In Focus

Findings from a Client Engagement and Attrition Study: Lessons Learned, Implications for Practice

A mom and her young daughter at Lake Worth West BRIDGES, one of 10 neighborhood gathering places in Palm Beach County that provide welcoming and fun opportunities for families to learn, share news, and build life-long relationships.

The Project. Like many service providers, the Children’s Services Council of Palm Beach County (CSC) has encountered challenges with engaging and retaining participants in its network of services for women and children, known as the Healthy Beginnings System of Care (HB System). The HB System connects pregnant women and families with young children to a comprehensive set of programs and services with the goals of promoting healthy births, reducing child abuse and neglect, and increasing school readiness. Through a highly coordinated, multi-stakeholder process, the HB System identifies families at risk for poor outcomes, assesses their strengths and needs, and connects them with the most appropriate programs and services in the HB System.

Prompted by data that showed too many eligible pregnant women and families declining or dropping out of HB services, the CSC commissioned Metis Associates to conduct a survey of disengaged families. The study sought to understand their reasons for drop-off and to identify recommendations for system improvement through a telephone survey of 534 women. The survey addressed respondents’ motivations for consenting to be contacted by HB System staff or enrolling in HB programs, knowledge of HB and their experiences with the system, reasons for drop-off, levels of satisfaction with and perceived value of HB services, unmet needs, and suggestions for how the HB System might better reach and retain individuals.

The Findings. Several key findings emerged from the survey. Among the most common themes was a lack of understanding among pregnant women and mothers about the HB System and its processes, especially among early droppers (i.e., those who were unable to be contacted or who did not complete the assessment). Despite the HB System’s highly systematic process, there were three main knowledge gaps that influenced drop-off:

  • A substantial proportion of respondents were unaware that they had consented to contact.
  • More than half of the unreachable respondents were unaware that an HB caseworker had been trying to contact them.
  • Some respondents lacked knowledge about the HB System.

Consistent with the literature, the results showed that among respondents aware of their drop-off, a lack of time was the most common barrier to engaging with or staying in the HB System (55%). About one-fifth (22%) of these women explained that work or school were competing priorities for their time.

The study results underscored the importance of culturally appropriate approaches to service delivery, as there were some pronounced differences in the reasons for system drop-off between minority and non-minority respondents. The largest differences were typically between Hispanic/Latino and White women. Hispanic/Latino respondents were more likely to shy away from services, mostly because of poor understanding of the system, not wanting someone coming to their home, being afraid or nervous, or worrying about what others might think of their participation. White respondents, on the other hand, were more likely to feel that they would not benefit from services. Compared to Hispanic respondents, White women were more likely to report that they did not need HB services, they had benefitted from services and no longer needed them, or that HB services were not helpful. Trends in reasons cited by Black women sometimes mirrored those of White women and sometimes mirrored those of Hispanic/Latino women.

Importantly, the reasons for drop-off were generally not related to a lack of satisfaction with the HB System—in fact, most respondents were satisfied with the staff and services and indicated that they would recommend the HB System to others.

Lessons Learned. While the study used a survey sample designed to resemble the population of Palm Beach County families discharged from the HB System, we believe that several key takeaways can be useful and applicable to the work of other agencies and organizations, such as other children’s services councils in Florida and systems of care nationally:

Clearly communicate system processes and benefits to families. In a system of care, connecting families to appropriate interventions can be a multi-step process in which families encounter multiple providers who work together to support the community. Since a lack of understanding about HB System processes and programming was a major factor that influenced drop-off, we recommend working with providers to establish clear and consistent communication practices to smooth families’ transitions from one stage in the system of care to the next. Critical information to communicate would include what services are offered, the benefits of services to women and their children, what individuals are agreeing to when they sign consent forms, and next steps to expect (for example, a call from a caseworker, an assessment, a call from a home visitor). Subsequent follow-up with families may be more successful if multiple types of contact information are collected and utilized, including cell phone numbers, alternative phone numbers, email addresses, and links to Facebook or other social media accounts.

Tailor outreach and engagement to family strengths, needs, and preferences. Just as practitioners strive to provide individualized services to families, they can incorporate customized and client-centered outreach and retention strategies when working with families. In addition, engaging families in discussions about program expectations, perceived needs and assets, and anticipated barriers and facilitators to participation could be used to inform which services are provided to the family, how they are provided, and how to help families overcome anticipated barriers.

Provide greater flexibility in programming, including light-touch options. Offering services at times or in formats that are more conducive to families’ schedules and preferences may help to engage families for whom time is a barrier to participation. For some families who are too busy to commit to or remain in a program, it may be beneficial to offer them temporary “light-touch” options so that they remain connected and willing to join more intensive services when they do have the time to participate. For families who do enroll in home visiting or other intensive programs, staff could revisit the client’s program preferences periodically and tailor the program structure—such as the time, location, duration, or frequency of visits—as needed to meet the family’s needs. This may be especially important for retaining families who experience major life changes, such as the birth of a child, returning to work, or getting a new job. Although practitioners strive to implement programs with fidelity, which often includes a prescribed dosage or schedule of services, it may be worth considering how providers might support families in a more flexible way to encourage continued participation.

Promote increased multi-cultural understanding among all providers who encounter the family. In a system of care like HB, this would include providers at every step in the HB System experience, from the entry point provider who introduces the HB System to the client, to the entry agency caseworker, to the home visitor. Especially in diverse communities like Palm Beach County, it is important for providers to be well equipped to authentically engage and build trusting relationships with families of all backgrounds, taking the time to understand and work with families’ unique strengths, needs, experiences, and perceptions.

Implications for the Field. Each community is unique. In thinking about your community, consider questions that emanate from this study’s findings, such as:

  • How do specific system or program processes in the community hinder or promote family engagement?
  • What practices do providers in the community employ to understand and address families’ barriers to participation?
  • How can the community tailor or customize current programming to address families’ strengths, needs, and barriers to participation?
  • Are providers in the community well equipped to serve a diverse population? Do different subgroups of clients feel equally comfortable, respected, and heard?

Furthermore, we recommend systematically studying reasons for attrition for your particular client population using both administrative data and qualitative methods. Administrative data can reveal patterns of disengagement (e.g., clients may be more likely to drop off at certain points in a system of care or from certain types of services, or certain subgroups of clients may be more likely to disengage than others), and qualitative data can shed light on the reasons behind and strategies for reducing disengagement. While our findings generally mirrored the literature, it was important to study client engagement and attrition within the particular context of CSC HB System to identify the most salient issues for these particular families and strategize about how best to address them. Applying similar primary data collection methods in other communities could ultimately help to improve program participation and retention, thus increasing the number of families who benefit from services.

The full issue brief is available here. The CSC HB work is led by Metis Managing Senior Associate Donna Wilkens. Please reach out to Donna at with comments or questions.