2 Program Staff Focus Group Protocol 1 (Co-definition Phas

OMB No: 0906-XXXX

Expiration Date: XX/XX/20XX

Public Burden Statement: This collection of information will be used to understand the strategies that have been used by ECHV programs to promote virtual child engagement. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this information collection is 0915/0906-XXXX and it is valid until XX/XX/202X. This information collection is voluntary. Data will be kept private to the extent allowable by the law. Public reporting burden for this collection of information is estimated to average 1.5 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Information Collection Clearance Officer, 5600 Fishers Lane, Room 14N39, Rockville, Maryland, 20857 or [email protected]. Please see https://www.hrsa.gov/about/508-resources for the HRSA digital accessibility statement.

Program Staff Focus Group Protocol

Phase 1: Co-Definition, Focus Group 1

Thank you for taking the time to talk with us today. My name is [NAME] and this is [co-facilitator/notetaker NAME(s)]. We work as research analysts with The Policy & Research Group (PRG). On behalf of the Health Resources and Services Administration (HRSA), and in collaboration with the Office of Planning, Research, and Evaluation (OPRE) in the Administration for Children and Families (ACF), we are implementing a project designed to identify, develop, study, and disseminate evidence-informed strategies and resources that early childhood home visiting (ECHV) programs may use to strengthen home visiting services, and, ultimately, achieve better outcomes for children and families. The focus of our discussion today is around strategies your program has implemented to promote child engagement and active participation, especially in virtual settings.

We are particularly interested in hearing about your experiences with trying to keep children interested, focused, and involved during virtual visits or visits conducted through video, including the strategies you use and why, and your perception of the benefits and challenges to these strategies.

Your participation in our discussion today is completely voluntary, and you can leave the call at any time. There is no penalty if you choose not to participate in this focus group. I may ask you a question directly, but you don’t have to answer anything you don’t want to. This is just an effort to make sure we hear from everyone today. Please know that the information you share today is confidential and only study staff will have access to the notes, recordings, and transcripts. Study staff may summarize what we discuss today to share with interested parties (e.g., staff in your program, HRSA, or other programs participating in the study), but no identifiable information or individual responses will be shared. We ask you to please respect each other’s privacy by not sharing any personal information or experiences discussed during the focus group.

I’m going to record our discussion today so that we can make sure we accurately capture what is said (that we remember the discussion correctly). By joining the discussion, you are agreeing to participate and to have the discussion recorded. Does anyone have any questions before I start recording? [Answer questions.]

As we are getting things set up to record and get our discussion underway – I’m going to drop a link to a quick survey in the Zoom Chat [or via email, if using phone]. The survey asks you to answer a few questions about yourself, so we have an understanding of who participated in our discussions. Like your participation in this discussion, filling out the survey is voluntary. You do not have to respond to all or any of the questions. Your name is not on the survey and will not be connected to your responses. By filling out the survey you are agreeing to allow the study team to see your responses and use your answers to describe (summarize) who was involved in the focus groups we conducted. Is everyone able to click on the link? [troubleshoot as necessary]. Great. If you are willing to fill out the survey, please take a few minutes to do so now and we’ll get started in [5 minutes, at TIME].

Ok. We are set up and I’m going to begin recording now. [Start to record.] Before we get started, I’d like us to set a few ground rules for the conversation.

[If using Zoom]

Since we are using Zoom today, I’ll keep my video on the whole time, but you can choose to have your video on or off. We want to make sure that everyone has the opportunity to have their thoughts and opinions heard. So, to avoid us talking over each other, I’ll be helping to direct the conversation. If you want to speak, you can let me know in the chat, click the “raise hand” button, or just chime in when there is a pause in conversation. Also, I want to emphasize that there are no right or wrong answers and we are interested in hearing both positive and negative comments and opinions – or whatever you think is important to share. We only ask that you do not use the names of clients or staff outside of this focus group to help maintain everyone’s privacy. Those are all of the guidelines I have - does anyone have additional guidelines for our conversation that you would like us to consider? Does anyone have any questions about Zoom or the guidelines for our discussion? [Confirm that everyone understands Zoom features and can mute/unmute.]

[If using Phone]

We want to make sure that everyone has the opportunity to have their thoughts and opinions heard. So, to avoid us talking over each other, I’ll be helping to direct the conversation. If you want to speak, you can chime in when there is a pause in conversation, otherwise, before we move on to different topics, I will provide an opportunity for people to voice their opinions. Also, I want to emphasize that there are no right or wrong answers and we are interested in hearing both positive and negative comments and opinions – or whatever you think is important to share. We only ask that you do not use the names of clients or staff outside of this focus group to help maintain everyone’s privacy. Those are all of the guidelines I have - does anyone have additional guidelines for our conversation that you would like us to consider? Does anyone have any questions about the guidelines for our discussion? [Confirm that everyone understands how to mute/unmute.]

In all, this should take about an hour to an hour and a half. Does anyone have any questions before we get started? [Answer questions.]

Part 1: Program Setting/Background

[This section builds our baseline understanding of the program and its use of strategies for virtual engagement. This section also addresses primary research question 1: What strategies do home visitors use to promote children’s active engagement and participation in virtual visits?]

During our previous conversations when we were identifying programs to participate in this study, you provided information about your program and how it operates. I’d like to briefly review that information with you and discuss any additional cultural, community, or program-specific contexts that we should be aware of and that influence your programming.

[Facilitator quickly reviews information on home visiting model used by the program, the setting and population served by the program, services offered to families, program capacity, current program staffing and caseload, and use of virtual service delivery. Ensure that we know:]

• population served (and location)

• # home visitors on staff and serving families

• # families enrolled and receiving services

• average or typical case load for home visitors

• frequency of/circumstances for virtual visits

Question: Is all of this information, correct? If not, what needs to be amended?

Question: Is there any other context we should know about how your program works?

• Probe: cultural, community, or program-specific contexts

• Follow-up: Is there anything else we should know about your program structure or service capacity as we start to think about strategies related to virtual service delivery?

Question: How do home visitors usually set up a virtual visit? (such as dropping off materials beforehand, planning a visit that involves going over paperwork rather than an activity, etc.)

Question: What strategies do home visitors use to ensure they are able to see the family’s environment and the child during virtual visits?

• Probe: guidance given to families to help them position their video

Okay, great. Now I’d like to discuss your perspectives on children’s engagement during virtual home visits. Throughout our discussion when I talk about engagement, I’m referring to a child’s level of interest and involvement in the home visit. This may be demonstrated by attentional focus (paying attention/listening, eye contact), emotional involvement (appropriate reaction to home visitor or caregivers’ actions, words, or activity/task), eagerness to participate (readily interacting with home visitor or caregiver), and/or active participation (completing tasks/activities as asked, verbal responses to questions/cues, appropriately interacting with home visitor or caregiver).

Question: Do you have any questions about what I mean by engagement or what that may look like?

[Address questions]

Ok. Now that we have a shared understanding of child engagement.

Question: How engaged (interested or involved) are children typically during a virtual home visit?

• Follow-up: How often do they demonstrate attentional focus, emotional involvement, and/or eagerness to participate during virtual home visits?

• Follow-up: How often do they complete tasks and respond to questions or participate in conversations?

Question: How is engagement different during in-person visits?

• Probe: Typical interactions during virtual visits, typical interactions during in-person visits, differences between the two

Question: Are there any parts of the virtual home visit that are particularly tricky or problematic, where you think children’s engagement could be improved?

• Probe: duration of visit/points in visits where attention drops off; instances home visitor is interacting with caregiver and not child; administration of screenings or assessments

[Before moving on to the next question, make sure everyone has had the opportunity to voice their opinions.]

Part 2: Virtual Engagement Strategies Implemented

[This section addresses primary research question 1: What strategies do home visitors use to promote children’s active engagement and participation in virtual visits? This section is intended to provide a shared foundational knowledge of the strategies used and how they have been implemented by the program.]

Thank you for going over information about your program and providing your thoughts on engagement in virtual visits. Now I am interested in hearing about strategies your program uses or has used to try and improve child engagement, when they are used, and how you use them.

And just to be clear, when I talk about engagement strategies, I’m referring to the specific strategies (not mandated by the home visiting model) home visitors have used to improve or encourage child interest and involvement during a home visit.

An engagement strategy may include one or a combination of the follow elements:

• A strategy to initially engage a child in the visit (spark interest and encourage involvement)

• A strategy to maintain child engagement once it is established

• A strategy to reengage or refocus a child who has lost interest/stopped participating.

An engagement strategy may also be an overall approach to the visit that is intended to be applied for the duration of the visit in order to continuously engage a child.

Question: Does anyone have any questions about how we are defining engagement strategies?

Today, we are especially interested in hearing about strategies you use during virtual visits. Some of these strategies might have started during the pandemic when virtual visits may have been more common or even the only way services were being delivered.

Over the course of our discussion, we want to hear about what you have been doing and we will work to understand how your experiences and practices align with the virtual engagement definition we are using for this study. The ultimate goal of the conversation will be to come up with a list of strategies that that your program may be interested in testing during this study and that reflect/encompass the study definition.

First, I am going to ask for people to share strategies your program has implemented, then I’ll ask some specific questions about the strategies.

Question: What strategies has your program implemented to try to engage children or get them to actively participate during virtual home visits?

• Follow-up: Have you used strategies intended to initiate engagement? maintain engagement? refocus a child who has lost interest? or some combination of these things?

• Follow-up: Are there any other strategies anyone wants to add?

[Facilitator makes a list as people share, then asks the following questions about the list strategies broadly.]

Question: What has been the outcome of using [strategy] in your experience (what does it do)?

• Probe: impact of [strategy] on children’s focus; emotional involvement; eagerness to participate; children’s active participation

Question: What does [strategy] require in terms of:

• Training/guidance/technical support

• Time for oversight/ongoing guidance

• Time to implement (such as dropping off materials)

• Materials (such as technology, or puppets, etc.)

Question: Considering what [strategy] requires - how practical or feasible is it for your program and home visitors to use this strategy?

• Probe: ease or difficulty for program to provide resources needed to implement [strategy]; ease or difficulty for home visitors to implement

Question: How well does [strategy] fit with the home visiting model that your program uses?

Question: How accepted is [strategy] by home visitors, administrators, and families?

• Probe: Who likes/dislikes it; how well liked or received is it; what is liked/disliked; response of families (negative/positive)

Question: How applicable and appropriate is [strategy] to/for all families and home visits?

• Follow-up: For whom, and in what instances, does [strategy] work best?

  • Probe: Content or purpose of visit, age of children, number of children, mode of visit; rapport between home visitor and family; length of time families have been in the program

• Follow-up: For whom, and in what instances, does [strategy] not work well? [Why/Please explain.]

Question: How does [strategy] vary from those used during in-person only service delivery?

Question: To what extent did home visitors use these particular engagement strategies before the COVID public health emergency (PHE) and how has your use of virtual engagement strategies changed over time?

• Follow-up: How did your approach or strategies change during the PHE?

  • Probe: restrictions on in-person contact; frequency of contact; content of communication; method of communication

Now that we have discussed the strategies you have used – let’s think bigger picture about the strategies we’ve discussed – especially in terms of how they compare to one another and how you make decisions about which specific strategies to use.

Question: Overall, which strategies do you think work the best for engaging children during virtual visits?

• Probe: similarities or differences for strategies that work best during in-person visits

Question: Do you think there are differences in how the strategies influence child engagement during home visits (either virtual or in person)?

• Probe: child focus; emotional involvement, eagerness to participate, active participation, direct interaction with home visitor, interaction with caregiver

Question: What considerations do you make when deciding which engagement strategy to use?

• Follow-up: Are some strategies more suitable for particular types of visits or situations? In what situations do you use specific strategies?

  • Probe: mode of visit, technology being used in visit, setting of visit, timing of visit (when in the day/week); timing during visit (point in visit needed); content/purpose of visit

• Follow-up: To what extent are the strategies you use dependent on the family/child you are working with?

  • Probe: family-size, age of children, cognitive capabilities, how long the family has been in the program, level of rapport with family

Question: Overall, which strategies do you think have the most potential to be scaled up/implemented at other programs?

Question: Is there anything else anyone wants to share about their experiences using the strategies we’ve been discussing?

[Before moving on to the next question, make sure everyone has had the opportunity to voice their opinions.]

Part 3: Facilitators of and Challenges to Implementation

[This section addresses barriers and facilitators to implementation and helps to respond to primary research question 2: How can the implementation of virtual engagement strategies be improved, especially sub question 2.a.: what facilitated implementation of these strategies? What are the barriers to implementation?]

In this section, I would like you to reflect on the strategies we’ve been discussing and share where the barriers and challenges have been. Are there general or program specific barriers to these strategies? I also would like to hear about how your program has succeeded in implementing these strategies and if there are tips or specifics you can think of regarding how to effectively implement engagement in virtual home visiting practices.

Question: Considering each of the strategies you’ve used: what barriers or challenges have come up when you’ve used them?

• Follow-up: Are there any program or home visiting model-specific barriers or challenges you can think of?

• Follow-up: What family/community/setting-specific barriers or challenges have come up or are relevant when implementing each of these strategies?

  • Probe: access to technology (computer/tablet/video/Wi-Fi/phone service); time constraints; access to child/family care; where the visit took place; when the visit took place (time of day/week)

Question: Does your program do anything that facilitates or makes implementing each of the strategies easier or more successful?

• Probe: assistance with technology; written or physical aids

[Before moving on to the next question, make sure everyone has had the opportunity to voice their opinions.]

Part 4: Perceptions of Strategies

[This section addresses two primary research questions: What strategies do home visitors use to promote children’s active engagement and participation in virtual visits? And how can the implementation of virtual engagement strategies be improved?]

In this section I am interested in you sharing details about the strategies you’ve used to engage children and families virtually and how they have gone. I am interested in your perception of the overall benefits or effect of these strategies on children and families and on home visits more generally.

Before we talk about what you see as the value of the strategies you’ve used, I’d first like to get your thoughts on the importance of child engagement.

Question: In your opinion, what is the value or benefit of keeping children engaged during a home visit?

• Probe: quality of home visit; quality of caretaker experience; rapport with child/caretaker; internalizing/understanding messages or information provided; satisfaction with program; home visit scheduling/attendance; length of time spent in program; participation in activities outside of home visits

[Facilitator makes a list of the perceived benefits to reflect on in next set of questions.]

Question: In your experience, which strategies would you say are most effective or promising, overall, with regards to the benefits we’ve discussed?

Question: Which strategies would you say are least effective, overall, with regards to the benefits we’ve discussed?

Now that we have an idea of how you see or understand the strategies to be working, I’d like to get a sense of how confident and comfortable you personally feel implementing these strategies.

Question: Which strategies do you feel most confident in your ability to implement?

• Probe: difference in level of confidence in virtual vs. in-person settings

Question: Which strategies do you feel least confident in your ability to implement?

• Probe: difference in level of confidence in virtual vs. in-person settings

Question: How do you feel about the guidance provided by your program and/or model for these strategies?

Question: Is there anything else you want to share about why you do /do not feel confident in your ability to implement a particular strategy?

[Before moving on to the next question, make sure everyone has had the opportunity to voice their opinions.]

Part 5: Wrap-up/Final Questions

[This section is the closing of the focus group and is used to make sure we address any outstanding questions and ensure we ask if anyone has anything additional to share before we end the focus group.]

Before we wrap-up, I want to reflect back on the strategies we’ve discussed and have you consider a “short list” that you are interested in testing or that you think other sites might be interested in testing during the study. Once we’ve talked to all of the sites participating in the study, we’ll send you a list of the strategies you identify here along with what other people are identifying as the most promising or appealing strategies We’ll need to make sure that the list of strategies aligns with or reflects the definition of engagement strategies we discussed previously, so we may need to consider some adjustments to some of the strategies.

Question: Considering our conversation - the strategies we’ve discussed, what you see as the benefits and challenges of those – are there any strategies that you feel are really rising to the top for you – that you definitely think your program should consider testing during this study? If so, can you identify the strategy and discuss why you think it should be kept on the list of strategies to consider?

• Follow-up: By a show of hands [If by phone, ask participants to say yes out loud] who thinks it should be kept on the list. Now a show of hands [if by phone, ask people to say no out loud] for people who think it should be dropped [facilitator notes #s].

Question: Are there any strategies that you think definitely should not be considered? Please explain why you think it should be dropped from the list of strategies to consider.

• Follow-up: By a show of hands who thinks it should be kept on the list. Now a show of hands for people who think it should be dropped [facilitator notes #s].

[Facilitator reviews the running list of strategies, including which strategies are to be included and not to be included. If there are some strategies that are not identified, ask the following questions.]

Question: Okay, it looks like there are a few strategies that no one has identified as either “keep” or “drop”. [Facilitator goes through the list one strategy at a time.] For [strategy], let’s see a raise of hands for people who think it should be kept on the list. Now a show of hands for people who think it should be dropped.

Great. Now we need to decide which strategies will remain on the list to consider. I suggest we keep a strategy on the list if a majority of you agree it should remain on the list and no one believes it definitely should be dropped. I’ll go through the list again, just to ensure you all agree with this strategy.

Question: [For each strategy]: [#] people said keep and [#] said drop. I’m going to [keep/drop] based on this – unless you all want to talk it through a little further. Does anyone one to talk about this strategy? [Facilitator asks group to talk out any disagreements and decide amongst themselves whether a strategy should remain.]

Question: Thinking about the study definition [repeat definition if needed], and this list of strategies – are there any that you think we may need to adjust if we want to consider them? If so, please identify the strategy and let’s discuss what adjustments you think could or should be made.

• Follow-up: [facilitator goes through the core elements of the definition one at a time for instance: 1) An engagement strategy may include one or a combination of the follow elements to initially engage, maintain engagement, or refocus a child; 2) an engagement strategy may also be an overall approach to the visit that is intended to be applied for the duration of the visit in order to continuously engage a child.] Does the strategy meet this part of the definition? If not, can you think of any elements of the strategy that would need to be added or adjusted?

Great. So, based on our conversation – this is the short list of strategies that you would like to consider for the study: [read list]. Again, we will include these along with strategies from other sites as we develop a final set of strategies that all sites can consider for the study. We will send this to you at least a week in advance of our next focus group so you have plenty of time to read through and discuss.

Question: In closing, is there anything else you’d like to share?

Thank you very much for participating in this discussion! If you have questions after you leave the call, feel free to contact me.

Our next focus group will be [provide timing] and will be the second focus group in Phase 1: Co-Definition, of the study process. Before we meet again, we will email everyone here a list of the different strategies discussed today. We will use this list as our starting point for the next focus group, during which we will decide, as a group, which strategy will be chosen for study implementation.

If you have any questions about the study, please contact Teresa Smith at The Policy & Research Group ([email protected] or (225) 281-3783).

If you have questions about your rights as a research volunteer, you can call Health Media Lab Institutional Review Board at (202) 549-1982.

The Policy & Research Group 11