Cultural Adaptation of an Evidence-Based Home Visitation Program: Hispanic Clients' Participation in and Perceptions of Program Delivery

Background: A concern in the implementation of EBPs is ensuring their relevance to diverse cultural groups to address issues of access to and engagement in quality care among minority ethnic groups. One source of tension in implementation is how EBPs can be used flexibly while maintaining adherence to a core model, as some flexible adaptation to cultural differences in local communities is commonly needed. The goal of this study is to examine the experience of Latino clients following a naturalistic cultural adaptation made to SafeCare®, a child neglect prevention model, during implementation in San Diego County. 

Method: This study draws from a large implementation trial of Safecare in San Diego County in which linguistic and cultural adaptations were made by local leaders to fit the needs of unique client characteristics.  Participants were subjects of a CPS investigation, referred by the local child welfare services agency. A majority (74%) were Latino, and 31% received services in Spanish. Clients completed questionnaires after each visit that measured home visitor adherence to core therapeutic components of Safecare, as well as quality of the client-home visitor relationship. Various multi-level regression models were run to examine adherence, working alliance, and satisfaction.

Results: During SafeCare implementation, Latino clients rated home visitors higher in adherence to the teach/model/observe component of adherence (p<.001) than non-Latino clients. Latino clients with an ethnic match with the home visitor rated home visitors higher on adherence to the psychoeducation (p<.05) and the teach/model/observe (p<.01) components than those without an ethnic match. Those who received the adapted Spanish intervention had higher levels of satisfaction (p<.05). Client and provider gender also influenced adherence. Home visitor age negatively impacted Latino client ratings of adherence and working alliance.

Conclusion: Perceptions of delivery of SafeCare during implementation in San Diego appear to be relatively consistent for Latino and non-Latino clients, implying that adaptations made locally are engaging Latino and Spanish-speaking clients in services without compromising adherence to the program model. In some cases, Latino clients reported receiving services that were more consistent with the SafeCare model than non-Latino clients, especially in how home visitors taught and modeled practices and behaviors. Among Latino clients, having a home visitor of the same ethnicity was associated with higher adherence ratings for the home visitor.  Clients who received the adapted intervention in Spanish were more satisfied with services than those who received it in English. Other characteristics at the home visitor level were associated with client experiences of service delivery, implying a need to look more closely at the provider role in EBP implementation, as suggested in previous findings.