How Does It Work? Enhanced Solution-Focused Kinship Navigation Case Management, Service Utilization, Caregiver Stress Reduction, and the Well-Being of Informal Kinship Caregivers in Washington State: A Cohort Study Using Causal Directed Acyclic Graphs

Background and Purpose: Kinship care is the prioritized placement to prevent maltreated children from entry into formal foster care systems. Roughly 3% of the U.S. child population were living with kinship caregivers, particularly in grandparent-headed households. Almost 90% of these children were in non-public kinship care. However, informal kinship caregivers of maltreated children often face significant caregiving stress, unmet needs, and limited access to resources. An enhanced solution-focused case management model of kinship navigation was implemented in a one-arm experiment to address such benefit and service disparities in Washington State. This study investigates the causal mechanisms underlying the efficacy of this enhanced intervention in improving the well-being of informal kinship caregivers, focusing on service utilization and stress reduction as mediators.

Methods: The study employed a cohort design within a natural experimental framework, utilizing directed acyclic graphs (DAGs) to identify causal pathways. Data were collected from informal kinship caregivers in exposed (n = 102) and unexposed groups (n = 121), with propensity score matching used to minimize selection bias. DAG-informed regression models were applied to estimate the causal effects of the enhanced kinship navigation model on caregiver well-being, while mediators such as service utilization and stress reduction were analyzed. Bootstrapping with 1000 samples were conducted to verify both mediation analyses. Finally, sensitivity analyses were conducted to evaluate the robustness of mediation pathways.

Results: The intervention significantly improved caregiver well-being, with an average increase of 3.21 points six months after case closure (Average Treatment Effect = 3.21, Std. Error = 0.56, 𝑝 < 0.001). Multiple mediators, including service utilization combined with its sequential, reduced caregiver stress, jointly accounted for 50% of the total causal effect (Average Causal Mediation Effect = 1.60 [CI: 0.64 - 2.56], 𝑝 < 0.001). Sensitivity analysis supported the robustness of such causal mediation effect (ρ=0.6) . On the other hand, the amount of service utilization alone did not significantly mediate the intervention's effect on caregiver well-being (Average Causal Mediation Effect = 0.032 [95% CI: –0.06 to 0.16], 𝑝 = 0.56), indicating that stress reduction was the primary mediator driving the observed improvements. However, sensitivity analysis suggested that this nonsignificant mediation effect may not be robust (ρ = 0.1), raising concerns that it could be influenced by unmeasured confounders. Notably, regional disparities in service utilization approached significance in the main effects model of causality (𝑝 = 0.06), suggesting that geographic variation in service access may be a potential confounder in the service utilization pathway.

Conclusions and Implications: This study provides novel evidence of the positive causal impact of solution-focused kinship navigation case management on the well-being of informal kinship caregivers. Types of services utilized and the social support received from navigators and peers in the intervention group may have contributed to greater stress reduction. While the pathway linking solution-focused kinship navigation case management, service utilization, reduced caregiver stress to caregiver well-being emerged as significant, the findings underscore the critical importance of improving service accessibility and availability to enhance stress reduction and overall intervention effectiveness.