In 2020, the childbirth rate in the United States was 15.4 per 1,000 women aged 15–19, a record low that has been declining since 1991 (Osterman et al., 2022). Youth with foster care histories are more likely to give birth during adolescence compared to those without foster care histories (Font et al., 2018; King et al., 2014; Shpiegel & Cascardi, 2015). One study found that over 40% of young women transitioning out of foster care had given birth at least once by age 21 (Shpiegel & Cascardi, 2018). Expectant (i.e., pregnant women and expecting partners) and parenting youth (EPY) with foster care histories face additional challenges compared to EPY without foster care histories. For example, exposure to traumas such as neglect; physical, sexual, and emotional abuse; domestic violence; and placement instability place children and youth in the child welfare system at a higher risk of experiencing mental health problems compared to the general population (Greeson et al., 2011; McGuire et al., 2018; Stone et al., 2021). Research also suggests that mothers in foster care, who often have less support and more surveillance of their parenting, have higher rates of their children being the subject of a child protective services investigation and having a child removed than those not in foster care (Dworsky, 2015). Among the pressures of parenthood, parents from foster care face limited resources for support and an ongoing threat of system involvement (Schelbe & Geiger, 2017).

Due to such challenges, EPY with foster care histories often have an increased need for mental health services, housing services, education and employment services, parenting skills training, and assistance purchasing basic child necessities (Narendorf et al., 2013; Radey et al., 2016a; Schelbe & Geiger, 2017). However, barriers to service access and utilization may exist, such as providers’ hours of service availability and concerns over being stigmatized by providers for being a young parent or involved in the child welfare system (Aparicio et al., 2015; Connolly et al., 2012; Narendorf et al., 2013). Being able to utilize services can help EPY with foster care histories receive needed support and overcome some of the challenges associated with parenthood and child welfare involvement. Research has largely focused on barriers to service utilization and less is known about factors that facilitate service utilization. To add to the literature about facilitators this qualitative study used an ecological systems theory framework, to explore the following research question: What facilitators of service utilization exist related to (a) service provider characteristics, (b) agency characteristics, and (c) system characteristics for EPY with foster care histories?

Literature Review

Ecological Systems Theory

Using ecological systems theory, this study assumes that EPY with foster care histories develop within a human ecosystem that comprises interrelated subsystems (Bronfenbrenner, 1979, 1994): the microsystem, mesosystem, exosystem, and macrosystem (Bronfenbrenner, 1994). The microsystem is a setting in which youth readily engage in face-to-face interactions. Several elements make up youth’s microsystem, including activities, roles, and interpersonal relations (Bronfenbrenner, 1989). Examples of microsystems settings include home and school. At home the youth plays the role of a child; at school the youth plays the role of a student. Within these settings, youth engage in proximal relationships with others such as peers, caregivers, and teachers. The mesosystem is the interrelationships between two or more settings that youth actively engage with, creating a “system of microsystems” (Bronfenbrenner, 1994, p. 1645). Supplementary links include people who engage with two or more of these settings of which the youth is a part (Shelton, 2019). The mesosystem examines the relationship between the different microsystem settings (e.g., home, school, and neighborhood) and the impact of this relationship on youths’ role and activities in each of the settings. The exosystem comprises one or more settings that the youth does not actively participate yet is affected by decisions and occurrences in the settings (Bronfenbrenner, 1994), such as parent’s workplace. The macrosystem “consists of the overarching pattern of micro-, meso- and exosystems characteristic of a given culture or subculture, with particular reference to the belief systems, bodies of knowledge, material resources, customs, lifestyles, opportunity structures, hazards, and life course options that are embedded in each of these broader systems” (Bronfenbrenner, 1994, p. 1645). These cultural values influence policies, laws, and institutions.

EPY with foster care histories develop within this ecosystem and are affected by each of the subsystems, often limiting their power and voice. For example, EPY may be impacted by their foster care placement (microsystem), relationship with their child welfare worker (mesosystem), extent to which information is coordinated between their providers (exosystem), and the policies governing child welfare services (macrosystem). Each of these levels can play an important role in either promoting service use among EPY or deterring them from accessing services. In this study, we explore the provider (microsystem), agency (microsystem) and system (macrosystem) characteristics that act as facilitators of service utilization among EPY.

Characteristics of Providers Serving EPY

Research has suggested that having positive relationships with service providers and other supportive adults is a protective factor for EPY with foster care histories (Greeson, 2013; Svoboda et al., 2012). However, EPY with foster care histories may mistrust providers and fear providers stigmatizing them for being a young parent or being involved in the child welfare system (Connolly et al., 2012; Ohene & Garcia, 2020). EPY with foster care histories benefit from having providers they perceive to be trustworthy and who can assist them in accessing a range of services (Connolly et al., 2012; Dworsky et al., 2021). Furthermore, professionals who relate to youth with foster care histories with empathy and positive regard provide opportunities for them to experience feelings of worth and value which are critical in building trust and resilience (Hass et al., 2014; Heyman et al., 2020).

EPY with foster care histories may struggle to access supports (Radey et al., 2016b) and often need to be taught how to utilize resources and ask for help (Schelbe & Geiger, 2017). Providers can support EPY with foster care histories by referring them to appropriate resources using a warm-handoff (e.g., a personalized referral) and helping them to navigate the process of accessing and utilizing needed services (Radey et al., 2016b). Providers could further benefit this population by gaining an understanding of their unique challenges, barriers, strengths, and assets as youthful parents with foster care histories. Youth with foster care histories may have had little control over their lives while in foster care (Hyde & Kammerer, 2009). Providers can give back some of that control by tailoring services to the needs expressed by youth and giving them opportunities for choices in services and responsibilities (Hayes et al., 2015; Heyman et al., 2020; Piel & Lacasse, 2017).

Characteristics of Agencies Serving EPY

As a strategy to constrain biases in social service work, some agencies have focused on contracting with providers who have linguistic and/or cultural backgrounds that match their clients or with whom clients can identify (Liu, 2013; Ojeda et al., 2021). Diversity of the child welfare and social service workforce may, in part, impact case worker decision making and case outcomes (Arroyo et al., 2019; Dettlaff et al., 2011; Wulczyn et al., 2013). However, matching clients and providers based on language or cultural background does not sufficiently address variances in service referrals and case outcomes (Lanesskog et al., 2020; Liu, 2013). Research suggests that providers also need to be culturally responsive (Lanesskog et al., 2015, 2020; Liu, 2013). As part of a multilevel systemic approach, agencies can adopt strategies such as investing in professional development trainings to strengthen the cultural humilty and responsiveness of providers and support diverse client populations, including the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) community (Gandy et al., 2013; Lanesskog et al., 2020).

In recent years, social service agencies have had an increased emphasis on trauma-informed training and practices. Children and youth in foster care disproportionately experience trauma (Bramlett & Radel, 2014) which can lead to negative short and long-term outcomes. Trauma-informed agencies acknowledge the presence and impacts of trauma and base their interactions with clients on the values of safety, trustworthiness, choice, collaboration, and empowerment (Fallot & Harris, 2009). Hales et al. (2019) found that clients at a nonprofit agency were more satisfied and less likely to discharge from services after the agency implemented a trauma-informed care framework, including staff training and purposeful client-staff partnerships. Training on trauma-informed practices have increased trauma-informed knowledge, practice, and collaboration between child welfare and agencies(Bartlett et al., 2016; Kramer et al., 2013; Lang et al., 2016).

EPY with foster care histories often struggle to access basic needs such as reliable and safe child care and transportation (Connolly et al., 2012; Radey et al., 2016a; Schelbe & Geiger, 2017). The lack of access to resources to address these tangible needs can impact their education, employment, and participation in medical appointments (Connolly et al., 2012; Dworsky & Gitlow, 2017; Radey et al., 2016a; Schelbe & Geiger, 2017). To address these barriers, some agencies provide EPY with childcare and transportation to attend services (Person et al., 2018). For example, schools can provide on-site child care and/or offer services in or at the youth’s home so they do not need to have transportation to access services (Person et al., 2018).

Importantly, the Family First Prevention and Services Act (FFPSA, 2018) allows for the use of Title IV-E funding for specific prevention services for reasonable candidates of foster care. Under the FFPSA provisions, the children of EPY in foster care are categorically eligible as reasonable candidates of foster care even if there are no other specific risks identified (Center for the Study of Social Policy, 2018). Agencies that adopt evidence-based in-home parenting-skills programs from among those identified in the Title IV-E Prevention Services Clearinghouse will be well-positioned to serve EPY. It is critical that agencies not only implement these evidence-based programs with fidelity, but also continue to actively recruit and train diverse staff committed to providing culturally relevant and responsive services, utilize trauma-informed lenses and approaches, and make necessary adaptations for this particular population. For example, in a pilot project that implemented Healthy Families America with EPY who were involved with foster care, Dworsky et al. (2021) found that increased engagement efforts, more flexibility to serve youth around the constraints or rules of their placements, the ability to continue to serve youth during episodes of run-away, detention, or hospitalization, and reduced caseloads were necessary to better serve the population.

Characteristics of Systems Serving EPY

EPY with foster care histories engage with multiple agencies and providers within the service system to access and utilize services and supports. EPY may receive services from schools, behavioral health agencies, healthcare clinics, workforce systems, and other agencies. Each of these agencies can help promote service utilization within their own agency and across other systems through interagency partnerships and coalitions (Mizrahi et al., 2012). Service navigation efforts are needed that involve representatives from the multiple systems with which EPY with foster care histories interact (Nesmith & Christophersen, 2014; Thompson et al., 2016). The children of EPY with foster care histories also are likely to be enrolled in multiple services (e.g., early intervention assessments or intervention, home-visiting programs or child abuse prevention programs) and EPY may also be participating in services to address their needs (e.g., independent living classes, psychoeducational training, tutoring, trauma treatment, mental health). Yet, these services are often not coordinated, are sometimes unnecessarily duplicative, and often do not provide a holistic approach to the EPY and child as a family. Research indicates that coordinated service delivery may be necessary to address the needs of EPY with foster care histories (Courtney et al., 2016; Dworsky & Gitlow, 2017; Radey et al., 2016a).

EPY with foster care histories can also benefit from services being delivered in various settings that are accessible and in spaces and places where they feel comfortable (Person et al., 2018). A growing trend is to increase the co-location of services or offer multiple services in the same physical location. For example, healthcare and behavioral healthcare services are increasingly integrated and include social workers (Lombardi et al., 2019). Some child welfare agencies have also developed interagency collaborations that include the co-location of staff from outside agencies within child welfare offices (Ogbonnaya & Keeney, 2018).

Current Study

Characteristics of providers, agencies, and systems can influence the service utilization of EPY with foster care histories. Studies have primarily focused on the needs of EPY with foster care histories and the barriers to services (Eastman et al., 2019). To increase service utilization, it also is important to consider the supports or facilitators which may remove barriers or help youth to overcome them. It is helpful to include the perspectives of both service providers and EPY with foster care histories. Providers implement services or supervise those who do. These individuals can help identify strategies to support service utilization. EPY are the focal group of these services, and their voices are critical to understanding what they view promotes engagement in services.

This qualitative study explores facilitators of service utilization related to service provider, agency, and system characteristics, using data from a community strengths and needs assessment that was conducted with service providers and EPY with foster care histories in a mid-sized urban county in a Southwestern state where the project was administered. Barriers to service utilization identified in the community strengths and needs assessment are reported in a separate manuscript by the authors (Villagrana et al., 2021). Our research question guiding this study was: What facilitators of service utilization exist related to (a) service provider characteristics, (b) agency characteristics, and (c) system characteristics for EPY with foster care histories?

Method

Sample and Recruitment Procedures

The study was approved by the Institutional Review Board at the researchers’ university. Participants were recruited from two groups: (a) EPY with a history of foster care and/or juvenile justice involvement and (b) service providers who serve EPY within one primarily urban county in a Southwestern state in which the project was administered. EPY and service providers participated in separate focus groups.

EPY

To meet eligibility criteria, EPY needed to identify as (a) pregnant, expecting, or parenting; (b) 12–24 years old; (c) history in foster care and/or the juvenile justice system; (d) not currently in foster care or extended care; and (e) residing within the primarily urban county in a Southwestern state. The researchers were unable to obtain the permission of the state child welfare agency in time for those currently in foster care to be included. Community agencies helped to recruit a convenience sample of EPY through flyers and referrals from service providers. EPY were invited to participate in either an interview or focus group, based on their preference and availability. Participants were compensated with a $25 gift card to a local vendor. EPY under the age of 18 signed an assent form, and their guardian signed a consent form. EPY over the age of 18 signed a consent form. Data were collected from a total of 11 EPY through in-person interviews (n = 4) and focus groups (n = 7).

Service Providers

To meet eligibility criteria, service providers had to identify as being (a) connected to a youth, child, and/or family-serving organization in the county and (b) at least 18 years old. Recruitment efforts were focused on service providers who represented the service areas of child welfare, juvenile justice, education, behavioral health, and reproductive health. Snowball sampling was used to recruit participants by emailing a flyer to potential participants suggested by the project’s Advisory Council, encouraging the project’s Advisory Council to share the flyer, presenting to community agencies and councils, and contacting agencies mentioned in completed interviews or focus groups. Providers were invited to participate in either an individual interview or focus group, based on their preference and availability. Service providers participating in the study received no compensation. All providers signed a consent form. Data were collected from a total of 28 service providers through two formats: in-person interviews (n = 5) and focus groups (n = 23).

Instruments and Data Collection

As part of the community strengths and needs assessment, the researchers created semi-structured interview guides for EPY (27 questions) and service providers (17 questions) related to available services, barriers, strengths, and gaps in service delivery for EPY in the county (interview guides are available upon request to the lead author). Areas of service included family planning, education, healthcare, concrete needs, and healthy relationships.

Between January and July 2019, two researchers conducted in-person interviews and focus groups. Interviews lasted 30–60 minutes and focus groups lasted 1.5–2 hours. The interviews and focus groups were audio-recorded and then transcribed verbatim for analysis.

Before each interview or focus group, we invited participants to complete a paper-and-pencil demographic questionnaire. EPY items were related to personal demographics (e.g., gender identity, age), history of system involvement (e.g., foster care history, juvenile justice history), and history of pregnancy and/or parenting (e.g., ages of children, current parenting status). Service provider items were related to personal demographics (e.g., gender identity, age), current employment and employment history (e.g., number of years working in social services), and type of services provided by their agency (e.g., mental healthcare, parent support groups).

Data Analysis

To prepare the data for qualitative analysis, interview and focus group transcriptions were entered into a table in for recording codes, quotes, and memos (La Pelle, 2004). The qualitative analysis was conducted in a five-step inductive process by the first three authors to identify codes and themes that emerged from the data. First, the first two authors independently read each transcript, identified passages related to the research questions (i.e., characteristics of service providers, agencies, and systems that facilitate EPY service utilization), and generated first-level codes. Related concepts, such as characteristics discouraging EYP service utilization emerged in the data but are beyond the scope of this paper (Villagrana et al., 2021). Second, the table was revised to include the columns of both coders. Utilizing this revised table, the third author generated first-level codes while observing the first-level codes developed by the other authors. Third, these three authors met to discuss the first-level codes and discussed possible second-level codes. Fourth, the first author reread each transcript and first-level codes (e.g., agencies don’t communicate about individuals, agencies don’t collaborate, legal barriers to sharing information) and generated second-level codes (e.g., lack of communication/coordination among agencies) from first-level codes on which two or more coders had agreed. As a result of this process themes emerged (e.g., systems integration), which included the feedback of all coders. To increase the study's trustworthiness, the authors engaged in peer debriefing and discussed the emerging codes throughout the process (Padgett, 2017). The first author kept an audit trail of the decisions made during the analysis (Lietz & Zayas, 2010; Padgett, 2017). Within the coding document, the authors also engaged in reflexivity by writing memos about personal biases and connections to the data (Charmaz, 2006).

To analyze data from the demographic questionnaires, descriptive statistics for quantitative variables were run using SPSS 25 for Windows.

Findings

Sample Characteristics

The majority of providers identified as female (75%), heterosexual (85.71%), and White or Caucasian (60.71%). Providers primarily held bachelor’s degrees (50%) and had worked with expectant/parenting populations for 5 to 9 years (32.14%). The majority of EPY identified as female (72.70%), heterosexual (81.80%), and Hispanic or Latina/o (27.27%), White (27.27%), or mixed race (27.27%). About half of the EPY had attended but not completed high school (54.50%). Roughly 80% of the youth were between the ages of 16–21 at the time of their first pregnancy or impregnating someone whereas 20% were 14–15 years old. The majority of EPY identified as having a foster care history (90.9%). Sample characteristics for service providers and EPY are provided in Table 1.

Table 1 Sample Characteristics of Providers and EPY
Full size table

Service Provider Facilitators

Three themes emerged from providers and EPY related to service provider characteristics that facilitated service utilization among EPY with experience in foster care: empathy and trustworthiness, supportive navigation, and youth-centeredness.

EPY and Provider Theme: Empathy and Trustworthiness

Providers and EPY expressed that when individual providers convey empathy and care, youth feel supported and are more willing to accept services. While discussing providers that young parents felt were supportive, an EPY shared, “They show us that we’re important. That we matter. They’ll help us.” Another added, “They actually care. They actually put their time and force into it.” Professionals who spent time with EPY without appearing to be rushed led young parents to feel supported, particularly those with few connections to families. One EPY stated, “You know, that’s really cool to have that support since my parents aren’t here to do that with me. It’s nice to have that person come in and show me that kind of stuff, [it] is pretty cool.” This sentiment was also illustrated by a provider who said:

You have to be a certain kind of person to do this kind of work. You have to care. You have to be able to go that extra mile knowing you’re not gonna get anything necessarily in return, but to help that individual.

Providers and EPY also discussed provider trustworthiness as a facilitator to service utilization. One provider discussed how EPY who need help with parenting may be reluctant to trust the provider enough to reveal their struggles, explaining that there is a:

. . . fear of disclosing what you did because you’re afraid of. . . a consequence. . . . If you were taken from your home. . . you’re gonna be fearful that your child is going to get taken from you for the smallest little thing.

EPY also shared the importance of trust given their past traumas. For example, one EPY said, “Being in foster care, you’re not gonna trust anyone else with your kid. And you don’t want your kids to go through what you went through.” Examples of behaviors that conveyed trustworthiness included case managers following through on referrals and appointment commitments. As one EPY said, “They actually keep their word. That’s what it is.”

EPY and Provider Theme: Supportive Navigation

Providers shared that it can be difficult for both EPY and professionals to navigate the different systems that youth are interacting with. Supportive navigation included being knowledgeable about available services and enrollment criteria, and accompanying EPY to service providers if needed. Throughout the interviews and focus groups, providers identified many services in the community to which they referred EPY to address education, health, mental health, parenting, concrete needs, and socioemotional well-being. A provider shared that it helps EPY to access resources if providers “know how to navigate the system, where to look for resources.”

EPY shared experiences of being referred to helpful services from agencies and providers. They learned about services from teachers, home visiting programs in the hospital, pregnancy classes, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and child welfare case managers. For example, one EPY said:

[My case manager and I are] very close. . . . I turn 21 this month. . . so it’s our last session together. And she’s like, “Well, I’m not gonna just leave you hanging.” So, she’s like, “I have this thing for you [a program with services for young parents], where I think you’d like it.”

A provider explained that a helpful navigation strategy is to go with EPY to appointments: “When we aren’t sure about how friendly, or even if we are sure [that] an organization is youth-friendly,... if the youth wants us, we’ll go with them to these appointments.” An EPY who was overwhelmed and confused about accessing WIC and parenting services explained, “This was my first baby. So I was like, ‘What are you talking about?’” She then explained that her worker “went with me to WIC so I didn’t have to go alone.”

EPY and Provider Theme: Youth-Centeredness

Setting manageable, youth-driven goals and giving EPY choices was seen as instrumental to their engagement with services. For example, one provider stated:

. . . finding ways to meet them where they're at [is critical]. They won't do services if they feel like they're being ordered to do things. They appreciate being able to set their own goals, whether that's with parenting goals or educational goals or whatever.

An EPY shared that they liked a parenting program because it “helps me achieve things that I wanna do. It helps me get the things that I want.”

One-way providers supported EPY in achieving these goals was to present information in ways young parents can absorb it. As an EPY stated, information is useful only if it “gets to the point.” Another provider described that, at their agency, EPY can choose which program is the best fit for them, “We had a lot of success when the youth signed up. We told them about all of the programs. We let them choose to sign up, versus a case manager saying, ‘Okay. I’m putting this referral in for you.’”.

Agency Facilitators

One theme emerged from both EPY and providers related to agency characteristics that served as facilitators to service utilization among EPY: availability of tangible supports. Two themes related to these agency characteristics emerged from providers only: representative diversity and inclusivity, and trauma-informed training and practice.

EPY and Provider Theme: Availability of Tangible Supports

Providing tangible supports was discussed as important for facilitating service utilization. Both EPY and providers identified lack of childcare and transportation as significant barriers to utilizing services. To address this barrier, some organizations provide on-site childcare or help connect youth to resources that can provide childcare. Additionally, group homes were helpful in providing child care while the youth were at work or school. A provider said:

We. . . try to remove barriers for our kiddos and we’ve identified that childcare is one of those, so we do try and pay for some of the childcare. . . . When we have kids that are [going to] vocational placements, [we] identify vocational placement[s] that [have] childcare.

Several EPY shared that their school provided on-site child care which allowed their child to come with them to school, or offered child care scholarships. A youth shared:

Being in foster care, you don’t get child care. . . . What happened was that my teacher [in my parenting group at my] high school, they offered a scholarship for in-home daycare. . . . I. . . have a house nearby my school so that we would drop off my kid and then go to school.

When discussing barriers to accessing basic needs, an EPY shared “I feel like I got lucky with all of this...I got some information from my [agency]...they know [about] resources like transportation.” A provider shared that EPY can have access to transportation to receive primary care through the state Medicaid agency that provides medical and dental coverage for children in foster care: “After 16, they can get a taxi, even, to transport them to the appointment so they don't have to tell anyone if they don't want to.” Another said, “We either will transport our clients to the places they need to go or we’ll get them bus passes or we’ll arrange for them to have Uber rides.”

Provider Theme: Representative Diversity and Inclusivity

Providers discussed the importance of having employees representing a range of diversity and with whom EPY could identify. A provider explained, “We try to assign case managers who can identify with the youth: non-English speaking, LGBTQ + , different religions. We try to include support team members who the youth can identify with.” Several providers discussed the importance of having providers who speak other languages. For example, a provider shared that at their agency, “Every single department has a bilingual Spanish speaker, if not more than one. We’re trying to at least reduce the language barrier on site.”

Provider Theme: Trauma-Informed Training and Practice

Providers shared that organizations have a growing emphasis on providing trainings on the impacts of trauma and engaging in trauma-informed practice. Providers felt that this was important for helping youth feel safe engaging in services, especially since EPY often feel stigmatized by providers both because they are young parents and have foster care backgrounds. A provider said that at their agency, “we've made a push to become trauma-informed lately and the whole youth engagement being more supportive.” Another provider shared that trauma-informed services are becoming more prevalent across agencies, “systems are becoming more trauma-informed and getting that background, I think that’s definitely helping better serve this population.”

System Facilitators

Three themes emerged from providers only related to system characteristics that served as facilitators of service utilization among EPY with experiences in foster care: the variety of service providers, systems integration, and co-location.

Provider Theme: Variety of Service Providers

Providers shared that many different agencies and service providers supported EPY in the county. They listed resources in the community that supported EPY with healthcare, education, parenting, concrete resources, and more. One provider said, “I'd say some of our strengths is we definitely have the agencies in place. We definitely have a lot of resources and things that we need.” Another said, “It's a big county, it's a highly populated county, so, just of necessity, there are gonna be more resources out there than there would be in an area that's very rural, or just has a smaller population density.” Having many service providers and agencies provided more opportunities for referrals and places for EPY to access services.

Provider Theme: Systems Integration

Providers also emphasized that it is not enough to have resources but that the agencies and services need to be integrated. Providers shared many examples of agencies collaborating to better serve EPY through coalitions and interagency partnerships. For example, “The [coalition] has just started a hub specifically for youth, which also includes training, professional development, and agencies who could put their services on there.” Partnerships across agencies were developed to make the integration of services and enrollment more streamlined. A provider said:

Prior to the [health insurance] policy change, young people actually had to sign an application [for health insurance] when they turned 18. A lot of young people may be transient, or they may not be working with their caseworkers regularly. Now, there is no application and signature requirement for them to get enrolled. It’s a quasi-semi-automatic enrollment process.

Provider Theme: Co-Location

Providers highlighted that some agencies are working toward having integrated healthcare models. A provider said:

A couple of our sites are working on an integrated care model, so there are . . . primary care physicians available at those sites. We are able to internally refer or refer out into the community and provide our kids with [Medicaid-] approved providers.

Another shared that the agency is providing their services at other agencies on a regular basis, “We have partnered with other organizations, meaning [it] can be a nonprofit or whatnot, across the state. There are certain days, like once a month or something, where they go [to apply for services]”. Other agencies are trying similar approaches with bringing multiple services into the same space for events. A provider talked about an event that moves to different cities each month:

It’s a one-stop-shop where different organizations or non-profits. . . set up a table. . . . It’s mostly targeted towards [the] homeless demographic. . . . I feel like, maybe with any kind of programs, they can start doing those types of events or even making it a monthly thing in different communities to make it more accessible for young parents or kids.

Discussion and Implications

Service providers, agencies, and systems serving EPY with foster care experiences represent a dynamic ecosystem impacting children, youth, and families in profound ways. The findings highlight that characteristics at the provider, agency, and system levels can serve as facilitators. This study provides a richer understanding of how EPY and service providers perceive the ecosystems of EPY and which characteristics contribute to their use of services. This discussion of facilitators at the provider, agency, and system levels also include practice implications.

Provider Facilitators

Provider empathy and trustworthiness were resounding themes in the responses of EPY and providers. Prior research has also emphasized the importance of professionals showing empathy to youth with foster care histories (Hass et al., 2014; Ohene & Garcia, 2020). Descriptions of trustworthy behaviors ranged from providers following through with scheduled appointments to spending time with EPY and showing them how to navigate a new service or experience. Service providers working with EPY may need to devote more time to engagement, rapport building, and attending to the emotional and physical intricacies of “meeting clients where they’re at” than in their work with those without foster care histories. These service providers may need training on responding empathically to youth who have developed coping skills aimed at keeping others at a distance, relying only on themselves, and not revealing too much to mandated reporters. Providers can engage EPY in discussions about what helps them build trust and/or diminish their trust in others to make better-informed service decisions. Providers can promote trusting relationships with EPY with foster care histories who are often concerned about their children being removed and placed in foster care (Schelbe & Geiger, 2017) by being upfront with EPY about what situations would lead them to make a report, make sure they are aware of services that would prevent the need for a report, and let them know how and to what extent they would be available to them during crisis or unplanned circumstances. Providing this information allows EPY with foster care histories to make informed decisions and increase their sense of control and power as well as supporting the development of honest relationships that can lead to a sense of trustworthiness.

EPY with foster care histories are more likely than those without a foster care history to face increased scrutiny and surveillance as parents, live in congregate care settings, move more frequently, and have significant instability in their caregiving and living arrangements in their history. Additionally, EPY with foster care histories may have a smaller network of connections, lack familial support, and have experienced a lack of modeled nurturing in their primary care relationships. Being responsive and attuned to these unique circumstances may require significant investments by providers in engaging youth and attending to trust in the relationship. Furthermore, while those with experience serving youth in foster care may understand these circumstances, EPY with foster care histories have unique needs due to their being expectant or parenting. Being youth-centered with this population may mean not only being responsive to their needs as youth, but also to their experiences as expectant and/or young parents. Providers may need to assist EPY in foster care with issues such as co-parenting with the other parent and navigating child support or family court visitation orders. They may also need to advocate for issues such as a youthful father in foster care being allowed to be present for the birth of his baby if that is the desire of both parents, even if being away from the placement “unsupervised” for longer than 24 hours poses challenges to the rules or policies of the placement or child welfare system. Finally, the caregivers and staff in their living environments and their child welfare case managers upon whom they must rely for support and assistance are also mandated to report them to the child welfare agency for concerns or problems that the parents of EPY not in foster care might address or fix (e.g. provide supervision to the child if a youthful parent stays out longer than they planned, provide extra financial assistance with formula if the youthful parent runs short on formula). Providers who work with this population will need to understand the unique dynamics facing their clients.

Providers possessing a working knowledge of services and the associated enrollment criteria were viewed as better able to identify services that suit the individualized needs of EPY with foster care histories. Those demonstrating youth-centered practices, such as communicating important information to EPY in plain language and in the primary language of the EPY were valued. Additionally, showing EPY how to access and navigate services was viewed as a facilitating characteristic. Providers’ ability to respect the EPY’s developmental need to exert control over their lives while balancing their need for empathy and guidance also was noted as a key facilitator. To help provide supportive navigation, providers can participate in professional social media sites that share information about services, systems, resources, and policies (Chan & Leung, 2018). Providers also may need to be allotted more time to accompany EPY with foster care histories to appointments rather than only referring them to agencies. They may also need more time to carefully investigate the usefulness or feasibility of services for this population, which is likely to become transitory, especially due to placement instability and the lack of affordable family housing.

Agency Facilitators

Agencies are also critical to supporting service utilization among EPY with foster care histories. To promote service utilization, agencies can provide tangible supports. To support EPY with transportation, agencies could provide bus passes, reimburse for taxi services, or meet EPY at locations in the community that they can easily access. To address issues with childcare, agencies could provide on-site childcare or have an environment where EPY with foster care histories can safely bring their children to appointments (Person et al., 2018). For example, agencies can have basic necessities available that parents may need when bringing a young child to an appointment (e.g., diapers, portable crib, toys). Additionally, providers can emphasize to EPY that they can bring children with them to appointments. To reduce the barriers of transportation and child care, agencies can also use community-based outreach and services provision models such as community outreach workers (Kimbrough-Melton & Melton, 2015) and family team meetings that are held around clients’ schedules (Kim et al., 2016).

Agencies can help staff understand how trauma and a lack of modeling of healthy parent–child relationships impact parenting attachment behaviors, capacities, and skills. To increase the ability of staff to develop and convey a sense of caring, agencies can help staff recognize biases they may have about EPY with foster care histories and provide supervision and training focused on changing attitudes and behaviors when needed. Agencies may better promote trusting relationships with EPY with foster care histories by providing more in-depth training to service providers on reporting suspected child abuse and neglect so as to limit reports that do not actually entail safety threats or imminent risk. Providers could work with their local child welfare systems to understand whether they need to report neglectful situations if the agency can immediately resolve or mitigate the neglect.

This study’s findings suggest that services and providers that demonstrate inclusivity, reflect the diversity of clients, are culturally responsive, and promote a culture and climate that values difference and social justice may help engage youth and facilitate service utilization. Active recruitment of people with a wide range of identities (e.g., different racial and ethnic identities, LGBTQ + identities), skills (e.g., fluency in multiple languages), and experiences (e.g., those with personal experiences as teen parents, foster care alumni) also has the potential to increase staff ability to empathize with EPY with foster care histories. The findings related to diversity and inclusion should prompt providers to conduct an environmental scan of their organization ensuring that there are no unintentional incidences of racism, heterosexism, or cissexism (e.g., not creating services designed specifically to address the needs of EPY who are of color, LGBTQ+). While assessing current practices at an agency, it would be imperative to include EPY with foster care histories to gain their perspectives on current practices and power dynamics affecting them. Programming supporting peer and kinship navigation approaches have also been successful in assisting parents in navigating multiple systems with which they interact (Abbott et al., 2019; Hernandez et al., 2014; Ojeda et al., 2020; Schmidt & Treinen, 2017) and may be well situated to address both empathy and staff diversity.

System Facilitators

Strengthening interagency collaboration and relationships at the system level is key to supporting service utilization, including building coalitions and developing co-located services. Through coalition-building, agencies can work together to ensure they meet the needs of this population. Based on the findings of this study, coalitions should include not only traditional child welfare service providers, but also representatives from schools, WIC, and physical and behavioral healthcare organizations that are likely to interact with EPY with foster care histories. Coalitions can identify aspects of the existing system that may retraumatize EPY (e.g., requiring that a youth repeatedly tell “their story” and share particular vulnerabilities associated with their time in care). To reduce the retelling of stories and increase shared communication between agencies supporting the same youth, agencies can develop information-sharing policies (Lee et al., 2015).

Agencies and systems can examine their practices and policies to ensure that EPY are not blamed or shamed for becoming pregnant or impregnating someone. Coalitions of multiple agencies, inclusive of representation of those with lived experiences, could also better leverage grant funding and state and federal dollars to procure funding to enhance services and meet the tangible needs of EPY. Additionally, EPY with foster care histories can be involved in designing services. Involving EPY in decision-making can help to reduce the power issues affecting service utilization, such as providers making all of the decisions. This would be especially critical for EPY transitioning from foster care, as they have distinct needs from transitioning youth who are not parents and distinct needs from young parents who are not transitioning from foster care. Though not mentioned in this study, housing for this population needs to be addressed as well as other tangible needs including childcare and transportation.

Increased resource-sharing and system integration between agencies and systems could allow more EPY with foster care histories to have more of their tangible needs met more swiftly. Agencies and systems can work closely with one another and develop the capacity to create shared case plans/treatment plans to enhance a holistic approach for working with the family, and also to capitalize on one another’s assets with respect to resources. For example, child welfare case managers can also include the providers of community-based services in teaming and staffing meetings so that unnecessary duplication of services can be prevented, gaps in services can be identified, eligibility for programs and services based on foster care status can be identified (e.g. foster youth being eligible for child care assistance and transportation to/from appointments related to their case plans), and treatment plans and case plans across agencies can be aligned.

Implications for Policy

The Family First Prevention Services Act (FFPSA) provides an opportunity for child welfare agencies to claim Title IV-E reimbursement for prevention services, including services for EPY. While many of the in-home parenting skills programs in the Prevention Clearinghouse may not be applicable to the multifaceted needs of EPY with foster care histories, both the Healthy Families America and Nurse Family Partnership programs have been rated “well-supported.” As these programs were also supported by the Maternal, Infant, Early Childhood Home Visiting (MIECHV) grants, they have familiarity with serving EPY, however,they may need adaptations to serve EPY in care (Dworsky et al., 2021). The identified facilitators of service utilization at the service provider, agency, and system levels within this study could help to inform program models and services.

Implications for Future Research

Future research is warranted on how the presence and dosage of the service provider, agency, and system facilitators identified in this study affect the well-being and outcomes of diverse EPY with foster care histories. Research on how these facilitators affect the outcomes of EPY with foster care histories could help to identify which facilitators have the greatest influence on service utilization. Researchers should also examine how perceived facilitators of service utilization may differ in use/relevance based on race/ethnicity, gender identity, age, or other identities of EPY. Research is also needed to better understand if the facilitators mentioned by providers are also considered important to some EPY. Additional research is also needed to examine the differences and similarities between facilitators of service utilization for EPY with and without foster care histories. Comparing the facilitators of both groups could help to develop more tailored programming specific to the needs of EPY with foster care histories.

Strengths and Limitations

A strength of this study was the inclusion of providers from a variety of sectors and EPY. Research often will include one or the other, but a richness is added when the perspectives of both providers and EPY are explored. Additionally, the sample of EPY included males, who may be less likely to be included in research. This study also moved the literature beyond just exploring the barriers of service utilization for EPY with foster care histories to also consider what facilitates service utilization.

The convenience sample was drawn from one primarily urban county in a Southwestern state, limiting the transferability of the study. Within this sample, EPY were recruited by community agencies, likely comprising EPY who were service-seeking or highly engaged with services at some level. These EPY may have differed from those youth who had fewer connections with community agencies. Not including youth currently in foster care also limited the findings. This needs assessment aimed to recruit EPY with foster care and/or juvenile justice histories, but only one participant had been involved with the juvenile justice system. EPY with foster care histories likely reflected on their current or most recent interactions with service providers that may not have been directly influenced (either positively or negatively) by their child welfare involvement. Facilitators of service utilization for EPY currently in foster care may be different from those not currently in care. Additionally, EPY were English-speaking and may have differed from those who did not speak English. The demographic questionnaire data was not linked to the participants’ qualitative interview or focus group data, which did not allow for the data to be analyzed considering the participants' identities.

Conclusion

This study explored the facilitators of service utilization among EPY with foster care histories. By implementing and engaging these EPY- and provider-identified facilitators within policies and practices at each level, EPY may be more likely to access needed services and address barriers associated with being a young parent with a foster care history. Taking a strengths-based approach to program and service planning is important, as client involvement in program planning can increase their satisfaction with services, which in turn has implications for both client retention and outcomes (James & Meezan, 2002). Engaging EPY with foster care histories can also give them back some power and control that is often held by providers, agencies, and systems. Although it is important to note the gaps in services, this study focuses on the facilitators that drive service use from the perspectives of both EPY and those who serve them. By better understanding the strengths in the ecosystems serving EPY, the field will have malleable intervention targets to examine how these facilitators influence positive health, mental health, parenting, education, employment, and housing outcomes for EPY.