Redefining Culture in the Cans Assessment Tool to Improve Assessment of the Social Determinants of Health

Background and Purpose: Racial and ethnic disproportionality and disparity exist across processes and outcomes in the child welfare system, including: at referral, at entry, during care, and in both short- and long-term outcomes. Interventions to ameliorate these disparities must take into account social determinants of health, which shape the lives of youth and their families. Most child welfare systems have mandated and comprehensive assessment tools. This presentation examines an effort to tailor such a tool to more precisely examine issues related to social determinants of health and the results of a mixed methods pilot study of the revised version.

Methods: A mixed methods two phase pilot study presented existing workforce members (n=179) with video case vignettes and asked them to rate the new cultural considerations domain items. We calculated intraclass correlation coefficients and examined item level variance to explore the inter-rater reliability of the tool and utilized Likert scale questions to understand the content validity. Qualitative, open ended questions asked further questions about content validity and usability. Finally, a subset of participants were invited to participate in affinity based focus groups (POC, multi-lingual, queer identified, white) to explore and member check the results of the pilot test. An advisory board of stakeholders was convened throughout the study period to inform and guide the process.

Results: The intraclass correlation coefficient (ICC) for the cultural consideration’s domain was .23 for vignette 1 and .24 for vignette 2, indicating poor inter-rater reliability. Conversely, the new items received strong endorsement from participants for face and content validity with over 90% of the participants indicating they agreed or strongly agreed that the items in the domain were clearly worded, the rating scale was clear and applicable, and the items were consistent with the ways in which they viewed cultural considerations in practice.

Focus group data suggests that the low ICC was likely due to: 1.) A hesitation by white identified clinicians to ask clients about culture and identity 2.) A lack of understanding about the role of culture in the delivery and receipt of services primarily, though not exclusively by white clinicians and 3.) A desire not to see “culture” as pathology by queer and BIPOC clinicians.

Conclusions and Implications: Existing assessment tools offer an opportunity to add variables or domains that focus the attention of social work staff on the impact of the social determinants of health on the child and family, however training must accompany the implementation of such measures. Findings suggest that the workforce requires specific instruction on how to ask about culture and identity and how to place the data gathered in the context of service delivery. Finally, clinicians holding marginalized identities may also view the addition of such variables as pathologizing of culture and identity, an issue that should be further explored in research.