault, it’s not because she’s been yelling and kind of really harsh with him.” The coach described how this parenting behavior was being repeated with the baby as the baby grew older and more independent, and how this behavior escalated with increased situational stressors on the mother.

The coaches observed that some of these mothers seemed to accept a chronic level of depression as part of life. Within this group of nine mothers, the PDSS (Beck & Gable, 2001, 2002) administered approximately 1 month after delivery found that four had positive screenings for major postpartum depression, another four had positive screenings for significant symptoms of postpartum depression, and one was in the normal adjustment range.

Confusion in emotional caretaking.

The mother’s lack of awareness of her own emotional needs created confusion between the emotional caretaking of the self and the child. Coaches described a near role reversal in emotional caretaking whereby a very young child was expected to understand the mother’s needs and feelings. Coaches, reflecting on the selected mothers in their caseload, described this confused state:

... there is a tendency to put a lot of adult... thought processes ... motives on the baby. Like, well, ‘He’s mad at me now,’ ‘He’s punishing me’... just kind of a lack of understanding of what an infant can and can’t understand and process....

They [mothers] expect their babies to understand their needs as women, as mothers, as adults ... that their babies should be able to understand those things ... right off the bat....

Difficulty in trusting others.

Mothers at the highest risk for child maltreatment were described by coaches as less able to trust and be open in communication with coaches. A coach of an older 40-year-old mother stated,

... she really struggles ... and wants to be a good mom but is very scared of being hurt again by what she sees as being hurt by the system and being taken advantage of... [She] walks on eggshells ... at least appears to be this great mom and is scared to ask for help.

Another coach described other mothers in her caseload stating “My other moms are really proactive ... they’re more trusting ... and request help in certain areas.”

Information from the AASQ (Hazan & Shaver, 1987) identified six out of nine mothers who had insecure attachment profiles with elevated anxious and/ or avoidant scores. An insecure attachment style may hamper a mother’s ability to develop supportive relationships with other adults that can in turn benefit herself and her child (Ainsworth, Blehar, Waters, & Wall, 1978).

Mothers lack support in navigating complicated and stressful life events

Multiple deprivations in family/community support and nonnurturing environments led to personal isolation and the promotion of life patterns that prevented mothers from navigating complicated and stressful life events and building and maintaining supports. This theme consisted of two categories.

A future of uncertainties.

Coaches identified that mothers had a genuine desire for their child to have a better life and receive a good education, but coaches also perceived these mothers as lacking the skills or resources necessary to engage people and situations in a manner that would most likely benefit themselves and their child. In one case, a mother’s uncertainty about how to approach a middle-school vice principal resulted in her daughter being suspended for an extended period of time. Other mothers, feeling overwhelmed, found themselves relegating care of their children to other adult family members or friends. Coaches perceived that instability in the mothers’ environmental created a lack of nurturing routines and supportive relationships. One coach described the plight of these mothers:

... none of [mothers] have vehicles ... faced with all these stressors ... they don’t have any way to escape ... get out of the house or ... go to the store ... there’s no one to really watch their children so they can’t even take a break from that... I think they feel suffocated….

Another coach stated that there is “instability in living situations ... moving around a lot, not always knowing where you’re going to be ... it is like ... I [mother] can’t do anything about this, I’ve got to accept it the way it is.”

As a result of the deprivation, coaches described mothers as having difficulty in internalizing hope and lacking an internal direction as to how to push forward. One coach, referring to her older mothers, shared that these women may think it is ridiculous to talk of hope and dreams, “They almost feel like it’s stupid to talk that way ... ridiculous to talk that way because everyone knows that’s not going to happen so why even get your hopes up about it.”

Isolated in life struggles.

Coaches verbalized that in many of these families, there was a lack of personal and financial support that relegated these mothers to a life where survival meant doing it all on their own.

Everyone’s clawing their way up ... out of this hole and no one can really help anyone else because they might lose their footing if they do. [They are]... very alone in their struggles. [Mothers]... reach a certain point and they just don’t know what to do... without the right coping mechanisms they just basically shut down.

Coaches identified that these mothers often suffered from added psychological stressors such as traumatic events, including sexual assault and abuse, depression, learning disabilities, minority status, or becoming mothers when they were teenagers. Four of these mothers shared with coaches that they had been sexually abused as children or young adults. A coach described one of her older mothers as not even having the “small things ... familial support... people working inside the family and that kind of encouragement to do something different or support ... .” Coaches shared concerns that at least four of these mothers had learning disabilities that could create even more stress and marginalization in their lives. Quantitative measures supported these observations in that six of the nine mothers scored 1 or greater standard deviations below the norm on the literacy measures, with an average reading score at the third grade level.

Mothers’ consistency with program engagement is mediated through a trusting and caring relationship with coaches

This theme reflects coaches’ perception that the levels of program engagement were influenced by the interplay between the mother’s multiple life distracters and the level of trust built between the mother and the coach. This theme consisted of two categories.

Need for genuine caring.

Engagement with the mothers was not always easy for the coaches or the mothers. Eight of the nine women fit the definition of “difficult-to-engage” mothers noted by Spieker et al. (2000). It was found that specific program materials and interventions could either increase involvement or cause psychological conflict for the mothers. One coach described how numerous disruptions caused her to have to “... reengage the mother... if a phone call comes in... a knock on the door... all takes precedence over what I’m doing.”

A coach described a teen mother exhibiting body language as “... like a wall coming down ... her gaze, she looks away ... .She is also not as verbal during those times.” The coach felt that this behavior occurred during parenting discussions in which the teen mother felt incompetent or lacked control over the environment for herself or her child. Another coach shared how a nutrition session with a 30-year-old mother with two children caused greater irritation and stress when “it became obvious that the mother had hardly any food in the house to feed the children breakfast.”

However, all the coaches felt that attentive human contact providing validation of the self and of being a good mother, providing opportunities for genuine communication with another person, and allowing mothers to express ideas were anchors for engagement in the parenting sessions. As one coach stated, “... just being able to relate to their situation and “basically how they’re feeling that day” increased the mother’s involvement with program materials. Coaches also observed that trust was facilitated for all nine mothers through video-taping of the mother and child interactions at the end of the parenting sessions, “... watching themselves ... and the interactions with their babies ... they really enjoy that portion of the session….”

Need for a committed coach relationship.

It was observed that building relationships with these mothers occurred over time and with the coaches’ ability to truly care about the mother and her child. This required coaches to meet the mother “where she is” physically, emotionally, and mentally, and to make her feel valued during all interactions and interventions. One coach expressed this as: “My heart opened to them immediately... their desire to have their children’s lives be better than theirs and to get the things they needed is very genuine, very heartfelt... I care about them.”

However, such relationships were not easily accomplished because coaches often felt burdened by the emotional energy and the time commitment required to maintain and support them. Coaches felt powerless to know how to help these mothers: “It even feels to me when I go to these homes like that hole is so deep I just don’t even know how to get out. I mean I even feel that.” The coach stated that a particular mother “needs me and seeks me out more than any of the others. I feel like if I don’t show up at her house that week she would be worse off….”

Coaches also felt that they could better validate the mother’s lived experiences if the mothers could identify with the coach in some way, for example age, race, history of childbearing, or other experiences. As one coach who had been a single mother stated,

... I just know what it feels like to be going from this relative’s house to that relative’s house trying to handle work and school. I feel that they look at that as wow, okay, she can identify with me and she knows she’s not just somebody ... with this project or this research that’s just here to probe.

Discussion

The ability of mothers to engage in this program was influenced by factors that are often not fully understood by those involved in home visitation programs. Public health nurses already have extensive experiences in providing maternal/infant health care and parenting education to vulnerable families in home visitation programs. To enhance this leadership role, it is important that nurses understand both the psychological and the contextual factors that influence the ability to engage. Home visitation coaches in this study demonstrated a continuous process of engagement in which they supported mothers to explore and discover self-care strategies and articulate ways to navigate life struggles. Over time, a foundation of trust and caring was built that enhanced these relationships and program engagement with these mothers.

Falk-Rafael (2000), using Watson’s theory of human caring, supports a holistic approach that recognizes the interconnectedness of both nurse to patient and patient to community relationships. Our study demonstrates that public health nurses who aspire to foster program engagement need to understand both the specific needs of the mother-infant dyad and the way in which the mother operates within her community to gain support, promote self-empowerment, and navigate critical points of life transitions.

This study also supports the findings of other studies in explaining why these women might be difficult to engage in outreach parenting and mental health programs. Previous research, consistent with our findings, cited the fact that the use of mental health services by African American women is shaped by life experiences and cultural values/beliefs invisible to most health practitioners (Waite & Killian, 2007), fear of being labeled as an unfit mother with the potential to lose custody of their children (Anderson et al., 2006), fear of the system due to a prior history of substance abuse or similar issues (Wager et al., 2004), and difficult life circumstances (Drummond, Letourneau, Neufeld, Steward, & Weir, 2008). While all the mothers in this study verbalized a need to be good parents and give their children better lives than their own, all were living in extreme poverty and lacked the emotional and financial support to shield them from the numerous personal and environmental stressors in their lives. Coaches also observed a significant level of depressive symptomatology in these women and noted that the women did not want to seek treatment.

SmithBattle’s (2003) research demonstrated how expert public health nurses who have the ability to alter interventions based on what they see and hear can redefine care strategies to meet the developmental and parenting needs of teen mothers. Although the results of this study are limited to coaches’ perceptions and experiences of engagement in program interventions of selected mothers from one site of a multisite intervention study, the findings strongly suggest that practitioners who are prepared to enter into a genuine and trusting relationship with these mothers will be more likely to engage at-risk women (Kneipp, Lutz, & Means, 2009). Also, tailored interventions must be based on the woman’s priorities and life experiences while also understanding how the mother perceives the world. The findings, when coupled with previous research, provide a deeper understanding of both health professionals’ experiences and the multiple issues surrounding these mother’s lives.

While this research identified commonalities across mothers’ levels of engagement, the authors acknowledge that looking at both teen mothers and older mothers who are perceived to be at the highest risk for abuse and neglect in the same study can be problematic due to differing developmental needs and life experiences. Therefore, it is important to keep in mind that this research may not have identified the specifics of these women’s lives clearly enough to illustrate their varied and multiple needs.

In conclusion, any intervention must incorporate the voices and worldviews of the participants that a particular program is to serve. This study showed that vulnerable mothers’ levels of engagement can be mediated by professionals who are sensitive to the individualized factors influencing the mothers’ lives and decisions. It will be essential in future research and program design to directly hear from mothers about their experiences of parenting, about being involved in a comprehensive intervention program, and what has and has not been helpful. Programs must continually be evaluated for the appropriateness and relevance of interventions and effectiveness in meeting the multifaceted needs of vulnerable families.