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Virtual home visitation: implementation barriers and facilitators

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Virtual home visitation: implementation barriers and facilitators

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Copyright 2023 Jessenia Natallie De Leon
Virtual home visitation: Implementation barriers and facilitators

By
Jessenia Natallie De Leon

A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(SOCIAL WORK)

December 2023

ii
Acknowledgements

To many family and friends, thank you for being my cheerleaders and inspiration to keep
moving forward. Without you, I would not have made it this far. I am eternally grateful for all your
unwavering support and encouragement.

I would like to express my sincere gratitude to my mentors at the University of Southern
California for their invaluable guidance and support throughout my academic journey. Their
motivation, expertise, and dedication have played a crucial role in shaping my research and
future endeavors.

Additionally, I would like to extend my heartfelt thanks to Atlantic Meditation in Long
Beach, CA (special shout out to our beloved three great teachers!) for their profound teachings
and the transformative method that nurtured my mental health and spirit. Their guidance has
enabled me to overcome the limitations that once hindered my personal and academic growth.

I am truly grateful for this experience and feel honored to represent the Latina
community.

TABLE OF CONTENTS
Acknowledgements...................................................................................................................... ii
List of Tables ............................................................................................................................... iii
List of Figures.............................................................................................................................. iv
Abstract ....................................................................................................................................... v
Introduction .................................................................................................................................. 1

Chapter 1: The Problem and Significance.................................................................................... 5
Defining Home Visitation....................................................................................... 5
Defining Virtual Home Visitation............................................................................ 6
Defining Toggling Versus Hybrid........................................................................... 8
Home Visitation and COVID-19 Pandemic........................................................... 9
Rapid Response Virtual Home Visitation (RR VHV)........................................... 11

Chapter 2: Theoretical Frameworks........................................................................................... 15
Kingdon’s Multiple Streams Framework.............................................................. 15
Consolidated Framework for Implementation Research (CFIR)......................... 17
Defining the CFIR.......................................................................................... 17
Updated Framework...................................................................................... 20
CFIR Applicability.......................................................................................... 20
Lack of Research Related to the Implementation of VHV............................. 21
Theory of Burnout............................................................................................... 23
Defining Burnout............................................................................................ 24
Addressing Burnout....................................................................................... 24
Burnout and Implementation......................................................................... 25

Chapter 3: Methodology............................................................................................................. 27
Parent Study Research Design........................................................................... 27
Participants…...................................................................................................... 29
Data…................................................................................................................. 29
Data Analyses..................................................................................................... 30
Focus Groups…............................................................................................ 30
Individual Interviews….................................................................................. 31
Survey Data…............................................................................................... 32
Burnout…................................................................................................ 32
Predictors…............................................................................................. 34
Demographics…….................................................................................. 34
Hierarchical Linear Modeling................................................................... 34

Chapter 4: Results...................................................................................................................... 35
Research Question 1: How Do Policies Play a Role in the Dissemination,
Implementation, and Delivery of VHV?............................................................... 35
Data............................................................................................................... 35
Understanding the Dissemination and Implementation of VHV:
Kingdon’s Multiple Streams Framework........................................................ 36
Problem................................................................................................... 36
Policy....................................................................................................... 38
Political.................................................................................................... 38
Understanding the Implementation and Delivery of VHV: CFIR…………….. 40
Inner Settings.......................................................................................... 40
Outer Settings.......................................................................................... 41
Conclusion..................................................................................................... 44
Research Question 2: What are perceived barriers and facilitators in
delivering/receiving services from provider and caregiver perspectives? .......... 46
Data............................................................................................................... 47
Barriers to VHV Implementation.................................................................... 48
Innovation................................................................................................ 48
Inner Settings.......................................................................................... 49
Individuals................................................................................................ 50
Implementation Process.......................................................................... 52
Conclusion..................................................................................................... 54
Facilitators to VHV Implementation............................................................... 56
Innovation................................................................................................ 56
Inner Settings.......................................................................................... 60
Individuals................................................................................................ 60
Implementation Process.......................................................................... 61
Conclusion..................................................................................................... 65
Research Question 3: Which factors are related to provider well-being
during the rapid implementation VHV?............................................................... 67
Data............................................................................................................... 67
Demographics......................................................................................... 67
Hierarchical Linear Modeling for Well-being................................................ 69

Chapter 5: Discussion................................................................................................................ 74
Limitations........................................................................................................... 77
Implications......................................................................................................... 78
Future Directions................................................................................................. 80

References................................................................................................................................. 82

Appendices................................................................................................................................. 88
Appendix A: Consolidated Framework for Implementation Research................. 89
Appendix B: Comparison Between Original and New CFIR............................... 95
Appendix C: 2022 RR VHV Participant Survey................................................. 109
Appendix D: Rapid Response Virtual Home Visitation Experts
by Experience (Caregiver) Semi- Structured Interview Guide.......................... 119
Appendix E: Rapid Response Virtual Home Visitation
Home Visitor Focus Group Guide..................................................................... 121

iii
List of Tables

Table 1: Hybrid Design Characteristics……………………………………………………………… 28
Table 2: Provider burnout questionnaire…………………………………………………………….. 33
Table 3: Survey Participant Demographics…………………….…………………………………… 68
Table 4: Descriptives and Correlations……………………………………………………………… 70
Table 5: Hierarchical Linear Model Predicting Well-being………………………………………… 71

iv
List of Figures

Figure 1: Kingdon’s Multiple Streams Framework…………………………………………………. 16

Figure 2: Consolidated Framework for Implementation Research……………………………….. 19

v
Abstract

Home visitation (HV) programs are an early intervention strategy where services are
rendered to families in their homes, focusing on addressing challenges including child abuse,
learning delays, and future behavioral issues. Ultimately, HV programs are intended to help
parents in supporting their children and protect vulnerable families from negative outcomes such
as adverse childhood experiences. This dissertation explores the implementation of virtual
home visiting (VHV) programs in response to the COVID-19 pandemic and its impact on
providers and caregivers. Using secondary data from a mixed methods study, this dissertation
aims to understand how policies impact implementation, identify implementation barriers and
facilitators, and examine factors related to provider burnout during rapid response VHV
implementation. Kingdon’s Multiple Streams Framework and the Consolidated Framework for
Implementation Research (CFIR) were applied to understand how policies impacted
dissemination, implementation, and delivery of VHV services throughout the course of the
pandemic. Categorized by CFIR domains (e.g., inner settings), caregiver and provider interview
data were identified challenges and facilitators to VHV implementation. Spanning four of five
CFIR domains, some barriers included limited access to technology and client engagement
while some facilitators included flexibility and accessibility. Using hierarchical linear modeling,
factors associated with less provider burnout included presence of supervisor support along with
the perception of adequate supervisor support and training. Future directions should consider
exploring policies, challenges, facilitators, and provider burnout longitudinally. Results from this
dissertation add to the HV field by applying Dissemination & Implementation concepts during a
wide-scale and rapid adoption of virtual platforms.

1
Introduction
Home visitation (HV) programs involve delivering services, typically by professionals like
social workers or nurses, directly to families within their homes (Traube et al., 2021c). These
programs are primarily a form of early intervention and are designed to address various
outcomes, including reducing low birth weight, preventing child abuse, decreasing reliance on
public assistance, addressing learning delays, and mitigating future behavioral issues (Supplee
& Duggan, 2019; Sweet & Applebaum, 2004). HV programs are flexible, catering to different
types of families (e.g., single teenage mothers), various age groups of children (usually from
birth to age five), and a range of services, including home safety measures (Duggan et al.,
2018).
In 2022, 138,000 parents and children were provided with over 840,000 home visits
through programs funded by the Maternal, Infant, and Early Childhood Home Visiting (MIECHV)
Program. This figure represents 15% of over 465,000 families who are currently eligible for and
needing such services (Health Resources & Service Administration, 2023). The MIECHV
Program is a U.S. federal initiative that funds evidence-based HV programs for vulnerable
families across the states, tribal entities, and territories. MIECHV was established as part of the
Affordable Care Act in 2010 and reauthorized in 2015. It sought to address critical issues
requiring prompt attention such as improving maternal and child health, preventing child
maltreatment, and promoting school readiness (Health Resources & Service Administration,
2023). MIECHV-funded programs largely focused on families who had a high school education
or less and lived at or below the poverty level guidelines. Among the families they served in
2022, 19% had a reported history of child maltreatment, 13% of households reported substance
use, and 9% were teenage mothers (Health Resources & Service Administration, 2023).
Families receiving HV services have benefited greatly from participating in such programs.
2
Specifically, 81% of caregivers were screened for depression within three months of services
delivery, as postpartum depression often impacts child outcomes. Moreover, 70% of children
enrolled in MIECHV programs were on track in receiving well-child visits with a medical
provider. Moreover, 79% families participating in MIECHV-funded HV programs reported
increased reading, story-telling, and singing to their children as proxy for school readiness
(Health Resources & Service Administration, 2023). Given the large number of families in need
of services provided through the HV programs, it is critical that these programs are not only
available and accessible but are also of high-quality.
Many families and individuals around the world experienced extreme difficulties during
the COVID-19 pandemic (the pandemic), with some families at higher risk due to preexisting
challenges (e.g., maternal depression or low income). Furthermore, stay-at-home orders and
social distancing measures resulted in immediate halting of in-person services for these families
further limiting access to HV programs. Policy changes and new funding streams called for
alternative service delivery through virtual platforms. Only a few HV programs have previously
provided services via virtual platforms prior to the pandemic, reaching different types of families
including those of children with disabilities (Hinton et al., 2017) or families who did not qualify for
in-person services due to geographic limitations or preferences (Traube et al., 2020). During the
pandemic, policies made it possible for HV programs to be brought to scale as a rapid response
to service needs. While there were existing resources for HV program delivery, much of the
rapid adaptations and quality delivery relied on provider capacity to implement HV programs
effectively. Whether it is the process of research to practice or policy to practice, innovations of
programs and services rely on providers to deliver these programs and services to their clients.
While burnout among providers within human service fields such as HV is well-studied (e.g.,
secondary trauma, compassion fatigue; Begic et al., 2019), burnout within the context of
3
innovation implementation (e.g., implementing virtual HV) is not much discussed. As such,
promoting the well-being of the provider should be a significant component during the
implementation of new programs. Even within the field of Dissemination and Implementation
(D&I), however, the focus of implementation is on how to support the “delivery” of an innovation
rather than on the “well-being” of providers so that they can commit to high quality delivery. As
such, while implementing innovations, innovation deliverers–in this case, HV providers–must be
supported throughout this learning process as they carry on delivering services as they learn to
adapt. In this dissertation, I discuss policies that enabled the rapid and wide-scale
implementation of virtual home visitation (VHV). Furthermore, I examine implementation factors
that support and hinder providers in delivering HV programs. Additionally, I explore provider
burnout in the context of the pandemic for providers delivering HV programs both in virtual
platforms and in-person, learning and adapting to innovations as they go. The following
questions will guide this dissertation:
Research Questions
1. How Do Policies Play a Role in the Dissemination, Implementation, and Delivery of
VHV?
2. What are perceived barriers and facilitators in delivering/receiving services from provider
and caregiver perspectives?
3. Which factors are related to provider well-being during the implementation of rapid
response VHV?
In the following section, I provide further details about the key concepts informing this
dissertation. In the first chapter, I will delve deeper into the problem and significance of VHV
programs, specifically describing HV programs, the adaptation to virtual platforms, and the
4
influence of the COVID-19 pandemic. The second chapter will thoroughly review the relevant
theoretical frameworks that guide this dissertation including the Kingdon’s Multiple Streams
Framework, Consolidated Framework for Implementation Research (CFIR), theory of burnout.
The third chapter will detail the methodology used in the parent study and the current
dissertation. The fourth chapter will highlight the results pertaining to each research question.
And the final chapter will include an overview of all findings, implications for policy and practice,
and future directions. Overall, this dissertation seeks to apply an innovative provider-centric lens
to D&I, in which research not simply focus on the intervention delivery but also the intervention
deliverer.

5
Chapter 1: The Problem and Significance
Defining Home Visitation
HV programs are a service-delivery strategy where service is rendered by providers
(e.g., social workers or nurses; Traube et al., 2021c) in the familiar setting of a family’s home for
the purpose of early intervention (Supplee & Duggan, 2019). These programs seek to address a
range of outcomes including low-birthweight, child abuse, reliance on public assistance, learning
delays, and future behavioral issues (Sweet & Applebaum, 2004). These programs also vary in
types of families served (e.g., single teenage mothers), ages of children (e.g., 0-5), and services
they provide (e.g., home safety; Duggan et al., 2018; Supplee & Duggan, 2019; Sweet &
Applebaum, 2004). HV providers engage families in a range of practices: providing resources to
support healthy pregnancies, encouraging early language development, modeling positive
parenting skills (e.g., praising constructive behavior), guiding parents through setting goals or
finding employment, and connecting families to local resources (Health Resources & Service
Administration, 2023). At its core, the goal of HV programs is to help a child by training and
supporting parents (Sweet & Applebaum, 2004). High quality HV services can yield positive
outcomes and protect vulnerable families from perinatal mental health risks and future adverse
childhood experiences (Shonkoff, 2016; Traube et al., 2021d).
During the pandemic, many aspects of HV programs were no longer available, due to
social restrictions and policy changes. This includes the in-home visits to assess for child safety
or family functioning, offering physical resources to families, or engaging face-to-face
(Korfmacher et al., 2021). Many programs faced the decision to shift to a suitable alternative
(e.g., using a virtual platform) or shut down services altogether. With policies supporting the
shift, HV service providers had to rapidly adapt to deliver all components of the HV programs
virtually efficiently and effectively. Then post-pandemic, providers had to adapt to the changing
6
service delivery approaches by finding a balancing between virtual and in-person HV service
modalities. Kingdon’s Multiple Stream Framework provides a comprehensive way to
comprehend how policies played a role in the shift in modalities and will be discussed later in
this dissertation. Furthermore, understanding the barriers and facilitators of implementing HV on
a virtual platform during and following the effects of the pandemic— where many providers were
toggling or switching between virtual and in-person service delivery– can help provide insights
to other areas of human service delivery. Useful D&I frameworks such as the Consolidated
Framework for Implementation Research (CFIR) can help guide the exploration of challenges
and facilitators in a systematic approach. This meta-theoretical framework offers consistent
terminology and descriptions of implementation phenomena applicable across diverse settings
for the purpose of predicting and/or explaining barriers and facilitators to implementation
effectiveness, thus categorizing it as a determinant framework (Damschroder et al., 2009). One
challenge/facilitator not always intentionally discussed during the implementation of an
innovation or program includes the well-being (or lack thereof) of the innovation deliverer. That
is, burnout among providers within human service fields such as HV is well-studied (e.g.,
secondary trauma, compassion fatigue; Begic et al., 2019; however, burnout within the context
of innovation implementation is not always discussed nor intentionally addressed. As such,
promoting the well-being of the provider should be a significant component during the
implementation of new programs.
Defining Virtual Home Visitation
There are various studies that have implemented a virtual service delivery modality with
different types of services. The use of virtual platforms, spanning many fields, has shown to be
effective, along with its own set of challenges for providers and clients. To start, Heimerl and
Rasch (2009) held over 200 therapeutic sessions (e.g., occupational therapy, physical therapy,
7
speech-language pathology, and psychology) using a telehealth service delivery model with
children (up to two years of age) participating in early intervention programs. The authors
concluded that services provided using telehealth platforms are a suitable alternative when in-
person services are not feasible. Similarly, Kelso and colleagues (2009) provided virtual
multidisciplinary services (e.g., occupational therapy, physical therapy, speech-language
therapy) and demonstrated savings of time and resources associated with the virtual delivery
model. Moreover, early intervention therapy services held on virtual platforms have resulted in
high levels of parental satisfaction (Cason, 2011) and served as a helpful resource to combat
personnel shortages and increasing demands for services. Overall, virtual interventions have
been beneficial in many ways, such as helping organizations cut costs and time associated with
travel, supervision, and missed appointments (Feil et al., 2008). However, some highlighted
barriers and concerns related to implementing telehealth as a delivery model including privacy
issues, concerns about quality of care, reimbursement policies, and access to technology
(Cason, 2011). While the use of virtual platforms for service delivery is not novel, there was a
rapid increase in the need for bringing virtual services delivery to scale in more recent years.
Similarly, HV programs have undergone some adaptations to increase access for
families, such as providing HV services virtually. VHV services have not been widespread but
have slowly increased with the rise in internet use (Feil et al., 2008). Although there have not
been many large-scale investments or development of virtual platforms for delivering HVs
(Traube et al., 2021c), some smaller-scale studies focused on VHV services have shown some
success (Hinton et al., 2017; Traube et al., 2020; Traube et al., 2021c).
For example, Traube and colleagues (2021b) conducted a qualitative study to assess
the impact of telehealth training among social work students providing telehealth services. This
study highlighted facilitators and challenges to delivering VHV and overall satisfaction of
8
services. The authors ultimately found that training, intervention curriculum, and ongoing
telehealth supervision were helpful in delivering VHV, while issues of telehealth operations and
technology acted as barriers for both providers to adequately provide services and for families
to receive services. It was also highlighted that a provider’s communication skills, clinical
knowledge, and ability to combine clinical experience with telehealth are crucial to engaging
with clients receiving telehealth services. Thus failure to cultivate these abilities and supporting
providers in delivering these services can negatively impact the providers as well as the clients
they aim to serve (Traube et al., 2021b). Another recent study conducted by Zeldman and
colleagues (2023) explored HV programs targeting early childhood obesity prevention. This
qualitative study sought to identify stakeholder attitude, subjective norms, perceived ease of
use, and behavioral factors related to using virtual platforms for HV. The authors found that
participants viewed technology use was flexible and time efficient but unstable internet access
and potential social disconnect were barriers to use (Zeldman et al., 2013). Overall, facilitators
included training, flexibility, and supervision.
Defining Toggling Versus Hybrid
Another crucial differentiation to make is between a hybrid model of in-person and virtual
service delivery and toggling between both platforms. The term hybrid used throughout this
dissertation refers to the intentional use of both in-person and virtual modalities while toggling is
referring to the act of switching between both modalities. Discussed later in this dissertation,
many providers reported toggling between both modalities as more of a strategy (e.g., to
increase contacts with clients when in-person was not suitable) and wanted to prioritize in-
person visits when possible. These phenomena are not explicitly outlined in previous research
but have been discussed more loosely. For example, Al-Taiar and colleagues (2023) explored
mother and HV provider perspectives of VHV during the pandemic. Among other findings, both
9
mothers and providers reported many benefits to in-person services and a preference for that
modality but also acknowledged the advantages of VHV. When asked about the prospective
role of VHV, several mothers and providers indicated that in-person services are a better and
preferred option but would resort to VHV to reach families when an in-person option is not
viable, such as when families are too busy to schedule in and prepare for an in-person visit (Al-
Taiar et al., 2023). This distinction is important to note since many HV programs switched to
primarily using a virtual service delivery during the pandemic then after the pandemic, some
states continued to allow the use of virtual platforms for service delivery while others are urging
prioritizing in-person delivery (Al-Taiar et al., 2023). Thus, hybrid modalities seem to be a more
intentional approach of incorporating both modalities but toggling between both types of delivery
options can be a tool to open access for families out of necessity or preference.
Home Visitation and COVID-19 Pandemic
The COVID-19 pandemic has caused chaos and additional strain in the lives of young
children and their families. Stressors such as the closure of childcare programs and schools, job
losses or reductions in work hours, and financial hardships can increase parental stress, hinder
effective parenting, and negatively impact children’s developmental trajectories (Prime et al.,
2020). Considering that HV programs have historically provided critical support for families of
infants and young children experiencing multiple stressors (Duffee et al., 2017; Filene et al.,
2013; National Home Visiting Resource Center, 2020), HV programs may act as a particularly
important buffer for families during the pandemic. To ensure this buffer remains accessible,
many organizations began offering VHV services by phone (two-way audio communications) or
by interactive videoconferencing. The use of VHV has yielded positive results when used to
deliver services for early intervention programs (Cason et al., 2012).
10
Moreover, a recently published report by the Home Visiting Applied Research
Collaborative (HARC; O'Neill et al., 2020) summarized a survey of evidence-based home
visiting programs conducted during the pandemic in the U.S. The report suggested that various
methods, including interactive video conferencing, telephone, and texting, have been used to
replace in-person visits. One significant challenge affecting providers and families identified is
that approximately half of families lacked stable internet access, which is not surprising given
existing literature highlighting the digital divide and the social injustice of inequitable internet
access and availability of necessary technology (Farakas & Romaniuk, 2020; Goldschmidt,
2020). The survey also documented additional issues faced by families, including parents
struggling with emotional capacity to engage in programs during the current circumstances and
concerns related to maintaining confidentiality. For providers, challenges included reduced
ability to deliver curricula effectively due to their own home environment issues (O'Neill et al.,
2020).
Self-Brown and colleagues (2022) conducted a study to explore VHV provider opinions
regarding the feasibility and effectiveness of using virtual delivery and understand the workforce
concerns in the COVID-19 context. The authors ultimately found that while providers largely felt
this was a suitable solution to continue offering their services, some difficulties remained, such
as those related to technology or ensuring accuracy of home safety assessments when unable
to view the home in person. Moreover, 40% of providers felt a degree of anxiety, worry or
depression and some providers felt challenged having a healthy work-life balance (Self-Brown
et al., 2022). Furthermore, since this was one of the first articles to assess the impact of the
pandemic on delivering VHV programs, they highlighted the importance of understanding how
the pandemic has affected providers, training availability, and the provider’s ability to deliver
services. Although these barriers may be from the provider perspective, it is important to note
11
that families are also affected by these challenges, as it impacts the providers’ ability to
adequately deliver these services.
In a study conducted by Korfmacher and colleagues (2021), 658 HV providers across
the U.S. were surveyed about the nature of their work with VHV during COVID-19 pandemic.
When inquiring about family engagement, providers did not find engaging with caregivers to be
difficult but 65% of providers felt they required different strategies while virtually delivering
services and 45% of providers reported needing to be more intentional with engagement.
Furthermore, 71% of providers reported they had difficulty engaging with children on virtual
platforms and keeping them within view. However, despite the drawbacks, about half of
respondents indicated that VHV made it easier to comment on or support parent-child
interactions. When inquiring about their own wellbeing, on average, providers did not report
significant amounts of stress or burnout, as they maintained a positive outlook on their work
(Korfmacher et al., 2021).
Overall, research indicates that there has been a mix of barriers and facilitators to using
virtual platforms for HV. While providers, families, and children may experience distinct barriers
or facilitators, there may overlap in how they are affected. With such a sudden shift in how
services were delivered during (and after) the pandemic, support was required to mitigate
challenges and enhance facilitators to maximize benefits for all parties involved.
Rapid Response Virtual Home Visitation (RR VHV)
To support the sudden increase in using a virtual modality, a Rapid Response Virtual
Home Visiting (RR VHV) collaborative emerged to disseminate empirical research and best
practices in VHV to providers and funders. While virtual platforms for service delivery existed
prior to the pandemic, the need for services to continue without disruption called for a rapid
adaptation of many programs across the U.S. Thus, leaders in the HV field across the U.S.
12
formed the RR VHV collaborative with the intention to provide rapid, best practice principles and
strategies to support home visiting professionals in maintaining meaningful connections with
families during the pandemic and its aftermath (Traube, 2021a). The RR VHV collaborative
produced 75 resources, 30 webinars, 5 model voice webinars, 6 e-learning modules, and a
policy brief of virtual home visitation. These resources covered content such as how to use
interactive video conferencing, conduct crucial activities (e.g., coaching and screening) virtually,
support workforce wellness, reflective supervision, and communicate cross-model messaging
about VHV.
The creation of these resources was developed with the following principles in mind:
accessibility, strengths-based approach, and shared responsibility. First, to encourage
accessibility, RR VHV resources were tailored to address HV professionals’ needs. The
resulting materials are available (and will continue to be) at no cost to providers through the
Institute of the Advancement of Early Support Professionals and other platforms. The strengths-
based approach aims to incorporate perspectives from diverse provider networks to ensure
inclusivity and expertise from various content areas and specific needs. Finally, RR VHV sought
to establish an efficient process for gathering and disseminating information involving many
stakeholders. The resulting content was developed with the combined perspectives of
participating provider networks. To emphasize the importance of shared responsibility, each
provider network was tasked with disseminating the work among their local providers in a timely
manner.
The RR VHV collaborative evaluated the process and outcomes of the initial period of
March 2020 through April 2021, representing the experience of 12,000 individuals. Capturing
these domains is necessary for establishing replicability and effectiveness. While the RR VHV
was created due to unprecedented circumstances, it can serve as a valuable resource for future
13
endeavors in home visitation, early childhood care and development, and other related fields
(Traube, 2021a).
This evaluation ultimately revealed that the RR VHV collaboration consisted of diverse
stakeholders with backgrounds in HV model development, model and HV field leadership,
research, and training. Stakeholders reported high levels of satisfaction with their teams’
process while also highlighting feeling respected and a sense of shared leadership.
Stakeholders were able to efficiently establish a system to inform and train their teams in best
practices in VHV, made possible through adequate and flexible funding. RR VHV content was
shared across almost all of the U.S. and internationally, speaking to the accessibility and
applicability. Furthermore, HV providers noted challenges in the transition to VHV (e.g.,
recruitment, parent-child interaction) but ultimately alluded to low levels of workplace stress,
high levels of personal wellbeing, and high satisfaction with service delivery and family
engagement. RR VHV filled the initial gap in service delivery support HV providers need to
effectively help families (Traube, 2021). While this evaluation reflected favorable results,
ongoing assessments of VHV are necessary to continue monitoring and supporting VHV
providers and the families they serve. As such, RR VHV collaborative collected another wave of
data to provide rapid feedback. This newly collected data will be used in this current
dissertation.
In addition to the many challenges and facilitators associated with virtual service delivery
for HV programs and other human services in general, there was also a sudden increase in use
of virtual platforms. This occurred without much guidance and very little was known about how
providers and caregivers would adapt to such changes. Thus, the findings of this dissertation
seek to systematically understand the implementation of these practices in the context of the
14
pandemic and how these practices are carried out now in the years following the pandemic and
in the future.

15
Chapter 2: Theoretical Frameworks
Kingdon’s Multiple Streams Framework
The pandemic impacted several industries warranting adaptations to occur as supported
by emergent policies to support such changes. Schools and universities had to physically shut
down, but virtual platforms allowed for classes to be held online. Even though hospitals and
clinics remained open, non-emergency appointments were either canceled or conducted
virtually. Similarly, face-to-face HV sessions had to halt altogether or a suitable alternative had
to be identified. To ensure continuity of care in medical fields and to keep businesses open,
policy changes were necessary to support these adaptations. One of the analytic frameworks in
political sciences used to explain how governmental policies are formed and/or changed is John
Kingdon’s Multiple Streams Framework (Kingdon & Stano, 1984; De Wals et al., 2019). This
comprehensive and widely-applied framework has been used to explore how various policies
around the world have been established, thus making it a sensible framework to use to explain
VHV adoption.
Kingdon’s Multiple Streams Framework highlights three streams that precedes a policy
change: problem, policy, and politics (Kingdon, 1984). First, the problem stream is an imminent
policy issue, requiring policymakers’ awareness. Secondly, the policy stream refers to the
availability of a solution that can address the prominent issue. This stream may involve parties
such as think tanks, experts, and other individuals who can create and promote proposed
solutions. Finally, the political stream highlights the political context and climate in which
decisions are made. This stream can encompass shifts in political leadership or public opinion
and significant events that influence the feasibility and support for changes in policy (Kingdon,
1995; Figueroa, 2018).
16

Figure 1. Kingdon’s Multiple Streams Framework
One prime example of Kingdon’s framework is illustrated in the policy analysis of
childhood obesity prevention program implementation in Iran (Taghizadeh et al., 2021). The
authors identified the policy stream to include a high rate of childhood and adolescent obesity
and related risk factors. The policy stream included a focus on preventing non-communicable
diseases in health systems, more workforce health centers, and promoting school-based health
programs (e.g., healthy meal choices). The authors discussed the impact of one of the World
Health Organization’s programs along with the implementation of a new health system plan in
Iran as part of the political stream. While all streams were activated and implementation was
going well, the authors also highlighted how other factors such as the pandemic curbed
progress in this arena (Taghizadeh et al., 2021).
Another instance where Kingdon’s Framework is applied is with telehealth care during
COVID-19 pandemic among nurses (Geise, 2020). The problem stream, a prominent issue
warranting a solution, was the imminent need of access to health care. Not only were death tolls
17
for patients infected rising, but many individuals needed medical attention, such as those with
chronic conditions, pregnancies, or acute illnesses. The policy stream, or a list of strategies to
address problems, would normally be carried out by means of introducing a bill to legislation or
speeches. However, due to the imminent need for a solution, this process had to be carried out
quickly. Finally, the political stream in this case is prominent in the global public opinion in that
something needed to be done, thus pressuring policymakers to act quickly. With the
convergence of the three streams, stakeholders opened the window of opportunity to make
healthcare accessible through telehealth (Geise, 2020).
The thorough and diverse application of Kingdon’s Multiple Streams Framework affirms
its applicability to the implementation VHV programs. The recent COVID-19 circumstances
initiated all three streams, warranting changes to be made for opening access for families to
receive services. Although social distancing measures and other restrictions have been lifted,
organizations are now adapting to a new normal. That is, whereas many programs were
adapted to be virtual, programs are now shifting back to in-person services and/or continuing to
leverage the use of a hybrid approach. Kingdon’s Framework is an optimal lens to explore the
context in which VHV program adaptations have been made prior to and following the
pandemic.
Consolidated Framework for Implementation Research (CFIR)
Many frameworks have emerged from Dissemination and Implementation (D&I)
research describing different organizational characteristics that impact the implementation of
programs and thus service effectiveness. While several factors may impact program
implementation, there is theoretical support linking specific elements with successful
implementation. One such D&I framework that could be applied to VHV programs is the CFIR.
Defining the CFIR. The CFIR is meta-theoretical in that it includes constructs from
various implementation theories. Overall, this framework strategically combines theories,
18
models, and frameworks [e.g., Conceptual Model for Implementation Effectiveness; Theory-
based Taxonomy for Implementation; Practical, Robust Implementation and Sustainability
Model (PRISM)] to offer consistent terminology and descriptions of implementation phenomena
applicable across diverse settings (Damschroder et al., 2009). The CFIR is one of the top five
accessed frameworks in D&I research since its publication (Skolarus et al., 2017). The purpose
of this framework is to predict and/or explain barriers and facilitators to implementation
effectiveness, thus categorizing it as a determinant framework (Damschroder et al., 2022).
While this framework can help guide the implementation process prospectively, the CFIR can
also be used to explain implementation outcomes by evaluating variations in detriments in
diverse implementation settings retrospectively (Damschroder et al., 2022). While CFIR does
not depict interrelationships or specific hypotheses, it offers an overarching list of constructs to
explore specifically what works in a myriad of contexts.
Additionally, CFIR constructs can be explored individually to maximize relevance and
used to guide assessments of implementation contexts, measure implementation progress, and
clarify research findings. This comprehensive framework outlines five distinct domains that
influence the implementation of an intervention: 1) innovation, 2) outer settings, 3) inner
settings, 4) individuals, and 5) implementation process (Damschroder et al., 2009; Damschroder
et al., 2022).

19

Figure 2. Consolidated Framework for Implementation Research
The first domain is centered around aspects of the innovation (e.g., object, project, or
intervention) that an organization or entity intends to incorporate into their practices
(Damschroder et al., 2022). This may include the cost and adaptability of the chosen innovation.
The second domain includes the outer settings that encompass the setting in which the inner
setting operates, including market pressure or external policies and incentives. The third
domain, inner settings, is where the innovation is implemented. This may include factors such
as structural characteristics (e.g., organization’s physical location), networks and
communication within the organization, and implementation climate (e.g. organization’s
readiness for change). The fourth domain refers to the individuals in the organization and their
relevant characteristics, such as knowledge about intervention, self-efficacy, and other personal
attributes that can also carry importance to successful implementation. Finally, the fifth domain
refers to the implementation process features, such as planning and evaluating that are also
20
associated with successful implementation (Damschroder et al., 2009). For a more detailed
view, please refer to Appendix A. Overall, the CFIR is an optimal tool for exploring the
implementation of VHV due to its versatility of use throughout all phases of implementation (Kirk
et al., 2016).
Updated framework. In more recent years, Damschroder and colleagues (2022) have
since updated the CFIR to improve its applicability during implementation. For example, one of
the adaptations made was changing the first domain from intervention to innovation and
renaming the receivers of the intervention recipients instead of patients. This allows for broader
application in settings where intervention and patients may not be relevant. Another change
made was removing Patients' needs & resources from the outer settings domain and replacing it
in the individuals domain to allow for more specificity when discussing several aspects of the
individuals involved. In the inner settings domain, infrastructure (i.e., physical, information
technology, and work) was added to account for resources available (or unavailable) for use
during implementation. For characteristics of individuals, several roles were added to
differentiate the individuals involved through every step of implementation and execution of
innovation, ranging from high-level leaders to implementation deliverers. The remaining
changes to the CFIR can be reviewed in Appendix B.
CFIR applicability. In its most current form, the CFIR is an optimal implementation
framework for a variety of reasons. To start, the CFIR points to many dimensions that would
impact the implementation of programs. This framework is ideal to explore various aspects of
implementing a program so that it can inform organizations on which aspects to address the
most to support success. As such, the CFIR can highlight perceived facilitators and barriers
from different domains as well as understand the intervention itself and the needs of different
parties involved.
21
The CFIR is also a useful tool in a rapid-cycle evaluation setting. RR VHV intended to
provide resources to HV providers in a timely manner to help them adapt to a virtual modality.
However, not many organizations were necessarily equipped to fully transition to virtual
platforms prior to the COVID-19 pandemic nor did providers have access to formal training;
Nonetheless, a rapid transition was called for with very little guidance. A rapid response was
warranted as it was crucial for families to still have continued access to services and for
providers to feel equipped to offer services. Accordingly, a rapid evaluation was also important
to assess how the transition was going and to identify strategies to continually improve service
delivery.
Lack of research related to the implementation of VHV. Furthermore, despite the
need for leveraging D&I research to understand the implementation of VHV, only a few studies
have done so. For example, Traube and colleagues (2022) conducted a study examining
provider and supervisor transition strategies as well as maternal-child outcomes during the
transition from in-person to virtual early childhood HV services in Los Angeles, California. The
authors found that HV providers delivering direct services and supervisors needed more support
specifically related to funding, technology, supervision, and model guidance. While HV providers
reported relative ease in transitioning to virtual services themselves, providers also believed that
families encountered greater difficulty with this transition. Moreover, providers identified a few of
the most helpful strategies to support this transition included training, ongoing reflective
supervision, and provision of technology (Traube et al., 2021c).
The authors of CFIR have continually acknowledged the need to improve the framework,
encouraging researchers to further develop the CFIR in different ways including applying it in
diverse settings, exploring relationships between constructs, and identifying and addressing
gaps (Damschroder et al., 2022). In line with this sentiment, one area that requires more
22
attention relates to the innovation deliverers. Both the original and most recent iteration of the
CFIR highlight the well-being of the innovation recipient under the “individual” domain. The need
construct under the characteristics subdomain is defined as “the individual(s) has deficits related
to survival, well-being, or personal fulfillment, which will be addressed by implementation and/or
delivery of the innovation” (Damschroder et al., 2022, p. 7). Well-being of the innovation
deliverer (e.g., HV provider) is not directly discussed as an important characteristic of the
individuals involved, much less what is needed to support their survival, well-being, or personal
fulfillment. Instead, the innovation deliverer’s capability, opportunity, and motivation for
innovation delivery are explicitly highlighted. These three dimensions are conceptualized as the
1) the interpersonal competence, knowledge, and skills to fulfill role, 2) availability, scope, and
power to fulfill role, and 3) the commitment to fulfill role, respectively (Damschroder et al., 2022,
p. 7). These speak to the individual’s ability to carry out their work without accounting for the
emotional capacity to do so. Since the well-being or other individual needs of the innovation
deliverer is not explicitly outlined as a necessary characteristic to consider, the framework does
not outline how these needs can be supported throughout implementation.
It must be mentioned that the implementation process domain discusses the collection
of data surrounding the priorities, preferences and needs of the deliverer as well as exploration
of the inner setting culture that may consider the shared beliefs, norms, and values surrounding
the needs of the innovation deliverers. However, these also do not necessarily speak to the
emotional needs of the individual in order to adequately implement or deliver the innovation.
Specifically, under the implementation process domain, specific needs of innovation deliverers
are not mentioned; therefore organizations are not clearly guided to intentionally focus on the
well-being or emotional capacity of their staff who implement and deliver the innovation.
Furthermore, the culture of the organization described under the inner settings domain speaks
23
to the broad treatment of staff and the organization’s shared values toward supporting the
needs of the deliverer. However, this does not account for the individuality of the deliverer who
could still be heavily influenced by their own well-being.
By using the CFIR to guide the implementation of these programs, program developers
can identify potential barriers and facilitators to implementation, tailor the services to the specific
needs of the target population and context to develop strategies to promote successful
implementation and sustainability over time. Previous research has applied CFIR to review
detriments of implementing HV programs (e.g., O'Donnell, 2022); however, none to date have
applied the newly updated CFIR domains nor has it been applied to programs first adapting to
online and now reverting back to in-person or to programs attempting to find a balance of in-
person and virtual services following the pandemic. Furthermore, considering how rapidly these
services have been adapted, it is imperative for families, providers, and funders to understand
how to maximize benefits and which areas of implementation are most crucial. Thus, this
framework will guide the current dissertation.
Theory of Burnout
HV programs have supported countless high-risk families, often mitigating the difficulties
they are enduring through offering these services. This can be taxing work and thus may impact
the well-being of the provider (Bride et al, 2007; Begic et al., 2019). That is, providers may
experience a hindrance in well-being, or burnout, due to HV programs typically engaging
families dealing with a variety of challenges such as living with low income, domestic abuse,
substance use, poor infant health, and child maltreatment (Adirim & Supplee, 2013; Paulsell et
al., 2010; West et al., 2018). Similarly to various human service professions such as healthcare
workers (Selamu et al., 2019; Wild et al., 2014) and teachers (Fye et al., 2020; Wehby et al.,
2012), many HV providers experience incidences of burnout (e.g., West et. al., 2018). Begic and
24
colleagues (2019) conducted a mixed methods study to examine risk and protective factors
associated with burnout and secondary traumatic stress. They found that among their sample (n
= 27), almost 75% of providers were experiencing moderate to high levels of burnout and about
¼ of participants reported an intent to leave their job (Begic et al., 2019). Additionally, Eaves
and colleagues (2022) investigated associations between HV provider professional quality of life
(e.g., burnout) and reflective supervision in a sample, finding that over 25% of participants were
above that threshold of significant burnout (n = 139).
Defining burnout. To start, it is imperative to define what burnout is and how it may
manifest. Burnout can be illustrated in three parts: exhaustion (emotional, physical, or both),
cynicism (depersonalization), and inefficiency (e.g., professional efficacy; Begic et al., 2019;
Maslach et al., 2001; West et al., 2018). Burnout among HV providers can manifest as negative
physical and mental health problems such as difficulty sleeping, moodiness, negative attitudes,
and substance abuse (Lee et al., 2013; Miller, 2011; West et al., 2018). On an organizational
level, provider burnout can also affect the entities they work for, in that providers may
experience lower levels of productivity, higher intent to leave organization, and increased
incidences of turnover (Begic et al., 2019; Lee et al., 2013; Maslach et al., 2001; Miller, 2011;
Swider & Zimmerman, 2010; West et al., 2018). Moreover, burnout can negatively impact client-
provider relationships (Lee et al., 2013; Showalter, 2010). Specifically, this phenomenon can
affect a provider’s decision-making and their ability to be present with their clients (Lloyd, King,
& Chenoweth, 2002; Maslach et al., 2001; West et al., 2018). Therefore, a provider’s level of
burnout can impact their ability to build meaningful relationships with the clients, limiting their
ability to assist clients in reaching their intended goals. With provider burnout affecting all levels
(e.g., clients, providers, and organizations), managing effects of burnout is essential.
Addressing burnout. Mitigating effects of burnout is essential for provider-family
relationships, the organizations, and providers themselves. Managing work stress requires
25
providers to feel sufficiently championed by their organization. One way this can be achieved is
through having supportive leadership. Begic et al. (2019) found that HV providers felt supported
by leadership when they were being provided with clear training and resources on how to
interact with clients. When interviewed, participants expressed gratitude for supervisors who
helped them cope with the emotional burden from work by using humor or sharing techniques
for self-care and setting boundaries. Beyond supportive leadership, peer support was also
highlighted to mitigate burnout. An evaluation of a HV program highlighted that providers often
rely on peer support to overcome challenges associated with their work (Finello et al., 2016).
Participants reported positive experiences when having casual conversations with peers, which
often included conversations on how to approach client situations and effective coping
strategies (Finello et al., 2016). Other studies echoed these findings, also discussing the
importance of protective factors such as supervisor and coworker support, consultant groups of
multidisciplinary professionals, training, and access to necessary supplies (Berlin et al., 2020;
West et al., 2018).
Burnout and implementation. Burnout during implementation of a new program is an
important element to consider achieving successful implementation. While many aspects of
burnout have been thoroughly researched in various settings (e.g., education; Freire et al.,
2020; Zhang et al., 2019), HV burnout during the implementation of new programs is vastly
understudied. This is particularly critical, as burnout in this field is often linked to detrimental
outcomes for the provider, clients, and organizations. Burnout among providers has been linked
to various negative outcomes such as mental health challenges for providers, high turnover
rates, and a decline in client engagement acting as a hindrance to service delivery and
experience. There are few studies explicitly focusing on burnout as a barrier during
implementation, particularly in the context of home visitation. One example explored well-being
26
during the implementation of the Early Head Start HV program and found a positive relationship
between providers’ perception of job demands (e.g., being overly busy or too many different
types of tasks) and provider burnout. The authors also highlighted that other factors should be
considered, including perceptions of limited support or personal safety (West, Berlin, & Harden,
2018). Moreover, Ross and colleagues (2023) conducted a study to investigate the relationships
between HV provider burnout, compassion fatigue, and compassion satisfaction in New York.
While many participants reported low levels of burnout, the authors found that low levels of job
satisfaction were associated with increased burnout. Moreover, providers experiencing anxiety
were more likely to also experience symptoms of burnout. Thus, similarly to other studies (e.g.,
Sama-Miller et al., 2018; West et al., 2018), the authors conclude that although not all
participants experienced burnout, other factors may mitigate burnout, such as higher job
satisfaction or presence of additional support including training, skill acquisition, and
professional development (Ross et al., 2023).
Furthermore, research around burnout during the implementation of VHV in recent years
has also been lacking. With the global pandemic interrupting business as usual for many
organizations, it was particularly difficult for HV programs, which were created to be conducted
in-person. With the rapid shift to using virtual platforms, the primary focus has been evaluating
provider and client perspectives for the purpose of elevating client reach and overall experience.
One such study qualitatively assessed providers’ perspectives on which elements were crucial
to attract and sustain families in VHV programs (Traube et al., 2021a). Overall, the authors
found that using specific engagement strategies, clearly communicating benefits for families,
strategically employing clinical skills, and a clear rationale for ending services were essential.
Various other studies also focused on client outcomes and how providers can further address
client needs (Jackson et al., 2021; Traube et al., 2022; Traube et al., 2021a). Traube (2021a)
conducted an outcome evaluation that explored provider burnout concluding that despite the
heightened stress levels experienced nationwide during the COVID-19 pandemic and social
27
unrest, home visitors reported a notable absence of workplace distress and showcased high
levels of personal well-being. While factors impacting provider burnout were not explicitly
explored, this literature set the foundation for future research exploring how provider well-being
can be supported while they tend to client progress particularly during a rapid implementation of
an adapted service delivery. Provider well-being has been researched throughout the years,
however, the recent adaptation of HV services on virtual platforms requires further exploration
and understanding of provider burnout as well as its repercussions, as they are delivering
services as they learn to navigate toggling between service modalities.
As such, to adequately meet the needs of clients, HV providers must be equipped with
the essential tools including having the emotional capacity or well-being to do so (West et al.,
2018). That is, having the capacity to meet client demands includes an individual’s well-being.
Thus, it is important to define and understand burnout among HV providers then further explore
how burnout can directly affect their service delivery.
Overall, the result of this dissertation will contribute meaningfully to D&I and HV fields.
Applying Kingdon’s framework and the CFIR to the evolution of HV delivery will emphasize the
role policies play during implementation of a new modality on a rapid and wide scale both during
a state of emergency and afterward. Furthermore, the application of the CFIR will emphasize
the challenges and facilitators to the implementation of VHV related to specific domains and
constructs that should be addressed from the perspective of crucial players (i.e., clients and
providers). This will help inform future implementations and adaptation on which struggles
hindered and which elements facilitated smooth implementation. Finally, burnout and mitigating
factors can be further understood in the context of implementation and how the well-being of the
innovation-deliverer (e.g., HV provider) is an important aspect to consider when implementing
an innovation (e.g., VHV services).

28
Chapter 3: Methodology
Parent Study Research Design
This dissertation used secondary data from a mixed methods evaluation study for the
Rapid Response Virtual Home Visitation (RR VHV). The RR VHV study used a hybrid type 3
effectiveness-implementation design, testing the effectiveness of the implementation strategy
and the intervention itself. The hybrid type 3 design was determined to be the best fit, as it tests
the implementation strategy, intervention itself, and intervention outcomes simultaneously.
Specifically, the process evaluation sought to identify effective collaboration strategies while the
outcome evaluation portion of the parent study intended to assess the impact of the RR VHV
implementation strategy and service level outcomes of the VHV modality. Table 1 below
summarizes the three types of hybrid style designs.
Table 1. Hybrid Design Characteristics
Study
Characteristic Hybrid Trial Type 1 Hybrid Trial Type 2 Hybrid Trial Type 3
Research aims
Primary aim: determine
effectiveness of a
clinical intervention
Coprimary aim: determine
effectiveness of a clinical
intervention
Primary aim: determine
utility of an
implementation
intervention/strategy
Secondary aim: better
understand context for
implementation
Coprimary aim: determine
feasibility and potential
utility of an implementation
intervention/strategy
Secondary aim: assess
clinical outcomes
associated with
implementation trial
Research
questions
(examples)
Primary question: will a
clinical treatment work in
this setting/these
patients?

Secondary question:
what are potential
barriers/facilitators to a
treatment’s widespread
implementation?
Coprimary question: will a
clinical treatment work in
this setting/these patients?

Coprimary question: does
the implementation method
show promise (either alone
or in comparison with
another method) in
facilitating implementation
of a clinical treatment?
Primary question: which
method works better in
facilitating
implementation of a
clinical treatment?

Secondary question: are
clinical outcomes
acceptable?
Note. Adapted from (Curran et al., 2012)
29
Participants
First, all HV providers and leadership who participated in VHV through the Alliance
Rapid Response listserv (n = 17,134), across the U.S. received an email inviting them to
participate in a quantitative survey and a subsample (n = 108) was invited to participate in focus
group interviews. Ultimately, 1,741 participants responded to the survey and 55 individuals
participated in focus groups.
Data
The survey (See Appendix C) consisted of 74 questions assessing workforce
demographics, toggling to VHV, satisfaction with VHV, and workforce well-being, and workforce
development. Data were collected in February 2023 with 1,741 individuals responding.
Participants were offered the opportunity to enter a lottery for an Amazon gift card if they
completed the survey.
Additionally, 108 providers who completed the survey were asked to voluntarily
participate in focus group interviews via zoom. There were seven to twelve individuals present
for each of the nine focus groups with a total of 55 individuals being interviewed. Focus groups
conducted with home visitors (n = 53) explored 11 questions including: 1) What was most
challenging about delivering in-person home visitation services? 2) What was most challenging
about delivering virtual home visitation services? The analysis of qualitative data is described in
detail in the methods section. Each interview lasted approximately an hour. Twenty-one
caregivers also participated in individual interviews via zoom but only 19 interviews were viable
due to low quality recording. The individual interview data collected from caregivers included
responses to the following questions: 1) What was most challenging about receiving in-person
home visitation services? 2) What was most challenging about receiving virtual home visitation
services? Duration of interviews with caregivers varied from five minutes to one hour. Individual
interviews and focus group interviews were semi-structured using interview guides, respectively
(See Appendix D & E). Interviews were completed in February 2023.
30
Data Analyses
This dissertation used qualitative data to answer the first two research questions and
quantitative data from the parent study to explore the third research question. While each
research question is focused on different aspects, this section will describe the analytic strategy
in general; the specific analyses for each aim will be described in its relevant sections.
Focus groups. Focus group interviews conducted for the parent study were analyzed
with a rapid qualitative approach utilizing template analysis. Template analysis uses a coding
template to develop hierarchies highlighting how themes relate to one another (King & Brooks,
2018). In this methodology, the principal investigator (PI) of the parent study co-led the
development of an initial coding template using a subset of the data at an early stage with this
dissertation’s author. The template was applied and refined to the entire dataset (King & Brooks,
2018). Template analysis is a highly organized approach that facilitates the creation of a
transparent audit trail, showcasing the process followed by the coding team to reach the final
thematic structure. Template analysis was selected for its rigorous and structured nature,
allowing for efficient completion within a shorter timeframe. Furthermore, this approach enables
the generation of detailed descriptions by employing a hierarchical coding system with four or
more levels.
For this dissertation, a collaborative approach was taken for data analysis and template
development. The coding team consisted of four members, including the current social work
doctoral candidate and three social work master’s students. NVivo 20 was primarily used for
qualitative data analysis. Following the steps outlined by Brooks et al. (2015), this dissertation
author began the template analysis process. Initially, the current author familiarized herself with
the data by reading transcripts from the focus groups. Three transcripts were selected for
coding to capture data variation, and preliminary coding will be conducted using NVivo 20. The
current author used a set of predetermined themes derived from the research questions to
guide the preliminary coding, such as benefits, challenges, and engagement strategies.
31
Concurrently, the current author trained the coding team by having the team all code two
transcripts as a group to model correct coding techniques. Thereafter, once training was
complete, the dissertation author organized emerging themes into meaningful clusters based on
similarities found in coded text segments. In the fourth step, a draft coding template was
developed based on the coding of the initial two focus groups interview transcripts. Upon
determining sufficient inter-rater reliability, the current author and the three research team
members applied this draft template to an additional transcript to assess its fit and make any
necessary adjustments. Once finalized, the template was used for individual coding by the team
members using NVivo 20. Throughout this process, team members documented additional
themes and codes in a shared Google document, which the current author monitored regularly.
Concurrent changes to the code structure were made in NVivo 20, accordingly. An audit trail
was maintained to track the development of the template analysis. After completing the
independent coding, the research team reconvened to discuss the findings and make final
adjustments to the coding template. To strengthen the inter-rater reliability score (kappa = 0.56),
each transcript was coded by two team members and any differences were discussed and
changes were maintained up to the current author’s discretion. After all coding was completed,
emerging themes were sorted according to domains and constructs illustrated in the CFIR.
Individual interviews. The individual parent interviews were analyzed with a rapid
qualitative approach utilizing template analysis. Template analysis uses a coding template to
develop hierarchies highlighting how themes relate to one another (King & Brooks, 2018). In this
methodology, the principal investigator (PI) of the parent study and the current author developed
an initial coding template using a subset of the data at an early stage with the current author.
The template was applied and refined to the entire dataset (King & Brooks, 2018). All parent
interviews were coded by the current author using NVIvo 20 for the qualitative data analysis.
Following the steps outlined by Brooks et al. (2015), the author familiarized herself with the data
by reading 5 transcripts from the individual interviews. Three transcripts were selected for
32
coding to capture data variation, and preliminary coding were conducted using NVivo 20. The
current author used a set of predetermined themes derived from the research questions to
guide the preliminary coding, such as benefits and challenges to receiving HV or VHV services.
Once finalized, the template was used for coding remaining interview transcripts using NVivo
20. After all coding was completed, emerging themes were sorted according to domains and
constructs illustrated in the CFIR.
Survey data. Normality for all variables of interest was assessed. Bivariate analyses
were conducted to explore relationships between all variables of interest. Demographic
variables included: race, gender, and number of years in the HV field, and role. Seven
predictors were of particular interest. The first five variables considered implementation
facilitators included whether providers received the following type of support to toggle between
virtual and in-person home visitation: training, consultation group, peer-to-peer support,
supervisor support, and technology. Participants who reported receiving each would receive a
“1” in those corresponding categories and providers who reported not receiving these reports or
had missing data would receive a ”0.” The next two predictors asked to report to what degree
they perceived training or supervision to be adequate when toggling between modalities. Finally,
the last predictor was whether or not HV providers made the decision of when to switch
between modalities. The outcome included burnout among those working in the HV field.
Burnout. The main outcome of interest comprises a 9-question scale based on the
Maslach Burnout Inventory (MBI). These questions will be measured using a seven-point Likert
scale ranging from Never to Everyday. An abbreviated version of the MBI was used (ɑ = 0.93;
Riley et al., 2018); Three items will represent each MBI subscales: Emotional Exhaustion (EE; ɑ
= 0.83), Depersonalization (DP; ɑ = 0.85) and Personal Achievement (PA; ɑ = 0.79). Scores
across all three subscales will be summed to create one aggregate score. Using the MBI as
originally created, higher additive scores on EE and DP subscales and lower scores on the PA
subscale indicate higher burnout (Maslach et al., 1996). For clarity, PA response values will be
33
reversed to be combined with EE and DP scores. Thus, a higher aggregate score will indicate
higher levels of burnout. Table 2 outlines the specific questions pertaining to burnout.
Table 2. Provider Burnout Questionnaire
Never A few
times a
year or
less
Once
a
month
or less
A few
times
a
month
Once
a
week
A
few
times
a
week
Everyday
Emotional Exhaustion
1. I feel emotionally
drained from my work.
0 1 2 3 4 5 6
2. I feel fatigued when I
get up in the morning and
have to face another day
on the job.
0 1 2 3 4 5 6
3. Working with people is
really a strain for me.
0 1 2 3 4 5 6
Depersonalization
4. I have become more
callous towards people
since I took this job.
0 1 2 3 4 5 6
5. I do not care what
happens to some of my
clients.
0 1 2 3 4 5 6
6. I feel that I treat some
clients as if they were
impersonal objects.
0 1 2 3 4 5 6
Personal Achievement
7. I feel exhilarated after
working closely with my
clients.
0 1 2 3 4 5 6
8. I feel that I am
positively influencing
other people’s lives.
0 1 2 3 4 5 6
34
9. I deal very effectively
with the problems of my
clients.
0 1 2 3 4 5 6

Predictors. To illustrate support that participants received, they were asked to report
specific types of support their model or organization offered to toggle between offering virtual or
in-person HV services. These categories include training, consultation group, peer-to-peer
support group, support from a supervisor, and technology (e.g., laptop, tablet, or internet
connection). Participants will receive a value of “1” in those corresponding categories and those
who reported not receiving these reports or had missing data would receive a ”0.” The next two
predictors asked to report to what degree they perceived training or supervision to be adequate
when toggling between modalities. Finally, the last predictor was whether or not HV providers
made the decision of when to switch between modalities.
Demographics. Demographics included participant gender, race/ethnicity, role, and
number of years working in the field. All demographic variables will be assessed categorically.
Hierarchical Linear Modeling. Predictors were assessed on a bivariate level and were
entered into the model to explore best model fit. Hierarchical linear modeling assessed
relationships of provider support and personal well-being. Providers were nested within the state
in which they live to account for any differences, such as state policies or community
demographics. Hierarchical analysis began with the fitting of an unconditional model to provide
baseline statistics for evaluating more complex models (Raudenbush & Bryk, 2002). All models
were analyzed using maximum likelihood estimates within STATA 16 software (StataCorp,
2019).

35
Chapter 4: Results
Research Question 1: How Do Policies Play a Role in the Dissemination, Implementation,
and Delivery of VHV?
Data
Research question one seeks to explore how policies impact service delivery. Kingdon’s
Multiple Streams Framework and the CFIR explains the implementation of VHV services
chronologically. That is, Kingdon’s Framework can be used to describe the widespread
dissemination and the development of the platform for implementation. The CFIR can be
applied to understand caregiver and provider perspectives during the implementation and
delivery of VHV services. First Kingdon’s Framework encompasses three streams leading to the
window of opportunity will be defined using terms relevant to how VHV services were carried out
since before the pandemic to the present. CFIR concepts will also be applied, as policies at
different levels can impact how services are delivered. Policies within inner and outer settings
will be of particular interest. Research into relevant policies (e.g., telehealth policies) will be
used to identify elements described by Kingdon’s Framework. Additionally, qualitative data from
providers (view methods section for detailed overview of qualitative data analysis) will be used
to explore any mention of policies either within the organization or outside of it. Specifically,
providers were asked to share who oversaw determining whether services would be delivered in
person or virtually, after COVID-19 restrictions were lifted. Moreover, to support their awareness
of which policies affected their service delivery. Responses to when providers were asked which
strategies they used to ensure they were sticking to the curriculum speaks to the provider’s
actions taken after having to abide by policy changes. The Multiple Streams Framework
illustrates that three streams are needed for policies to change: problem, policy, and political.

36
Understanding the Dissemination and Implementation of VHV: Kingdon’s Multiple
Streams Framework
Problem. First, a persistent problem must exist, warranting a change to ensue. To start,
HV services started in the U.S. as early as the 1880s to encourage universal kindergarten and
promote maternal and infant health by providing health support to immigrant communities
(Duffee et al., 2017). More recently, a federal initiative— also recognizing vulnerable families’
needs— funded evidence-based HV programs to support vulnerable families across the U.S, as
part of the Affordable Care Act in 2010 (Health Resources & Service Administration, 2023).
Specifically, HV programs were created with the intention of supporting caregivers (e.g., young
mothers) throughout the early years of child rearing (ages 0-5), typically those who are low-
income, under 21 years old, single parent, and/or less than high school education level (Traube
et al., 2022). The majority of individuals receiving HV services are experiencing more than one
of these challenges (National Home Visiting Resource Center, 2019). As such, in 2022, 138,000
parents and children were provided with over 840,000 home visits through programs. However,
this only represents 15% of over 465,000 families who are currently eligible for and need such
services (Health Resources & Service Administration, 2023). Thus, a need for intervention has
been long established.
On January 31, 2020, the U.S. declared a public health emergency due to the novel
coronavirus, SARS-CoV-2, leading to the COVID-19 illness. Many states promptly, including
New York and California, initiated state-wide or local stay-at-home policies. These policies were
intended to prevent the spread of COVID-19. Some of these policies also included directing
health care providers to prioritize in-person care to those with the highest need, with many
routine services (e.g., behavioral health services) being categorized as low priority (Suran,
2022). Outside of healthcare, many other aspects of daily life were also impacted. That is, the
COVID-19 pandemic resulted in unprecedented strain on individuals and families all over the
world.
37
A multitude of stressors including the closure of childcare programs and schools, job
loss or reductions in work hours, and financial hardships are linked to increased parental stress,
hinder effective parenting, and negatively impact children’s developmental trajectories (Prime et
al., 2020). Higher rates of mental health issues, life disruptions, and violence in the home
followed the economic downfall and stay-at-home order (Williams et al., 2021). Such poor
mental and physical health incidences are often linked to a sense of social isolation and
loneliness. Parents with low-income also disproportionately experience more worry about
infection and are more likely to feel their lives are disrupted by the outbreak (Hamel et al., 2020;
Panchal et al., 2020; Williams et al., 2021). Moreover, mothers to young children are at
increased risk during this difficult period, specifically for depression, stress, and parental burnout
(Cameron et al., 2020; Cluver et al., 2020; Griffith, 2020; Traube et al., 2022). This increased
risk can also impact children in the home, as family issues related to child maltreatment among
0–5-year-olds include substance use, inadequate resources, and domestic violence (Child
Family Services Agency, 2019). Considering that HV programs have historically provided critical
support for families of infants and young children experiencing multiple stressors (Duffee et al.,
2017; Filene et al., 2013; National Home Visiting Resource Center, 2020), uninterrupted access
to HV programs may act as a particularly important buffer for families during the pandemic.
However, large-scale social distancing measures initiated by states and counties to prevent the
transmission of COVID- 19 led to home visitors no longer being able to visit families in their
homes, leaving high-risk mothers at even greater risk for prenatal and postpartum mental health
difficulties, parenting challenges, and social isolation (Traube et al., 2022). One such provider
shared their experience with no longer being able to meet with clients its impact:
We were part of public health, and we were obviously on the ground for COVID.
Like first people on the ground for COVID in our community, we actually had to
shut down our programs. We were not able to do our home visiting programs...
And so it took a while for us to get back, and so we had to do a lot of rebuilding
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both with our clients and with the people that we're used to making referrals to
us. So it was very hard. It was hard losing our cases and not being able to meet
with them.
Policy. Next, the policy stream refers to the availability of a solution that can address the
issue. This stream can involve parties such as think tanks, experts, and other individuals who
can create and promote proposed solutions. In light of restrictions resulting from COVID-19, the
demand for increased access for services paved the way for the implementation of virtual
service delivery across several fields. For example, the Centers for Medicare & Medicaid
Services (CMS) announced initial telehealth flexibilities in March 2020, which were expanded by
the passage of the Coronavirus Aid, Relief, and Economic Security (CARES) Act and other
legislation that allowed for telehealth to be delivered at the same payment level as in- person
visits for the duration of the pandemic (Samson et al., 2021). This set of Medicare telehealth
flexibilities allowed broader use of telehealth during the pandemic and were intended to ensure
beneficiaries had continued access to care despite the pandemic (Samson et al., 2021). In
broader application, many schools held classes online and various places of employment also
elected to use virtual platforms to continue business. With the greater use of technology, HV on
a virtual platform became much more reasonable and accessible.
Political. Finally, the political stream highlights the political context and climate in which
decisions are finalized. This stream can include shifts in political leadership or public opinion
and significant events that influence the feasibility and support for changes in policy. With the
clear need that many underserved communities had, paired with the increased risk brought forth
by the pandemic, lawmakers were moved to act swiftly.
In December 2020, the Consolidated Appropriations Act, 2021 was signed, providing
MIECHV awardees the opportunity to make necessary practice and policy changes in response
to the public health emergency (Health Resources & Services Administration, 2023). This new
law allowed organizations to allocate MIECHV funds towards training HV providers to conduct
39
virtual visits, purchase necessary equipment, and provide emergency supplies for families.
Following this, in March 2021, the American Rescue Plan Act of 2021 was signed into law. This
allotted $150 million for MIECHV-funded organizations to continue supporting expectant
mothers and families with young children during the COVID-19 pandemic. This act specifically
sought to attribute funding toward seven classifications of uses including hazard pay,
technology, and HV provider training (Health Resources & Services Administration, 2023).
Additionally, the Health Resources & Services Administration awarded a total exceeding $120
million toward MIECHV program awardees in May and December 2021. These funds were also
intended to support HV activities and fortify the organizations to better serve communities during
the public health emergency. However, since the public health emergency classification ended
on May 11, 2023, not all of these changes were sustained. Fortunately, MIECHV awardees are
able to continue allocating funds for reasonable uses, including expenses to support
implementation of virtual and hybrid HV services (Health Resources & Services Administration,
2023). These funding streams paved the way for organizations to shift gears and provide care in
Providers and caregivers alluded to the change in HV service delivery in support
continuity of care. Providers described their experience with service delivery changes over time,
with many sharing they have toggled between in-person and virtual multiple times.
We started off, traditionally doing in-person. Then, when COVID [spread] we
switched over to virtual, and now we're mostly in person. But we're still doing
virtual, for you know, if the family or the home visitor was exposed to COVID, or if
they're sick, or something like that.
Another provider shares how their shift in service delivery occurred and how it is taking place
most recently.
It was actually 3 years ago in March that we got sent home, and we had to do a
complete 180 from a home visitation program to providing virtual services. So we
did it virtually. Really, however, the families whatever worked for them, whether
40
that be Zoom or Whatsapp or Facetime. We just tried to make it work, and we're
just now within the last probably 6 months getting back to normal quote unquote
normal, and the expectation is, we're back in the home. But now that we've
shown that we can do it virtually, we can offer that as an option to parents, if that
is their preference. But we are more and more getting comfortable with [in-home]
visits again.
Overall, there were major shifts throughout the course of the pandemic, with many providers still
shifting modalities most presently. Kingdon’s Framework and provider experiences highlight
how the dissemination of VHV services began, setting the foundation for widespread
implementation. Next, the CFIR will be used to explain how the implementation and delivery
was experienced from the provider perspective.
Understanding the Implementation and Delivery of VHV: CFIR
Telemedicine, telehealth, and other virtual medical services are not a new occurrence
but have been increasing in use. The onset of the COVID-19 pandemic called for a reliance on
alternative methods of service delivery for many health-related interventions. Within the field of
HV services, there was a rapid increase of virtual service delivery to ensure clients were able to
receive crucial services. To explore how policy impacted HV service delivery, the CFIR will be
explored. The CFIR outlines relevant areas related to policy, primarily within the inner and outer
setting domains. Interview and focus group data will be explored for themes related to inner and
outer settings of the CFIR.
Inner Settings
There were many inner setting policies and practices that shaped the use of VHV. Many
providers shared that their organizations’ culture was recipient-centered and that their
organization was able to provide resources to families. To start, many providers discussed how
organizations allowed for the clients’ preferences to be accounted for when deciding whether to
41
continue offering services virtually, following the initial stages of the pandemic-related
restrictions. For example, one provider shared the following:
We always follow the parents' lead, and when we're assigning new families, we
really encourage the [staff to] make that part of the conversation when [they’re]
signing the enrollment paperwork, and just let them know that we're flexible.
Furthermore, providers and their organizations noted barriers to having access to technology
and sought to aid, as illustrated by this provider’s account:
So we did go after grants to help with tablets and laptops, which was very helpful,
and we also found some hotspots that we were able to share.
However, not all organizations had the capacity to provide such resources.
I work for a very small nonprofit. So getting devices that could go to homes
wasn't something that was available for us, or even providing hotspots and that
sort of stuff. So the technology portion was a challenge for some and access to
internet. I live right in town, and I can't even use my cell phone to some pictures
sometimes. So it's really interesting.
Overall, inner setting policies and practices shaped the way services were delivered. However,
these organizations did not exist in a vacuum, as they were also influenced by other external
factors.
Outer Settings
The outer setting encompasses the environment in which the inner setting (e.g., HV
program’s organization) is situated. In this case, providers described outer setting elements
related to critical incidents, policies & laws, and partnerships & connections. First, many
providers alluded to many shifts in service delivery methods, such as whether HV could be
completed virtually, have been guided by the COVID-19 pandemic. All providers who reported
working in the HV field prior to the pandemic shared they were primarily trained for in-person
HV, with a few providers conducting HV sessions over the phone when extreme weather
42
conditions persisted. Those who were onboarded during the pandemic were primarily delivering
their HV sessions virtually. During the height of the spread of COVID-19, policies, and laws (i.e.,
stay-at-home orders and social distancing restricted) prevented providers from meeting with
clients in-person. That is, some organizations had to either shift to using an alternative modality
(e.g., video conferencing) or shut down completely. Over time, service delivery modalities (e.g.,
virtual or in-person) shifted. As the pandemic and resulting policies were enacted and later
lifted, HV services also continued to shift. Agencies have varied in the way they deliver services
now; For example, some agencies continue offering hybrid HV services:
Obviously before the pandemic, it was all in the home. And then, after the
pandemic, we did Zoom Meetings, and sometimes it was Facetime; just whatever
was easier for the client, but as long as we could, you know, see them, and they
could see us, and we could share them the curriculum that we were doing and go
over stuff, and so we would actually do a visit and that way, but because we had
to get supplies and stuff to them. Then we would bag things up and drop things
off at their porch. We would leave them their materials for the week, and so we
would drop off and then do zoom. Then [after restrictions were lifted] we go back
to doing home visits. Not everyone was comfortable with that. So we still did a
hybrid or if the weather was nice enough outside on their porch or whatever. And
then, you know, we were still doing some zoom with the ones that weren't
comfortable enough to have anyone in their home yet.
Other agencies shifted from fully in-person to all virtual, then shifting back to primarily in-person
service delivery.
We were fully in person, and then we shifted to completely virtual for like 6
months, and then they started to let us do outside visits and porch drop off, and
things like that. And then we were just meeting however families could. Some
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were only via the phone and most of them were on zoom. Lots of zoom visits.
And now back to fully in person.
Many agencies also began in person, then pivoted to virtual services, with a slow transition to
in-person in the present but being flexible according to the families’ preferences or needs.
Right now we have it as the client’s choice. So we have a mixture of some clients
that used to do in-person before the pandemic that want to go back to in-person,
and then some that we had enrolled during the pandemic that are so used to
doing virtual that we're easing them into in person, but it's up to them. It's their
choice, and we leave it up to them, or you know, if they're sick, or if there's a
situation where they don't want us in the home.
Furthermore, the decision of whether to continue using virtual platforms was largely dictated by
the COVID-19 factors, families, and partner organizations. For example, many providers shared
they were able to see clients in person again after vaccinations became available and some
were encouraged to wear masks when being in enclosed areas with clients. Additionally,
providers discussed how many in-person visits were halted due to any illnesses among the
client’s household or themselves and instead had to be rescheduled or changed to a VHV
session. Finally, some providers spoke about how the decisions for continued use of virtual
platforms were influenced by many external organizations or agencies, such as “host agencies”,
government health departments, and sometimes funders. Some providers alluded to their
organization considering a myriad of voices in this decision, as illustrated by this provider’s
account:
We have to follow the University’s standards [since] we also have in their
guidelines. Also the Health Department standards, and we also [tried] to think of
all the so many people that had a role to play. And then organizationally was our
leadership team met and come up with a plan there and talk to Staff to see who
is comfortable, and who wasn't comfortable to give an insight from them; and
44
everybody had kind of differing opinions on how to approach the situation of
going back into the homes with families, and we also talked to our families, and
did a survey with them to get their feedback of when they were comfortable, and
how they would like for us to approach that if they wanted Staff to wear PPE and
what that would look like for them.
Conclusion
Overall, policies play a significant role in the dissemination, implementation, and delivery
of VHV services. Both Kingdon’s Multiple Streams Framework and the CFIR are valuable
frameworks to explain how policies supported the rapid adoption of virtual platforms and how
they influence VHV delivery following the end of the state of emergency. First, Kingdon’s
Framework lends an important perspective, as the three critical streams–problem, policy, and
politics–illustrate how the widespread dissemination of virtual platforms was introduced across
many fields, including within the HV field. The longstanding challenges many underserved
families faced were augmented with the pandemic, requiring policymakers’ attention. Changes
across other fields, such as in the medical field, helped identify a suitable strategy for continuing
care on virtual platforms. Finally, policymakers and funders were pressured to support the
strategic implementation of technology its continued use despite no longer being under a state
of emergency. This led to policy changes such as the Consolidated Appropriations Act, 2021
allowing for organizational discretion to reallocate funds to support the adoption of virtual
platforms, making it more accessible to clients in need. Related laws and policies created the
foundation for the implementation of VHV to occur. While providers did not explicitly mention
specific policies that impacted their work, they still expressed an awareness of how policies
impacted their services.
Furthermore, policies within and external to the organizations offering HV services
allowed for prompt pivoting and toggling of service modalities over the course of the pandemic.
Guided by the CFIR, the inner setting context highlighted how many providers perceived their
45
organizational culture to be recipient-centered. Specifically, client preferences and needs (e.g.,
technological) were prominent themes that were discussed. Relatedly, the outer setting context
was described to involve influences from the pandemic, external policies, and partnership &
connections. The application of both frameworks provides a thorough analysis of how policies
support the implementation in VHV from initial stages working toward long-term sustainment in
the future.

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Research Question 2: What are perceived barriers and facilitators in delivering/receiving
services from provider and caregiver perspectives?
The CFIR domains will help categorize and understand which elements of VHV &
toggling approaches were challenges and/or facilitators to implementation. Parents and HV
providers were asked to discuss challenges and facilitators of in-person, VHV, and toggling
between in-person and virtual modalities. VHV and toggling between modalities are of particular
interest, as these modalities were implemented on a wider scale most recently.
For the purposes of applying the CFIR, the innovation is using any degree of virtual
service delivery. While VHV has existed prior to the pandemic, there was a rapid adoption of
these services across agencies often not prepared to do so as well as a heavy reliance on such
modalities that were otherwise not previously used as a primary source of delivery. Over the
course of time, virtual service delivery became a tool that was alternated with in-person service
delivery. This alternation, or toggling, paved the way for varying degrees of hybrid service
delivery, depending on the needs and preferences of organizations and families. That is,
providers who were interviewed shared that almost all of them started HV in-person, with a few
providers offering services virtually due to extenuating circumstances such as poor weather.
With such shifts over time, barriers and facilitators to implementing this innovation arose.
To start, barriers to implementing VHV will be discussed. It is important to first highlight,
however, that toggling between two modalities was more of a tool rather than a distinct modality.
Providers and parents generally discussed VHV when either solely conducting virtual visits or as
part of a hybrid approach. Therefore, VHV will be referred to as any time providers or caregivers
engaged in virtual service delivery regardless of whether it is their primary modality of use.
Additionally, when parents were asked to describe any challenges they faced, many
interviewees shared they did not experience any significant barriers and if they had, only a few
were mentioned. Providers provided insight on which barriers they faced as well as challenges
47
they perceived their families were experiencing. Generally, providers and families shared they
experienced barriers related to VHV spanning across most domains. Although outer setting
factors were mentioned, they were not mentioned as being a challenge or facilitator. As such,
the outer setting domain will be discussed in a subsequent section. The following CFIR domains
will be used to categorize the arising themes: innovation, inner settings, individuals, and
implementation process.
Data
This section will explore the perceived barriers and facilitators to the implementation of
VHV. This question will be explored from the perspective of caregivers and providers. The data
used to answer this research question were from the parent interviews and provider focus
groups. Parent interviewees (n = 19) were majority White (57%) and all were female. For
providers, 63% of respondents were White, all but one respondent identified as female, and
65% were home visitors.
The individual interview data collected from caregivers (n = 19) included responses to
the following questions regarding implementation barriers: 1) What was most challenging about
in-person home visitation services? 2) What was most challenging about receiving virtual home
visitation services? Focus groups conducted with home visitors (n = 53) explored the following
questions: 1) What was most challenging about delivering in-person home visitation services?
2) What was most challenging about delivering virtual home visitation services? The individual
interview data collected from caregivers (n = 19) to explore facilitators included the following
questions: 1) What did they like most about receiving in-person home visitation services? 2)
What did they like most about receiving virtual home visitation services? Questions posed in
focus groups conducted with home visitors (n = 55) explored the following questions: 1) What
did you like most about delivering in-person home visitation services? 2) What did they like most
about delivering virtual home visitation services? The analysis of qualitative data is described in
detail in the methods section.
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Barriers to VHV Implementation
Innovation. The innovation domain of the CFIR refers to the object or program being
implemented. Constructs in this domain that can be considered barriers include source,
evidence-base, relative advantage, adaptability, trialability, complexity, design, and cost
(Damschroder et al., 2022). When discussing challenges related to VHV, the complexity and
cost of the innovation was highlighted. To start, speaking to the complexity of the innovation,
providers discussed the learning curve related to implementing VHV. For instance, providers
shared there was a learning curve to implementing this new practice due to the use of new
technology.
Technology was a huge issue here in Alabama. and the learning curve, just
showing everyone what to do and how to do it. We used video messaging
through messenger. We also used Facetime. You know anything that we could
use.
Moreover, a common innovation related challenge was the cost of the innovation for the families
and organizations to use these technologies long-term. This construct speaks to whether or not
purchasing and operating costs are affordable (Damschroder et al., 2022), thus presenting a
challenge directly related to the innovation itself. Many providers shared that their families were
not always able to cover the cost of continued access to the technology necessary for VHV,
such as families from low socioeconomic backgrounds.
The downside was that we service a lot of underserved families. So, if people
were not working to pay bills, the first thing to go are these services, you know,
like phones. So what they did was, you know, either got landline phones or what
we call burner phones, where you just add minutes to it. So, a lot of times it was
whether or not they had the technology to even, you know, see us. So
sometimes this resorted to just a phone call. They didn't have the phones to [use
video conferencing] for all of the appointments. And then, after a while, it was
49
hard to get in contact with folks, because their phones are all disconnected, due
to lack of payment. So that's what we ran into a whole lot.
Even when families did have the necessary technology, they may have to share it with other
family members.
We also had challenges with participants who had a lack of access to
technology. There's one computer in the home and their grade 3 kid had to be on
for their school on the computer or the Wi-fi with spotty.
Overall, the complexity and cost of the innovation posed as common challenges related directly
to the innovation.
Inner Settings. The inner settings domain is comprised of the settings in which the
innovation is implemented. Inner settings for this dissertation can mean within the organization
itself or within the clients’ spaces in which HV providers and clients interact. Providers and
families discussed challenges related to the inner settings domain, specifically, the availability of
materials and equipment (e.g. technology; under the available resources construct) and access
to knowledge and information (e.g., adequate training). First, a few caregivers interviewed
relayed that access to adequate technology and WIFI was limited. This construct speaks to
availability—or lack thereof—of resources within the inner settings (e.g., within the organization
or within the communities). A few caregivers shared that they had unreliable WIFI, which would
impact their receipt of services. Similarly, many providers highlighted inadequate availability of
technology for their families to receive services. One provider shared that despite their best
efforts, families did not always have access to the technology or virtual platforms to fit their
needs.
So we are working with very low-income families and a lot of times we had
trouble. Some people couldn't use zoom, so we would try Google meet. Some
people couldn't do that. So we had to kind of individualize each family, and that
just took some time to get used to and our home visitors were comfortable with
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the different options available to them. And we also, you know, we have families
doing visits on their phones, which wasn't always the most ideal. So we did go
after grants to help with tablets and laptops, which was very helpful, and we also
found some hotspots that we were able to share. But even then, like when the
whole family was working remotely, the bandwidth was an issue, so we had older
siblings going to school and parents working from home. So that was a challenge
in the beginning.
Many providers spoke to the challenge of not having adequate access to information and
knowledge. Specifically, some providers reported that they lacked the training to offer VHV or
hybrid services. Some providers felt they were “thrown in” to using VHV service delivery and not
provided with formal training. One such provider shared their experience to be the following:
We just kind of learned on the fly because our program, like you said, just
completely shut down. So, we were trained to do in-person so with virtual, we
kind of had training through our intermediary and our state program manager.
Kind of best practice, and ‘what what's working’ and kind of just sharing some
notes throughout the State for what worked well for others. But yeah, we didn't
really have any training, per se.
As illustrated, providers and families discussed challenges related to the inner settings domain,
involving the availability of materials and equipment (e.g. technology) and access to knowledge
and information (e.g., adequate training).
Individuals. The next domain that providers specifically discussed challenges
encompass the individuals domain. Individuals involved throughout the implementation of the
innovation can involve clients, leaderships from all levels, and innovation deliverers. Individual
characteristics is a subdomain that includes the constructs such as an individual’s needs,
capabilities, opportunities, and motivation can also impact the success of implementation.
Barriers for innovation deliverers (e.g., HV providers) and recipients were most discussed.
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Providers discussed barriers related to all constructs under the characteristics subdomain (e.g.,
capabilities).
To start, many providers described feeling “they weren’t doing enough” and reported
their capability to serve their clients was hindered by various reasons such as not having
adequate training or due to the shortcomings of the technology. One such provider shared more
about their experience:
You don't get to actually see the family. You only get the picture of what they
want [to show you]. You don't know what's going on around them...When we
finally got to see a kid in person, what [they] were telling us on the developmental
screenings was not really what's happening…So things were definitely missed
quite a bit.
Moreover, many providers reported feeling they had a diminished opportunity to fulfill their roles
for a myriad of reasons. Many providers felt the opportunity to conduct holistic assessments of
the needs of clients was sometimes diminished due to the constraints of being on a virtual
platform. That is, some providers feared VHV may lend to limited observations of nonverbal
cues (e.g., body language), inaccurate safety assessment of home environment, and insufficient
assessment of child’s development. The following is an account of one provider’s perspective:
Sometimes the family was dealing with some pretty tough stuff, and you didn't
know. you know if it was a domestic issue you didn't know who was in the room.
You didn't know what Mom felt comfortable talking about, and that was definitely
challenging. I had to search pretty hard for what I found to be good about virtual.
There was a lot of stuff you miss, when a toddler just runs past the screen for a
brief second, you know, developmentally.
In terms of the motivation characteristic of the individuals domain, one supervisor shared that
they believed their providers’ motivation to stay with their organization was also impacted.
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And I think the biggest thing I know about my home visitors, miss kind of like you
were saying. Is that face to face interaction? You know I'd want home as to come
to me a year into it. And just be like this is not the job I signed up for.
Overall, barriers related to individuals included those for innovation deliverers (e.g., HV
providers) and recipients; Providers discussed barriers related to all constructs under the
characteristics subdomain: capabilities, opportunities, and motivation.
Implementation Process. The implementation process domain discusses some key
strategies and processes during implementation of an innovation. The most commonly
discussed barriers were under the constructs teaming and engagement. To illustrate teaming
challenges, a few providers indicated that having to work remotely and the loss of staff due to
turnover affected their ability to connect with others. The following illustrates how one provider
felt isolated during the height of COVID-19:
The isolation is the biggest challenge for both the home visitors, and for the
families, because. you know, not only were we not in homes, we weren't in office
quite a bit, either. So you don't have that support from your fellow home
visitors…You can email people [but] that's not the same. It's not the same…
Especially because we had quite a few newer staff so kind of not having that
connection with both families, and it was just harder to know what was really
going on. It's easy to put on a smile for 5 minutes and say, ‘Everything is going
great’ when you know something's going on.
Additionally, client engagement—or innovation recipient engagement—was discussed most
commonly among providers and clients. This subdomain specifically encompasses encouraging
individuals to participate in the use of intervention or the implementation process. From the
caregivers’ point of view two participants shared they felt their young children were not
necessarily engaged during the use of VHV services, one of which also attributed this
disconnect due to a change in provider.
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It was a little harder to, I guess, connect with the person, but that could also be
because…they kept switching me from person to person. Yeah, so it can be a
little bit harder to connect with the person. Or sometimes I think [my child]
thought she was watching a TV show and not talking to an actual person,
especially when she was a very little baby.
Providers also shared this sentiment and many believed engagement in the use of VHV was
lower for parents and their children alike. That is, many providers highlighted they felt parents
were more distracted when delivering VHV and interactions with children were diminished. One
provider shared that some parents were distracted during errands and did not allow for a fully
engaged session:
Virtual was really hard, because there was just that piece missing like it's just not
as personal, and it's just much easier to be distracted, and I feel like there was a
lot of like ‘I can take this call’ or ‘I can do this zoom on my phone, so that means I
can do it in the car, or I can do it in the grocery store’, and it's like oh, that's not,
you know, it's not what it's supposed to be. That's not how this is supposed to go,
but you know… just meet your clients where they’re at, and that's what that looks
like. It's just you dealing with doing these packets with someone that's in the
grocery store and in their car driving.
Additionally, many providers reported engagement with children was also strained, as many
mentioned how their young clients would often not be able to sit still, often taking the device with
them.
It was really hard to get some families to commit to video, especially with kids of
a certain age of kids who just wanted to hold the phones and run away. And so if
the little kids were easier and the older kids were easier. But it was that one and
a half [year old]. They just want to hold the phone because they used to
Facetime with grandma and everything. So that was really challenging. So for
54
sure, our families hated the video visits, but they did them because it was better
than nothing.
Ultimately, the most commonly discussed barriers for the implementation process domain were
under the constructs teaming and engagement, which impacted providers and their clients.
Conclusion
To conclude, providers and caregivers described various challenges related to the
implementation of VHV. The challenges within the innovation domain included the complexity
and cost of the innovation. Many participants described the learning curve that providers and
clients experienced, particularly during beginning stages of implementation. Some individuals
also expressed difficulty for some families to obtain the necessary tools (e.g., WIFI) to support
smooth implementation. Furthermore, providers and families discussed challenges related to
the inner settings domain, specifically, the availability of materials and equipment (e.g.,
technology) and access to knowledge and information. For example, some providers shared
there was a lack of formal training during the time of implementation. In terms of challenges for
individuals domain, innovation deliverers (HV providers) and recipients (clients) were identified
to be the individuals experiencing the most challenges. Many providers described feeling “they
weren’t doing enough” and reported their capability to serve their clients was diminished by
reasons such as not having adequate training or due to the shortcomings of the technology.
Furthermore, providers spoke to the diminished opportunity to fulfill their roles; Many providers
felt the opportunity to conduct holistic assessments of the needs of clients was sometimes
wanting due to the constraints of being on a virtual platform, including VHV platforms may limit
observations of nonverbal cues (e.g., body language), inaccurate safety assessment of home
environment, and insufficient assessment of child’s development. Finally, the implementation
process was hindered due to teaming issues (e.g., isolation) and diminished engagement with
children and caregivers. Ultimately, there was overlap in consensus regarding hindrances
related to implementation, most of which were highlighted by providers.
55
Overall, these results are in line with previous research in that major barriers included
difficulty with technology, engagement, and accuracy in assessments. Moreover, this is one of
very few, if any, that explicitly use CFIR to guide the understanding of barriers, thus making this
process more systematic and easier to understand from a D&I perspective. While many barriers
that were identified were unsurprising, one theme that was distinct was the sense of providers
feeling their capability was hindered due to limited access to necessary resources. Their
awareness of what contributes to these barriers illustrates their perspectives can contribute to
addressing these issues to better serve their clients. Moreover, although providers were asked
to describe barriers affecting their work and the client experience, it was also interesting to note
that parents had very little to say regarding hindrances in services, alluding to the fact that VHV
could be contributing to a more positive experience than providers believe.

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Facilitators to VHV Implementation
There were many facilitating factors that contributed to the implementation of VHV
services. Using the CFIR, factors will be categorized and described by specific dimensions.
Providers and caregivers discussed facilitators across the following domains: innovation, inner
settings, individuals, and implementation process. The outer setting domain was previously
explored in depth in response to the first research question.
Innovation. Despite its many challenges, many providers and caregivers described
various facilitators to the implementation of VHV and toggling modalities. First, the innovation
itself had many advantageous dimensions that facilitated implementation. Overall, parents
highlighted scheduling, flexibility, and comfort to be an increased relative advantage. Caregivers
shared that the option to have virtual services allowed them to find more flexibility, related to
scheduling, accommodating the times they are not home to host the HV provider, or as an
alternative to cancel an in-person visit due to illness in the home. Furthermore, caregivers
reported an increased ease in scheduling appointments, whether it was to accommodate their
work schedules or their baby’s sleep schedules. In terms of increased comfort, many caregivers
expressed they felt more comfortable not having to prepare their home for visitors but still be
able to receive the services they needed. One such parent discussed how all of these
advantages applied to them:
I didn't necessarily have to, it's bad to say, but like [rush] to clean up. Not that the
house was in a disarray or anything, but I think it's convenient, and then also
scheduling, because I think. At one point, I was also at home during the day for
work, and so it was much easier to just pop on the screen and have to visit than
trying to coordinate with her coming over. And then, when I went back to work, I
could easily do my appointments on my flex Fridays. And it was just easier.
Providers also highlighted similar sentiments relating to all three advantages. Some providers
shared that although they preferred in-person interactions, they had an easier time rescheduling
57
clients when they were virtual, as there were more available time slots. One provider shared the
following:
It was easier to get some families rescheduled through all of that. But again, I still
feel like the-in person is our preferred method, and what families prefer. But
there's just the challenge of sometimes getting the enough hours in the day and
days of the week. That work for everybody at the same time, for the stars to align
is sometimes difficult.
Many providers also spoke to the flexibility that resulted for both the clients and themselves:
I like the flexibility with people with newborns because, you know, you all know
that you can schedule, and you show up at their door, and you know you can tell
the baby just fell asleep, and Mom would really love a shower. But you know,
here you are, so it's time to do the visit and to do what we need to do. But when I
was home I had the flexibility to say, okay, I've been a block out from 9 to noon.
You tell me when's a good time. You know, because I don't want you to feel
pressured just because it's nine o'clock that you have to choose me over taking a
shower by yourself. Take a shower, and then we can meet at 10. So I like the
flexibility.
Providers also noted that their clients seemed more comfortable when using a virtual platform,
whether it was due to not having to clean their home for an in-person appointment or because
they were more willing to share about themselves. One provider shared the following:
It was a lot easier when we did virtual. Sometimes the moms aren't wanting to
get the house clean, or, you know, get up and straighten up. And with virtual they
could set up [the camera with] the wall behind them. They didn't, you know, have
to show us everything because it's rough, you know, sometimes for them. So the
virtual gave them a chance to still have the visit but couldn't see everything.
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Additionally, providers highlighted other relative advantages to having access to a virtual
platform. Three overarching themes providers discussed included increases in efficiency,
accessibility to services and connection with the family. When speaking to efficiency, many
providers mentioned that they were able to schedule more HV appointments per day, given that
they no longer had to account for travel time.
It was definitely a time saver because It's a lot of screen time. We were in front of
our tablets a lot, but you could do a lot of visits. You could pack them in without
worry about travel, because we cover an entire county, which is quite spread out.
So it did make it easier.
Moreover, many providers shared they believed offering virtual services provided families with
increased access to services, particularly those experiencing housing instability. One provider
shared their experience:
If a parent is homeless but maybe they still have their phone. You know. There
were so many programs that were giving out laptops and things like that so they
were able to feel more secure and contacting us and having virtual visits instead
of feeling like, you know, we need to go to a hotel which some people don't want.
[Virtual services] does have the benefit of us being able to reach more parents,
that maybe even really we had some programs out here in [our county] that got
full. And so some of our programs were able to take them, even though they lived
over 60 miles away, you know.
Relatedly, many providers mentioned that offering virtual services enabled clients to feel more
connected to service providers (e.g. ability to receive services when in-person is not ideal) and
offered them an opportunity to connect with other adults as part of a support system. One
example of this is highlighted by one provider’s account:
And sometimes we're maybe the only grown-up human they've had contact with.
So even talking to one of us on the phone or, you know, through zoom. Whatever
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helps. Let them feel connected to another grown up. Our community’s a rural
community, and [we] have very little public transportation. So, some of our
families are, you know, out there without [adult contact]. If the dad works and the
Mom's home, she can't go anywhere, so they do appreciate some kind of
connection, for sure.
When speaking to the adaptability of the innovation, one overarching theme was increased
creativity lending to better adaptation. Adaptation of an innovation signifies that it can be
modified and tailored to adjust to the needs or context in which it will be implemented. Many
providers viewed VHV services to be a modification of traditional in-person services, where they
can interact with children and families despite not being able to see them in person. Moreover,
providers shared that they could modify the curriculum to fit the online platform and refine to the
needs and limitations of the context. Despite other providers viewing this as a challenge, some
providers welcomed this as an added benefit.
It was definitely a little more of an interactive, you know, a little more creativity
with how to do that and engage. One thing that I really did feel was very eye
opening is that as a home visitor, you bring things into the home with ideas, and
when you do a virtual. You rely on the families to have things prepared, and they
really do have things around their homes that we could be using for those
learning opportunities. So from that standpoint I really enjoyed that.
Lastly, many providers spoke to the saved cost related to using VHV service delivery. Many
providers shared they could dedicate the time reserved for traveling to client homes to instead
offer more appointment options for families. Not only were providers reducing the “wearing
down of their cars” but the organizations were also able to reallocate funds from mileage
reimbursements to cover other immediate expenses.
Another thing I just thought of was program wise. We had a lot of savings and
mileage, so all the mileage that we had put for travel, we didn't have any travel,
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and so we were able to get the grants modified so that we can use it for more
emergency supplies. So that was a great thing to be able to get clients,
emergency supplies, groceries, things like that because of all the savings and
mileage that we had.
Inner Settings. Overall, providers highlighted facilitators related to information
technology infrastructure, recipient centeredness, tension for change, and available resources.
Many providers emphasized that their handout and documentation had been digitized and
electronically accessible to their clients for their VHV, through email, on the organization’s
website, or even through text, facilitating easier communication and competition of the
curriculum. Furthermore, various providers and caregivers shared how the use of VHV was
facilitated through recipient-centered beliefs in that many organizations allowed the continued
use of virtual platforms to deliver services to accommodate the needs of the families. Many
providers also discussed that a prominent facilitator was the tension for change, as restrictions
resulting from COVID-19 pandemic led to many organizations unable to deliver services and
clients without crucial resources. As such, many organizations sought to adapt and provide
services virtually. Availability of resources was also an important facilitator to implementing VHV
services. Many providers shared that external and reallocation of internal funding became
available to provide the materials and equipment (e.g., tablets and hotspots) necessary to
deliver virtual services. While not all providers had the same experience, many providers
discussed the most helpful training–as many indicated they did not receive any other formal
training on VHV-was offered through RR VHV; one HV supervisor shared their experience:
I do find it incredibly helpful that newer staff can go back and look at previous
webinars on their site they wouldn't have seen. They're still very helpful. My
program appreciates it. Still, [available] as a resource.
Individuals. Next, providers and caregivers shared how roles and characteristics under
the individuals domain served as facilitators for implementation. Specifically, providers
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highlighted how implementation facilitators and innovation deliverers were particularly important.
One prominent implementation facilitator that providers spoke about was RR VHV collaborative.
As previously mentioned, not many providers reported receiving training for VHV but some
noted that the resources RR VHV offered was crucial. One participant discussed how RR VHV
resources helped them.
I did spend a lot of time watching the Rapid Response [trainings], attending the
workshops, because. even though I wasn't like physically working, I was at home
working, and I needed to continue to keep this going. And then we did the Zoom
Meetings, phone call meetings. text meetings, you know. Just, however, we
could connect with it.
Caregivers also expressed their gratitude that regardless of any challenges, providers often
showed they were capable and motivated to fulfill their roles of implementing and delivering
crucial services, as illustrated by one caregiver’s account:
The worker that we have currently, she's been very supportive of that process of
getting my son into [ABC program], which is a program that helps kids. He has a
language delay or had a language delay due to that gap of like a year and a half
of no day care during Covid. And so she was an integral part to him, getting
linked to [ABC program], like putting in the referral, you know, helping us with the
process, being present for the meeting, providing support with what she had
encountered or experience with my child. So we are really thankful for the
program.
Implementation Process. Many dimensions of the implementation process were
explored, particularly relating to teaming, assessing needs, and tailoring strategies. First, some
providers shared that they often worked with their colleagues to strategize on how to implement
VHV services; this included making resource “drop offs” together for their clients or discussing
best practices. Furthermore, many providers indicated that their organizations would survey or
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ask clients (and sometimes providers within their agencies) for their preferences and needs in
order to best deliver services (e.g., whether they would want to continue VHV services in the
future). Many providers highlighted various strategies that facilitated the implementation of VHV
that would most benefit their clients. The most participants mentioned strategies included
meeting families outside the home (e.g., nearby parks or libraries), delivering resources to
families, group sessions, toggling between modalities, and modeling. Strategies that supported
providers included group activities and reflective supervision.
First, while many families enjoyed meeting in-person, restrictions preventing in-person
contact during COVID-19 or due to the preference of not wanting other people inside their
homes, providers would meet with families at a neutral location while at a safe distance. One
provider described their experience:
Once vaccinations started happening, and things started opening up a little bit,
we were able to offer meetings like outside in person, when we weren't doing
home visits. But we could meet outside and [follow] masking policies and things
like that.
Additionally, delivering resources to clients was a common strategy used by many providers, to
provide tools necessary to families for upcoming appointments and facilitate engagement.
I would deliver the curriculum a day before the visit so that I knew that the parent
would have the curriculum, and when we sat down to do the visit I would ask
them to show me the physically, pick up the curriculum and put it on the camera,
so I knew that they were looking at what I was looking at.
Providers also shared they developed group sessions with different families to foster better
engagement and address isolation challenges among families. The following is an example of
one provider’s experience.
When we would do our socializations, because we were also doing those on
where [clients] all come together at once. We were going out and delivering the
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materials to each family and just dropping it off at their door. You know we didn't
have to see them necessarily, but we did that. We just went above and beyond,
and just did it. No one our directors, and what not, didn't say ‘This is what you
should do.’ but we wanted to be the most successful. We could with the virtual
platform by providing them with the activity in advance, so that when they came
on the social zoom they had the materials, and everyone was. It was pretty cool,
because everybody was doing the craft, you know, at the same time. And then
we say, oh, let us see your frog, or whatever it was, and they would all hold it up
and stuff, and we go around the zoom.
It was also clear that there were mixed feelings about only conducting in-person visits or just
virtual. As such, many providers shared that even if their organizations are encouraged to be
fully in-person, virtual sessions can be used as a tool to avoid canceling sessions altogether and
allowing them to meet the client where they are. Thus, most providers delivered their sessions
in a hybrid approach. One provider shared their experience:
We had to do a complete 180 from a home visitation program to providing virtual
services. So we did it virtually. Really, however, the families whatever worked for
them, whether that be Zoom or Whatsapp or Facetime. We just tried to make it
work, and we're just now within the last probably 6 months getting back to normal
quote unquote normal, and the expectation is, we're back in the home. But now
that we've shown that we can do it virtually. We can offer that as an option to
parents, if that is their preference.
Moreover, various providers shared there was a shift in how they interacted with families.
Whereas before providers would model behaviors for parents to follow, providers would
empower parents through the act of coaching. Whether it was encouraging parents to identify
materials already in their possession to complete activities or allowing providers to be a quiet
observer, this introduced a different way of supporting families.
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We've been moving really forward to the parent coaching model instead of the
medical model that we had previously… COVID happened and it forced us to go
remote. It really forced that parent coaching right? Because I do not expect a
two-year-old or one year old to engage with me on a TV screen. It's not realistic.
So I didn't need the mom to be chasing... He does not even need to know that I
existed in the room. I was just the eyes and the little voice, you know, piece in
Mom's ear. So that parent coaching was a lot easier to do... You don't tell a 2-
year-old to get away from him when they run over to you... So it was all coaching.
Relatedly, providers spoke to the primary strategies that helped overcome implementation
barriers: group activities and reflective supervision. Group activities were often based on RR
VHV resources and seemed to make a great impact on team dynamics and on the individual
level. Reflective supervision was also important to many providers and supervisors, as it
allowed for more refinement of practice and social support. One supervising provider shared
their organization’s strategy:
Last year, we had biweekly staff meetings where we would share a lot of
information and give updates and have trainings and things but then our staff
really wanted to connect. So, we actually took a lot of the ideas from the [RR
VHV] webinars, and we had an alternate biweekly time, where we would play fun
games, and we kind of just hung out, and the staff. I really wanted them to take
ownership and make it their time. So they all took terms, leading the group and
we found a lot of cool ideas online that we implemented, you know, scavenger
hunts around your house and come show everybody else what you found, and
that kind of stuff. I think one of the things that has been really cool for our team.
Later last year we did a few outdoor in-person group events. We had a summer
group with a cookout and a local pool and that kind of stuff. And then in the fall
they had a parent playgroup at a playground, and that was really neat because
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the team was working towards a collective goal. and I think it really brought them
together.
Conclusion
Overall, there were many facilitators related to the implementation of VHV, spanning all
CFIR domains. Regarding the innovation, parents highlighted scheduling, flexibility, and comfort
to be an increased relative advantage. Three overarching themes of relative advantages
providers discussed included increases in efficiency, connection with the family, and
accessibility to services. In terms of the adaptability of the innovation, one prominent theme was
increased creativity lending to better adaptation. Lastly, many providers spoke to the saved cost
related to using VHV service delivery. Many providers shared they could dedicate the time
reserved for traveling to client homes to instead offer more appointment options for families.
When discussing inner setting related factors, providers highlighted facilitators related to
information technology infrastructure, recipient centeredness, tension for change, and available
resources. These factors included the infrastructure to digitize curriculum, adapting to client
needs, and a rise in available resources (e.g., tablets) to help facilitate the implementation of
VHV. Moreover, highlighted how implementation facilitators and innovation deliverers were
particularly important, which are part of the individuals dimension of the CFIR. Caregivers
expressed their appreciation for their providers going above and beyond for their clients,
speaking to the providers’ capability and motivation to implement and deliver crucial services.
Lastly, providers highlighted important aspects of the implementation process including teaming,
assessing needs, and tailoring strategies. Providers shared they often worked together to
provide clients the best service possible, such as dropping off resources to client homes and
providing group activities. Undoubtedly, providers and families found many benefits from the
implementation of VHV. Many aspects described by the CFIR served as facilitators to
implementation and contributed to favorable experiences.
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Many of the cited facilitators were common across previous research, particularly
flexibility and efficiency. Similarly to barriers to implementation, there were also distinct
facilitators that have not been previously captured in past research. For example, strategies
identified by participants including seeing clients outside of home or toggling to virtual service
delivery have not been identified before. These are critical pieces to highlight as more is learned
about how to effectively implement VHV services. Particularly because not many parents had
negative experiences with their HV services, it implies that HV providers are able to identify
quality strategies that are effective and helpful. As such, the more facilitators and strategies are
discussed, the better the client experience.

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Research Question 3: Which factors are related to provider well-being during the rapid
implementation of VHV?
Burnout among HV providers can have far-reaching consequences, affecting both the
well-being of providers and the effectiveness of the organizations they work for. Physically and
mentally, burnout can lead to difficulties such as sleep problems, mood swings, negative
attitudes, and even substance abuse. At an organizational level, it can result in decreased
productivity, a higher intention to leave the organization, and increased turnover rates.
Moreover, burnout can strain the relationships between providers and clients, influencing
decision-making and a provider's ability to be fully present with their clients, ultimately limiting
their capacity to help clients achieve their goals. Consequently, addressing burnout becomes
paramount. Effective strategies for managing burnout include the presence of supportive
leadership within organizations. Providing clear training and resources for client interactions and
emotional coping mechanisms can help HV providers feel supported and resilient. Peer support
is also crucial, as informal conversations among colleagues can offer insights into client
situations and effective coping strategies. Studies highlight the importance of protective factors
such as supervisor and coworker support, multidisciplinary consultant groups, training
opportunities, and access to necessary supplies. While mitigating burnout has been crucial
across many fields, burnout of the innovation deliverer is not often discussed during
implementation. As such, this chapter will explore which types of resources/support significantly
relate to less burnout.
Data
Demographics. The majority of participants identified as female (n = 1,677), White (n =
880), over 3 years of experience, and are home visitors.

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Table 3. Survey Participant Demographics
n %
Gender
Male 19 1.11
Female 1,677 98.24
Non-binary/Third gender 11 0.64
Race
White 880 51.73
Hispanic or Latino 413 24.28
Black or African American 303 17.81
AAPI
a
32 1.88
Mixed Race 14 0.82
American Indian or Alaska Native 59 3.47
Years in Field
Less than 1 year 129 9.42
1-2 years 162 11.83
3-5 years 302 22.06
6-10 years 276 20.16
10 + years 500 36.52
Role
Home Visitor 967 69.87
Manager 70 5.06
Supervisor 191 13.8
Director 49 3.54
Other 107 7.73
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a
Note. AAPI: Asian American & Pacific Islander.
Hierarchical Linear Model for Well-being
In the initial phase of analysis, Pearson’s correlations were calculated between all
variables to explore bivariate relationships and screen for collinearity issues. See Table 4.
No collinearity issues were present; thus all predictor variables were retained for hierarchical
linear modeling (HLM) analysis. An unconditional model was first used to examine reported
levels of burnout to provide baseline statistics for evaluating more complex models
(Raudenbush & Bryk, 2002). Ultimately, a full model included demographic variables and
provider-focused implementation facilitators as predictors and provider burnout as the outcome
of interest. Demographic variables included: race, gender, and number of years in the HV field,
and role. The first five variables considered implementation facilitators included whether
providers received the following type of support to toggle between virtual and in-person home
visitation: training, consultation group, peer-to-peer support, supervisor support, and technology.
Participants who reported receiving each would receive a “1” in those corresponding categories
and providers who reported not receiving these reports or had missing data would receive a ”0.”
The next two predictors asked to report to what degree they perceived training or supervision to
be adequate when toggling between modalities. Finally, the last predictor was whether or not
HV providers made the decision of when to switch between modalities. All models were
analyzed using full maximum likelihood within STATA 16 software (StataCorp., 2019).

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The equation for the full model is as follows:
Burnoutij = !0j + !1j Raceij + !2jGenderj + !3j YearsInFieldij+ !4j Roleij + !1j trainingij +
!1jConsultationGroupij + !1j PeerSupportij + !1j SupervisorSupportij + !1j Technologyij + !1j
AdequateSupervisionij + !1j AdequateTraining + μ oj + r ij
The unconditional model showed that the mean score of burnout was 11.51 units (SE =
0.29). The full model reflected that compared to their white counterparts, participants identifying
as mixed race reported 6.33 more units of burnout, holding all other variables constant (p =
0.004). No other race reported significantly different results. Additionally, compared to male
participants, female participants reported 5.85 fewer units of burnout, when all other variables
were held constant (p = 0.005). Moreover, when exploring the relationship between years in the
field and burnout, those with 6-10 years reported 1.88 units more burnout (p = 0.022), compared
to those with less than 1 year of experience and accounting for all other variables. When
compared to HV direct providers, participants in managerial and supervisory positions were
reporting 2.68 (p = 0.005) and 1.78 (p = 0.004) more units of burnout, respectively.
Table 5. Hierarchical Linear Model Predicting Well-being
Variable Coef. Std. Err. p-value
[95% Conf. Interval]

Race
Hispanic or Latino -0.617 0.539 0.252 -1.673 0.439
Black or African American -0.953 0.586 0.104 -2.100 0.195
AAPI -1.729 1.699 0.309 -5.060 1.602
Mixed race 6.327 2.186 0.004 2.043 10.612
American Indian or Alaska
Native 0.813 1.117 0.467 -1.377 3.002

Gender
Female -5.854 2.085 0.005 -9.942 -1.767
Non-binary/Third gender 0.947 3.335 0.776 -5.589 7.484

Years in Field
72
1-2 years 1.259 0.878 0.152 -0.463 2.980
3-5 years 1.440 0.800 0.072 -0.129 3.009
6-10 years 1.877 0.817 0.022 0.276 3.478
More than 10 years 1.011 0.769 0.189 -0.496 2.519

Role
Manager 2.679 0.949 0.005 0.820 4.539
Supervisor 1.781 0.617 0.004 0.571 2.991
Director 0.159 1.112 0.887 -2.020 2.337
Other 0.642 0.822 0.435 -0.969 2.252

Adequate Supervision -0.728 0.243 0.003 -1.204 -0.252
Adequate Training -0.606 0.244 0.013 -1.084 -0.128
Training 0.481 0.433 0.266 -0.367 1.330
Consultation Group -1.252 0.734 0.088 -2.690 0.187
Peer Support 0.156 0.458 0.733 -0.741 1.054
Supervisor Support -1.194 0.463 0.010 -2.101 -0.288
Technology -0.708 0.438 0.106 -1.567 0.151
HV Decision to Toggle -0.309 0.433 0.474 -1.157 0.538
Intercept 20.771 2.272 0.000 16.319 25.223

Furthermore, the presence of supervisor support corresponded with 1.10 fewer units of
burnout compared to those who did not report burnout (p = 0.010). Finally, for every unit
increase of perceived adequacy of supervisor support, participants reported 0.73 fewer units of
burnout (p = 0.003). Similarly, every unit increase of perceived adequacy in training correlated
to 0.61 units fewer units of burnout, holding all other variables constant (p = 0.015). Ultimately,
2.82% of variation in burnout occurs between states.
Clearly, the presence supervisor support as well as perception of adequate training and
supervisor support were associated with lower levels of burnout, while others were not
significantly related. That is, not only did it matter whether supervisor support was present, the
degree to which it was perceived to be adequate was also important. Although the presence of
training was not significantly associated with burnout, the level of agreement that the available
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training was adequate was also inversely related to burnout. These findings are consistent with
previous research regarding burnout. However, this is an important finding when it comes to its
influence on burnout during implementation. This is because not only are providers delivering
services but they are also learning to implement a new service simultaneously, possibly adding
another cause for burnout. It must be noted that the average level of burnout was 11.51 units
(SE = 0.29) when nesting providers within their prospective states. This level is not particularly
high, indicating that these providers' well-being is fairly positive. However, since these
participants were part of the RR VHV listserv, this indicates that they had access to some
existing resources and tools other providers in general may not have had accessed. This
implies that this sample’s access to resources through RR VHV could have played a role in
mitigating burnout. Another explanation for this can be that providers in this field are fairly
resilient when faced with these changes. These providers may be accustomed to adapting and
learning as they interact with clients. Moreover, switching to online platforms could have
afforded providers flexibilities and convenience, that was otherwise not available when
conducting sessions completely in-person. Overall, these findings serve as a foundation to
understand what role resources play in protecting providers from burnout during the
implementation of VHV and as they find a new balance between modalities after the pandemic.
Future research should further explore how provider burnout impacts client experience long-
term during implementation and which supports are necessary to mitigate burnout. While well-
being is not an intention focus in the CFIR, these finds may provide a basis of rationale for
incorporating these dimensions in the future.

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Chapter 5: Discussion
This dissertation sought to understand the rapid and wide-scale implementation of VHV
during and following the COVID-19 pandemic through provider and client perspectives.
Specifically, this dissertation sought to explain the role policies play throughout all steps of
rapidly incorporating virtual platforms within the HV field: dissemination, implementation, and
delivery. Moreover, identifying barriers and facilitators to VHV implementation following the
COVID-19 pandemic was also a main focus. Finally, this dissertation sought to identify which
factors are associated with lower levels of burnout among providers as a way to facilitate
implementation.
Throughout the COVID-19 pandemic, policies within and external to HV service
organizations enabled rapid adaptation of service delivery methods. Both Kingdon's Multiple
Streams Framework and the CFIR were applied to understand the role of policies. First,
Kingdon’s Framework was applied to explain the initial stages of the incorporation of VHV: the
dissemination and initial stages of implementation. This framework helped illustrate how the
pandemic affected policies across the problem, policy, and politics streams, emphasizing the
increased challenges faced by underserved communities. The adaptation of virtual platforms for
client care, inspired by changes in other fields like healthcare, became a valuable strategy.
Policymakers and funders facilitated the transition to technology-enabled care, even beyond the
state of emergency, although specific policy impacts on providers' work were not explicitly
mentioned. Secondly, the CFIR provides a structured lens to understand the role policies play—
within and outside of the organization–-specifically during the implementation and delivery of
VHV. Thus, guided by the CFIR, the inner organizational context emphasized a client-centered
culture, with a focus on meeting client preferences and technological needs. The outer context
encompassed influences from the pandemic, external policies, and partnerships.
Given the widescale and rapid nature of VHV implementation, this dissertation serves as
both a retrospective and current assessment— as the implementation of VHV is still ongoing—
75
of implementation barriers and facilitators during unprecedented circumstances. These findings
provide support for organizations to understand the challenges providers experience while
implementing and delivering services in order to better support them. Furthermore, the benefits
highlighted by providers and clients could provide a basis for rationale why policies should
continue to allow the ability to use VHV when appropriate, as the overall sentiment is that
leveraging virtual platforms have been a suitable method to reach clients when in-person
methods were not a viable option.
As noted by many providers and some caregivers, the implementation of VHV involved
notable barriers. These barriers encompassed various dimensions of the innovation, particularly
its complexity and cost. The learning curve for both providers and clients, especially during the
initial stages of implementation, was also a prominent issue. Some families faced difficulties in
obtaining the necessary tools like Wi-Fi for smooth implementation, highlighting the inequitable
access that some families experience. The inner settings domain contained barriers related to
the availability of materials and equipment, including technology, as well as access to
knowledge and information. Providers noted a lack of formal training during implementation,
potentially affecting their ability to perform their job and the client’s experience. Due to the rapid
nature of implementation required to continue care during the pandemic, organizations—the
inner setting— may not have been immediately equipped to support all families or providers with
necessary tools. Moreover, challenges in the individuals domain, affecting both HV providers
and clients, were noted; Providers expressed feelings of inadequacy and limitations in serving
their clients due to insufficient training and technological shortcomings. The virtual platform
constrained the holistic assessment of client needs, as it limited observations of nonverbal cues,
safety assessments of home environments, and assessments of child development.
Additionally, teaming issues and reduced engagement with children and caregivers hindered the
implementation process. While many of these barriers align with prior research, this dissertation
uniquely applied the CFIR to systematically understand barriers, elevating the necessary
76
perspectives of providers and caregivers. Interestingly, parents had relatively little to say about
hindrances in services, suggesting that VHV might offer a more positive experience for them
compared to providers' perceptions. Moreover, multiple caregivers expressed their sincere
gratitude for all the efforts HV providers have put forth. Nonetheless, more awareness of
possible barriers to implementation in this unique context can help inform the ongoing
implementation of VHV.
The implementation of VHV highlighted several facilitating factors that spanned across
all CFIR domains and allowed for the implementation of VHV services. Parents appreciated the
scheduling flexibility, comfort, and increased relative advantages. Providers, on the other hand,
noted increased efficiency, improved connections with families, and enhanced service
accessibility as overarching themes of relative advantages. The adaptability of VHV was a key
theme, with increased creativity enabling better adaptation. Cost savings, attributed to reduced
travel time, were also a prominent facilitator mentioned by providers. Within the inner setting,
facilitators related to information technology infrastructure, recipient-centeredness, a willingness
for change, and available resources played crucial roles. These included the ability to digitize
curriculum, adapting services to meet client needs, and the availability of resources like tablets
to support VHV implementation. The importance of implementation facilitators and the
individuals dimension of the CFIR was highlighted, with caregivers appreciating providers'
dedication and motivation to deliver essential services. Additionally, providers emphasized
aspects of the implementation process such as teamwork, needs assessment, and tailored
strategies, with collaborative efforts to enhance service quality. These facilitators align with
previous research, particularly in terms of flexibility and efficiency. However, some distinct
facilitators, such as creative strategies like seeing clients outside of the home, were identified in
this study. These findings suggest that home visiting providers are able to identify effective
strategies to enhance VHV implementation, ultimately contributing to a positive client
77
experience. Collectively, the identification of facilitators and effective strategies enhances the
understanding of successful VHV service delivery.
Quantitative results revealed that various types of support were associated with differing
levels of burnout among providers, emphasizing the significance of the perceived adequacy of
these supports. Specifically, the presence and perceived adequacy of supervisor support and
perceived adequacy of training were linked to lower levels of burnout. These findings align with
previous research on burnout, underscoring their importance in the context of implementation.
It's noteworthy that the average level of burnout among the participants was relatively low,
possibly due to their access to existing resources and tools through the RR VHV initiative. This
implies that access to resources may have played a role in mitigating burnout among this
sample. These findings provide a foundational understanding of how resources can protect
providers from burnout during VHV implementation and as they navigate the transition between
modalities after the pandemic. Future research should further explore the long-term impact of
provider burnout on the client experience during implementation and identify the necessary
supports to alleviate burnout. Additionally, based on these findings, considering the effects of
innovation deliverers’ (e.g. VHV providers) well-being in implementation frameworks like CFIR
could be valuable and support successful implementation.
Limitations
While this dissertation provides valuable insights into both D&I and HV fields, it is
important to acknowledge its limitations. Identifying and discussing the limitations of this study is
essential to ensure a comprehensive understanding of its findings and implications. The
limitations in this study include the generalizability of the current sample, inter-rater reliability
scores, using cross-sectional data, and using burnout as a proxy for well-being.
One of the primary limitations of this dissertation was using a sample of individuals
participating in RR VHV. While this was a diverse sample, findings may not be generalizable to
other individuals who did not receive the same access to training and materials. That is,
78
perception of training or well-being for this sample of individuals may have been different
compared to other providers who had only had access to training or support provided by their
organizations. Another limitation is the inter-rater reliability score (kappa = 0.56) among the
coding team who analyzed the focus group interviews. This may affect consistency in
assessments and validity of the analysis. However, to overcome this shortcoming multiple steps
were taken. Specifically, the coding matrix and protocol were continually refined to include the
valuable and diverse perspectives of the individuals on the coding team; additionally, two team
members coded each transcript and any differences were discussed as a team.
Moreover, while cross-sectional data have been valuable for this dissertation in
understanding VHV implementation, it is crucial to recognize and address the inherent
limitations associated with this research approach. Because cross-sectional data capture
information at a specific moment, we cannot make causal claims about the relationships
observed in our study. This limitation restricts our ability to infer causality or establish temporal
sequences. The use of cross-sectional data limits the tracking of changes or developments over
time, which may be essential for understanding dynamic processes within our research domain.
For example, it would be difficult to establish the true impact of well-being of providers, as it may
take time to see its long-term effects. However, while cross-sectional data have limitations
related to causality, temporal ambiguity, and long-term effects, they remain a valuable tool in
this dissertation to build future research on.
Finally, assessing well-being based solely on burnout may not provide a holistic view of
a provider’s well-being. Many other factors, such as physical health or elements related to
secondary traumatic stress (e.g., Begic et al., 2019) can provide a more comprehensive
assessment of well-being. Thus future research should focus on integrating more elements to
assess well-being.
Overall, the limitations in this study including the generalizability of the current sample,
inter-rater reliability scores, using cross-sectional data, and using burnout as a proxy for well-
79
being may impact the generalizability of results. However, this dissertation took measures to
mitigate the impact of any shortcomings and more importantly, leveraged important data to
inform HV and D&I fields during an unprecedented experience of a pandemic.
Implications
Having examined the data and results, it is important to consider the implications of this
dissertation. In this section, the implications of the research findings for the implementation of
VHV are explored. As previously discussed, this dissertation revealed the critical role policies
play for disseminating, implementing, and delivering VHV; identified barriers and facilitators
across CFIR domains; and highlighted factors that relate to less burnout. Thus, this section
explore includes implications to policies, practice, and research as they pertain to the current
findings.
Policy changes were crucial to the implementation of VHV services throughout the
course and following the COVID-19 pandemic. The current research could inform policymakers
of the increased accessibility and positive experiences many providers and caregivers have had
with VHV thus far. For example, despite some drawbacks, toggling between in-person and VHV
has been a commonly used tool to increase client engagement, as discussed by many providers
and caregivers. This signifies that policymakers should continue supporting policies that allow
VHV to be leveraged to increase access for families during times in-person sessions are not
feasible. On the other hand, results from this dissertation highlighted existing inequities during
implementation and delivery. For example, not all families had continued access to the
technology or support that is required to receive virtual services, thus hindering their experience.
While policies such as funding reallocation to address these inequities permitted organizations
to provide these resources, these policies can change and limit accessibility in the future. This
further supports the notion that research should further explore VHV implementation so that
policies can support equitable experiences for families in need.
80
Many organizations pressured HV providers to continue delivering services while
implementing new practices. Since the implementation had to occur quickly, there was some
shortsightedness related to the innovation implementation in context of support for delivery.
While in D&I research, factors such as those highlighted in the CFIR are deemed imperative to
implementation, these are often compromised during rapid implementation. Thus, it is important
to understand which factors are crucial and non-negotiable when implementing in real-world
context, where circumstances are not always favorable. Additionally, it is important to recognize
the value of provider well-being during implementation and service delivery, as providers are the
drivers of implementation while oftentimes simultaneously delivering services. Thus, mitigating
burnout for these individuals should be a priority when seeking to successfully implement new
practices.
Moreover, research findings from this dissertation can be used to establish the
foundation for understanding rapid implementation during and following the pandemic. Beyond
its immediate applications, this research contributes to the ongoing dialogue how to strengthen
D&I research and its applicability in the HV field. Although there are a few studies that highlight
some of these areas of barriers, facilitators, and protective factors, very few to date have
intentionally applied a D&I lens through the incorporation of the CFIR to understand
implementation and service delivery (e.g., Traube, 2021a). While VHV has existed prior to the
pandemic and these practices have been in play for a few years now, HV organizations are still
finding a new normal in a balance of VHV and in-person services signifying that the
implementation process is still in progress. Overall, the findings from this dissertations sheds
light on experiences and expertise from providers and the clients they serve to better
understand the implementation of VHV.
Future Directions
Future directions in this research should further explore dimensions of VHV that can help
its sustainability over time. Given that policies have allowed for continued use for now, it is
81
important to continue learning how to improve and sustain these practices. Relatedly, barriers
and facilitating factors may change over time and thus should be continually assessed to
improve the implementation. This research could help establish a foundation for understanding
that burnout plays a significant role in the delivery of services as well as during the
implementation of adapted services. Thus, future research should consider intentionally
outlining provider burnout and protective factors as part of implementation so organizations can
support those who drive the delivery and implementation of programs.

82
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R. (2023). Home visitation program staff attitudes and intentions towards using digital
technology to educate families about preventing early childhood obesity: A qualitative
study. Maternal and Child Health Journal, 1–9. https://doi.org/10.1007/s10995-023-
03731-3

Zhang, Zhang, S., & Hua, W. (2019). The impact of psychological capital and occupational
stress on teacher burnout: Mediating role of coping styles. The Asia-Pacific Education
Researcher, 28(4), 339–349. https://doi.org/10.1007/s40299-019-00446-4
88
Appendices
Appendix A: Consolidated Framework for Implementation Research…………………………… 89
Appendix B: Comparison Between Original and New CFIR………………………………………. 95
Appendix C: 2022 RR VHV Participant Survey…………………………………………………… 109
Appendix D: Rapid Response Virtual Home Visitation Experts by Experience
(Caregiver) Semi- Structured Interview Guide…………………………………………………….. 119

Appendix E: Rapid Response Virtual Home Visitation Home Visitor Focus Group Guide…… 121
89
APPENDIX A
CONSOLIDATED FRAMEWORK FOR IMPLEMENTATION RESEARCH
I. Innovation domain
Innovation: The “thing” being implemented , e.g., a new clinical treatment, educational program, or city service
Project Innovation: [Document the innovation being implemented, e.g., innovation type, innovation core vs.
adaptable components, using a published reporting guideline. Distinguish the innovation (the “thing” that continues
when implementation is complete) from the implementation process and strategies used to implement the
innovation activities that end after implementation is complete)]
Construct name Construct definition
The degree to which:
A. Innovation
Source
The group that developed and/or visibly sponsored use of the innovation is reputable, credible,
and/or trustable
B. Innovation
Evidence Base
The innovation has robust evidence supporting its effectiveness
C. Innovation
Relative
Advantage
The innovation is better than other available innovations or current practice
D. Innovation
Adaptability
The innovation can be modified, tailored, or refined to fit local context or needs
E. Innovation
Trialability
The innovation can be tested or piloted on a small scale and undone
F. Innovation
Complexity
The innovation is complicated, which may be reflected by its scope and/or the nature and
number of connections and steps
G. Innovation
Design
The innovation is well designed and packaged, including how it is assembled, bundled, and
presented
H. Innovation
Cost
The innovation purchase and operating costs are affordable
II. Outer Setting domain
Outer Setting: The setting in which the Inner Setting exists, e.g., hospital system, school district, state. There may
be multiple Outer Settings and/or multiple levels within the Outer Setting, e.g., community, system, state
Project Outer Setting(s): [Document the actual Outer Setting in the project, e.g., type, location, and the boundary
between the Outer Setting and the Inner Setting.]
Construct name Construct definition
The degree to which:
A. Critical
Incidents
Large-scale and/or unanticipated events disrupt implementation and/or delivery of the
innovation
90
B. Local
Attitudes
Sociocultural values (e.g., shared responsibility in helping recipients) and beliefs (e.g.,
convictions about the worthiness of recipients) encourage the Outer Setting to support
implementation and/or delivery of the innovation
C. Local
Conditions
Economic, environmental, political, and/or technological conditions enable the Outer Setting to
support implementation and/or delivery of the innovation
D.
Partnerships &
Connections
The Inner Setting is networked with external entities, including referral networks, academic
affiliations, and professional organization networks
E. Policies &
Laws
Legislation, regulations, professional group guidelines and recommendations, or accreditation
standards support implementation and/or delivery of the innovation
F. Financing Funding from external entities (e.g., grants, reimbursement) is available to implement and/or
deliver the innovation
G. External
Pressure
External pressures drive implementation and/or delivery of the innovation
Use this construct to capture themes related to External Pressures that are not included in the
subconstructs below
1. Societal
Pressure
Mass media campaigns, advocacy groups, or social movements or protests drive
implementation and/or delivery of the innovation
2. Market
Pressure
Competing with and/or imitating peer entities drives implementation and/or delivery of the
innovation
3.
Performance
Measurement
Pressure
Quality or benchmarking metrics or established service goals drive implementation and/or
delivery of the innovation
III. Inner Setting domain
Inner Setting: The setting in which the innovation is implemented, e.g., hospital, school, city. There may be multiple
Inner Settings and/or multiple levels within the Inner Setting, e.g., unit, classroom, team
Project Inner Setting(s): [Document the actual Inner Setting in the project, e.g., type, location, and the boundary
between the Outer Setting and the Inner Setting.]
Construct name Construct definition
The degree to which:
Note: Constructs A – D exist in the Inner Setting regardless of implementation and/or delivery of the
innovation, i.e., they are persistent general characteristics of the Inner Setting
A. Structural
Characteristics
Infrastructure components support functional performance of the Inner Setting
Use this construct to capture themes related to Structural Characteristics that are not included
in the subconstructs below
1. Physical
Infrastructure
Layout and configuration of space and other tangible material features support functional
performance of the Inner Setting
91
2.
Information
Technology
Infrastructure
Technological systems for tele-communication, electronic documentation, and data storage,
management, reporting, and analysis support functional performance of the Inner Setting
3. Work
Infrastructure
Organization of tasks and responsibilities within and between individuals and teams, and
general staffing levels, support functional performance of the Inner Setting
B. Relational
Connections
There are high quality formal and informal relationships, networks, and teams within and
across Inner Setting boundaries (e.g., structural, professional)
C.
Communications
There are high quality formal and informal information sharing practices within and across
Inner Setting boundaries (e.g., structural, professional)
D. Culture There are shared values, beliefs, and norms across the Inner Setting
Use this construct to capture themes related to Culture that are not included in the
subconstructs below
1. Human
Equality-
Centeredness
There are shared values, beliefs, and norms about the inherent equal worth and value of all
human beings
2. Recipient-
Centeredness
There are shared values, beliefs, and norms around caring, supporting, and addressing the
needs and welfare of recipients
3. Deliverer-
Centeredness
There are shared values, beliefs, and norms around caring, supporting, and addressing the
needs and welfare of deliverers
4. Learning-
Centeredness
There are shared values, beliefs, and norms around psychological safety, continual
improvement, and using data to inform practice
Note: Constructs E – K are specific to the implementation and/or delivery of the innovation
E. Tension for
Change
The current situation is intolerable and needs to change
F.
Compatibility
The innovation fits with workflows, systems, and processes
G. Relative
Priority
Implementing and delivering the innovation is important compared to other initiatives
H. Incentive
Systems
Tangible and/or intangible incentives and rewards and/or disincentives and punishments
support implementation and delivery of the innovation
I. Mission
Alignment
Implementing and delivering the innovation is in line with the overarching commitment,
purpose, or goals in the Inner Setting
J. Available
Resources
Resources are available to implement and deliver the innovation
Use this construct to capture themes related to Available Resources that are not included in
the subconstructs below
92
1. Funding Funding is available to implement and deliver the innovation
2. Space Physical space is available to implement and deliver the innovation
3. Materials
& Equipment
Supplies are available to implement and deliver the innovation
K. Access to
Knowledge &
Information
Guidance and/or training is accessible to implement and deliver the innovation
IV. Individuals domain
Individuals: The roles and characteristics of individuals
Roles subdomain
Project Roles: [Document the roles applicable to the project and their location in the Inner Setting or Outer Setting.]
Construct name Construct definition
A. High-level
Leaders
Individuals with a high level of authority, including key decision-makers, executive leaders, or
directors
B. Mid-level
Leaders
Individuals with a moderate level of authority, including leaders supervised by a high-level
leader and who supervise others
C. Opinion
Leaders
Individuals with informal influence on the attitudes and behaviors of others
D.
Implementation
Facilitators
Individuals with subject matter expertise who assist, coach, or support implementation
E.
Implementation
Leads
Individuals who lead efforts to implement the innovation
F.
Implementation
Team Members
Individuals who collaborate with and support the Implementation Leads to implement the
innovation, ideally including Innovation Deliverers and Recipients
G. Other
Implementation
Support
Individuals who support the Implementation Leads and/or Implementation Team Members to
implement the innovation
H. Innovation
Deliverers
Individuals who are directly or indirectly delivering the innovation
I. Innovation
Recipients
Individuals who are directly or indirectly receiving the innovation
93
Characteristics subdomain
Project Characteristics: [Document the characteristics applicable to the roles in the project based on the COM-B
system [29] or role-specific theories.]
Construct name Construct definition:
The degree to which:
A. Need The individual(s) has deficits related to survival, well-being, or personal fulfillment, which will
be addressed by implementation and/or delivery of the innovation
B. Capability The individual(s) has interpersonal competence, knowledge, and skills to fulfill Role
C. Opportunity The individual(s) has availability, scope, and power to fulfill Role
D. Motivation The individual(s) is committed to fulfilling Role
V. Implementation Process domain
Implementation Process: The activities and strategies used to implement the innovation
Project Implementation Process: [Document the implementation process framework and/or activities and strategies
being used to implement the innovation. Distinguish the implementation process used to implement the innovation
(activities that end after implementation is complete) from the innovation (the “thing” that continues when
implementation is complete).
Construct name Construct definition:
The degree to which individuals:
A. Teaming Join together, intentionally coordinating and collaborating on interdependent tasks, to
implement the innovation
B. Assessing
Needs
Collect information about priorities, preferences, and needs of people
Use this construct to capture themes related to Assessing Needs that are not included in the
subconstructs below
1. Innovation
Deliverers
Collect information about the priorities, preferences, and needs of deliverers to guide
implementation and delivery of the innovation
2. Innovation
Recipients
Collect information about the priorities, preferences, and needs of recipients to guide
implementation and delivery of the innovation
C. Assessing
Context
Collect information to identify and appraise barriers and facilitators to implementation and
delivery of the innovation
D. Planning Identify roles and responsibilities, outline specific steps and milestones, and define goals and
measures for implementation success in advance
E. Tailoring
Strategies
Choose and operationalize implementation strategies to address barriers, leverage facilitators,
and fit context
94
F. Engaging Attract and encourage participation in implementation and/or the innovation
Use this construct to capture themes related to Engaging that are not included in the
subconstructs below
1. Innovation
Deliverers
Attract and encourage deliverers to serve on the implementation team and/or to deliver the
innovation
2. Innovation
Recipients
Attract and encourage recipients to serve on the implementation team and/or participate in the
innovation
G. Doing Implement in small steps, tests, or cycles of change to trial and cumulatively optimize delivery
of the innovation
H. Reflecting &
Evaluating
Collect and discuss quantitative and qualitative information about the success of
implementation and/or the innovation
Use this construct to capture themes related to Reflecting & Evaluating that are not included in
the subconstructs below
1.
Implementation
Collect and discuss quantitative and qualitative information about the success of
implementation
2. Innovation Collect and discuss quantitative and qualitative information about the success of the innovation
I. Adapting Modify the innovation and/or the Inner Setting for optimal fit and integration into work
processes

95
APPENDIX B
COMPARISON BETWEEN ORIGINAL AND NEW CFIR

This additional file maps the original CFIR (published in 2009) constructs to the updated
CFIR (published in 2022) constructs.

Original CFIR
No specific guidance provided at the framework-level in
the original CFIR
Updated CFIR
Framework Guidance:
The CFIR is intended to be used to collect data
from individuals who have power and/or
influence over implementation outcomes. See the
CFIR Outcomes Addendum for guidance on
identifying these individuals and selecting
outcomes [1].

The CFIR must be fully operationalized prior to
use in a project:
1) Define the subject of each domain for the
project (see guidance for each domain below).
2) Replace broad construct language with
project-specific language if needed.
3) Add constructs to capture salient themes not
included in the updated CFIR.
I. INTERVENTION CHARACTERISTICS DOMAIN
No specific guidance provided at the domain-level in the
original CFIR.
I. INNOVATION DOMAIN
Innovation: The “thing” being implemented [2],
e.g., a new clinical treatment, educational
program, or city service.

Project Innovation: [Document the innovation
being implemented, e.g., innovation type,
innovation core vs. adaptable components, using
a published reporting guideline [3–6]. Distinguish
the innovation (the “thing” that continues when
implementation is complete) [2,7] from the
implementation process and strategies used to
implement the innovation [8,9] (activities that
end after implementation is complete) [10].]
Old Construct Name Old Construct
Definition
Construct Name Construct Definition
The degree to which:
Intervention Source Perception of key
stakeholders about
whether the
intervention is
externally or
internally
developed.
A. Innovation
Source
The group that
developed and/or visibly
sponsored use of the
innovation is reputable,
credible, and/or
trustable.
Evidence Strength & Quality Stakeholders’
perceptions of the
quality and validity
of evidence
supporting the
belief that the
B. Innovation
Evidence-Base
The innovation has
robust evidence
supporting its
effectiveness.
96
intervention will
have desired
outcomes.
Relative Advantage Stakeholders’
perception of the
advantage of
implementing the
intervention
versus an
alternative
solution.
C. Innovation
Relative Advantage
The innovation is better
than other available
innovations or current
practice.
Adaptability The degree to
which an
intervention can be
adapted, tailored,
refined, or
reinvented to meet
local needs.
D. Innovation
Adaptability
The innovation can be
modified, tailored, or
refined to fit local
context or needs.
Trialability The ability to test
the intervention on
a small scale in the
organization, and
to be able to
reverse course
(undo
implementation) if
warranted.
E. Innovation
Trialability
The innovation can be
tested or piloted on a
small scale and undone.
Complexity Perceived difficulty
of implementation,
reflected by
duration, scope,
radicalness,
disruptiveness,
centrality, and
intricacy and
number of steps
required to
implement.
F. Innovation
Complexity
The innovation is
complicated, which may
be reflected by its scope
and/or the nature and
number of connections
and steps.
Design Quality and Packaging Perceived
excellence in how
the intervention is
bundled,
presented, and
assembled.
G. Innovation
Design
The innovation is well
designed and packaged,
including how it is
assembled, bundled, and
presented.
Cost Costs of the
intervention and
costs associated
with implementing
that intervention
including
investment, supply,
and opportunity
costs.
H. Innovation Cost The innovation purchase
and operating costs are
affordable.
97
II. OUTER SETTING DOMAIN
No specific guidance provided at the domain-level in the
original CFIR.
II. OUTER SETTING DOMAIN
Outer Setting: The setting in which the Inner
Setting exists, e.g., hospital system, school
district, state. There may be multiple Outer
Settings and/or multiple levels within the Outer
Setting (e.g., community, system, state).

Project Outer Setting(s): [Document the actual
Outer Setting in the project, e.g., type, location,
and the boundary between the Outer Setting and
the Inner Setting.]
Old Construct Name Old Construct
Definition
Construct Name Construct Definition
The degree to which:
Patient Needs & Resources The extent to
which patient
needs, as well as
barriers and
facilitators to meet
those needs, are
accurately known
and prioritized by
the organization.
None Construct separated and
relocated; see Roles
Subdomain: Innovation
Recipients;
Characteristics
Subdomain: Need; and
Inner Setting Domain:
Culture: Recipient-
Centeredness.
None Construct added in
the updated CFIR.
A. Critical Incidents Large-scale and/or
unanticipated events
disrupt implementation
and/or delivery of the
innovation.
None Construct added in
the updated CFIR.
B. Local Attitudes Sociocultural values (e.g.,
shared responsibility in
helping recipients) and
beliefs (e.g., convictions
about the worthiness of
recipients) encourage
the Outer Setting to
support implementation
and/or delivery of the
innovation.
None Construct added in
the updated CFIR.
C. Local Conditions Economic,
environmental, political,
and/or technological
conditions enable the
Outer Setting to support
implementation and/or
delivery of the
innovation.
Cosmopolitanism The degree to
which an
organization is
networked with
other external
organizations.
D. Partnerships &
Connections
The Inner Setting is
networked with external
entities, including
referral networks,
academic affiliations, and
professional
organization networks.
External Policies & Incentives A broad construct
that includes
E. Policies & Laws Legislation, regulations,
professional group
98
external strategies
to spread
interventions
including policy
and regulations
(governmental or
other central
entity), external
mandates,
recommendations
and guidelines,
pay-for-
performance,
collaboratives, and
public or
benchmark
reporting.
guidelines and
recommendations, or
accreditation standards
support implementation
and/or delivery of the
innovation.
None Construct added in
the updated CFIR.
F. Financing Funding from external
entities (e.g., grants,
reimbursement) is
available to implement
and/or deliver the
innovation.
None Construct added in
the updated CFIR.
G. External
Pressure
External pressures drive
implementation and/or
delivery of the
innovation.
Use this construct to
capture themes related to
External Pressures that
are not included in the
subconstructs below.
None

Subconstruct added
in the updated
CFIR.
1. Societal
Pressure
Mass media campaigns,
advocacy groups, or
social movements or
protests drive
implementation and/or
delivery of the
innovation.
Peer Pressure Mimetic or
competitive
pressure to
implement an
intervention;
typically, because
most or other key
peer or competing
organizations have
already
implemented or in
a bid for a
competitive edge.
2. Market
Pressure
Competing with and/or
imitating peer entities
drives implementation
and/or delivery of the
innovation.
99
None See Outer Setting:
External Policies &
Incentives
construct.
3. Performance-
Measurement
Pressure
Quality or benchmarking
metrics or established
service goals drive
implementation and/or
delivery of the
innovation.
III. INNER SETTING DOMAIN
No specific guidance provided at the domain-level in the
original CFIR.
III. INNER SETTING DOMAIN
Inner Setting: The setting in which the
innovation is implemented, e.g., hospital, school,
city. There may be multiple Inner Settings and/or
multiple levels within the Inner Setting, e.g., unit,
classroom, team.

Project Inner Setting(s): [Document the actual
Inner Setting in the project, e.g., type, location,
and the boundary between the Outer Setting and
the Inner Setting.]
Old Construct Name Old Construct
Definition
Construct Name Construct Definition
The degree to which:
None No specific
guidance provided
at the domain-level
in the original CFIR.
Note: Constructs A – D exist in
the Inner Setting
regardless of
implementation and/or
delivery of the innovation,
i.e., they are persistent
general characteristics of
the Inner Setting.
Structural Characteristics The social
architecture, age,
maturity, and size
of an organization.
A. Structural
Characteristics
Infrastructure
components support
functional performance
of the Inner Setting.
Use this construct to
capture themes related to
Structural Characteristics
that are not included in
the subconstructs below.
None

Subconstruct added
in the updated
CFIR.
1. Physical
Infrastructure
Layout and configuration
of space and other
tangible material
features support
functional performance
of the Inner Setting.
None

Subconstruct added
in the updated
CFIR.
2. Information
Technology
Infrastructure
Technological systems
for tele-communication,
electronic
documentation, and data
storage, management,
reporting, and analysis
support functional
performance of the Inner
Setting.
None

Subconstruct added
in the updated
CFIR.
3. Work
Infrastructure
Organization of tasks and
responsibilities within
and between individuals
100
and teams, and general
staffing levels, support
functional performance
of the Inner Setting.
Networks & Communications The nature and
quality of webs of
social networks
and the nature and
quality of formal
and informal
communications
within an
organization.
B. Relational
Connections
There are high quality
formal and informal
relationships, networks,
and teams within and
across Inner Setting
boundaries (e.g.,
structural, professional).
C. Communications There are high quality
formal and informal
information sharing
practices within and
across Inner Setting
boundaries (e.g.,
structural, professional).
Culture Norms, values, and
basic assumptions
of a given
organization.
D. Culture There are shared values,
beliefs, and norms across
the Inner Setting.
Use this construct to
capture themes related to
Culture that are not
included in the
subconstructs below.
None

Subconstruct added
in the updated
CFIR.
1. Human
Equality-
Centeredness
There are shared values,
beliefs, and norms about
the inherent equal worth
and value of all human
beings.
None

Subconstruct added
in the updated
CFIR.
2. Recipient-
Centeredness
There are shared values,
beliefs, and norms
around caring,
supporting, and
addressing the needs and
welfare of recipients.
None

Subconstruct added
in the updated
CFIR.
3. Deliverer-
Centeredness
There are shared values,
beliefs, and norms
around caring,
supporting, and
addressing the needs and
welfare of deliverers.
None See Inner Setting:
Learning Climate
construct.
4. Learning-
Centeredness
There are shared values,
beliefs, and norms
around psychological
safety, continual
improvement, and using
data to inform practice.
None No specific
guidance provided
at the domain-level
in the original CFIR.
Note: Constructs E – K are
specific to the
implementation and/or
delivery of the innovation.
101
Implementation Climate The absorptive
capacity for
change, shared
receptivity of
involved
individuals to an
intervention and
the extent to which
use of that
intervention will
be rewarded,
supported, and
expected within
their organization.
None Construct removed from
the updated CFIR;
reclassified as an
antecedent assessment in
the CFIR Outcomes
Addendum [1].
Tension for Change The degree to
which
stakeholders
perceive the
current situation
as intolerable or
needing change.
E. Tension for
Change
The current situation is
intolerable and needs to
change.
Compatibility The degree of
tangible fit
between meaning
and values
attached to the
intervention by
involved
individuals, how
those align with
individuals’ own
norms, values, and
perceived risks
and needs, and
how the
intervention fits
with existing
workflows and
systems.
F. Compatibility The innovation fits with
workflows, systems, and
processes.
Relative Priority Individuals’ shared
perception of the
importance of the
implementation
within the
organization.
G. Relative Priority Implementing and
delivering the innovation
is important compared to
other initiatives.
Organizational Incentives &
Rewards
Extrinsic
incentives such as
goal-sharing
awards,
performance
reviews,
promotions, and
raises in salary and
less tangible
incentives such as
H. Incentive
Systems
Tangible and/or
intangible incentives and
rewards and/or
disincentives and
punishments support
implementation and
delivery of the
innovation.
102
increased stature
or respect.
Goals & Feedback The degree to
which goals are
clearly
communicated,
acted upon, and
fed back to staff,
and alignment of
that feedback with
goals.
I. Mission
Alignment
Implementing and
delivering the innovation
is in line with the
overarching
commitment, purpose, or
goals in the Inner Setting.
Learning Climate A climate in which:
a) leaders express
their own fallibility
and need for team
members’
assistance and
input; b) team
members feel that
they are essential,
valued, and
knowledgeable
partners in the
change process; c)
individuals feel
psychologically
safe to try new
methods; and d)
there is sufficient
time and space for
reflective thinking
and evaluation.
None Construct renamed and
relocated; see Inner
Setting: Culture:
Learning-Centeredness.
Readiness for Implementation Tangible and
immediate
indicators of
organizational
commitment to its
decision to
implement an
intervention.
None Construct removed from
the updated CFIR;
reclassified as an
antecedent assessment in
the CFIR Outcomes
Addendum [1].
Leadership Engagement Commitment,
involvement, and
accountability of
leaders and
managers with the
implementation.
None Construct separated,
renamed, and relocated;
see Individuals Domain:
Roles Subdomain: High-
Level & Mid-Level
Leaders; and
Characteristics
Subdomain: Motivation.
Available Resources The level of
resources
dedicated for
implementation
and on-going
operations
J. Available
Resources
Resources are available
to implement and deliver
the innovation.
Use this construct to
capture themes related to
Available Resources that
103
including money,
training, education,
physical space, and
time.
are not included in the
subconstructs below.
None

Subconstruct added
in the updated
CFIR.
1. Funding Funding is available to
implement and deliver
the innovation.
None

Subconstruct added
in the updated
CFIR.
2. Space Physical space is
available to implement
and deliver the
innovation.
None

Subconstruct added
in the updated
CFIR.
3. Materials &
Equipment
Supplies are available to
implement and deliver
the innovation.
Access to knowledge and
information
Ease of access to
digestible
information and
knowledge about
the intervention
and how to
incorporate it into
work tasks.
K. Access to
Knowledge &
Information
Guidance and/or training
is accessible to
implement and deliver
the innovation.
IV. CHARACTERISTICS OF INDIVIDUALS
No specific guidance provided at the domain-level in the
original CFIR.
IV. INDIVIDUALS DOMAIN
Individuals: The roles and characteristics of
individuals.
None: Roles Subdomain added in the updated CFIR. ROLES SUBDOMAIN
Project Roles: [Document the roles applicable to
the project and their location in the Inner or
Outer Setting.]
Old Construct Name Old Construct
Definition
Construct Name Construct Definition
None See Inner Setting:
Leadership
Engagement.
A. High-level
Leaders
Individuals with a high
level of authority,
including key decision-
makers, executive
leaders, or directors.
None See Inner Setting:
Leadership
Engagement
B. Mid-level
Leaders
Individuals with a
moderate level of
authority, including
leaders supervised by a
high-level leader and
who supervise others.
None See Process:
Engaging: Opinion
Leaders.
C. Opinion Leaders Individuals with informal
influence on the attitudes
and behaviors of others.
None See Process:
Engaging: External
Change Agents.
D. Implementation
Facilitators
Individuals with subject
matter expertise who
assist, coach, or support
implementation.
None See Process:
Engaging: Formally
Appointed Internal
Implementation
E. Implementation
Leads
Individuals who lead
efforts to implement the
innovation.
104
Leaders &
Champions.
None Construct added in
the updated CFIR.
F. Implementation
Team Members
Individuals who
collaborate with and
support the
Implementation Leads to
implement the
innovation, ideally
including Innovation
Deliverers and
Recipients.
None Construct added in
the updated CFIR.
G. Other
Implementation
Support
Individuals who support
the Implementation
Leads and/or
Implementation Team
Members to implement
the innovation.
None Construct added in
the updated CFIR.
H. Innovation
Deliverers
Individuals who are
directly or indirectly
delivering the
innovation.
None See Outer Setting:
Patient Needs &
Resources.
I. Innovation
Recipients
Individuals who are
directly or indirectly
receiving the innovation.
None: Characteristics Subdomain added in the updated
CFIR.
CHARACTERISTICS SUBDOMAIN
Project Characteristics: [Document the
characteristics applicable to the roles in the
project based on the COM-B system [11] or role-
specific theories.]
Old Construct Name Old Construct
Definition
Construct Name Construct Definition:
The degree to which:
Knowledge & Beliefs about the
Intervention
Individuals’
attitudes toward
and value placed
on the intervention
as well as
familiarity with
facts, truths, and
principles related
to the intervention.
None Construct removed from
the updated CFIR.
Self-efficacy Individual belief in
their own
capabilities to
execute courses of
action to achieve
implementation
goals.
None Construct removed from
the updated CFIR.
Individual Stage of Change Characterization of
the phase an
individual is in, as
he or she
progresses toward
skilled,
enthusiastic, and
None Construct removed from
the updated CFIR.
105
sustained use of
the intervention.
Individual Identification with
Organization
A broad construct
related to how
individuals
perceive the
organization and
their relationship
and degree of
commitment with
that organization.
None Construct removed from
the updated CFIR.
Other Personal Attributes A broad construct
to include other
personal traits
such as tolerance
of ambiguity,
intellectual ability,
motivation, values,
competence,
capacity, and
learning style.
None Construct removed from
the updated CFIR.
None Construct added in
the updated CFIR.
A. Need The individual(s) has
deficits related to
survival, well-being, or
personal fulfillment,
which will be addressed
by implementation
and/or delivery of the
innovation.
None Construct added in
the updated CFIR.
B. Capability The individual(s) has
interpersonal
competence, knowledge,
and skills to fulfill Role.
None Construct added in
the updated CFIR.
C. Opportunity The individual(s) has
availability, scope, and
power to fulfill Role.
None Construct added in
the updated CFIR.
D. Motivation The individual(s) is
committed to fulfilling
Role.
V. PROCESS
No specific guidance provided at the domain-level in the
original CFIR.
V. IMPLEMENTATION PROCESS DOMAIN
Implementation Process: The activities and
strategies used to implement the innovation.

Project Implementation Process: [Document
the implementation process framework [12]
and/or activities and strategies [8,9] being used
to implement the innovation. Distinguish the
implementation process used to implement the
innovation (activities that end after
implementation is complete) from the innovation
(the “thing” that continues when implementation
is complete) [2,7,10].]
106
Old Construct Name Old Construct
Definition
Construct Name Construct Definition:
The degree to which
individuals:
None

Construct added in
the updated CFIR.
A. Teaming Join together,
intentionally
coordinating and
collaborating on
interdependent tasks, to
implement the
innovation.
None

Construct added in
the updated CFIR.
B. Assessing Needs Collect information
about priorities,
preferences, and needs of
people.
Use this construct to
capture themes related to
Assessing Needs that are
not included in the
subconstructs below.
None

Subconstruct added
in the updated
CFIR.
1. Innovation
Deliverers
Collect information
about the priorities,
preferences, and needs of
deliverers to guide
implementation and
delivery of the
innovation.
None

Subconstruct added
in the updated
CFIR.
2. Innovation
Recipients
Collect information
about the priorities,
preferences, and needs of
recipients to guide
implementation and
delivery of the
innovation.
None Construct added in
the updated CFIR.

C. Assessing
Context
Collect information to
identify and appraise
barriers and facilitators
to implementation and
delivery of the
innovation.
Planning The degree to
which a scheme or
method of
behavior and tasks
for implementing
an intervention are
developed in
advance and the
quality of those
schemes or
methods.
D. Planning Identify roles and
responsibilities, outline
specific steps and
milestones, and define
goals and measures for
implementation success
in advance.
None

Construct added in
the updated CFIR.
E. Tailoring
Strategies
Choose and
operationalize
implementation
strategies to address
107
barriers, leverage
facilitators, and fit
context.
Engaging Attracting and
involving
appropriate
individuals in the
implementation
and use of the
intervention
through a
combined strategy
of social
marketing,
education, role
modeling, training,
and other similar
activities.
F. Engaging Attract and encourage
participation in
implementation and/or
the innovation.
Use this construct to
capture themes related to
Engaging that are not
included in the
subconstructs below.
None

Subconstruct added
in the updated
CFIR.
1. Innovation
Deliverers
Attract and encourage
deliverers to serve on the
implementation team
and/or to deliver the
innovation.
None

Subconstruct added
in the updated
CFIR.
2. Innovation
Recipients
Attract and encourage
recipients to serve on the
implementation team
and/or participate in the
innovation.
Opinion Leaders Individuals in an
organization who
have formal or
informal influence
on the attitudes
and beliefs of their
colleagues with
respect to
implementing the
intervention.
None Subconstruct relocated;
see Individuals Domain:
Roles Subdomain: Opinion
Leaders.
Formally appointed internal
implementation leaders
Individuals from
within the
organization who
have been formally
appointed with
responsibility for
implementing an
intervention as
coordinator,
project manager,
team leader, or
other similar roles.
None Subconstructs combined,
renamed, and relocated;
see Individuals Domain:
Roles Subdomain:
Implementation Leads.
Champions “Individuals who
dedicate
themselves to
supporting,
108
marketing, and
‘driving through’
an
[implementation]”,
overcoming
indifference or
resistance that the
intervention may
provoke in an
organization.
External Change Agents Individuals who
are affiliated with
an outside entity
who formally
influence or
facilitate
intervention
decisions in a
desirable direction.
None

Subconstruct renamed
and relocated; see
Individuals Domain: Roles
Subdomain:
Implementation
Facilitators.
Executing Carrying out or
accomplishing the
implementation
according to plan.
G. Doing Implement in small
steps, tests, or cycles of
change to trial and
cumulatively optimize
delivery of the
innovation.
Reflecting & Evaluating

Quantitative and
qualitative
feedback about the
progress and
quality of
implementation
accompanied with
regular personal
and team
debriefing about
progress and
experience.
H. Reflecting &
Evaluating
Collect and discuss
quantitative and
qualitative information
about the success of
implementation and/or
the innovation.
Use this construct to
capture themes related to
Reflecting & Evaluating
that are not included in
the subconstructs below.
None

Subconstruct added
in the updated
CFIR.
1.
Implementation
Collect and discuss
quantitative and
qualitive information
about the success of
implementation.
None

Subconstruct added
in the updated
CFIR.
2. Innovation Collect and discuss
quantitative and
qualitative information
about the success of the
innovation.
None

Construct added in
the updated CFIR.
I. Adapting Modify the innovation
and/or the Inner Setting
for optimal fit and
integration into work
processes.
Note. Adapted from (Damshroder et al., 2022)
109
Appendix C

2022 RR VHV PARTICIPANT SURVEY

When completing this survey, please reflect back about your experience delivering home
visitation services in 2022. During this period, many of your organizations may have
provided in-person and/or virtual home visitation. When the survey asks about “in-person”
home visitation it is referring to a home visitor physically visiting a home. When the survey
asks about “virtual home Visitation” it is referring to home visits provided by video
conference or phone.

Background:
1. What is your age? ______

2. What is your race/ethnicity?

a. American Indian or Alaska Native
b. Asian
c. Black or African American
d. Native Hawaiian or other Pacific Islander
e. White (not Hispanic)
f. Hispanic or Latino
g. Other _________________
3. What is your gender?
a. Male
b. Female
c. Non-binary
d. Gender nonconforming
e. Prefer not to say
f. Other _________________

4. What state do you live in? (Drop down of all states; US Territories)

5. What is your role in your organization?
a. Home Visitor
b. Manager
c. Supervisor
d. Director
e. Other _______________

6. What is your highest level of education completed?
a. High School Diploma or GED
b. Associates Degree or Trade/Tech School
c. Bachelor’s Degree
d. Master’s Degree
110
e. Doctorate Degree
f. Other _______________________

7. Which home visiting model are you a part of?
a. Attachment and Biobehavioral Catch-Up (ABC)
b. Avance
c. BabyTalk
d. Centering Health Care
e. Child First
f. CHIP VA
g. Early Head Start
h. Family Connects
i. Families Forward VA
j. Family Spirit
k. Health Families America (HFA)
l. Health Connect One Doula
m. Healthy Steps
n. Home instruction for Parents of Preschool Youngsters (HIPPY)
o. MESCH
p. Nurse Family Partnership (NFP)
q. Nurses for Newborns
r. Parents as Teaches (PAT)
s. ParentChild+
t. SafeCare
u. Welcome Baby Los Angeles
v. Welcome Baby, other
w. Other:_______________________________

8. How long have you been working in the field of home visiting?
a. Less than 1 year
b. 1-2 years
c. 3-5 years
d. 5-10 years
e. More than 10 years

Virtual Home Visitation Service
9. During 2022 what percentage of your visits were provided by videoconferencing?
a. 0%
b. 10%
c. 20%
d. 30%
e. 40%
f. 50%
111
g. 60%
h. 70%
i. 80%
j. 90%
k. 100%

10. During 2022 what percentage of your visits were provided by telephone?
a. 0%
b. 10%
c. 20%
d. 30%
e. 40%
f. 50%
g. 60%
h. 70%
i. 80%
j. 90%
k. 100%

11. How did you or your organization decide when to switch between service delivery
modalities? (check all that apply)
a. Funder driven
b. Family choice
a. Home Visitor Decision
b. Organizational/Employer Decision
c. Using Local Data (e.g. county public health)
d. State government mandates
e. Federal mandates
f. Unsure
g. Other:

12. What supports specifically have been offered by your model or organization to
move/toggle between offering virtual (videoconference and telephone) and in person
home visitation?
a. Training
b. Consultation group
c. Peer to peer support group
d. Support from a supervisor
e. Technology (e.g. Laptop/tablet/internet connection)

13. How difficult was it for you to adapt to toggling between virtual and in person visits?
a. Not at all challenging
112
b. A bit challenging
c. Moderately challenging
d. Extremely challenging
e. I have been unable to adapt

14. How difficult was it for your families to adapt to toggling between virtual and in-person
visits?
a. Not at all challenging
b. A bit challenging
c. Moderately challenging
d. Extremely challenging
e. Unable or resistant to virtual visits

15. How engaged do you feel your families are during virtual visits?
a. Not at all engaged
b. Briefly engaged
c. Somewhat engaged
d. Mostly engaged
e. Very engaged

16. How engaged do you feel your families are during in-person visits when you went to
their home?
a. Not at all engaged
b. Briefly engaged
c. Somewhat engaged
d. Mostly engaged
e. Very engaged

17. How are you accommodating families?
a. Evening visits
b. Weekend visits
c. Early morning visits
d. Telephone visits
e. Video visits
f. Outdoor visits
g. Other. Specify: ______________________________________________

18. What barriers exist for engaging your families?
a. Remembering appointments
b. Distractions at home
c. Multiple children
d. Limited internet access
e. Balancing schedules of other children
f. Other. Explain:
113

19. What services/referrals/education/resources have been a challenge to provide in 2022,
during the pandemic?
a. Housing
b. Basic needs
c. Breastfeeding
d. Mental health
e. Domestic violence
f. Child development
g. Food
h. Child maltreatment
i. Other. Describe:____________________________

Alternating or toggling between in-person and virtual home visitation

20. What area has been the most challenging to complete in 2022 when toggling between in-
person and virtual home visitation?
a. Recruitment
b. Enrollment
c. Consent
d. Screening
e. Parent child interaction
f. Supervision

Strongl
y
Disagre
e
Disagree Neither
Agree or
Disagree
Agree Strongly
Agree
34. Toggling between virtual and in-
person home visitation was
stressful.
0£ 1£ 2£ 3£ 4£
35. I had adequate training for to
provide client care by toggling
between virtual and in-person
home visitation.
0£ 1£ 2£ 3£ 4£
36. I had adequate supervision to
toggle between virtual and in-
person home visitation.
0£ 1£ 2£ 3£ 4£
37. I experienced feelings of
frustration toggling between
virtual and in-person home
visitation.
0£ 1£ 2£ 3£ 4£
38. I had adequate technical support to
toggle between virtual and in-
person home visitation.
0£ 1£ 2£ 3£ 4£
114

Please answer the following questions regarding your thoughts about transitioning or
toggling between virtual and in-person home visitation.
Strongl
y
Disagre
e
Disagree Neither
Agree or
Disagree
Agree Strongly
Agree
41. It is easy to transition between
virtual and in-person home
visitation.
0£ 1£ 2£ 3£ 4£
42. I feel confident transitioning
between virtual and in-person
home visitation
0£ 1£ 2£ 3£ 4£
43. I feel at ease transitioning between
virtual and in-person home
visitation
0£ 1£ 2£ 3£ 4£
44. Transitioning between virtual and
in-person home visitation gives me
the chance to build and keep a
personal bond with each of my
clients.
0£ 1£ 2£ 3£ 4£
45. I get more done in my day when I
transition between virtual and in-
person home visitation.
0£ 1£ 2£ 3£ 4£
46. Transitioning between virtual and
in-person home visitation allows
me to see more families.
0£ 1£ 2£ 3£ 4£
47. I am able to meet my families’
needs well through transitioning
between virtual and in-person
home visitation.
0£ 1£ 2£ 3£ 4£
48. I prefer virtual home visits over
visits that are in person.
0£ 1£ 2£ 3£ 4£
49. For the most part, I am satisfied
with the work I’ve done
transitioning between virtual and
in-person home visitation.
0£ 1£ 2£ 3£ 4£
39. I was concerned about my ability to
provide care when toggling
between virtual and in-person
home visitation.
0£ 1£ 2£ 3£ 4£
40. I was able to engage families when
toggling between in-person and
virtual home visitation.
0£ 1£ 2£ 3£ 4£
115
50. I am better able to reach my clients
if I can alternate between virtual
and in-person home visitation.
0£ 1£ 2£ 3£ 4£
51. I am concerned about the lack of
physical contact I have with my
clients while providing care
through virtual home visitation.
0£ 1£ 2£ 3£ 4£
52. Providing care through virtual
home visitation is just as effective
as in person care.
0£ 1£ 2£ 3£ 4£
53. Being able to transition between
virtual and in-person home
visitants has improved my provider
client relationships.
0£ 1£ 2£ 3£ 4£
54. I find communication with my
clients is easy through in-person
visitation.
0£ 1£ 2£ 3£ 4£
55. In-person visitation allows me to
have more frequent contact with
my clients.
0£ 1£ 2£ 3£ 4£
Measure Information for Analyses and Results
Questions 1-12 came from a University of Missouri quality improvement survey of telehealth
services that surveyed clients, providers and coordinators. Becevic et. al 2015 cited below.
Patients were changed from clients. In original survey questions 2 and 3 were a combined
question. Question 10 treat was changed to meet. Questions 13-18 were from developed by the
study team from the results of the below three qualitative studies on the implementation of
telehealth.
Becevic, Mirna PhD; Boren, Suzanne PhD; Mutrux, Rachel BA; Shah, Zalak HI; Banerjee, Sruti
MHA, HI User Satisfaction With Telehealth, The Health Care Manager: October/December
2015 - Volume 34 - Issue 4 - p 337-349 doi: 10.1097/HCM.0000000000000081
Hicks, L. L., Fleming, D. A., & Desaulnier, A. (2009). The application of remote monitoring to
improve health outcomes to a rural area. Telemedicine and e-Health, 15(7), 664-671.
doi:http://dx.doi.org.libproxy1.usc.edu/10.1089/tmj.2009.0009
Sandberg, J., Trief, P. M., Izquierdo, R., Goland, R., Morin, P. C., Palmas, W., . . . Weinstock, R.
S. (2009). A qualitative study of the experiences and satisfaction of direct telemedicine providers
in diabetes case management. Telemedicine and e-Health, 15(8), 742-750.
doi:http://dx.doi.org.libproxy1.usc.edu/10.1089/tmj.2009.0027
Brown, S. (2017). Primay care provider's perceptions of telehealth adoption (Order No.
AAI10163004). Available from APA PsycInfo®. (1925843562; 2017-05718-184). Retrieved
from http://libproxy.usc.edu/login?url=https://search-proquest-
com.libproxy1.usc.edu/docview/1925843562?accountid=14749

Personal Well Being
116

The following are 9 statements of job-related feelings. Please read each statement carefully
and decide if have felt this way about your job during the shift to virtual home visitation. If
you have never had this feeling, check the “never” box after the statement. If you have had
this feeling, indicate how often you feel it by checking the box that best describes how
frequently you feel that way.

Never A few
times a
year or
less
Once
a
month
or less
A few
times
a
month
Once
a
week
A
few
times
a
week
Everyday
56. I feel emotionally
drained from my work.
0£ 1£ 2£ 3£ 4£ 5£ 6£
57. I feel fatigued when I
get up in the morning and
have to face another day
on the job.
0£ 1£ 2£ 3£ 4£ 5£ 6£
58. Working with people is
really a strain for me.
0£ 1£ 2£ 3£ 4£ 5£ 6£
59. I have become more
callous towards people
since I took this job.
0£ 1£ 2£ 3£ 4£ 5£ 6£
60. I do not care what
happens to some of my
clients.
0£ 1£ 2£ 3£ 4£ 5£ 6£
61. I feel that I treat some
clients as if they were
impersonal objects.
0£ 1£ 2£ 3£ 4£ 5£ 6£
62. I feel exhilarated after
working closely with my
clients.
0£ 1£ 2£ 3£ 4£ 5£ 6£
63. I feel that I am
positively influencing
other people’s lives.
0£ 1£ 2£ 3£ 4£ 5£ 6£
64. I deal very effectively
with the problems of my
clients.
0£ 1£ 2£ 3£ 4£ 5£ 6£

Measure Information for Analyses and Results

Three items from each MBI subscale: Emotional Exhaustion (EE), Depersonalization (DP) and
Personal Achievement (PA). The following reference includes the items and validity and
reliability information.

117
Riley, M. R., Mohr, D. C., & Waddimba, A. C. (2018). The reliability and validity of three‐item
screening measures for burnout: Evidence from group‐employed health care practitioners in
upstate New York. Stress and Health, 34(1), 187-193.

Each subscale is scored by summing up its items, higher scores on EE and/or DP subscales, and
lower scores on the PA subscale indicating higher burnout (Maslach et al., 1996).

Workforce Development
65. Are you a supervisor in your organization?
a. Yes (If yes, move to question 66.)
b. No (If no, survey is complete)

66. How long have you been a supervisor?
a. 0-2 years
b. 3-5 years
c. 5-7 years
d. 7-9 years
e. 10-15 years
f. 15-20 years
g. 20+

67. What percentage of your home visitation supervisory staff left your organization or team in
2022? Round to the nearest percentage listed:
a. 0%
b. 5%
c. 10%
d. 20%
e. 30%
f. 40%
g. 50%
h. 60%
i. 70%
j. 80%
k. 90%

68. What percentage of your home visitation staff left your organization or team in 2022? Round
to the nearest percentage listed:
a. 0%
b. 5%
c. 10%
d. 20%
e. 30%
f. 40%
g. 50%
h. 60%
118
i. 70%
j. 80%
k. 90%

69. Have you had to change your hiring practices between 2020-2022 due to the COVID-19
pandemic?
a. Yes
i. Describe
b. No

70. Have you had to change on-boarding-training practices between 2020-2022 due to the
COVID-19 pandemic?
a. Yes
i. Describe
b. No

71. Have you invested in professional development and/or wellness support in the period of
2020-2022?
a. Yes
i. Describe
b. No

72. Does your organization measure model fidelity?
a. Yes
i. Describe
b. No
73. What level of model fidelity did your organization achieve during the 2021 performance
period?
74. Round to the nearest percentage listed:
a. 0%
b. 5%
c. 10%
d. 20%
e. 30%
f. 40%
g. 50%
h. 60%
i. 70%
j. 80%
k. 90%
l. 100%

119
APPENDIX D
RAPID RESPONSE VIRTUAL HOME VISITATION EXPERTS BY EXPERIENCE
(CAREGIVER) SEMI- STRUCTURED INTERVIEW GUIDE

Materials Needed:
Pencil/Pen
Questionnaire

A. Introductions
1. Introduce yourself.
2. Share link to Family demographic survey in chat:
https://usc.qualtrics.com/jfe/form/SV_5AQkLVnlnkt7G0S
3. Explain the purpose of the interview by saying:

Thank you for taking the time to be interviewed today. My name is [DATA COLLECTOR
NAME]. I am a from the University of Southern California. We have been asked to talk to
families that have received in-person and virtual home visitation. We asked you to participate in
this interview because you received both in-person and virtual home visitation services and
therefore have a unique perspective to share. I ask you to be honest – good and bad. Your
feedback will be used as part of a comprehensive evaluation of the Rapid Response Virtual
Home Visitation. Everything you are thinking is important to us. There is no “right” or “wrong”
answer. We value your opinion. Participation is completely voluntary and you may quit or leave
at any time.

If you are ready, we will move onto the interview. This interview is expected to take 60 minutes.
You may skip any questions that you do not want to answer, although we would certainly
appreciate it if you would answer as many as possible. [DOUBLE CHECK ZOOM IS
RECORDING. IF NOT, CLICK RECORD TO CLOUD]

1. How has your family received their home visitation services (in-person? Virtual?)?

2. What type of home visitation services did you receive first, in-person, phone, or video?

3. Have you switched between virtual home visitation (home visitation by video conference
or phone) and in-person home visitation?

4. Does your family have a preference for in-person or virtual home visitation?

5. Did you have the opportunity to choose whether you received in-person or virtual
services?

Let’s talk about in-person home visitation (skip if they haven’t received in-person)
6. What did they like most about receiving in-person home visitation services?
120

7. What was most challenging about in-person home visitation services?

Now we are going to ask specific questions about virtual home visitation (home visitation
by video conference or phone).
8. What did they like most about receiving virtual home visitation services?

9. What was most challenging about receiving virtual home visitation services?

I have a few questions to wrap up.
10. How was it switching between virtual and in-person home visits?

11. Would your family be interested in receiving a mixture of virtual and in-person home
visits (e.g. a hybrid approach) in the future?

Summarize and thank participant by saying:
I appreciate you sharing your experiences and ideas with me. This has been a very informative
session and I want to thank you very much for all the information you have shared with us today.
I know that what you have shared with me will help us to better serve children and their families.
I will now turn off the audio-recorder and conclude the interview.

121
APPENDIX E
RAPID RESPONSE VIRTUAL HOME VISITATION HOME VISITOR FOCUS GROUP
GUIDE

Materials Needed:
Pencil/Pen
Questionnaire

A. Introductions
1. Introduce yourself.

2. Take attendance on spreadsheet

3. Share the link to the Demographic Survey for Home Visitors in chat:
https://usc.qualtrics.com/jfe/form/SV_cIJYUFc15PI8WTs
4. Explain the purpose of the interview by saying:

Thank you for taking the time to be interviewed today. My name is [DATA COLLECTOR
NAME]. I am a from the University of Southern California. We have been asked to talk to home
visitors that have provided in-person and virtual home visitation. We asked you to participate in
this interview because you participated in the Rapid Response to Virtual Home Visitation and
therefore have a unique perspective to share. I ask you to be honest – good and bad. Your
feedback will be used as part of a comprehensive evaluation of the RR VHV. Everything you are
thinking is important to us. There is no “right” or “wrong” answer. We value your opinion. This
should be a conversation so there is no need to raise your hand to answer questions. Just chime in
and feel free to speak to one another too. Participation is completely voluntary and you may quit
or leave at any time. If you are ready, we will move onto the interview. This interview is
expected to take 60 minutes. The goal is to better understand your experiences receiving virtual
and in-person home visitation resources through the RR VHV. If you are ready, I will now turn
on the audio-recorder. You may skip any questions that you do not want to answer, although we
would certainly appreciate it if you would answer as many as possible. [Verify Zoom is
Recording in top left of screen. Record to the cloud ]

1. Let’s take a moment and have each person share their preferred name and organization
you work for.

2. How have you delivered home visitation services. For example, in-person, using zoom,
on the phone?

3. Were you initially trained as an on-ground or virtual home visitor?

4. Have you switched between providing virtual home visitation (home visitation by video
conference or phone) and in-person home visitation?

122

5. Did the families you served have a preference for in-person or virtual home visitation?

6. How did you decided when to switch between virtual and in-person home visitation?

Let’s talk about in-person home visitation
7. What did you like most about delivering in-person home visitation services?

8. What was most challenging about delivering in-person home visitation services?

Now we are going to ask specific questions about virtual home visitation (home visitation
by video conference or phone).
9. What did they like most about delivering virtual home visitation services?

10. What was most challenging about delivering virtual home visitation services?

11. How did you ensure you were sticking to your curriculum when making the transition to
virtual home visitation?

Summarize and thank participant by saying:
I appreciate you sharing your experiences and ideas with me. This has been a very informative
session and I want to thank you very much for all the information you have shared with us today.
Make sure you fill out the survey so we can compensate you for your time. I know that what you
have shared with me will help us to better serve children and their families. I will now turn off
the recorder and conclude the interview.

Abstract (if available)

Abstract Home visitation (HV) programs are an early intervention strategy where services are rendered to families in their homes, focusing on addressing challenges including child abuse, learning delays, and future behavioral issues. Ultimately, HV programs are intended to help parents in supporting their children and protect vulnerable families from negative outcomes such as adverse childhood experiences. This dissertation explores the implementation of virtual home visiting (VHV) programs in response to the COVID-19 pandemic and its impact on providers and caregivers. Using secondary data from a mixed methods study, this dissertation aims to understand how policies impact implementation, identify implementation barriers and facilitators, and examine factors related to provider burnout during rapid response VHV implementation. Kingdon’s Multiple Streams Framework and the Consolidated Framework for Implementation Research (CFIR) were applied to understand how policies impacted dissemination, implementation, and delivery of VHV services throughout the course of the pandemic. Categorized by CFIR domains (e.g., inner settings), caregiver and provider interview data were identified challenges and facilitators to VHV implementation. Spanning four of five CFIR domains, some barriers included limited access to technology and client engagement while some facilitators included flexibility and accessibility. Using hierarchical linear modeling, factors associated with less provider burnout included presence of supervisor support along with the perception of adequate supervisor support and training. Future directions should consider exploring policies, challenges, facilitators, and provider burnout longitudinally. Results from this dissertation add to the HV field by applying Dissemination & Implementation concepts during a wide-scale and rapid adoption of virtual platforms.

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Asset Metadata

Creator De Leon, Jessenia Natallie (author)

Core Title Virtual home visitation: implementation barriers and facilitators

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Degree Conferral Date 2023-12

Publication Date 09/11/2023

Defense Date 08/31/2023

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag CFIR,dissemination & implementation,OAI-PMH Harvest,provider well-being,virtual home visitation

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Kim, Bo-Kyung Elizabeth (committee chair), Graddy-Reed, Alexandra (committee member), Mor Barak, Michalle (committee member), Oh, Hans (committee member), Traube, Dorian (committee member)

Creator Email deleon@usc.edu,jdeleon27@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113308535

Unique identifier UC113308535

Identifier etd-DeLeonJess-12367.pdf (filename)

Legacy Identifier etd-DeLeonJess-12367

Document Type Dissertation

Format theses (aat)

Rights De Leon, Jessenia Natallie

Internet Media Type application/pdf

Type texts

Source 20230912-usctheses-batch-1096 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the author, as the original true and official version of the work, but does not grant the reader permission to use the work if the desired use is covered by copyright. It is the author, as rights holder, who must provide use permission if such use is covered by copyright.

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA

Repository Email cisadmin@lib.usc.edu