care, health and development Child: Original Article bs_bs_banner
doi:10.1111/cch.12091
Experiences of housing insecurity among participants of an early childhood intervention programme H. Turnbull, K. Loptson and N. Muhajarine Saskatchewan Population Health and Evaluation Research Unit, University of Saskatchewan, Saskatoon, SK, Canada Accepted for publication 16 June 2013
Abstract
Keywords child development, complex needs, early intervention, home visitation, housing, programme retention Correspondence: Hayley Turnbull, Saskatchewan Population Health and Evaluation Research Unit, University of Saskatchewan, 501-121 Research Drive, Saskatoon, SK, Canada S7N 1K2. E-mail: [email protected]
Objectives To understand the barriers to programme success among high-needs families in KidsFirst, an early childhood intervention programme. Methods Using a qualitative approach, a secondary analysis was performed using the qualitative data set (111 interviews and focus groups with 242 participants) from the KidsFirst programme evaluation. Data analysis was conducted to identify common experiences among high-needs families in the programme and barriers to programme success. Results Participants identified housing insecurity as a major factor impeding programme delivery, retention and successful outcomes. Housing insecurity was shown to create or exacerbate ongoing crises among high-needs families. Only after housing insecurity was addressed were families able to benefit from the KidsFirst programme. Conclusions The findings of this research suggest that until baseline material security is established for high-needs families, early childhood development (ECD) interventions will be limited in meeting their objectives. In order to have the most effect for those living in poverty, helping families to achieve basic material security, including secure housing, should precede the targeted provision of psychosocial ECD supports. This finding has implications for how ECD intervention programmes could more effectively be designed and whom they should target.
Introduction Early childhood development (ECD) is an influential determinant of lifelong health (Keating & Hertzman 1999; Irwin et al. 2007; National Scientific Council on the Developing Child 2010). As such, numerous interventions have been developed to ensure that children get a healthy start (Hertzman 1998; McCain & Mustard 1999; Olds et al. 2007). In the Canadian province of Saskatchewan, KidsFirst is an ECD intervention programme, serving vulnerable families with children from prenatal to age five, in nine geographically targeted areas. KidsFirst is delivered primarily through home visitation, carried out by para-professionals who are trained and supervised by professional home visiting supervisors (Gates et al. 2010). Participa-
© 2013 John Wiley & Sons Ltd
tion is voluntary and programme intake is done primarily through in-hospital birth screenings and referrals (Muhajarine et al. 2007). By identifying and providing support to vulnerable families with young children KidsFirst ultimately aims to reduce disparities in maternal and child health. Many ECD interventions including KidsFirst aim to improve the outcomes of children living in poverty by enriching their psychosocial environments through home visitation programmes. A recent systematic review looking at home visiting ECD interventions internationally, demonstrated mixed results on the impact of such interventions (Peacock et al. 2013). Additionally studies have found that the effectiveness of ECD interventions delivered through home visitation by paraprofessionals varies across programmes and within programmes
435
436 H. Turnbull et al.
(Gomby 2005; Staerkel & Spieker 2006; Harding et al. 2007). Most home visitation intervention programmes have high percentages of families who either refuse to participate or if they do, leave prematurely (approximately 40% and 50% respectively). The dropout rates among high-risk families are even higher, above 50% for the highest risk families (Gates et al. 2010). The home visitation literature shows consistently that although families experiencing multiple risks are the most in need of ECD interventions, they are the least likely to be served by such programmes (Bugental et al. 2002; BakermansKranenburg et al. 2005; Gomby 2005; Klebanov 2005; Niever et al. 2010). Little research has been performed to understand why the families who may need support the most do not benefit from such programmes and to identify specific barriers to programme participation and success. In accordance with previous literature, the KidsFirst programme evaluation found that the extent to which KidsFirst succeeds in meeting its objectives varies according to the level of need of the family; although the programme has brought about improved outcomes in stable and relatively lower risk families, many high-needs families show no improvements or are not being retained for a sufficient length of time (Muhajarine et al. 2010a). ‘High-needs’ refers to a family’s level of need for the multiple services and is determined at the outset of the programme through a systematic and in-depth assessment of a family’s risks (for a descriptive example of a high-needs family see Muhajarine et al. 2010b). High-needs families face a combination of risk factors such as domestic violence, maternal depression/mental illness, substance abuse, developmental challenges, social isolation and extreme parenting stress (Muhajarine et al. 2010b). In light of this finding, and in order to fill the research gap in this area, we sought to understand common experiences of high-needs families that resulted in the limited success of the KidsFirst programme among these families.
Methods In order to better understand the experiences of high-needs families in the KidsFirst programme we utilized the qualitative data collected during the KidsFirst programme evaluation. The KidsFirst programme evaluation was a 3-year study, which took place from 2007 to 2010 and used a multi-stage, mixed methods approach to assess whether the programme achieved its objectives. The evaluation approach has been described in detail previously (for these details see Muhajarine et al. 2007). The main phase of the programme evaluation was comprised of quanti-
© 2013 John Wiley & Sons Ltd, Child: care, health and development, 40, 3, 435–440
Table 1. Interview and focus group participants Interviews
Focus groups
9 Programme manager interviews
10 Staff focus groups consisting of home visitors, home visitor supervisors and support staff 7 Supporting agency focus groups 7 Management committee focus groups 2 Combined supporting agency/ management committee focus groups 1 Early Childhood Development Unit (ECDU) focus group
31 Parent interviews 1 Aboriginal Elder interview 15 Home visitor supervisor interviews 28 Home visitor interviews Total number of interviews: 84 Total number of interview participants: 87
Total number of focus groups: 27 Total number of focus group participants: 155
tative and qualitative research. For a detailed report of the evaluation findings see Muhajarine et al. (2010b). This study involved a secondary survey of the qualitative data collected during the KidsFirst programme evaluation. A qualitative study was chosen in order to capture the depth and dimension of experiences among high-needs families in KidsFirst. A detailed description of the research design, participant recruitment, interview and focus group guides and qualitative data collection is provided in a previous report (Muhajarine et al. 2010b). For this study, we reviewed preexisting data consisting of transcripts from 111 semi-structured interviews and focus groups involving 242 participants (see Table 1). The data set included participants from all levels of the KidsFirst programme including families in the programme, as well as those responsible for delivering and overseeing the programme (i.e. home visitors, home visiting supervisors, programme managers, supporting agency representatives and management committee members). This diversity in participants provided us with a source of triangulation within our sample as we were able to corroborate the findings across different participant groups (Bogdan & Biklen 2006). To protect the anonymity of KidsFirst staff all home visitors, home visiting supervisors and programme managers are quoted as KidsFirst staff in the results section.
Data analysis The transcripts were entered into a database for coding using ATLAS.ti software (Pope et al. 2000). A basic interpretive qualitative approach was taken, focusing on uncovering meaning from the research participants’ perspectives (Merriam 2002). Three trained and experienced qualitative researchers collectively developed a coding list related to a theme that emerged during the primary qualitative study: ‘barriers to programme
Experiences of housing insecurity
success for high-needs families’. When disagreements arose, they were resolved by discussion among the research team until clarity and consensus was reached. This process allowed the researchers to compare emerging codes and settle on a clear descriptor and definition for each code. Throughout the coding process there were ongoing discussions and consultations between the researchers to ensure that coding was consistent. A constant comparative method was applied to continuously compare the experiences and views of participants (Glaser 1965). Data were compared between interviews from the same participant type, between interviews from differing participant types, between sites, and between data collection methods to develop themes. Findings were compared continuously between researchers until consensus on themes was attained among the researchers. We received approval for the project from the University of Saskatchewan Research Ethics Board. As well, ethics authorization was provided by either the Health Region or Education Board at each site.
Results The aim of our study was to understand the common experience of high-needs families that resulted in limited success of the KidsFirst programme for them. Here we present participants’ perspectives on why the impact of KidsFirst was limited in high-needs families. We found that all participant types at the staff and management level identified housing insecurity as an overarching theme that impeded programme retention and success for high-needs families. We present our results by exploring the pathways through which housing impacts programme success: (1) insecure housing is a fundamental crisis for high-needs families; (2) housing insecurity has numerous negative impacts on families; (3) housing insecurity makes it difficult to help and retain families; and (4) when families have secure housing, they can begin to successfully address other issues.
Insecure housing is a fundamental crisis for high-needs families I had a family at one point in time where she was homeless and she was living in the hotel here and she went from a relative to another relative to the hotel and she had no where to live. She had 2 small kids and the whole time you have to deal with what’s most important and what was most important was finding her a home. (KidsFirst staff member 7; Site 5)
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Participant consistently identified housing insecurity as a fundamental issue facing low-income families in the province of Saskatchewan. Unaffordable rents affected the majority of families in the programme. However, high-needs families were the least likely to secure or retain stable housing. In addition, these families were the most transient, the most vulnerable to other crises arising from personal and material insecurity, and the least likely to benefit from the programme. Many KidsFirst families faced the threat of household eviction, overcrowding, rodent and insect infestations, and economic dependence on abusive partners. I mean it wasn’t unusual to go to a home where there was maybe two sisters and their four kids living together or mom and a daughter and three kids or whatever. Now because of housing here we’re going into homes, we’ve been in like a little two bedroom house where there were 18 people. (KidsFirst staff member 2; Site 1) We’re seeing lots of young women in particular sharing housing with other young women with kids; and as soon as you get that kind of overcrowding in housing there are all kinds of things that you see as a result, so increased illness in young children which leads to increased hospitalization rates for young children. (KidsFirst staff member 10; Site 1)
Housing insecurity has numerous negative impacts on families Insecure housing was reported to have a snowball effect, negatively impacting other areas of crisis in the lives of families. Participants stated that mental health and addictions issues, as well as situations of domestic violence, were all made worse by the lack of stable housing. The KidsFirst staff indicated that poor housing negatively affected parenting and relationships. The housing outlook for lots of our families is often very problematic and I think it can contribute to some of the challenges in parenting and even in relationships, and the way we problem solve. It is amazing what having one location that you call home and a fridge that you call yours can do to your security. (KidsFirst staff member 1; Site 5) Other families faced difficulties applying for jobs or trying to access other social services without a phone number or mailing address. Also, food insecurity was exacerbated in families that had no refrigerator in which to store food because they lacked a stable home.
© 2013 John Wiley & Sons Ltd, Child: care, health and development, 40, 3, 435–440
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Housing insecurity makes it difficult to help and retain families Study participants indicated that a lack of stable housing undermined effective programme outcomes and positive parenting. KidsFirst staff noted that it is difficult to deliver programme curriculum without first ensuring that the basic material needs of families are met. Moreover, staff noted that is difficult for parents to concern themselves with ECD programming when there are struggling with crises surrounding housing instability and homelessness. And if you have a family that is struggling with safe affordable housing it would be very difficult to help them with some of the other issues they’re dealing with. That’s the top of their mind, if their basic needs aren’t being met. (Management Committee member 6; Site 7) Although KidsFirst attempted to address all sources of crisis in families without stable housing, home visitors reported being unable to regularly contact their families or to provide them with ongoing and consistent support. Home visitors shared that the families who might have benefitted most from KidsFirst services were the most difficult to reach and that these families often dropped out. Participants suggested that many families left the programme because of their transient lifestyle. Many participants shared how high risk families were very mobile. Without a phone or a stable address, families were very hard to reach, difficult to track and consequently, are often not retained in the programme. Sometimes you really struggle with some of the moms that are very transient. You are constantly running around trying to find them. (KidsFirst staff member 7; Site 4)
When families have secure housing, they can begin to successfully address other issues Participants emphasized that housing is a necessary foundation that families can build on. Once families are adequately housed, they can begin to successfully address other issues in their lives including health issues, parenting practices and food security. When families are in good housing they do better, when they are in substandard housing, overcrowded housing there are always more problems. Hardly ever do families do well when the housing is really substandard so housing would be one area for programme improvement. (KidsFirst staff member 4; Site 5)
© 2013 John Wiley & Sons Ltd, Child: care, health and development, 40, 3, 435–440
To get them into a better housing situation is going to improve their lives, and make things more affordable for them. That’s going to change the way that they see their own environment. It’s going to change how they feel about themselves. (KidsFirst staff member 5; Site 2) Staff members repeatedly noted that once families were housed in adequate and stable housing, they were able to make continual improvement to their lives. Participants shared how families with housing were able to gain employment and access other social services that may have been otherwise out of reach. Once somebody is in housing, it’s the biggest factor to change. Once they have good housing, they want to continue to change, and we’ve seen that within our families; that once we get them in stable, good housing, and it’s clean and they feel good about it, they want to go forward. They want to continue setting goals and meeting goals. (KidsFirst staff member 2; Site 8)
Discussion Through this study we sought to understand the common experience of high-needs families in the KidsFirst programme to determine why the programme demonstrated limited success among these families. Housing insecurity emerged as a common hardship facing high-needs families, which, in turn, prevented them from optimally benefitting from the KidsFirst programme. Given that many high-needs families experience episodic homelessness and are highly transient as a result of difficulty they face in securing a stable home, it is a conundrum to offer them support in the form of home visitation without first helping them secure a stable residence. Mothers with young children, such as the participants of KidsFirst, have a unique experience of homelessness and housing insecurity. For women with children, homelessness and housing insecurity can result in having their children apprehended and removed from their care (Center for Equality Rights in Accommodation 2002; Townson 2005). Woman facing housing instability therefore may be less likely to be involved with services because they feel they the need to hide their housing instability in order to keep their children. They may also be more likely to remain in domestically violent households because there are no other housing options (Delaney & Kesten 2010; Jones et al. 2012). Furthermore housing insecurity is associated with poor health, lower weight and developmental risk among young children (Cutts et al. 2011). Programme initiation, retention and delivery were impeded in families facing housing insecurity. This finding supports a conclusion drawn by
Experiences of housing insecurity
Staerkel and Spieker (2006) who also found that housing insecurity prevented families from participating in and benefitting from home visiting ECD intervention. An extensive body of research has documented the detrimental impact of material deprivation on ECD (for example, see Holmes and Kiernan 2013). Besides the psychological stress of being insecurely housed, those experiencing extreme housing stress are often unable to meet their other essential needs (Rauh et al. 2008). As echoed by participants in this study, housing is the cornerstone of a healthy life for families. Addressing housing instability is a necessary foundation for families to begin addressing other needs. Getting basic government issued personal identification in order to access medical care and other social services is very difficult without a fixed address. Additionally, addressing mental health issues, buying and storing food, obtaining education and employment and focusing on parenting and child development are nearly impossible without a stable and affordable home. Many ECD interventions aim to improve the outcomes of children living in poverty by enriching their psychosocial environments; however, for some families, their basic material needs are not being met, and they are hard pressed to participate in psychosocial and educational interventions Although the finding that housing insecurity acts as a barrier to the success of a home visitation programme is not surprising, little research has looked directly at the role of housing insecurity as a primary barrier to the success of ECD intervention programmes with the most vulnerably families. The fact that housing insecurity is such a widely identified problem indicates that resources might be better allocated in attempts to support high-needs families. The issue of housing availability and affordability is complex and cannot simply be addressed by one programme. However, helping families to achieve basic material security should precede, or coincide with, the targeted provision of psychosocial ECD supports in order to reach, retain and have the most effect for families living in poverty. More importantly, reducing material depravity would improve the living environment and health of families with young children and reduce disparities in maternal and child health which, in and of itself, may reduce the need for ECD interventions like KidsFirst.
Limitation As previously discussed high-needs families were the least likely to be retained in the programme. Further more participants were required to have been KidsFirst clients for a minimum of 6 months prior to the interview. Consequentially the families that met the inclusion criteria were predominantly classified as lower
439
and medium needs. For this reason we were heavily reliant on information provided by staff and management regarding the reasons why high-needs families continue to struggle despite the support of KidsFirst. Although our reliance on staff, supervisors and managers for this information was a limitation, housing was consistently identified as a barrier to programme success in interviews and focus groups at every KidsFirst site and across other participant types. Future research should include the perspectives of high-needs families who are not retained in the programme.
Key messages • The effectiveness of ECD interventions delivered through home visitation by paraprofessionals varies across programmes and within programmes. • Little research has been performed to understand why some families do not benefit from such programmes and to understand the barriers to programme participation and success. • Participants identified housing insecurity as a major factor impeding programme delivery, retention and successful outcomes. • In order to have the most effect for vulnerable families living in poverty, helping families to achieve basic material security should precede the targeted provision of psychosocial ECD supports. • Our findings have implications for how ECD intervention programmes could more effectively be designed and whom they should target.
Conflict of interest None to declare.
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Center for Equality Rights in Accommodation (2002) Women and Housing in Canada: Barriers to Equality. Available at: http:// www.equalityrights.org/cera/docs/CERAWomenHous.htm (last accessed 30 April 2011). Cutts, D. B., Meyers, A. F., Black, M. M., Casey, P. H., Chilton, M., Cook, J. T., Geppert, J., Ettinger de Cuba, S., Heeren, T., Coleman, S., Rose-Jacobs, R. & Frank, D. A. (2011) US housing insecurity and the health of very young children. American Journal of Public Health, 101, 1508–1514. Delaney, D. & Kesten, S. (2010) Saskatchewan’s Housing Crisis: Addressing the Needs of Women and Children Who Have Experienced Violence. Provincial Association of transition houses and services Saskatchewan. Available at: http:// abusehelplines.org/wp-content/uploads/2011/04/ PATHS-Report-Saskatchewans-Housing-Crisis.pdf (last accessed on 26 July 2013). Gates, R., Nickel, D., Muhajarine, M. & the Evaluation Research Team (2010) The Effectiveness of Home Visitation Interventions Similar to KidsFirst, Saskatchewan: A Focused Literature Review. Saskatchewan Population Health and Evaluation Research Unit, Saskatoon. Available at: http://kidskan.ca/wp-content/uploads/2013/05/ 3a-Home-Visiting-Lit-Review-KidsFirst-Evaluation-2009.pdf (last accessed 26 July 2013). Glaser, B. (1965) The constant comparative method of qualitative analysis. Social Problems, 12, 436–445. Gomby, D. S. (2005) Home visitation in 2005: Outcomes for children and parents: Invest in Kids Working Paper No. 7. Committee for Economic Development. Invest in Kids Working Group. Harding, K., Galano, J., Martin, J., Huntington, L. & Schellenback, C. J. (2007) Healthy Families America effectiveness: a comprehensive review of outcomes. Journal of Prevention and Intervention in the Community, 34, 149–179. Hertzman, C. (1998) The case for child development as a determinant of health. Canadian Journal of Public Health, 89, 14–19. Holmes, J. & Kiernan, K. (2013) Persistent poverty and children’s development in the early years of childhood. Policy & Politics, 41, 19–42. Irwin, L. G., Siddiqi, A. & Hertzman, C. (2007) Early Childhood Development: A Powerful Equalizer. A Final Report for the World Health Organization’s Commission on Social Determinants of Health. Available at: http://www.who.int/social_determinants/ resources/ecd_kn_report_07_2007.pdf (last accessed 26 July 2013). Jones, M. E., Shier, M. L. & Graham, J. R. (2012) Intimate relationships as routes into and out of homelessness: insights from a Canadian city. Journal of Social Policy, 41, 101–117. Keating, D. P. & Hertzman, C. (1999) Developmental Health and the Wealth of Nations. Social, Biological, and Educational Dynamics. Guilford Press, New York, USA. Klebanov, P. K. (2005) Evaluating Early Childhood Intervention Programs: Comments on Kitzman, Knitzer, and Lipman and Boyle. National Center for Children and Families Teachers College,
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Columbia University. Available at: http://www.enfantencyclopedie.com/Pages/PDF/KlebanovANGxp.pdf (last accessed 25 November 2010). McCain, N. & Mustard, F. (1999) Reversing the real brain drain: early years study. Ontario Children’s Secretariat. Merriam, S. (2002) Introduction to Qualitative Research. Jossey-Bass, San Francisco, USA. Muhajarine, N., Glacken, J., Cammer, A. & Green, K. (2007) KidsFirst Program Evaluation-Phase 1: Evaluation Framework. Saskatoon: Saskatchewan Population Health and Evaluation Research Unit. Available at: http://www.education.gov.sk.ca/adx/aspx/ adxGetMedia.aspx?DocID=182,136,107,81,1,Documents &MediaID=4761&Filename=KidsFirst+Evaluation+Framework +July+31+2007+Final.pdf (last accessed 26 July 2013). Muhajarine, N., Nickel, D., Shan, H. & the Evaluation Research Team (2010a) Saskatchewan KidsFirst Evaluation: Summary of Findings and Recommendations. Saskatoon: Saskatchewan Population Health and Evaluation Research Unit. Available at: http://kidskan.ca/ 2010/10/15/kidsfirst-evaluation-summary-of-findings-and -recommendations-2010/ (last accessed 26 July 2013). Muhajarine, N., Loptson, K., Shan, H., Turnbull, H., Premji, S., Leggett, T., McMullin, K. & the Evaluation Research Team (2010b) KidsFirst Program Evaluation: Report of the Qualitative Study. Saskatoon: Saskatchewan Population Health and Evaluation Research Unit. Available at: http://kidskan.ca/2010/10/15/ kidsfirst-evaluation-report-of-the-qualitative-study-2010/ (last accessed 26 July 2013). National Scientific Council on the Developing Child (2010) Early experiences can alter gene expression and affect long-term development: Working paper no. 10. Availalble at: http:// developingchild.harvard.edu/resources/reports_and_working _papers/working_papers/wp10/ (last accessed 26 July 2013). Niever, M. A., Van Egeren, L. A. & Pollard, S. (2010) A meta analysis of home visiting programs: moderators of improvements in maternal behaviours. Infant Mental Health Journal, 31, 499–520. Olds, D. L., Sadler, L. & Kitzman, H. (2007) Programs for parents of infants and toddlers: recent evidence from randomized trials. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 48, 355–391. Peacock, S., Konrad, S., Watson, E., Nickel, D. & Muhajarine, N. (2013) Effectiveness of home visiting programs on child outcomes: a systematic review. BMC Public Health, 13, 1–14. Pope, C., Ziebland, S. & Mays, N. (2000) Qualitative research in health care: analyzing qualitative data. British Medical Journal, 320, 114–116. Rauh, V., Landrigan, P. J. & Claudio, L. (2008) Housing and health: intersections of poverty and environmental exposures. Annals of the New York Academy of Sciences, 1136, 276–288. Staerkel, F. J. & Spieker, S. (2006) Unstable housing – a significant challenge for home visiting programs: an early head start case example. Journal of Family Social Work, 10, 61–76. Townson, M. (2005) Poverty issues for Canadian women: background paper. Status of Women Canada.
doi:10.1111/cch.12091
Experiences of housing insecurity among participants of an early childhood intervention programme H. Turnbull, K. Loptson and N. Muhajarine Saskatchewan Population Health and Evaluation Research Unit, University of Saskatchewan, Saskatoon, SK, Canada Accepted for publication 16 June 2013
Abstract
Keywords child development, complex needs, early intervention, home visitation, housing, programme retention Correspondence: Hayley Turnbull, Saskatchewan Population Health and Evaluation Research Unit, University of Saskatchewan, 501-121 Research Drive, Saskatoon, SK, Canada S7N 1K2. E-mail: [email protected]
Objectives To understand the barriers to programme success among high-needs families in KidsFirst, an early childhood intervention programme. Methods Using a qualitative approach, a secondary analysis was performed using the qualitative data set (111 interviews and focus groups with 242 participants) from the KidsFirst programme evaluation. Data analysis was conducted to identify common experiences among high-needs families in the programme and barriers to programme success. Results Participants identified housing insecurity as a major factor impeding programme delivery, retention and successful outcomes. Housing insecurity was shown to create or exacerbate ongoing crises among high-needs families. Only after housing insecurity was addressed were families able to benefit from the KidsFirst programme. Conclusions The findings of this research suggest that until baseline material security is established for high-needs families, early childhood development (ECD) interventions will be limited in meeting their objectives. In order to have the most effect for those living in poverty, helping families to achieve basic material security, including secure housing, should precede the targeted provision of psychosocial ECD supports. This finding has implications for how ECD intervention programmes could more effectively be designed and whom they should target.
Introduction Early childhood development (ECD) is an influential determinant of lifelong health (Keating & Hertzman 1999; Irwin et al. 2007; National Scientific Council on the Developing Child 2010). As such, numerous interventions have been developed to ensure that children get a healthy start (Hertzman 1998; McCain & Mustard 1999; Olds et al. 2007). In the Canadian province of Saskatchewan, KidsFirst is an ECD intervention programme, serving vulnerable families with children from prenatal to age five, in nine geographically targeted areas. KidsFirst is delivered primarily through home visitation, carried out by para-professionals who are trained and supervised by professional home visiting supervisors (Gates et al. 2010). Participa-
© 2013 John Wiley & Sons Ltd
tion is voluntary and programme intake is done primarily through in-hospital birth screenings and referrals (Muhajarine et al. 2007). By identifying and providing support to vulnerable families with young children KidsFirst ultimately aims to reduce disparities in maternal and child health. Many ECD interventions including KidsFirst aim to improve the outcomes of children living in poverty by enriching their psychosocial environments through home visitation programmes. A recent systematic review looking at home visiting ECD interventions internationally, demonstrated mixed results on the impact of such interventions (Peacock et al. 2013). Additionally studies have found that the effectiveness of ECD interventions delivered through home visitation by paraprofessionals varies across programmes and within programmes
435
436 H. Turnbull et al.
(Gomby 2005; Staerkel & Spieker 2006; Harding et al. 2007). Most home visitation intervention programmes have high percentages of families who either refuse to participate or if they do, leave prematurely (approximately 40% and 50% respectively). The dropout rates among high-risk families are even higher, above 50% for the highest risk families (Gates et al. 2010). The home visitation literature shows consistently that although families experiencing multiple risks are the most in need of ECD interventions, they are the least likely to be served by such programmes (Bugental et al. 2002; BakermansKranenburg et al. 2005; Gomby 2005; Klebanov 2005; Niever et al. 2010). Little research has been performed to understand why the families who may need support the most do not benefit from such programmes and to identify specific barriers to programme participation and success. In accordance with previous literature, the KidsFirst programme evaluation found that the extent to which KidsFirst succeeds in meeting its objectives varies according to the level of need of the family; although the programme has brought about improved outcomes in stable and relatively lower risk families, many high-needs families show no improvements or are not being retained for a sufficient length of time (Muhajarine et al. 2010a). ‘High-needs’ refers to a family’s level of need for the multiple services and is determined at the outset of the programme through a systematic and in-depth assessment of a family’s risks (for a descriptive example of a high-needs family see Muhajarine et al. 2010b). High-needs families face a combination of risk factors such as domestic violence, maternal depression/mental illness, substance abuse, developmental challenges, social isolation and extreme parenting stress (Muhajarine et al. 2010b). In light of this finding, and in order to fill the research gap in this area, we sought to understand common experiences of high-needs families that resulted in the limited success of the KidsFirst programme among these families.
Methods In order to better understand the experiences of high-needs families in the KidsFirst programme we utilized the qualitative data collected during the KidsFirst programme evaluation. The KidsFirst programme evaluation was a 3-year study, which took place from 2007 to 2010 and used a multi-stage, mixed methods approach to assess whether the programme achieved its objectives. The evaluation approach has been described in detail previously (for these details see Muhajarine et al. 2007). The main phase of the programme evaluation was comprised of quanti-
© 2013 John Wiley & Sons Ltd, Child: care, health and development, 40, 3, 435–440
Table 1. Interview and focus group participants Interviews
Focus groups
9 Programme manager interviews
10 Staff focus groups consisting of home visitors, home visitor supervisors and support staff 7 Supporting agency focus groups 7 Management committee focus groups 2 Combined supporting agency/ management committee focus groups 1 Early Childhood Development Unit (ECDU) focus group
31 Parent interviews 1 Aboriginal Elder interview 15 Home visitor supervisor interviews 28 Home visitor interviews Total number of interviews: 84 Total number of interview participants: 87
Total number of focus groups: 27 Total number of focus group participants: 155
tative and qualitative research. For a detailed report of the evaluation findings see Muhajarine et al. (2010b). This study involved a secondary survey of the qualitative data collected during the KidsFirst programme evaluation. A qualitative study was chosen in order to capture the depth and dimension of experiences among high-needs families in KidsFirst. A detailed description of the research design, participant recruitment, interview and focus group guides and qualitative data collection is provided in a previous report (Muhajarine et al. 2010b). For this study, we reviewed preexisting data consisting of transcripts from 111 semi-structured interviews and focus groups involving 242 participants (see Table 1). The data set included participants from all levels of the KidsFirst programme including families in the programme, as well as those responsible for delivering and overseeing the programme (i.e. home visitors, home visiting supervisors, programme managers, supporting agency representatives and management committee members). This diversity in participants provided us with a source of triangulation within our sample as we were able to corroborate the findings across different participant groups (Bogdan & Biklen 2006). To protect the anonymity of KidsFirst staff all home visitors, home visiting supervisors and programme managers are quoted as KidsFirst staff in the results section.
Data analysis The transcripts were entered into a database for coding using ATLAS.ti software (Pope et al. 2000). A basic interpretive qualitative approach was taken, focusing on uncovering meaning from the research participants’ perspectives (Merriam 2002). Three trained and experienced qualitative researchers collectively developed a coding list related to a theme that emerged during the primary qualitative study: ‘barriers to programme
Experiences of housing insecurity
success for high-needs families’. When disagreements arose, they were resolved by discussion among the research team until clarity and consensus was reached. This process allowed the researchers to compare emerging codes and settle on a clear descriptor and definition for each code. Throughout the coding process there were ongoing discussions and consultations between the researchers to ensure that coding was consistent. A constant comparative method was applied to continuously compare the experiences and views of participants (Glaser 1965). Data were compared between interviews from the same participant type, between interviews from differing participant types, between sites, and between data collection methods to develop themes. Findings were compared continuously between researchers until consensus on themes was attained among the researchers. We received approval for the project from the University of Saskatchewan Research Ethics Board. As well, ethics authorization was provided by either the Health Region or Education Board at each site.
Results The aim of our study was to understand the common experience of high-needs families that resulted in limited success of the KidsFirst programme for them. Here we present participants’ perspectives on why the impact of KidsFirst was limited in high-needs families. We found that all participant types at the staff and management level identified housing insecurity as an overarching theme that impeded programme retention and success for high-needs families. We present our results by exploring the pathways through which housing impacts programme success: (1) insecure housing is a fundamental crisis for high-needs families; (2) housing insecurity has numerous negative impacts on families; (3) housing insecurity makes it difficult to help and retain families; and (4) when families have secure housing, they can begin to successfully address other issues.
Insecure housing is a fundamental crisis for high-needs families I had a family at one point in time where she was homeless and she was living in the hotel here and she went from a relative to another relative to the hotel and she had no where to live. She had 2 small kids and the whole time you have to deal with what’s most important and what was most important was finding her a home. (KidsFirst staff member 7; Site 5)
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Participant consistently identified housing insecurity as a fundamental issue facing low-income families in the province of Saskatchewan. Unaffordable rents affected the majority of families in the programme. However, high-needs families were the least likely to secure or retain stable housing. In addition, these families were the most transient, the most vulnerable to other crises arising from personal and material insecurity, and the least likely to benefit from the programme. Many KidsFirst families faced the threat of household eviction, overcrowding, rodent and insect infestations, and economic dependence on abusive partners. I mean it wasn’t unusual to go to a home where there was maybe two sisters and their four kids living together or mom and a daughter and three kids or whatever. Now because of housing here we’re going into homes, we’ve been in like a little two bedroom house where there were 18 people. (KidsFirst staff member 2; Site 1) We’re seeing lots of young women in particular sharing housing with other young women with kids; and as soon as you get that kind of overcrowding in housing there are all kinds of things that you see as a result, so increased illness in young children which leads to increased hospitalization rates for young children. (KidsFirst staff member 10; Site 1)
Housing insecurity has numerous negative impacts on families Insecure housing was reported to have a snowball effect, negatively impacting other areas of crisis in the lives of families. Participants stated that mental health and addictions issues, as well as situations of domestic violence, were all made worse by the lack of stable housing. The KidsFirst staff indicated that poor housing negatively affected parenting and relationships. The housing outlook for lots of our families is often very problematic and I think it can contribute to some of the challenges in parenting and even in relationships, and the way we problem solve. It is amazing what having one location that you call home and a fridge that you call yours can do to your security. (KidsFirst staff member 1; Site 5) Other families faced difficulties applying for jobs or trying to access other social services without a phone number or mailing address. Also, food insecurity was exacerbated in families that had no refrigerator in which to store food because they lacked a stable home.
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Housing insecurity makes it difficult to help and retain families Study participants indicated that a lack of stable housing undermined effective programme outcomes and positive parenting. KidsFirst staff noted that it is difficult to deliver programme curriculum without first ensuring that the basic material needs of families are met. Moreover, staff noted that is difficult for parents to concern themselves with ECD programming when there are struggling with crises surrounding housing instability and homelessness. And if you have a family that is struggling with safe affordable housing it would be very difficult to help them with some of the other issues they’re dealing with. That’s the top of their mind, if their basic needs aren’t being met. (Management Committee member 6; Site 7) Although KidsFirst attempted to address all sources of crisis in families without stable housing, home visitors reported being unable to regularly contact their families or to provide them with ongoing and consistent support. Home visitors shared that the families who might have benefitted most from KidsFirst services were the most difficult to reach and that these families often dropped out. Participants suggested that many families left the programme because of their transient lifestyle. Many participants shared how high risk families were very mobile. Without a phone or a stable address, families were very hard to reach, difficult to track and consequently, are often not retained in the programme. Sometimes you really struggle with some of the moms that are very transient. You are constantly running around trying to find them. (KidsFirst staff member 7; Site 4)
When families have secure housing, they can begin to successfully address other issues Participants emphasized that housing is a necessary foundation that families can build on. Once families are adequately housed, they can begin to successfully address other issues in their lives including health issues, parenting practices and food security. When families are in good housing they do better, when they are in substandard housing, overcrowded housing there are always more problems. Hardly ever do families do well when the housing is really substandard so housing would be one area for programme improvement. (KidsFirst staff member 4; Site 5)
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To get them into a better housing situation is going to improve their lives, and make things more affordable for them. That’s going to change the way that they see their own environment. It’s going to change how they feel about themselves. (KidsFirst staff member 5; Site 2) Staff members repeatedly noted that once families were housed in adequate and stable housing, they were able to make continual improvement to their lives. Participants shared how families with housing were able to gain employment and access other social services that may have been otherwise out of reach. Once somebody is in housing, it’s the biggest factor to change. Once they have good housing, they want to continue to change, and we’ve seen that within our families; that once we get them in stable, good housing, and it’s clean and they feel good about it, they want to go forward. They want to continue setting goals and meeting goals. (KidsFirst staff member 2; Site 8)
Discussion Through this study we sought to understand the common experience of high-needs families in the KidsFirst programme to determine why the programme demonstrated limited success among these families. Housing insecurity emerged as a common hardship facing high-needs families, which, in turn, prevented them from optimally benefitting from the KidsFirst programme. Given that many high-needs families experience episodic homelessness and are highly transient as a result of difficulty they face in securing a stable home, it is a conundrum to offer them support in the form of home visitation without first helping them secure a stable residence. Mothers with young children, such as the participants of KidsFirst, have a unique experience of homelessness and housing insecurity. For women with children, homelessness and housing insecurity can result in having their children apprehended and removed from their care (Center for Equality Rights in Accommodation 2002; Townson 2005). Woman facing housing instability therefore may be less likely to be involved with services because they feel they the need to hide their housing instability in order to keep their children. They may also be more likely to remain in domestically violent households because there are no other housing options (Delaney & Kesten 2010; Jones et al. 2012). Furthermore housing insecurity is associated with poor health, lower weight and developmental risk among young children (Cutts et al. 2011). Programme initiation, retention and delivery were impeded in families facing housing insecurity. This finding supports a conclusion drawn by
Experiences of housing insecurity
Staerkel and Spieker (2006) who also found that housing insecurity prevented families from participating in and benefitting from home visiting ECD intervention. An extensive body of research has documented the detrimental impact of material deprivation on ECD (for example, see Holmes and Kiernan 2013). Besides the psychological stress of being insecurely housed, those experiencing extreme housing stress are often unable to meet their other essential needs (Rauh et al. 2008). As echoed by participants in this study, housing is the cornerstone of a healthy life for families. Addressing housing instability is a necessary foundation for families to begin addressing other needs. Getting basic government issued personal identification in order to access medical care and other social services is very difficult without a fixed address. Additionally, addressing mental health issues, buying and storing food, obtaining education and employment and focusing on parenting and child development are nearly impossible without a stable and affordable home. Many ECD interventions aim to improve the outcomes of children living in poverty by enriching their psychosocial environments; however, for some families, their basic material needs are not being met, and they are hard pressed to participate in psychosocial and educational interventions Although the finding that housing insecurity acts as a barrier to the success of a home visitation programme is not surprising, little research has looked directly at the role of housing insecurity as a primary barrier to the success of ECD intervention programmes with the most vulnerably families. The fact that housing insecurity is such a widely identified problem indicates that resources might be better allocated in attempts to support high-needs families. The issue of housing availability and affordability is complex and cannot simply be addressed by one programme. However, helping families to achieve basic material security should precede, or coincide with, the targeted provision of psychosocial ECD supports in order to reach, retain and have the most effect for families living in poverty. More importantly, reducing material depravity would improve the living environment and health of families with young children and reduce disparities in maternal and child health which, in and of itself, may reduce the need for ECD interventions like KidsFirst.
Limitation As previously discussed high-needs families were the least likely to be retained in the programme. Further more participants were required to have been KidsFirst clients for a minimum of 6 months prior to the interview. Consequentially the families that met the inclusion criteria were predominantly classified as lower
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and medium needs. For this reason we were heavily reliant on information provided by staff and management regarding the reasons why high-needs families continue to struggle despite the support of KidsFirst. Although our reliance on staff, supervisors and managers for this information was a limitation, housing was consistently identified as a barrier to programme success in interviews and focus groups at every KidsFirst site and across other participant types. Future research should include the perspectives of high-needs families who are not retained in the programme.
Key messages • The effectiveness of ECD interventions delivered through home visitation by paraprofessionals varies across programmes and within programmes. • Little research has been performed to understand why some families do not benefit from such programmes and to understand the barriers to programme participation and success. • Participants identified housing insecurity as a major factor impeding programme delivery, retention and successful outcomes. • In order to have the most effect for vulnerable families living in poverty, helping families to achieve basic material security should precede the targeted provision of psychosocial ECD supports. • Our findings have implications for how ECD intervention programmes could more effectively be designed and whom they should target.
Conflict of interest None to declare.
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