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Jane Leer  
Zoelene Hill  
Imari Z. Smith  
Karen Carmody  
Lisa A. Gennetian  

Studying Context, Interrogating Structural Discrimination to Improve the Reach and Equitable Delivery of Universal Home Visiting Models

Jane Leer, Duke University

Zoelene Hill, New York Academy of Medicine

Imari Z. Smith, Duke University

Karen Carmody, Director of Early Childhood Prevention Programs, Center For Child and Family Health; Assistant Professor, Duke University

Lisa A. Gennetian, Pritzker Professor of Early Learning Policy Studies, Duke University

A growing number of cities, counties, and states across the US now offer universal models of home visit services to all families of young children. Unlike the small-scale, targeted studies that have been the focus of most of the home visit research to date, universal models have the potential to achieve population level impact because they are offered to all eligible families. However, achieving population-level impact requires near universal participation, which is a major challenge. As programs scale up, participation often declines, and the factors that explain what drives engagement are not well understood.

Our research team sought a State and Local Policy Work Grant from SPSSI to address this policy relevant research gap. We aim to better understand family engagement in universal models of home visit services, with a focus on how the racialized context within which home visits operate may impact engagement. Since December 2021, we have been conducting interviews and focus groups with Black parents in Durham, North Carolina, where home visits are intended to be universal but in practice reach less than 75% of Black families (compared to 92% of Latinx and White families). These qualitative data have revealed how experiences of discrimination shape engagement in home visits and highlighted the critical role of local networks of care that extend beyond formal service providers. Parents described how the quality of medical care they received when giving birth influenced their decision to participate in home visits, especially when home visits were framed as an “extension of the care received in the hospital.” Parents also emphasized the importance of trusted local networks and services provided by people they can feel safe with; and others described feelings of isolation and a desire to be more connected to services like home visits, had they been made aware of such programs during the pre- and post- natal period. Based on these findings, we developed a nation-wide survey experiment to examine how experiences of discrimination, home visit framing (e.g., “new baby wellness visit,” versus “nurse home visit”), and social networks influence decisions to engage in home visits across racial-ethnic groups in the US.

Our research process has evolved along the way, and we have encountered several challenges—ranging from how to recruit community participants in the middle of a pandemic, to how to equitably engage with community partners. I look forward to discussing the strengths and challenges of applied policy work in Puerto Rico at the SPSSI Summer Conference!

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