"It Starts from the Top": Caseworker, Leaders, and Triple -P Providers Perceptions of Implementation Processes and Contexts

Background: Decades of research shows that parenting and casework services as usual are ineffective in reducing risk factors associated with maltreatment and foster care involvement (Asgary-Eden & Lee, 2011). Although CW leaders consequently recognize the impetus to implement ESPIs like TripleP to achieve intended outcomes, they aren’t privy on how to optimize the inner and outer context to promote implementation. While clinicians cite inner and outer contextual factors that may influence implementation (Aarons et al., 2011), how factors are theoretically linked, and whether there is agreement between different actors about these relationships in CW agencies remains unknown. To generate theory and guidance on how to promote implementation, data from caseworkers, leaders, and TripleP providers addressed these aims: 1) Which factors embedded within the inner and outer contextual factors are theoretically linked, and 2) To what extent do different actors agree upon these relationships?  

Methods: CW workers (n=12), supervisors and directors (n=8), and Triple-P providers (n=2) participated in 30-80 minute 1:1 semi-structured interviews. Over 70% of the sample identified as female (n=16) and African American (n=16), ranged in age from 23-49 years (µ=33), and earned a bachelor’s (n=8) or master’s degree (n=13).  Interviews were audio recorded, transcribed, and reviewed for accuracy. Following procedures outlined by Strauss and Corbin (1990), themes were generated by relying upon Grounded Theory methods: labeling phenomena (open coding), identifying significant codes (focused coding) and making connections between categories, thereby generating themes (axial coding).

Results: Eight major themes that influence implementation were revealed: 1) outer context (external agencies, court, and intra-organizational collaboration), 2) organizational culture (norms to refer or not to refer to ESPIs), and 3) organizational climate (psychological impact of work environment and impact on attitudes and services provided). These three processes influence 4) organizational readiness (members' change commitment) and opens opportunities to engage in cultural exchanges, defined as the extent to which attitudes, perceptions, and actions change as a result of information exchanged between colleagues  (theme 5). These exchanges reinforce perceptions and beliefs about ESPIs (theme 6). With perceptions cemented, behaviors are implemented (theme 7). These behaviors include whether and how evidence is disseminated by supervisors, if caseworkers decide to refer parents to TripleP, and the extent to which TripleP providers engage parents. These conditions, subsequently, influence whether intended outcomes (positive parent-child interactions) are achieved (theme 8).

Discussion: Overall, findings revealed that the various actors agreed upon major themes. However, leaders highlighted differences with respect to some categories, underscoring additional responsibilities of building inter- and intra- organizational networks and training caseworkers and supervisors who are unaware of TripleP. Leaders revealed they had to overcome insurmountable barriers to achieve intended outcomes: create cultural norms to refer to TripleP, cultivate shared responsibility and intrinsic motivation to increase organizational readiness, and increase accurate and timely cultural exchanges with colleagues between and within organizational networks. Findings underscore the need to develop strategies to address these inner and outer contextual barriers during the pre-implementation process. Survey research should examine whether hypothesized relationships are supported by a larger sample.