Opportunities to Strengthen Child Abuse Prevention Service Systems: A Jurisdictional Assessment of Child Welfare Interventions
Abstract
Objective: Effective service systems are necessary to address the prevalence and impacts of child abuse. The current study introduced a jurisdictional approach for assessing child abuse prevention service systems to identify service system gaps or opportunities to strengthen child abuse prevention. Method: We used quantitative descriptive analysis and thematic analysis to analyze and synthesize results of a desktop assessment/analysis of 30 individual programs with child abuse prevention objectives operating in a single jurisdiction in Australia. Results: Qualitative themes for strengthening services included program model line of sight, documented models of service provision, evidence-based programs, and culturally competent service provision. Conclusions: The current study highlights the importance of evaluating existing service systems at scale. Results present an opportunity for learning about how to improve service system design for families with multiple and complex needs, such as having clear and documented service models; tailoring programs and program components to the specific needs of target groups, including cultural and language needs; determining appropriate dosing of programs and services; including strong clinical and cultural governance; ensuring the workforce is suitably qualified and/or trained, including cultural competencies; and including regular and ongoing evaluations of programs and services to determine effectiveness and highlight areas for improvement. These findings are relevant for practitioners, program funders, program developers, and policymakers.
Child maltreatment is a major social welfare problem leading to death, serious injury, and long-term and significant impacts on the child, with more severe maltreatment associated with a greater number and severity of these outcomes (e.g., Carr et al., 2018). Although it is difficult to accurately quantify the prevalence of child maltreatment due to differences in the way it is reported and recorded, as well as criteria applied by child protection agencies in triaging reports of child abuse (Stoltenborgh et al., 2015), it is estimated that up to 36% of children worldwide have experienced a form of child abuse and neglect (World Health Organization, 2014). Despite many strategies designed to reduce child maltreatment being implemented globally, maltreatment rates are not decreasing (Gilbert et al., 2012), and the problem is likely to be more substantial than assumed (e.g., Parton, 2020).
In Australia in 2019–2020, approximately 486,300 notifications (i.e., reports of alleged child abuse and neglect, child maltreatment, or harm to a child) were received by Australian child protection agencies. Families known to Australian child protection systems are more likely to be from lower socioeconomic areas (i.e., postal areas of relative disadvantage based on a combination of income, education, employment, occupation, housing, and other variables such as family structure) and experience income and housing stress, parental mental health concerns, substance use problems, and domestic violence (Australian Institute of Health and Welfare [AIHW], 2021). Australian Aboriginal and Torres Strait Islander children and families are significantly overrepresented in Australia’s child protection systems compared to non-Indigenous children (AIHW, 2021). The reasons for this are multiple and complex and are connected to historical and ongoing dispossession, marginalization, denigration, and racism as well as the legacy of forced removal and cultural assimilation policies, intergenerational effects of previous separations from culture and family, poor service design and delivery, a lack of understanding regarding cultural differences in child-rearing practices and family structures, and a higher likelihood of Indigenous families living in lower socioeconomic areas (i.e., postal areas of relative disadvantage; AIHW, 2021; Human Rights and Equal Opportunity Commission, 1997).
The responsibility for statutory child protection in Australia lies with the eight individual state and territory governments (AIHW, 2021), but the processes across the child protection system are similar. For example, concerns about a child are reported to the relevant child protection authority; reports are either triaged to investigation, dealt with by other means such as referral to a wide variety of voluntary family support services (e.g., programs typically provided by nongovernment organizations to provide support and advice to families, develop parenting skills, and/or prevent dysfunction and maltreatment), or no action is taken (AIHW, 2021). Support services may be used instead of or in addition to statutory intervention. Nongovernment organizations are typically responsible for the provision of universal, secondary, and intensive support services. In 2019–2020, 62% of the approximately 486,300 notifications received were dealt with by other means, such as referral to a support service (AIHW, 2021). The total recurrent expenditure on child protection services (including family support services, intensive family support services, protective intervention services, and care services) in Australia was $6.9 billion in 2019–2020, yet the number of reports increased by 37% between 2015–2016 and 2019–2020 (AIHW, 2021).
In the late 1990s, in recognition of an overwhelming demand on child protection services and an attempt to focus on prevention and early intervention, Australia began moving toward a differential response model for families reported to child protection agencies. Several countries (e.g., Australia, Canada, New Zealand, United States) have now adopted a differential response model (also called “alternative response,” “dual track,” “multiple track,” or “multiple response systems”) for responding to cases judged as having no grounds for formal investigation by the relevant statutory child protection agency (AIHW, 2021; Bromfield, 2015; Fluke et al., 2019; Herrenkohl et al., 2020). Differential response essentially enables more than one response to reports of child maltreatment, offering an alternative for families judged as being at low risk by diverting them away from traditional statutory child welfare involvement and into, for example, community-based family support services (Bromfield, 2015; Herrenkohl et al., 2020). Although many factors influence outcomes (e.g., appropriate screening of families, the ability and willingness of a family to engage with services, appropriate resourcing, etc.; Bromfield, 2015; Herrenkohl et al., 2020), for differential response to effectively prevent families from being involved or having repeat involvement with child welfare, family support services must effectively address family needs. Ideally, only low-risk families are referred for these services. However, criticisms exist regarding assumptions about families and that those families diverted to differential response pathways are characterized by multiple and complex needs (Bartholet, 2014). Thus, interventions effective at responding to high levels of complexity and risk are essential.
There is an abundance of critical and informative literature evaluating programs and interventions designed to address family risks and needs (e.g., Al et al., 2012; Barlow et al., 2006; Casillas et al., 2016; Peacock et al., 2013; Prosman et al., 2015; Schweitzer et al., 2015; van der Put et al., 2018). Yet, there is clear evidence that adherence to evidence-based practice in child service systems is low (Arney et al., 2013), and evaluations of programs tend to focus on individual services rather than on the service system. Whether government investments are well targeted to produce intended outcomes has not, to our knowledge, previously been assessed rigorously at scale in Australia, or elsewhere.
To address this gap, the current study provides an illustrative example of the assessment of programs and services within an existing service system. We assessed a portfolio of government-funded child abuse prevention programs operating in a single jurisdiction to identify opportunities to strengthen child abuse prevention and assist with service system planning. The term “prevention” here encompasses the prevention of child protection involvement and prevention of reabuse and renotification/rereport to child protection agencies but excludes children under formal child protection orders or other care arrangements (i.e., removed from their family of origin by the statutory child welfare agency). This paper presents a mixed-methods analysis and synthesis of the results of a desktop assessment/analysis of 30 individual programs. The assessment aimed to answer the following three key research questions:
1. What were the characteristics of programs designed to prevent child abuse?
2. To what extent were program models logically aligned, matched to evidence, and culturally competent given the program target group?
3. Taking a broad system view, were there any service system gaps or opportunities to strengthen child abuse prevention?
To answer the first two research questions, we used quantitative descriptive analysis to synthesize individual program outcomes and assess the child abuse prevention services within a single jurisdiction. For completeness and utility (Bryman, 2006) and to answer the third research question, we conducted thematic analysis of the rationale for each individual assessment outcome to identify jurisdiction-level themes and identify gaps and opportunities to strengthen child abuse prevention efforts.
Method
Sample Selection
A list of programs and services () being provided to families by both government and nongovernment organizations in one jurisdiction in Australia in 2017 were collated by a central government department from various government funding agencies. The list included programs and services designed to address a spectrum of risk, from families with no apparent risk (e.g., universally delivered programs) to families where child abuse was already identified. From this list, the research team assessed 83 programs that had outcomes proximal to child abuse and/or neglect prevention (as defined earlier). To enable a fair assessment against child abuse prevention objectives, we only included programs with an explicitly identified primary () or secondary () objective of child abuse and/or neglect prevention (as defined earlier) for further assessment (). A small number of programs had more than one focus or provided multiple services. In these cases, the current assessment pertained only to service elements related to child abuse prevention. The assessment reports for the 30 eligible programs formed the qualitative data for the thematic analysis.
An example of a program with a primary objective of child abuse prevention is an intensive family preservation program designed for families with children at high risk of removal due to identified child maltreatment; the program has an explicitly stated outcome of reducing child abuse (e.g., aiming to reduce notifications/reports and/or reduce the number of children entering out-of-home care). A program with a secondary objective of child abuse prevention may target families that display common risk factors for child abuse and thus are at high risk of entering the child welfare system; there are explicit objectives around preventing child abuse (e.g., strengthening parent–child interaction and parenting skills in families vulnerable to child neglect). An example of a program that was excluded from assessment is an early literacy program whose target group may experience multiple and complex problems that the program does not directly address, nor does the program change the environments children are living in. Although important and beneficial for other objectives, such programs were not deemed to have child abuse prevention objectives, and children were not likely to be safer as a result of their involvement with the program.
Procedure
We conducted all program assessments concurrently using a methodology that was developed by Author 2 and Author 4 during technical assistance with child and family services and abuse and neglect prevention programs. The original methodology was based on findings from Segal et al. (2012) suggesting that program components that are matched to need are likely to be most effective. Specifically, Segal et al. (2012) found that clear alignment between a program’s target group, objectives, theory of change, and program components were strongly associated with program efficacy. Segal and colleagues also found that an appropriately skilled workforce with access to requisite training was crucial. Likewise, De Silva et al. (2014) suggested that evaluators need to understand the how and why of intervention effectiveness, which requires a theory-driven approach and the inclusion of specific information in evaluations (e.g., workforce core competencies). Starting with these fundamental concepts and elements of practice design, we expanded the assessment model to include additional implementation details: dose (i.e., duration and intensity of service provision), referral pathways, program reach (i.e., location of services), and cultural competency (Fixsen et al., 2005; Moore et al., 2015). In line with evidence-based practice, the fit with current evidence also formed part of our assessment model. We adapted and refined the model to be suitable for jurisdiction-wide assessment in addition to program-specific assessment.
Data Extraction and Interpretation
Detailed information about each program’s target group, outcomes, activities, dose, referral pathways, program reach, workforce, and cultural considerations were collected from service providers and compiled into a standardized program summary. We then used information from the program summaries to develop a logic model for each program included in the study. Methods were refined as we completed two phases of data collection. First, we extracted data from key program documentation (e.g., service agreements, websites, program overviews, etc.; programs). Once our procedure and content format were well developed, we stopped this data extraction process and replaced it with an open text survey ( programs). An example from the open text survey regarding the target group is, “Who is eligible for the program or service? Do you have target or priority groups? Are there any specific inclusion or exclusion criteria? What are the characteristics of your clients who have received your service over the past 2 years?” Exemplar responses were provided for each item and were based on the comprehensive descriptions from the initial data extraction methodology (e.g., “The target group for the service is children and their families, where children are residing with their families, but are at moderate to very high risk of removal due to, for example, physical and/or emotional abuse and/or neglect of children and/or intrafamilial sexual abuse (where perpetrator does not have immediate or imminent access to the child). Priority for service is given to families referred by the statutory department, and to Aboriginal and Torres Strait Islander Families. Over the past two years, the families presenting to the service have a range of issues including current or past treatment for a mental health issue; drug and alcohol related issues; or domestic violence that currently impacts on their parenting ability.”). Program provider responses to the open text survey were then inserted into the program summary template and used to further develop the logic models.
Reflecting a public health approach, the current study applied five population groupings of increasing complexity to the target group characteristics, adapted from an existing model codeveloped by Author 2 and Author 4 for a public inquiry into the Northern Territory child protection system (Bamblett et al., 2010): Level 1—families that were meeting their children’s needs (herein referred to as no indicated risk); Level 2—families that were meeting their children’s needs but were vulnerable to future problems (herein referred to as vulnerable); Levels 3 and 4—families that were not meeting all of their children’s needs but may be able to with support (Level 3 families were assessed as being open to receiving support, herein referred to as high risk/maltreating–voluntary; Level 4 families were assessed as requiring statutory involvement to comply with supports, herein referred to as high risk/maltreating–statutory); Level 5—children had been removed from their family of origin due to child maltreatment (herein referred to as child in care). Where target group characteristics fit multiple levels, we applied a population level range.
Interrater Reliability and Peer Review
During the project establishment phase, program information was dual coded by two independent members of the research team and then reviewed by the first author to ensure consistency. This process involved checking the accuracy of the extracted information and identifying missing information. The research team discussed any discrepancies identified during this process.
Vetting
Each individual program summary incorporating a logic model was provided to the second author for vetting, which involved reviewing the program summary and logic model for consistency of approach and interpretation and to identify additional information needed from the program provider.
Verification
Prior to assessment, the vetted program summaries and logic models were sent to program providers to be verified for accuracy. The verification process also provided an opportunity for the program providers to clarify and fill any information gaps. Where clarification was needed and/or missing information was identified, a bespoke survey was sent to the service provider requesting specific pieces of information. For example, where the service provider identified assessment as an activity but no further information was provided, they may have been asked which assessment approach, models, or tools were used and what training staff had undertaken; where a particular therapeutic approach to service provision was named, the service provider may have been asked if the approach was delivered in whole or part, who it was delivered to, and what the minimum requirements of staff delivering this approach were (e.g., qualifications and experience). Additional information and amendments were incorporated into the program summary and logic model prior to assessment.
Conflict of Interest Protocol
In line with the Australian Code for the Responsible Conduct of Research (National Health and Medical Research Council et al., 2018), we developed a conflict-of-interest protocol. All team members nominated any perceived conflicts of interest; when conflicts existed, the research team discussed the nature of the conflict. When it was appropriate for a conflicted team member to continue in the assessment process, the program was dual coded by a team member with no conflict, and this person took the lead in the assessment. The primary type of conflict was where a team member had previous involvement in the evaluation of an included program or had previous professional connections to the program or its developers.
Quantitative Assessment Procedure
Specific skills were required to undertake the assessments. An assessment panel comprising senior members of the research team with research, clinical, and sectoral experience and expertise in child maltreatment applied the quantitative evaluation frame to the program information. All assessments were undertaken in a group context using a consensus and critical challenge approach (e.g., Arakawa & Bader, 2022). This approach involved individual group members questioning and challenging the content of the programs, as well as any potential factors that may influence individual group members’ attitudes and decisions about the program, before reaching a consensus about a program’s assessment.
Logic Assessment
An assessment of the alignment between various program factors (e.g., target group, activities, outcomes) was undertaken for each individual program using a scale developed for the current study (e.g., appropriateness of components for target group, alignment of program components to stated service outcomes). Depending on the alignment of these factors, as determined by the assessment panel using standardized assessment criteria, programs received a score of 1 (well developed), 2 (sound), 3 (adequate), 4 (misaligned), 5 (destructive), or 6 (not assessable), with each score representing specific criteria developed for the current study.
Evidence Matching
We conducted a series of rapid evidence assessments to determine whether the programs, or program components, were likely to be effective for child abuse prevention. Programs were first allocated into groups of similar programs and services (e.g., family support, parenting interventions) for evidence matching purposes. If a program did not fit into a group with other programs, individual evidence matching was undertaken where possible. We searched for both national and international evidence (approximately 25,000 records) using systematic search principles. We included systematic reviews and meta-analyses, and when these were not available or conclusions from these reviews were limited, we relied on primary research studies. Although a formal search of the grey literature was not part of our rapid evidence assessments, we contacted experienced researchers with subject-matter expertise to identify other relevant evidence. Results of the studies found through the rapid evidence assessment were analyzed to determine the overall effectiveness of programs in preventing or reducing child maltreatment (e.g., looking at change across time for child protective service reports, self-report measures), risk factors for child maltreatment (e.g., domestic violence, family functioning, parent functioning, parenting stress), or other vulnerabilities (e.g., socioeconomic factors, social supports). In addition, we matched the target population characteristics, program components/activities, service location, intensity and duration, and workforce to the included programs and services to determine the applicability of the evidence to the included programs and services. Based on the rapid evidence assessments, programs were classified as (a) supported by evidence (i.e., clear evidence supporting the program in preventing or reducing child maltreatment or risk factors for child maltreatment in that target population), (b) partially supported by evidence (e.g., where the program included a mixed target group, the program may have been supported for one population but not for another), (c) not supported by evidence (i.e., clear evidence that the program type did not prevent or reduce child maltreatment or risk factors for child maltreatment), or (d) not assessable against evidence (e.g., no evidence existed to match the program against, or the program was not articulated clearly enough to match to evidence).
We used rigorous quality assessment processes to ensure that the quality of evidence in the literature was high. Systematic reviews, meta-analyses, and experimental and quasi-experimental evaluations were given the most weight. The methodological quality of systematic reviews and meta-analyses were assessed using a modified version of the AMSTAR (Assessing the Methodological Quality of Systematic Reviews) critical appraisal tool for systematic reviews (Shea et al., 2007). The AMSTAR is a reliable and valid 11-item audit tool used to determine the methodological quality of systematic reviews and meta-analyses for academic purposes. We modified the original AMSTAR to prioritize assessment items that were most relevant to our evidence-matching process (e.g., was the scientific quality of the included studies used appropriately in formulating conclusions?). Primary studies were assessed for quality using a quality assessment tool we developed based on a purposefully developed extraction template. Items included in the quality assessment tool reflected the minimum information required (a) for applicability to the current study (e.g., do the outcome measures include a child abuse prevention/reduction focus?) and (b) to draw conclusions about the efficacy/effectiveness of the interventions (e.g., is the study a pre–post design, does the study have a comparison group, were the groups equivalent at the start of the intervention?). We consulted existing checklists (e.g., the CASP Checklists and the Downs and Black checklist; Critical Appraisal Skills Program, 2019; Downs & Black, 1998) to compile relevant items.
Cultural Competency
Program information was reviewed by researchers from an Australian Aboriginal research unit for an assessment of the program’s cultural competence in relation to Australian Aboriginal or Torres Strait Islander clients. Specific program features reflecting cultural safety, consideration of cultural need, and cultural input/governance (as defined by the Victorian Aboriginal Child Care Agency, 2008, 2010) were considered. An assessment template was populated for each program where key criteria—such as adaptation of services, cultural awareness training, and the inclusion of Aboriginal practitioners and Aboriginal governance or advisors—were assessed. Based on this assessment, programs received a score of 0 (cultural destructiveness), 1 (cultural blindness), 2–3 (cultural precompetence), or 4 (cultural competence to proficient; Victorian Aboriginal Child Care Agency, 2010).
Overall Assessment
Based on the logic and evidence matching assessments, each program was given an overall assessment outcome: (a) supported for child abuse prevention or (b) not supported for child abuse prevention in current form. A minimum standard was applied to the assessment of individual programs. If a program had a well-developed, sound, or adequate logic and was supported or partially supported by evidence, it was supported for child abuse prevention. In contrast, if a program had a misaligned program logic, was not supported by evidence, or had any destructive elements, it was not supported overall for child abuse prevention in its current form. Given the anticipated state of the field in relation to cultural competence, we determined that, in agreement with the project funder, the cultural competency assessment outcomes would be used to consider the performance of the sector as a whole but would not be included in the overall assessment of individual programs. For every program, we created an individualized assessment that included a written rationale identifying strengths, limitations, or gaps and opportunities for model strengthening.
Analysis
Quantitative Analysis
We used IBM SPSS Statistics 24 for all quantitative analysis. Descriptive statistics were used for the quantitative synthesis of the program characteristics and individual program assessment outcomes.
Qualitative Analysis
We conducted thematic analysis of the written rationale for each individual assessment outcome. Thematic analysis involved a familiarization phase of reading and rereading the content of the descriptive rationales for assessment outcomes until an initial coding frame was developed (Braun & Clarke, 2006). The coding frame included content related to program components (e.g., approaches to service provision, key components), evidence (e.g., evidence of effectiveness for the target group, or the intensity and duration of delivered services), workforce (e.g., qualifications, training), the logical deduction of the model (e.g., contingent outcomes), and cultural competency (e.g., cultural training, input, governance, adaptation of services). Content from the descriptive rationales for assessment outcomes was systematically coded in NVivo 12 using this coding frame. Codes were collated into potential themes and subthemes before these were reviewed (Braun and Clarke, 2006). Using unique counts from the data, subthemes were then classified as either strong (identified in the majority of programs), moderate (identified in approximately half of all programs), or weak (identified in only a small number of programs).
Results
The description of the programs—including their objectives, funders and providers, program types, target groups, activities, format, intensity, duration, and workforce qualifications—are provided in the sections that follow. We then present our assessment of the logic, evidence matching, and cultural competence of the programs together with the associated qualitative synthesis.
Program Characteristics
Child Abuse and Neglect Prevention Objective
Of the 30 programs included for assessment, 25 (83.3%) were assessed as having a primary objective of child abuse and/or neglect prevention, with the remaining 5 (16.7%) assessed as having a secondary objective of child abuse and/or neglect prevention.
Program Funders and Providers
Programs were funded by a variety of different government departments, including child welfare (, 30.0%), education (, 26.7%), health (, 20.0%), human services (, 20.0%), and police (, 3.3%). Nongovernmental service providers were most common (, 66.7%), with the remainder of programs being delivered by government providers.
Program Types
Most programs were classified as intensive and nonintensive family support services ( [43.3%] and [23.3%], respectively). For our analysis, we applied a minimum cutoff of 4 hours per week for intensive family support based on the Australian Report on Government Services (Productivity Commission, 2019). The remaining programs included coordinated service responses (e.g., sharing client information and/or assessments of child and family risk between a multidisciplinary team with no direct service provision to children and families; , 13.3%) and parenting education/skills development, nurse home visiting, peer support, domestic violence victim support, problem sexual behavior support services, and an education curriculum (, 3.3% each).
Target Group
Half of all programs were assessed as targeting high risk/maltreating populations (both voluntary and statutory; , 50.0%). The remainder targeted populations that were vulnerable to high risk/maltreating–voluntary (, 20.0%); vulnerable to child in care (, 10.0%); no indicated risk to high risk/maltreating–voluntary (, 6.7%); or no indicated risk to high risk/maltreating–statutory, vulnerable to high risk/maltreating–statutory, or high risk/maltreating–voluntary only (, 3.3% each). One program was assessed as a universal education curriculum delivered in schools and therefore, we could not apply population complexity levels. Further examination of the target group revealed 5 programs that were designed for a lower level target group but were delivering services to higher levels. Specifically, 4 programs (13.3%) designed for vulnerable and high risk/maltreating–voluntary were assessed as delivering services to high risk/maltreating–voluntary and high risk/maltreating–statutory populations, and 1 program (3.3%) designed for no indicated risk to high risk/maltreating–voluntary was delivering services to no indicated risk to high risk/maltreating–statutory populations.
Activities
Activities varied between program types, but the majority of programs provided a form of assessment (, 86.7%), referral to other services (, 83.3%), and coordinated service responses/collaborative case management (, 83.3%). Approximately two thirds of programs offered case management (, 66.7%); a form of therapy, counseling, or therapeutic support (, 66.7%); parenting education/skills development (, 63.3%); and practical support (, 60%). Advocacy services (, 56.7%) and brokerage funding (i.e., the use of designated funds to purchase services or goods to address family needs; , 46.7%) were offered in approximately half of programs. A small number of programs also offered group work (e.g., parenting groups, therapeutic groups; , 26.7%); support to develop social networks (, 13.3%); a formal module-based program (, 10.0%); community events or community engagement (, 10.0%); report services (e.g., assessment or court reports; , 6.67%); and health services, cultural support, consultancy or training, case consultation, or targeted intervention (not further specified; , 3.3% each).
Format
Almost all services were offered in person (, 93.3%); less often, services were provided by phone (, 43.3%). Program format included individual (, 36.7%), family (, 26.7%), and group-based services (, 16.7%). In-home was the most common location for service provision (, 70.0%), but other locations were also offered to accommodate family need (e.g., in office, community, and public locations) when required. Most services operated during standard business hours (e.g., 9 a.m.–5 p.m.; , 26.7%) or extended business hours (e.g., 7 a.m.–7 p.m.; , 33.3%), with a very small number offering out-of-hours or on-call services (, 6.7%).
Intensity and Duration
As expected per definitions, the dose of programs varied greatly between intensive family support programs and other program types. The 13 intensive family support programs were typically characterized by intensive and step-down periods of 6 months duration each, for a total duration of 12 months (, 92.3%). Intensive periods ranged from up to and including 4 hours per week (, 7.7%) to up to and including 12 hours per week (including both in-person client work and other duties such as case notes; , 38.5%); the step-down ranged from up to and including 5 hours per week (, 7.7%) to up to and including 7 hours per week (inclusive of in-person and other duties; , 38.5%). Other program types () did not specify an intensive/nonintensive period but ranged from no set allocation of hours/as needed/per client need/not specified (, 52.9%) to up to and including 3 hours per week (, 11.8%), with duration typically either not being specified or of no set total duration (, 64.7%).
Workforce Qualifications
For the majority of programs, the preferred qualification for workers was a tertiary qualification in a related field (e.g., social work, human services; , 36.7%) or a tertiary qualification with experience/further training (, 40%). However, the minimum requirements for half of programs (irrespective of program type) was no formal qualification and instead included demonstrated knowledge and competencies in the area of service delivery (, 50.0%), with only a small number of programs stating the same preferred and minimum requirements (, 6.7% tertiary; , 13.3% tertiary plus experience/further training).
Quantitative Synthesis
The results for each of the logic, evidence matching, and cultural competency assessments are presented in Figure 1. Outcomes of the Logic, Evidence Matching, and Cultural Competency Assessments ()
Logic Assessment
Over half of all programs were assessed as either having a sound () or adequate () logic model, with just under half being classified as misaligned (). One program was assessed as being well developed, and 1 was not assessable due to the program model not being clearly articulated. No program was assessed as having any destructive elements.
Evidence Matching Assessment
The majority of programs () were not supported by evidence. Six programs were partially supported, whereby they were supported for a lower risk target group (e.g., vulnerable) but not for higher risk groups (e.g., high risk/maltreating–voluntary and high risk/maltreating–statutory). Five programs were supported by evidence, and 1 was deemed not assessable against existing evidence due to the lack of defined program model, intensity and duration, and the approaches used within it.
Cultural Competency Assessment
Thirteen programs were assessed as being at the cultural precompetence point of the cultural competency continuum, with just over a third of programs () assessed at the cultural blindness point. Four programs were assessed as culturally competent to proficient, and two were considered not suitable for assessment due to services being provided exclusively for migrant or refugee individuals or families. No program was assessed at the cultural destructiveness point of the continuum.
Overall Assessment
We were able to indicate an overall assessment outcome for all programs. The majority of programs (, 63.3%) were not supported for child abuse prevention in their current form. Of these, approximately half () were assessed as having both a misaligned logic and were not supported by evidence, 6 programs were assessed as having an adequate or sound logic but were not supported by evidence (e.g., where a program had a plausible model but the program dose did not match to what the evidence suggested was required for the target population, there was an adaptation to the delivery of a standardized evidence-based program with no evaluation running alongside, or there was no formal model to match the program to), and 2 programs were assessed as having a misaligned logic but were partially supported by evidence. Of the remaining 2 programs, 1 received an assessment of a misaligned logic but was not assessable against evidence, and the other was not supported by evidence and had a logic model that was not assessable. The remainder of programs (, 36.7%) were supported for child abuse prevention.
Qualitative Synthesis
Most program models were either well articulated or relatively well articulated, allowing us to undertake thematic analysis. Four broad themes emerged, each with several subthemes (noted under each theme).
Theme 1: Program Model Alignment
We examined the logic models developed for each program to identify gaps in the line of sight from workforce to target group, activities, and outcomes. Subthemes included workforce capacity, multiple contingencies to meet stated outcomes, and key components of a program or service.
Workforce Capacity. Workforce capacity was a moderate subtheme present across the program assessments. Thematic analysis of workforce capacity revealed that the workforce within the programs evaluated was largely underqualified and/or underprepared. That is, it was rare to find a requirement for formal preemployment qualifications (including supervised experience) in an area that was appropriate to service delivery and/or postemployment workforce training and development in specific components of a program model (e.g., therapeutic approaches). Although some programs had appropriate tertiary-level qualifications as a minimum requirement, others had lower qualification minimum requirements (e.g., certificate level) or to a lesser degree, no minimum qualifications. A limited number of programs specified that enrolment in or working toward a degree or certificate-level qualification was appropriate. Further, where a program specified an approach to service delivery, there was an absence of documentation for the workforce being trained in this approach. For example, a program may have stated that it offered cognitive behavior therapy, but the workforce was not qualified to deliver these approaches, nor was there any in-service training to upskill the workforce in how to deliver these approaches appropriately and effectively. A service with highly qualified clinicians along with in-service training in the service approaches, clinical supervision, and governance were optimally suited to the target group. In the current assessments, however, this was not required to meet minimum requirements. A minimum standard was met by having either appropriate qualifications or in-service training. Programs should be encouraged to meet minimum standards in the first instance but ultimately, they should strive for optimal workforce capacity.
Multiple Contingencies to Reach Stated Outcomes. A second weak to moderate subtheme relates to programs or services having multiple contingencies to reach their stated outcomes. For example, programs stated they provided a specific activity (e.g., parenting education/skills development or therapeutic services), but they met this requirement through referral to another program rather than providing this activity directly. In doing so, multiple contingencies to achieving program outcomes are introduced (e.g., a referral must be accepted, the client must attend that service, the service must be effective, etc.) and the outcome of, for example, improving parenting skills is not achievable by the program directly.
Key Components. Analysis revealed that a small number of programs had a complete absence of one or more key components in the program model. For example, a program may have stated an outcome around increasing parenting skills, but no parenting skills activities were noted in the program model, nor was there any close alignment with any other parenting education program to address this deficit. The absence of key components was most often found for parenting and therapeutic components. Although this finding pertained to just a small number of programs (i.e., a weak theme), it was a critical limitation for these programs. Programs need to be supported to either provide the necessary components of a service to directly meet client needs or change their program outcomes to accurately reflect the services they provide.
Theme 2: Documented Models of Service Provision
A second broad theme identified though thematic analysis related to the documented models of service provision—specifically, what was being offered to families and how it was being delivered. Subthemes included informal approaches, approaches inappropriate for the target population, and the types of program models.
Informal Approaches. We identified several programs that included critical activities but were not able to identify the specific approaches they used within the activities they were offering (e.g., parenting skills or therapeutic approaches). For example, they identified using informal or ad hoc approaches only. This was a weak to moderate subtheme evident in the programs assessed.
Approaches Inappropriate for the Target Population. Programs that provided information about specific approaches typically used approaches that best fit a general population rather than the specific needs and complexity of the target group (e.g., some programs used a parenting program that was designed for populations such as families enrolled an early childhood development program, teen mothers, and parents with irritable babies rather than families with multiple and complex needs). Inappropriate approaches for the target group was a weak subtheme across the program assessments. Programs that performed well in this area had clear, structured approaches to service provision that met the specific presenting needs and complexity of the target population.
Types of Program Models. The final subtheme relating to documented models of service provision emerged from analysis of the workforce and components. Essentially, we found two types of program models, both of which were considered appropriate: (a) professional and (b) programmatic. The professional model involved no formal approach, but prerequisite qualifications were matched to the service activities (e.g., a highly qualified and trained mental health practitioner providing therapy to clients). The programmatic model was where the program had a specific named approach they used, with pre- or postservice training and accreditation in the program model. For some programs, the approach to service provision was unclear (we were unable to quantify this variation in the coding frame); this warrants further exploration.
Theme 3: Evidence-Based Programs
The third theme emerged from the evidence matching process. Subthemes in this area related to program dose, evidence-based activities, and target-group drift.
Program Dose. Thematic analysis revealed that programs were both over- and underdosed compared to what was found in the literature. Overdosed programs were those where service delivery was too long in duration. Those that were underdosed had a program duration that was too short, or the intensity was insufficient. Conflicting arguments seemed to emerge from the program documentation, the first being that the greater the complexity of a family, the greater the duration should be. However, there was also an intensity cost whereby programs of longer duration typically had lower intensity. This was a moderate subtheme evident in the program documentation, but the existing evidence did not suggest that longer duration with lower intensity would be helpful for families with multiple and complex needs (e.g., Al et al., 2012; van der Put et al., 2018). It was also noted that, in general, programs did not appear to undertake parenting capacity or readiness-to-change assessments to inform the dose of services. Programs considered to be well developed had a well-considered program dose matched to what evidence suggested would be effective for the given target group.
Evidence-Based Activities. Evidence for the inclusion of broad activities (e.g., parenting skills, counseling) within program models was found in the literature (van der Put et al., 2018). However, many programs included informal approaches to service provision, outsourced components to other services, or were not delivering approaches as intended. Thus, we were unable to match evidence to many of the approaches within components, or approaches were not supported by evidence. This was a moderate to strong subtheme emerging from the program assessments. Programs need to be supported to include evidence-based activities within their program models.
Target-Group Drift. There was a tendency for some programs that were designed for vulnerable families to be provided instead to high risk/maltreating families. This was a weak to moderate subtheme emerging from the analyses. Exploration of the reasons underpinning the target-group drift were beyond the scope of the current analysis but warrant further examination to inform program improvements.
Theme 4: Culturally Competent Service Provision
The fourth theme was related to cultural competence. Subthemes included cultural input and governance, adaptation of services to meet cultural and language needs, and cultural competence training.
Cultural Input and Governance. A moderate to strong subtheme emerging from the thematic analysis related to cultural input, governance, and leadership. Although most programs stated that Australian Aboriginal children and families were a priority target group, it was rare to find Australian Aboriginal staff employed in programs to provide cultural leadership. Further, mechanisms to facilitate other cultural input into service provision were lacking (e.g., inviting input from Australian Aboriginal communities and agencies on the development of culturally safe practices; including Australian Aboriginal senior management and board members to ensure organizations operated within a strong cultural framework that understands and acknowledges history, impact on families and communities, and contemporary issues). It was rare for non-Aboriginal agencies to demonstrate all these characteristics. In contrast, programs at the culturally competent to proficient point of the cultural competency continuum displayed these characteristics.
Adaptation of Services to Meet Cultural and Language Needs. Although some programs noted that services were provided to preserve and enhance cultural identity and connection with community, it was rare to find any specific indication of service adaptation to meet different language or cultural needs. For example, it was rare that programs noted the regular use of interpreters to address language barriers. This subtheme warrants further exploration as we were unable to quantify it using the current coding frame.
Cultural Competence Training. A weak to moderate subtheme that emerged from the findings related to cultural competence training. Although most programs provided basic cultural awareness and/or competency training, it seemed some programs relied on this one-off training to meet minimum standards for cultural competency. A small number of programs acknowledged that a range of skills, knowledge, and understanding were required when working with Australian Aboriginal children and families, but they did not provide the basic training (i.e., cultural awareness and competency training) to ensure these requirements were realized in practice. In addition, a small number of programs neither acknowledged the need for cultural awareness and competency training nor provided training to program staff. Program funders and organizations need to support continuing professional development in this area.
Discussion
To identify opportunities for strengthening child abuse prevention, the current study introduced a jurisdiction-wide approach to assessing a child abuse prevention service system at scale. The synthesis of results from 30 individualized child abuse prevention program assessments within a single jurisdiction in Australia demonstrated that there was a high degree of commonality in the approach to program design and common areas for strengthening program models. By assessing programs across an entire jurisdiction, the magnitude of the need to strengthen the child abuse prevention response becomes clear.
Generally, we found a lack of evidence-based approaches within program components (where identified), with many components being delivered in an informal and ad hoc way. Evidence suggests that to be most effective, program components should be matched to need and capable of addressing the different facets of child maltreatment (e.g., De Silva et al., 2014; Segal et al., 2012). For example, general parenting groups are likely to be insufficient or inappropriate for parents currently experiencing complex problems and could exacerbate these problems rather than help (e.g., strategies relating to structure and routine may not be suitable for parents who use violence and demonstrate coercive control). Based on our findings, greater attention needs to be given to ensure that specific approaches within program components can be described, are matched to need, and are evidence based for the specific target population rather than the general population. In relation to Australian Aboriginal and Torres Strait Islander families specifically, Tilbury (2012) suggested that services should have their applicability and effectiveness within the Australian context assessed with a critical focus on the safety, stability, development, and well-being of Australian Aboriginal families. Services for Aboriginal families should also be place-based and delivered by Aboriginal community-controlled organizations so services are culturally appropriate (Social Compass, 2020). Further recommendations for service models for Australian Aboriginal families include involving Aboriginal communities in the design of service models; using tools and materials designed for Aboriginal people and that incorporate locally designed content (i.e., local language); having appropriately skilled local Aboriginal workers to deliver services; incorporating bicultural teams; investing in community engagement and development activities; having strong cultural governance; and having services that are culturally strong, strengths based, trauma informed, and family led (Social Compass, 2020). Strengthening program models will ultimately increase the likelihood that these programs will be effective and scalable.
Clear themes around program dose and workforce capacity also emerged. Based on the evidence, there is no practical rationale for why families with multiple and complex needs are being provided lower intensity interventions. However, it is possible that the target groups were mistakenly assumed to be low risk (e.g., if referred through a differential response model), and therefore the evidence for low-risk families may have been applied in development of the assessed programs. Where drift had obviously occurred (i.e., programs designed for low-risk families being provided to high-risk families), this may be due to, for example, insufficient monitoring of family characteristics over time, resulting in a mistaken assumption that the target group was lower risk (e.g., Lonne et al., 2015). Drift may also be the result of insufficient capacity to work with high-risk and maltreating families. We found no evidence suggesting that a program designed for lower complexity will be effective for higher complexity. In line with a public health approach, continuous monitoring of the target population is required if programs are to clearly align with the characteristics of the target population (World Health Organization, 2019). Therefore, programs need to be clearly aligned with the characteristics of the target population, as determined by an assessment of family characteristics (e.g., domestic and family violence, substance addiction, mental health concerns, housing instability/homelessness, criminal activity, etc.) rather than how they have been assessed by child welfare prior to referral to the program or service. Any prior assessments may be based on limited, single-incident information (Arney et al., 2018; Octoman, 2019).
Our finding that the workforce was largely underqualified to perform their specified roles is concerning for the safety and success of families and may contribute to poor outcomes for children and families, but this is equally concerning for the workforce itself. There is no clear clinical or therapeutic rationale for the significant disparity between the required workforce qualifications indicated in the evidence and the workforce qualifications found in the programs assessed (i.e., low-level qualifications and/or training are unlikely to be sufficient given the complexity of the target population identified). Working in the child welfare sector is challenging, and the field is known for its difficulties in attracting and retaining staff (McFadden et al., 2015). In their longitudinal examination of burnout and job satisfaction among child welfare workers in the United States, Lizano and Mor Barak (2015) found that those without specialized child welfare training (i.e., unprepared for their roles) were at greater risk of stress and burnout. Further, Lizano and Mor Barak (2015) suggested that role ambiguity may lead to workers disengaging and developing feelings of depersonalization. High staff turnover and decreased organization productivity and success may result when underqualified, underprepared workers engage with families without a clear or culturally safe program model. For these reasons, it is important that programs and services ensure that the workforce providing interventions is adequately qualified and directly prepared to provide the approaches specified within their key program components (e.g., demonstrated accreditation to nominated therapeutic approaches, parenting programs, etc.).
In the context of the current study, it is important to acknowledge that services and programs operate within a challenging environment. For example, services face limited funding, competitive tender/bidding processes to win funding for service provision, challenges recruiting and retaining the workforce, and a lack of availability of outcomes data across systems to help inform program monitoring and outcomes (e.g., Child Protection Systems Royal Commission, 2016; Royal Commission into the Protection and Detention of Children in the Northern Territory, 2017). Barriers such as these must be removed if services are to make the necessary changes to service provision for children and families. In addition, although a full discussion is beyond the scope of the current paper, barriers to using research in policy and practice (e.g., accessibility, time, resourcing, training, etc.) must be addressed. For example, Arney et al. (2013) outlined a number of strategies (e.g., understanding and accommodating the influence of environmental context) for overcoming such barriers.
Overall, the current study presents a grim picture of the child abuse prevention programs in the jurisdiction studied. However, we found instances where attention was clearly given to the line of sight between who the target group was, how their needs would be addressed, who would deliver services, and the evidence for specific approaches. For example, in one program the assessment and therapy components were particularly strong, with several evidence-based approaches relevant to the client group named, and the assessment of client needs was clearly linked to the therapeutic plan and interventions used. Further, the workforce was highly qualified and prepared with additional in-service training in the named approaches. This exemplar program also had a strong model of clinical governance. Services deemed culturally competent or proficient highlighted the importance of practice being culturally relevant to reduce inequalities and increase the quality and effectiveness of care. Additionally, the services deemed culturally competent or proficient also had strong cultural governance and frameworks in place and established mechanisms to ensure client feedback was received and used to inform and share service delivery. Although cultural competency training will likely impart some knowledge, cultural competency is a continual process of learning and should be at the core business of services.
Creating a rigorous approach to service delivery does not stifle innovation. The public health model is one of the most widely applied frameworks for innovative and strategic planning regarding service provision (e.g., recognizing the types and ranges of services needed and identifying service gaps along a continuum). The World Health Organization (2014) public health approach to violence prevention outlined the four steps to effective intervention design: (a) surveillance, (b) identify risk and protective factors, (c) implementation, and (d) develop and evaluate interventions. These steps involve defining the problem by collecting information about the problem, establishing why the problem occurs, finding out what works to prevent violence, and implementing effective and promising interventions, including monitoring impact. Improving design and evaluation of complex interventions will ultimately increase the likelihood that the intervention will be effective, sustainable, and scalable.
There may be times when, due to population change or the emergence of new evidence, that some existing interventions are identified as no longer being the best investment and de-implementation (also commonly referred to as disinvestment or de-adoption; Niven et al., 2015) of nonindicated interventions may be warranted. De-implementation of nonindicated interventions has been primarily situated within health and medicine (e.g., Niven et al., 2015). For example, the National Institute for Health and Clinical Excellence has supported England’s National Health Service efforts to identify interventions warranting de-implementation (Garner & Littlejohns, 2011). Yet, less research in this area has focused on human and social services (McKay et al., 2018). De-implementation of nonindicated interventions within the child abuse prevention service system could allow governments to use limited budgets to strengthen existing interventions and/or invest in new indicated interventions and evaluations. Although beyond the scope of the current discussion, previous authors have outlined frameworks and important considerations for de-implementation of existing interventions (e.g., Garner & Littlejohns, 2011; McKay et al., 2018; Niven et al., 2015).
Limitations
Although the current study has demonstrated the importance of including an assessment of the existing service system and proposes a methodology for undertaking standardized assessment of the service system at scale, limitations exist. First, as is the nature of a desktop assessment, the current study was unable to assess discrepancies between what programs were designed to do and what was being implemented in practice (i.e., an assessment of fidelity). This type of assessment would be possible using the current methodology in jurisdictions in which there has been jurisdiction-wide implementation of named approaches. At the time of writing, the study jurisdiction had not implemented this approach, although this practice is widespread elsewhere. Replication of this process in other jurisdictions should include attention to fidelity, but this was not possible in the current study due to the limited number of named approaches that were being implemented in this jurisdiction. Further, our analyses were mainly descriptive, and assessments did not include measurements of program or client outcomes. Additionally, although the current study included cultural competency assessments for Australian Aboriginal and Torres Strait Islander people, we did not assess the appropriateness of service delivery for families from other cultural backgrounds. We also acknowledge that rapid evidence assessments do not allow for an exhaustive literature search; thus, our evidence matching process may not have identified all literature relevant to the programs assessed. For this study, we did not formally search the grey literature, and therefore the evidence matching assessments are subject to publication bias in both review articles and primary studies. It should be noted that many unpublished program evaluations exist in the grey literature, and future research could consider the inclusion of these. It is also necessary to acknowledge that our findings were a snapshot in time, and the sector is changing and will continue to change. For example, the sector is changing to focus more on evidence-informed common practice elements and service models as well as outcomes-based commissioning of services. In contrast, a key strength of the presented methodology is that the assessment approach requires a set of specific skills, including research and clinical skills in the area of the service system being assessed as well as an understanding of evaluation and the service system under investigation. In this study, this was achieved by assembling an assessment panel where these skills were prerequisite.
Conclusion
The current study highlights the importance of evaluating existing service systems at scale to highlight areas for improvement and to inform ongoing epidemiological investigations and new intervention design. Although the current study was conducted within one jurisdiction in Australia, the findings are not unique to Australia. Globally, child welfare systems are overwhelmed by demand. Results from the current study are relevant to practitioners, program funders, program developers, and policymakers, presenting an opportunity for learning about how to improve service system design. There is a clear need for increased investment dedicated toward disrupting the cycle of child abuse and reducing both the impacts and size of the problem over time. We recommend targeting investments toward high-quality services and supports at critical points of intervention tailored to the needs of specific target groups. A one-size-fits-all approach will be insufficient. Ongoing research into key populations and their characteristics and needs will inform decision-making regarding priority populations, critical points of intervention, and innovations.
The authors would like to acknowledge and thank Samantha Parkinson, Hayley Wilson, James Herbert, Mary Salveron, Victoria Parsons, Jenna Meiksans, Martine Hawkes, Rebecca Bilton, Samantha Finan, Stewart McDougall, Kat Sharp, Rosa Flaherty, Kerry Lewig, Kate Greenfield, and Lesley-Ann Ey for their contributions to the evaluation of programs and services and/or evidence reviews. The authors also acknowledge and thank those who provided and/or verified information for the evaluations of programs and services and those who supported this work, and the Aboriginal Leadership Group, which provided valuable advice on the work undertaken for this study. Finally, the authors would like to acknowledge the contributions and support of the project funder.
Notes
Sarah Cox, PhD, is a research fellow at the Australian Centre for Child Protection, University of South Australia.
Leah Bromfield, PhD, is a professor at the Australian Centre for Child Protection, University of South Australia.
Alwin Chong, BA, is a director at Arney Chong Consulting.
Fiona Arney, PhD, is a director at Arney Chong Consulting.
Correspondence regarding this article should be directed to Sarah Cox, GPO Box 2471, Adelaide, South Australia, Australia, 5001 or via e-mail to [email protected].
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