In 2008, there were approximately 772,000 substantiated cases of child maltreatment in the US. Not all racial and ethnic groups are equally affected. Rates among African-American children, for example, were 17 per thousand compared with 9 per thousand for Caucasian children. It is easy to assume that different ethnic groups need slightly different responses. But do they?

There is a significant push for public agencies to adopt evidence-based interventions with parents who are at high risk of maltreating their children, or who have perpetrated maltreatment. There is mounting evidence that such programs can reduce maltreatment risk. There is also strong evidence that high fidelity is critical to program effectiveness.

Human creativity means that there is also a natural desire to fiddle with programs – to adapt them. This can yield benefits. Studies show that practitioners can feel a greater sense of independence, ownership and competence: they feel they are doing their best for families. Families, meanwhile, are more likely to keep attending the program and have better communication with the practitioner.

So an important implementation challenge is how to balance the need to modify program to address cultural and other differences amongst families, against the need to retain fidelity to the details of a proven intervention.

Researchers from Georgia State University, US, argue that producing separate versions of an intervention is counter-productive, but that case-by-case adaptation can improve both practitioners’ and participants’ engagement.

The researchers investigated the value of cultural adaptations, focusing on the SafeCare program. SafeCare targets risk factors for child physical abuse and neglect. Modules include treating childhood illnesses and injuries, making the home safe, engaging with children in fun activities, getting on well with children and preventing troublesome behavior. SafeCare is generally provided in weekly home visits lasting 1-2 hours over 18-20 weeks.

The team conducted telephone interviews with 11 practitioners with experience of implementing SafeCare with diverse providers and whose clients were always or often from child welfare agencies. The researchers wanted to find out what adaptations these practitioners were already making to better serve diverse populations, and what additional adaptations they felt were needed.

The practitioners stressed the importance of gaining trust during initial home visits. Some suggested that matching home visitors and parents by race or ethnicity and language increased families’ receptiveness. But there was consensus that where matching was not possible, it was not a major obstacle to engagement.

Flexibility about program logistics was deemed important for retaining families. Some sessions were held in different environments, such as McDonalds or a relative’s home. It was also considered important to be sensitive about important cultural events, even if this meant appointments being postponed.

Another adaptation was to include important caretakers besides parents in the intervention. Grandmothers play a particularly important role in some African-American families, for instance. Some Latino families, by contrast, were keen to involve their children in sessions, showing the home visitor what techniques they had used with the child.

Practitioners spoke of the value of learning about the culture and beliefs of the families they were working with. In the module on health, for example, they would try to be open to discussing and working with home remedies and spiritual beliefs. Similarly, the “active ignoring” concept was not used with African-American parents, because practitioners found it undermined these parents’ concern to keep children in line, and the practitioners interpreted this concern as a cultural belief.

Several participants reported developing materials to augment those from SafeCare. This might involve adding pictures, or simplifying the language on handouts.

As for additional adaptations, it was recommended that lower literacy levels be used in some materials and that more pictures be incorporated. The Spanish translation needed to be less literal: “time out,” for example, had accidentally morphed into “take the baby outside.”

None of these existing or proposed adaptations are in the SafeCare program per se but as far as the practitioners were concerned they made the program work better.

This said, all 11 study participants were firmly against developing adapted versions of SafeCare for particular ethnic groups or cultures. They argued that this would have limited value or even be harmful because it risked stereotyping.

Instead, they advocated an individualized approach for specific local populations or families. Participants made adjustments to content and delivery to account for cultural differences but they did this on a case-by-case basis.

The Georgia State University researchers also point out that extensive adaptations could limit the reach of SafeCare and other evidence-based programs, as there would need to be “more extensive, costly training of providers in the various versions of the program, as well as in the assessment approaches to determine which families are appropriate for the adapted program versus the standard intervention.”

The case against producing multiple versions is made even stronger by the lack of compelling evidence that structured cultural adaptations promote better outcomes for ethnic minority families. So, adjust, modify, tinker on a case-by-case basis, but leave core content alone, and don’t worry about producing new versions.

Reference
Self-Brown, S., Frederick, K., Binder, S., Whitaker, D., Lutzker, J., Edwards, A., & Blankenship, J. (2011). Examining the need for cultural adaptations to an evidence-based parent training program targeting the prevention of child maltreatment. Children and Youth Services Review, 33, 1166-1172.