A Quasi-Experimental Study on Training Child Welfare Workers on Youth Sexual Health

Abstract

Purpose:

This quasi-experimental pilot study evaluated the preliminary efficacy of training designed to increase child welfare workers’ (N = 156) knowledge, attitudes, and behaviors related to communicating with youth involved in the child welfare system about sexual and reproductive health (SRH).

Method:

Preintervention and 3-month follow-up survey data were collected from intervention participants (n = 69) who registered for a sexual health training and comparison participants (n = 87) who registered for other child welfare trainings.

Results:

Participants in the SRH training showed more positive behavioral beliefs, self-efficacy, and knowledge of SRH compared to date- and region-matched comparison participants at the 3-month follow-up; there was no difference between the groups on intentions or past month communication with clients regarding SRH.

Conclusion:

Findings suggest that although SRH training may be effective in changing child welfare workers’ attitudes about SRH, additional efforts may be needed to alter intentions and behaviors.

Keywords

sexual and reproductive health child welfare youth in foster care training

Youth with child welfare involvement often have histories of maltreatment, family disruption, and violence exposure (Taussig et al., 2016). Such adverse experiences can lead to a host of negative outcomes, including unwanted sexual and reproductive health (SRH) outcomes (Winter et al., 2016). Youth involved in child welfare are disproportionately impacted by sexually transmitted infections (STIs) and unintended pregnancy (Winter et al., 2016). Multiple studies have determined that about half of females aging out of foster care report a pregnancy by age 19 (Combs et al., 2018; Courtney et al., 2016; Dworsky & Courtney, 2010), which is more than two times greater than pregnancy rates in a national sample of youth of similar age and racial composition (Dworsky & Courtney, 2010). Such SRH outcomes have critical and long-lasting implications for child well-being. For example, adolescents who are parents are more likely than their counterparts to evidence more adverse economic, behavioral, and physical health outcomes, and their children are more likely to experience maltreatment (Basch, 2011; Domenico & Jones, 2007).

Research indicates that disproportionate rates of unwanted sexual health outcomes can be driven by a lack of knowledge and access to SRH education and services (Basch, 2011; Domenico & Jones, 2007). Preventive intervention approaches to improve SRH outcomes for youth are typically delivered through parents, schools, or communities and largely comprise direct education and service provision to youth (Jaccard et al., 2002; Jones et al., 2011). However, intervening through these systems is problematic for youth involved in child welfare as they frequently experience disruptions in relationships with their families, schools, and communities (Constantine et al., 2009; Craven & Lee, 2006; Love et al., 2005). Recent research has addressed this gap by testing SRH research–supported curricula (Combs et al., 2019) and by developing and testing new SRH curriculum specifically designed for youth involved in juvenile justice and foster care systems (Covington et al., 2016). Although specialized SRH education is an essential step in reaching this group, multi-session, group-based sexuality education may be limited in reach for youth involved in child welfare, who are often transient and hard to reach. A multi-session curriculum is practical and effective in settings such as juvenile justice centers, residential treatment centers, or group homes where youth are a “captive audience.” However, such approaches may be limited when youth are living with birth or foster parents, and where transportation and scheduling are barriers to consistent attendance (Geiger & Schelbe, 2014).

As the primary broker of services, the child welfare system, and specifically caseworkers, is distinctively positioned to fill education and service gaps related to SRH for youth involved in the child welfare system (Garwood et al., 2015; Power to Decide, 2016; Winter et al., 2016). Additionally, studies show that youth involved in child welfare want caseworkers and foster parents to be more proactive in communicating with them about SRH (Constantine et al., 2009; Love et al., 2005). Despite this, little is known about the frequency or extent to which child welfare workers talk with youth about SRH, or what factors lead workers to communicate with youth. The limited evidence suggests that SRH topics infrequently arise between youth and workers (Combs & Taussig, in press; Constantine et al., 2009; Dworsky & Dasgupta, 2014; Pilgrim, 2012). A recent study with 201 child welfare workers found that caseworkers believed that youth had a great need for SRH information and services, although on average, workers communicated about SRH issues with only 24% of their adolescent caseload in the past month. This study also found that workers’ subjective norms and self-efficacy were positively associated with their intentions to communicate and that having intentions to communicate was positively associated with communicating with youth about SRH (Combs & Taussig, in press). Ultimately, this study and others concluded that although caseworkers tend to believe that communication about SRH is valuable, little communication between caseworkers and youth seems to occur (Combs & Taussig, in press; Constantine et al., 2009; Dworsky & Dasgupta, 2014; Pilgrim, 2012).

Shedding light on the discrepancy between attitudes and behavior, research suggests that caseworkers feel unprepared to engage in these topics and desire more training in this area (Constantine et al., 2009; Courtney et al., 2016; Dworsky & Dasgupta, 2014; Love et al., 2005). In a study in three California counties, one third of caseworkers felt they did not have adequate training to talk to youth or foster parents about SRH (Constantine et al., 2009). In a 2009 Illinois survey with 94 child welfare workers, 71% reported wanting more tools and training on communicating about sexual health with youth (Dworky & Dasgupta, 2014). As a result, the state of Illinois offered a training on sexual health for caseworkers and foster parents across the state in 2013. An evaluation of this training included a convenience sample of 228 caseworkers and foster parents and consisted of pre- and posttraining surveys and qualitative interviews (no comparison group). This study found that both discomfort and lack of knowledge around sexual health impeded child welfare workers from communicating about SRH. The evaluation concluded that there is a pressing need for training child welfare workers on SRH of youth involved in their services and called for further research with more rigorous designs, specifically research with comparison groups (Dworsky & Dasgupta, 2014).

Guiding Framework

The theory of planned behavior (TPB) has proven to be an effective model for predicting and changing a wide array of behaviors, including parents’ communication with their children related to SRH risks (Ajzen, 2006; Cederbaum et al., 2013; McEachan et al., 2011; Stiffman et al., 2004). Applied to this topic, the TPB offers a useful framework to understand how positive beliefs and attitudes may lead to increased communication with youth regarding SRH information and services. In the TPB, behavior is guided by three beliefs or attitudes: behavioral beliefs, subjective norms, and self-efficacy. Behavioral beliefs are a person’s attitude toward or about a behavior; subjective norms are one’s perception of what others believe about the behavior; and self-efficacy is the extent to which one believes that they are able to carry out the behavior. These three constructs inform a person’s behavioral intention. Behavioral intention attempts to capture the amount of effort a person is willing to spend to implement a behavior, and the actual behavior is the realization of those intentions (Ajzen, 1991).

In the application of TPB to caseworkers’ communication with youth about SRH, adjustments specific to a child welfare context are warranted. For individuals specifically acting in a professional role and on behalf of an agency, additional factors must be considered. The Gateway Provider Model (GPM) is a framework for understanding what leads professionals to link adolescents to care or services and assumes that youth obtain services after direction or guidance from adults, such as teachers and caseworkers, and that these adults act as a gateway to services (Stiffman et al., 2004). The GPM posits that a provider’s perception of need, knowledge of services, and environment plays important roles in the decision to refer youth to services.

Applied to the topic of child welfare workers’ communication with youth about SRH and for the purposes of this study, behavioral beliefs reflect caseworkers’ attitudes of how acceptable or important it is to communicate about SRH topics with youth. Behavioral beliefs overlap with the GPM construct, perception of youth need, thus perception of need is largely included in behavioral beliefs. Subjective norms refer to perceptions of colleagues’ beliefs regarding SRH communication, and self-efficacy includes perceptions of one’s ability to communicate with youth on SRH topics. Knowledge of services and policies regarding SRH is a unique and stand-alone construct from the GPM. The outcomes, intent to communicate and communication, are defined as the transference of, or intention to transfer, any information related to SRH to youth on one’s caseload, including topics such as pregnancy, STIs, healthy relationships, or SRH informational resources or clinics. A recent study using a cross-sectional design tested the relationships between these constructs in a path analysis and found that self-efficacy and subjective norms were the only constructs with statistically significant associations on intent to communicate and that intent was the only statistically significant predictor of workers’ actual communication with clients. Additionally, self-efficacy had a significant indirect effect on communication; the relationship between self-efficacy and communication was mediated by intentions (Combs & Taussig, in press). Although the previous study found subjective norms, self-efficacy, and intent to be most predictive of communication, the current study examined a training’s effect on all six constructs, as they are considered critical to driving behavior.

Current Study

Ensuring that youth involved in the child welfare system have adequate knowledge, education, and access to services to prevent undesired outcomes is an essential reproductive right with critical implications for youth well-being. The child welfare system can serve as a gateway to reducing barriers and increasing access to SRH education and services; however, it has been largely unutilized and untested. This study used a quasi-experimental design to evaluate the preliminary efficacy of training designed to increase child welfare workers’ knowledge, attitudes, and behaviors related to communicating with youth on their caseloads about SRH information and services. The TPB and GPM were guiding frameworks for the intervention approach and measurement model. Thus, this study compares changes in knowledge, behavioral beliefs, subjective norms, self-efficacy, intent to communicate, and past month communication between caseworkers who received a sexual health training to those who did not. It was hypothesized that the training would positively influence child welfare workers’ knowled1ge, attitudes, and communication with youth measured 3 months after the intervention.

Method

Participants

All study participants in this quasi-experimental study were registered child welfare professionals for trainings offered by a statewide child welfare training system between August and December 2018. The intervention group consisted of child welfare professionals who registered for one of eight offerings of a sexual health training; the comparison group consisted of registered child welfare professionals for one of 18 date- and region-matched offerings of other trainings. The 18 non-SRH trainings included topics such as worker safety, confidentiality, medical aspects of child abuse, and domestic violence. Both intervention and comparison participants were recruited to complete a pretraining and 3-month posttraining survey on their knowledge, attitudes, and behaviors related to communicating with youth about SRH.

In total, 325 child welfare staff in the state were eligible for the study (i.e., county-based child welfare staff who registered for one of the 26 eligible trainings). The flow of participants diagram in Figure 1 details recruitment and retention. Four child welfare professionals were not recruited due to nonworking emails. Of the 321 child welfare professionals recruited, 156 consented and completed the pretraining survey for an overall recruitment rate of 48.6% (67.0% for intervention participants and 39.9% for comparison participants, χ²(1) = 20.5, p < .001). At recruitment, child welfare professionals were only registered for a training and could ultimately decide to not attend their respective training. Overall, 75.0% of study participants (85.5% of intervention participants and 66.7% of comparison participants, χ²(1) = 7.3, p = .007) attended the training they registered for at recruitment and 25.0% canceled or no showed. The quarter that canceled or no-showed were included in the 3-month follow-up and in analyses. At the 3-month posttraining follow-up, 94.2% of the 156 participants (n = 147) completed the follow-up survey. The 3-month follow-up response rate for the intervention group was 91.3% (two of the six nonresponding intervention participants no longer had working emails) and 96.6% for the comparison participants. Since attrition was quite small, attrition analyses were not conducted.

Figure 1.
Flow of participants diagram.

Table 1 displays the preintervention descriptive statistics of the total sample. Participants primarily identified as female/woman and as White/Caucasian. Most participants had 4 or more years of child welfare experience and were caseworkers with direct contact with youth. Over half of the sample had a graduate degree; the majority were trained in the field of social work. Although data on nonresponders were not available, descriptive statistics on gender, race, and education for all county-based child welfare professionals in 2019 were available and provide some comparison for this sample. Of the county-based child welfare staff active in the training system during 2019, 87.0% identified as female, 74.3% identified as White, 19.2% as Hispanic/Latino, and 5.4% as Black; over half (55.7%) had a bachelors degree, and 37.3% had a masters degree. These demographics are generally reflective of the sample in this study.

Table 1.
Preintervention Descriptive Statistics.

Variable Total (N = 156) Intervention (n = 69) Comparison (n = 87) χ²

n % n % n %

Gender (n = 154)

Female 144 93.5 65 94.2 79 92.9 0.10

Male 10 6.5 4 5.8 6 7.1

Race (n = 150)

White 104 69.3 44 66.7 60 71.4 0.39

Person of color 46 30.7 22 33.3 24 28.6

Position (n = 156)

Caseworker 118 75.6 51 73.9 67 77.0 0.20

Other 38 24.4 18 26.1 20 23.0

Experience (n = 156)

<4 years 75 48.1 28 40.6 47 54.0 2.79

>4 years 81 51.9 41 59.4 40 46.0

Highest degree (n = 154)

Bachelors or high school 90 58.4 38 55.9 52 59.8 0.33

Graduate degree 64 41.6 30 44.1 34 39.1

Discipline (n = 153)

Social work 77 50.3 36 52.1 41 48.8 0.17

Other 76 49.7 33 47.8 43 51.2

Theoretical Constructs N M (SD) N M (SD) N M (SD) t test

Behavioral beliefs 156 4.47 (0.55) 69 4.55 (0.46) 87 4.02 (.61) 1.69

Self-efficacy 156 4.23 (0.54) 69 4.31 (0.56) 87 4.16 (.52) 1.69

Subjective norms 156 3.52 (0.74) 69 3.59 (0.75) 87 3.46 (.74) 1.13

Knowledge 156 2.53 (0.88) 69 2.54 (0.88) 87 2.53 (.87) 0.05

Intent 98 1.64 (1.25) 45 1.83 (1.24) 53 1.24 (.19) 1.40

Communication 93 0.24 (0.08) 45 0.28 (0.31) 48 0.20 (.28) 1.44

Note. N = 156. None of the statistical tests was significant at p < .05.

Procedures

Recruitment followed the schedule of the sexual health trainings. Once a sexual health training was scheduled, up to three date- and region-matched comparison group trainings were selected for each of the eight sexual health trainings. Selection criteria for comparison group trainings were based on date and region and specifically included trainings that (1) occurred 3 weeks before or after a sexual health training and (2) were in the same region as the sexual health training. Given that participants in nonsexual health trainings were likely to have less interest in SRH and hence potentially less interest in study participation, comparison trainings were oversampled in order to achieve a ratio of two potential comparison participants for each intervention participant when possible in order to reach similar numbers of intervention and comparison participants. Roughly 1 week prior to each training, participants were emailed an invitation to participate, which contained a link to the pretraining survey. Every child welfare participant who consented and completed the pretraining survey was included in the study and was eligible for the 3-month follow-up survey. Three months after the training, follow-up emails were sent with a link to the posttraining survey. All participants were compensated with a US$10 e-gift card to Amazon for completing each 10-min survey (for a total of US$20 possible). A university’s institutional review board approved all study procedures.

Project-Designed Training

As shown in Table 2, the 6.5-hr in-person training delivered through the state’s child welfare training system had three major objectives to (1) help child welfare professionals understand and recognize SRH risks for youth involved in child welfare, (2) become familiar with and explore relevant online and local resources and services, and (3) build comfort and skills in communicating about SRH topics. The training used a problem-based learning (PBL) approach in which participants are presented with questions, problems, or scenarios through which they must explore and find answers and solutions. PBL aligns with the TPB outcomes as it focuses less on specific information transference and instead allows participants to engage with topics in a way that shifts attitudes and build skills through interactive activities. Specifically, behavioral beliefs were addressed through activities in which participants reflected on their own values, the needs of youth, and how trauma may impact risks. A large component of the training was dedicated to building self-efficacy by learning strategies and practicing skills to communicate with youth and caregivers. The training targeted knowledge through covering healthy development and identifying services and resources relevant to youth. Table 2 displays how the three aims of the training map onto core content and facilitation techniques. The training utilized a range of case study, teach-back, and reflection activities to create opportunities for participants to explore SRH risks specific to youth involved in child welfare, resources available, and options for communicating with youth. A training manual was developed, and the lead developer delivered all eight offerings observed in this study.

Table 2.
Sexual Health Training: Goals, Core Content, and Facilitation Techniques.

Goal Core Content Facilitation Techniques

Recognize risks
Explore sexual and reproductive health risks specific to youth involved in child welfare (e.g., elevated rates of pregnancy/sexually transmitted infection [STIs], impact of trauma on development, lack of trusted adults)

Recognize range of values around sexual and reproductive health

Age-appropriate healthy development

Freewriting

Reflection and discussion

Case studies

Interactive activities

Teach-back

Become familiar with resources
Policies, and local and online resources (e.g., laws of consent, teen-friendly clinics, web resources for youth and parents)

Basic health information related to sexuality and reproduction (e.g., contraception and STIs)

Interactive activities

Short lecture

Case studies

Teach-back

Build comfort and skills
Starting a difficult conversation

Answering difficult questions

Practicing conversations

Case studies

Role-plays

Measures

With the TPB and GPM as the theoretical framework of the measurement model, the pretraining and 3-month posttraining surveys asked about caseworkers’ knowledge, attitudes, and past month behaviors related to communicating with youth about SRH topics.

Theoretical constructs

Items were developed following Ajzen (2006), a TPB questionnaire construction article developed to help researchers design TPB questionnaires, and adapted from a study of parent–child sexual health communication (Cederbaum et al., 2013), an evaluation of an SRH training for caseworkers in Illinois (Dworsky & Dasgupta, 2014), and an adaptation of the Parent–Adolescent Communication Scale (Fisher et al., 2009). For each operationalized construct (except for subjective norms and knowledge), participants were asked to answer questions regarding four topics:
Methods of pregnancy prevention or contraception (e.g., condoms, intrauterine devices, implants, birth control pills);

Protection against STIs or HIV (e.g., condom use or testing for STIs);

Healthy romantic and sexual relationships;

Resources, education, or services (e.g., local clinics/education, pamphlets, or websites).

Behavioral beliefs

Behavioral beliefs assessed participants’ beliefs regarding whether youth have a need for SRH education and whether caseworkers should communicate about SRH with youth (Ajzen, 2006). Participants rated how much they agreed with the following statements on a 5-point Likert-type scale (1 = strongly disagree, 5 = strongly agree): (1) I believe that youth in foster care HAVE A NEED for education and/or services related to (topics a–c listed above) and (2) I believe that CASEWORKERS SHOULD COMMUNICATE with youth in foster care about (topics a–d listed above). The seven items had strong reliability with a Cronbach’s α of .88 and were averaged to create a mean behavioral beliefs construct.

Subjective norms

Subjective norms assessed participants’ perceptions of their coworkers’ and supervisors’ beliefs about communicating with youth about SRH (Ajzen, 2006). Participants rated how much they agreed with the following statements on a 5-point Likert-type scale (1 = strongly disagree, 5 = strongly agree): (1) MY PEERS at work believe that caseworkers should communicate and/or help connect youth in foster care to SRH information or services, (2) MY SUPERVISORS at work believe that caseworkers should communicate and/or help connect youth to SRH information or services, and (3) SRH discussions regularly arise between youth and caseworkers in my county. The items had strong reliability with a Cronbach’s α of .80. The three items were combined as a mean score to create an overall norms construct.

Self-efficacy

Eight items were used to measure self-efficacy (Ajzen, 2006; Cederbaum et al., 2013). Items included (1) I am CAPABLE of communicating with youth in foster care about (topics a–d listed above) and (2) I am COMFORTABLE communicating with youth in foster care about (topics a–d listed above). Response options were on a 5-point Likert-type scale (1 = strongly disagree, 5 = strongly agree). The items had strong reliability (Cronbach’s α of .89) and were combined into a mean score to create an overall self-efficacy construct.

Knowledge of services and policies

Knowledge was measured with four items regarding knowledge (i.e., correct answers) of services and policies. Two true/false questions included: (1) at age 13, youth can access reproductive health services confidentially and without parental/guardian consent in Colorado and (2) at age 17, youth can access reproductive health services confidentially and without parental/guardian consent in Colorado. Participants were also asked to name a specific local resource or clinic for youth and an online resource or educational material. True/false answers were coded to indicate correct answers, and open-ended responses about resources/services were recoded as “1” to indicate that a resource was identified and “0” to indicate “Don’t Know” or a nonspecific answer (e.g., “any medical provider,” “internet,” or “Google”). The four knowledge items were summed to create an overall knowledge index that indicated the number of “correct” answers (ranging from 0 to 4).

Intent to communicate

Intent items assessed how many adolescents a worker intended to communicate with regarding SRH over the coming month (Cederbaum et al., 2013). The items were thinking about the adolescents (aged 12–18) on your caseload now, within the next month, and roughly HOW MANY DO YOU INTEND to communicate about (topics a–d listed above). Response options included (0) none, (1) a few, (2) some, (3) most, and (4) all. Only participants with a current caseload of adolescents were included in these items (n = 98). The overall intent construct had strong internal consistency (Cronbach’s α of .94), and the four items were combined into a mean score to create an overall intentions construct.

Communication

For the purposes of this study, communication was defined as the transference of any information related to SRH to youth regarding topics a–d listed above. This construct was developed with adaptations from various studies measuring communication about sexual health (Dworsky & Dasgupta, 2014; Fisher et al., 2009; Pilgrim, 2012). In order to measure communication, participants were first asked how many adolescents were on their caseload in the past month. They were then asked: Thinking about the past month, of the adolescents aged 12–18 years on your caseload, with approximately how many DID YOU COMMUNICATE ABOUT (topics a–d listed above). Numeric responses to the communication items were divided by the number of youth on a caseload to create a percentage of one’s caseload with whom caseworkers discussed each specific topic over the past month (e.g., percent of adolescent caseload with whom caseworker discussed pregnancy prevention). Only participants with a past month adolescent caseload were asked these items (n = 93). The percentages for the four topics were averaged to create a mean SRH communication score.

Control variables

Control variables included gender, race/ethnicity, child welfare role, years of experience in child welfare, highest degree, and field of degree. Participants identified as either female (coded 0) or male (coded 1). Since control variables had numerous categories with small numbers, dichotomous variables were constructed, including race/ethnicity (0 = White, 1 = person of color), type of position (0 = direct work with youth, 1 = indirect work with youth), years of experience (0 = less than 4 years, 1 = more than 4 years), highest degree (0 = bachelor degree or less, 1 = graduate degree), and discipline (0 = social work, 1 = other).

Analyses

Preintervention differences were explored by group status (i.e., intervention vs. comparison) and by training attendance (i.e., attended or no showed). Specifically, χ² tests were conducted to examine differences between groups on dichotomous demographic variables, and t tests were conducted to examine differences on continuous theory-based constructs. After assessing differences between groups, differences were explored between intervention and comparison participants at the 3-month follow-up on the theoretical constructs through regressions that controlled for the preintervention measure of the respective construct. An intent-to-treat model was used, meaning that intervention participants who did not attend the sexual health training were still included in the intervention group. This is considered a more rigorous approach than a treatment-on-the-treated model, which would exclude participants who dropped out of the intervention (i.e., no showed to the training). As a robustness test, we explored a treatment-on-the-treated model, and results were the same. We present the intent-to-treat results as they are the more conservative and rigorous approach.

Sample sizes for regressions on intent to communicate and past month communication were smaller due to only a portion of the sample carrying a current or past month caseload with adolescents. Regressions on behavioral beliefs, subjective norms, self-efficacy, and knowledge included 147 participants; the regression on intent included 82 participants, and the regression on communication included 79 participants. Analyses were conducted in SPSS Statistics Version 25.

Results

Preintervention Differences by Group Status

As shown in Table 1, no significant differences were found on preintervention demographic variables or preintervention theoretical construct scores between intervention and comparison participants. Although not shown in a table, the same tests were conducted to assess differences between the participants who attended and participants who no-showed to a training. No significant differences on demographics or preintervention theoretical construct scores were found between participants who attended and no-showed to trainings.

Outcome Analyses

After controlling for respective preintervention scores, being in the sexual health training was significantly associated with greater knowledge, more positive behavioral beliefs, and higher self-efficacy at 3-month postintervention (see Table 3). Intervention status did not have an impact on subjective norms, intentions, or communication. For variance explained in these six regressions (R ²), the preintervention measure of the theoretical construct and group status explained between 11% of variance for knowledge and 38% of variance for communication.

Table 3.
Regression Analyses.

Dependent Variable B SE β p Value R ²

Three-month post behavioral beliefs (n = 147) .23

Preintervention behavioral beliefs .36* .07 .41 <.001

Intervention group .22 .07 .22 .003

Three-month post subjective norms (n = 147) .31

Preintervention norms .55* .07 .56 <.001

Intervention group .09 .1 .06 .365

Three-month post self-efficacy (n = 147) .37

Preintervention efficacy .56* .07 .58 <.001

Intervention group .16* .07 .15 .022

Three-month post knowledge (n = 147) .11

Preintervention knowledge .26* .08 .27 .001

Intervention .34 .14 .23 .004

Three-month post intent (n = 82) .28

Preintervention intent .57* .10 .55 <.001

Intervention group −.21 .24 −.08 .385

Three-month post communication (n = 79) .38

Preintervention communication .58* .08 .62 <.001

Intervention group .04 .05 .06 .501

p < .05. p < .01. p < .001.

Discussion and Applications to Practice

Results showed that 3 months after training, participants in the sexual health training had more positive behavioral beliefs regarding the importance and need for workers to communicate about SRH, greater knowledge of services and policies related to SRH, and higher self-efficacy to communicate about SRH compared to comparison participants in other trainings. These findings may be conservative given that behavioral beliefs and self-efficacy were high at preintervention and vulnerable to a ceiling effect; however, they still evidenced statistically significant increases. Although the intervention and comparison groups were comparable at preintervention on observed variables, self-selection into the study and the intervention group is a limitation of these findings, and it is possible that other explanations related to unobserved group differences may account for improved outcomes. At the 3-month follow-up, differences between the intervention and comparison groups were not observed on subjective norms, intentions, or communication. Despite the lack of observed intervention effects on the primary outcomes (i.e., intent to communicate and past month communication about SRH), it is promising that a 6.5 hr training had observable effects 3 months later on knowledge, behavioral beliefs, and self-efficacy, which are constructs often considered prerequisites for behavior change.

Lack of significant findings on intent to communicate and actual communication with youth regarding SRH could be explained in several ways. The first involves measurement time frames. While the follow-up survey was administered 3 months after the intervention, survey items specifically asked about “past month” behaviors. It is possible that workers in the sexual health training communicated with youth in the first or second month after training but did not feel the need to do so in the third month. Further, the sexual health training covered communication related to sexual health topics with youth and their caregivers, but the survey only assessed workers’ communication with youth. It is possible that intent to communicate and communication with caregivers increased, but the measure did not assess this. Another potential explanation for lack of effects on intentions and communication is that the sample size in this study was relatively limited for participants who carried an adolescent caseload. The sample size dropped more than 40% between those who could answer questions on attitudes and knowledge and those who carried an adolescent caseload and could also answer items about intentions and communication at both the preintervention and the 3-month follow-up. Specifically, for intervention analyses on communication, roughly half of the full 3-month follow-up sample (79 participants) carried an adolescent caseload at both the preintervention and the 3-month follow-up. This limited the power to detect a small to moderate effect on intentions and communication, unlike other measures that did not require current or past month caseloads.

Findings in this study are consistent with other pilot studies examining the impact of child welfare worker training. For example, Project Focus sought to increase caseworkers’ referral of youth involved in child welfare to research-supported mental health treatments and programs (Dorsey et al., 2012; Fitzgerald et al., 2015). Project Focus provided a 9-hr in-person caseworker training over 2 days and 8 hr case-based consultation over 16 weeks; thus, Project Focus provided significantly more support than the current study’s 6.5-hr training intervention. In the randomized controlled trial evaluating Project Focus, significant positive effects were found on knowledge of research-supported programs and caseworkers’ ability to classify mental health problems and match them to research-supported programs. However, effects were not found on the main behavior change outcome, referrals to research-supported programs (Fitzgerald et al., 2015). Researchers proposed that one explanation for an increase in knowledge but not in referrals could be due to the need for an organizational component or supervisor involvement in an intervention that targets direct facilitators of services, like caseworkers (Dorsey et al., 2012; Fitzgerald et al., 2015).

Similarly, while the current study’s findings of improvements in workers’ behavioral beliefs, self-efficacy, and knowledge are promising, worker training alone may not be sufficient to produce effects on intentions and behaviors. Although focusing on the facilitator of services (e.g., caseworkers) offers a promising opportunity for increasing the ability to link youth with effective services and education in resource- and time-constrained settings like child welfare in which workers are balancing many competing concerns, organizational and supervisor support may be essential. This may be even more important for topics, such as SRH, that can be perceived as taboo or controversial in nature. A meta-analysis of 47 studies examining the relationship between intent and behavior found that in situations where the behavior had the potential for social reaction, the relationship between intent and behavior was weaker (Webb & Sheeran, 2006). Communicating about SRH with youth involved in child welfare likely has at least the perception of social reaction. Further, within a workplace, subjective norms may play a more significant role as workers are professionals doing a job on behalf of an agency. A prior cross-sectional study with the same sample used in the current study tested the relationships between each of the study constructs. This study found that subjective norms and self-efficacy were the most important contributors to behavioral intent for communicating with youth about SRH topics (Combs & Taussig, in press). Given that the application of these constructs is within a professional setting where separation of personal beliefs is expected and given that they involve topics that are controversial in nature, organizational and administrative support around communicating with youth about SRH may be helpful to realize effects on intent and communication. Indeed, research in the field of child welfare has noted the particularly powerful role of supervisors and emphasizes the benefit of supervisor support on a range of outcomes (Chenot et al., 2009).

Despite this, it is particularly encouraging that the intervention had an impact on self-efficacy, which has been shown to be essential for behavior change. According to Ajzen’s hypothesized model and empirical evidence for the TPB, self-efficacy is a particularly important construct for behavioral outcomes (Ajzen, 1991; Santa Maria et al., 2015). Additionally, self-efficacy has consistently proven to be a critical factor for transference of skills learned in trainings to the execution of those skills in practice (Blume et al., 2010; Grossman & Salas, 2011). Studies on the transference of learned skills into behavior show that individuals who have more confidence in their ability are more likely to carry out a difficult task and that individuals must believe in their ability to perform skills before the skill can be realized (Blume et al., 2010; Grossman & Salas, 2011). Given that preintervention self-efficacy was relatively high in this sample, it is notable that self-efficacy was significantly improved among intervention participants. Further, as described above, our prior study examining the interrelationship of constructs found that self-efficacy was the strongest predictor of intent to communicate and that it had an indirect effect on communication through intent (Combs & Taussig, in press). The significant effect of the intervention on self-efficacy in the current study suggests that training can impact this critical construct.

The intervention also had significantly positive effects on knowledge. Knowledge of services and policies may contribute to self-efficacy and communication in a unique way, as it demonstrates that one has specific and critical information that is easily passed along to youth or their caregivers. Although quality or content of communication was not captured in this study, knowledge of services and policies may be a key to improving the quality of communication such that it goes on to increase youths’ access to resources and services.

Limitations

Despite the many strengths of this study including a comparison group, low attrition rate, and thorough measures, there are several limitations related to both internal and external validity. In addition to the sample size issues noted above, self-selection bias is a major concern. Both the intervention and comparison groups were convenience samples, and the overall participation rate was 48.6%, with the intervention group having a statistically significant higher recruitment rate than the comparison group. Because caseworkers self-selected into the trainings, those who comprised the intervention group may have differed from those in the comparison group on any number of unobserved factors related to communication, beyond just demographic and employment variables. It is likely that those attending the sexual health training were more interested in SRH and more motivated to take action in this area than those who did not select to attend this training. Further, individuals in any training who were also willing to participate in this study may differ from those who declined participation. Since data on nonresponders were unavailable, it was unclear the extent of selection bias. However, as noted in the Method section, descriptive statistics for all 2019 child welfare professionals who attended trainings through this state’s child welfare training system were available and suggested that this study’s sample was similar to county-based child welfare staff in regard to gender, race, and education.

Measures used in this study were adapted from existing studies and measures and were robust with multiple items and strong reliability; however, none of the items had been used previously nor were any standardized or validated. Several measurement issues were noted above in relation to explanation of null findings on intent and communication (i.e., time frame of survey questions and questions specifically about youth vs. caregivers). Additionally, all measures were self-reported, which is prone to social desirability and recall bias. The 1-month time frame on communication items was intended to ameliorate recall bias, as previous studies asked for communication over one’s career in child welfare or past 2 months.

Policy and Practice Implications

Training child welfare workers on SRH of youth involved in child welfare may be a promising avenue for child welfare systems to support workers and youth. Rather than adding to the already overwhelming responsibilities of caseworkers, training on SRH of youth involved in child welfare can increase competencies to address issues workers currently encounter and have few resources. Further, regular trainings on this topic have the potential to positively impact subjective norms and may indicate organizational support. This type of intervention (i.e., caseworker trainings) can also be cost-effectively integrated as a part of current child welfare practice. Most states require that child welfare workers complete a certain amount of ongoing training hours to maintain their competencies. Trainings, particularly within a system in which they are already mandated, carry efficiency of scale and can be cost-effective as existing systems are already in place for ongoing training. Also, while this study focused on child welfare workers, caregivers are also a promising avenue. Training both caregivers and workers concurrently so that they are getting consistent messaging may be another way to improve outcomes (Albertson et al., 2018).

According to training transference literature and empirical evidence, self-efficacy should be a focus through an emphasis on skill-building, increasing comfort, and tools that make discussions easier. Providing professionals with tools that facilitate conversations and resources for referrals and education is crucial. For example, specific resources, like prewritten text messages or handouts regarding pertinent SRH issues may facilitate transference of critical information or initiate conversation with little extra burden on the child welfare worker. However, training direct facilitators of services alone is likely insufficient to yield changes in behavior. Administrative champions, organizational leadership, and supervisory supports that clarify subjective norms, offer guidance, and encourage behaviors may be needed.

Given that very little research exists on the topic of caseworkers’ communication about SRH with youth, the research needs are vast. Areas for priority are replication studies as well as studies that reduce selection bias. Other pertinent next steps for research include investigation of items and constructs used to create measures so that there are standard measures which can be used across studies for comparison of findings. Additionally, research on the consistency, content, and quality of communication with youth as well as reasons why caseworkers may or may not communicate with various youth would reveal important insights to this topic. The ultimate goal of this research is to increase the agency, autonomy, and access of youth involved in child welfare services to make SRH decisions that improve their lives; future studies should therefore go beyond testing whether training changes workers’ behavior and also whether this improves SRH outcomes for youth.

Variable	Total (N = 156)	Intervention (n = 69)	Comparison (n = 87)	χ²
Gender (n = 154)
Female	144	93.5	65	94.2	79	92.9	0.10
Male	10	6.5	4	5.8	6	7.1
Race (n = 150)
White	104	69.3	44	66.7	60	71.4	0.39
Person of color	46	30.7	22	33.3	24	28.6
Position (n = 156)
Caseworker	118	75.6	51	73.9	67	77.0	0.20
Other	38	24.4	18	26.1	20	23.0
Experience (n = 156)
<4 years	75	48.1	28	40.6	47	54.0	2.79
>4 years	81	51.9	41	59.4	40	46.0
Highest degree (n = 154)
Bachelors or high school	90	58.4	38	55.9	52	59.8	0.33
Graduate degree	64	41.6	30	44.1	34	39.1
Discipline (n = 153)
Social work	77	50.3	36	52.1	41	48.8	0.17
Other	76	49.7	33	47.8	43	51.2
Theoretical Constructs	N	M (SD)	N	M (SD)	N	M (SD)	t test
Behavioral beliefs	156	4.47 (0.55)	69	4.55 (0.46)	87	4.02 (.61)	1.69
Self-efficacy	156	4.23 (0.54)	69	4.31 (0.56)	87	4.16 (.52)	1.69
Subjective norms	156	3.52 (0.74)	69	3.59 (0.75)	87	3.46 (.74)	1.13
Knowledge	156	2.53 (0.88)	69	2.54 (0.88)	87	2.53 (.87)	0.05
Intent	98	1.64 (1.25)	45	1.83 (1.24)	53	1.24 (.19)	1.40
Communication	93	0.24 (0.08)	45	0.28 (0.31)	48	0.20 (.28)	1.44

Goal	Core Content	Facilitation Techniques
Recognize risks	Explore sexual and reproductive health risks specific to youth involved in child welfare (e.g., elevated rates of pregnancy/sexually transmitted infection [STIs], impact of trauma on development, lack of trusted adults) Recognize range of values around sexual and reproductive health Age-appropriate healthy development	Freewriting Reflection and discussion Case studies Interactive activities Teach-back
Become familiar with resources	Policies, and local and online resources (e.g., laws of consent, teen-friendly clinics, web resources for youth and parents) Basic health information related to sexuality and reproduction (e.g., contraception and STIs)	Interactive activities Short lecture Case studies Teach-back
Build comfort and skills	Starting a difficult conversation Answering difficult questions Practicing conversations	Case studies Role-plays

Dependent Variable	B	SE	β	p Value
Three-month post behavioral beliefs (n = 147)	.23
Preintervention behavioral beliefs	.36***	.07	.41	<.001
Intervention group	.22**	.07	.22	.003
Three-month post subjective norms (n = 147)	.31
Preintervention norms	.55***	.07	.56	<.001
Intervention group	.09	.1	.06	.365
Three-month post self-efficacy (n = 147)	.37
Preintervention efficacy	.56***	.07	.58	<.001
Intervention group	.16*	.07	.15	.022
Three-month post knowledge (n = 147)	.11
Preintervention knowledge	.26***	.08	.27	.001
Intervention	.34**	.14	.23	.004
Three-month post intent (n = 82)	.28
Preintervention intent	.57***	.10	.55	<.001
Intervention group	−.21	.24	−.08	.385
Three-month post communication (n = 79)	.38
Preintervention communication	.58***	.08	.62	<.001
Intervention group	.04	.05	.06	.501

Footnotes

Acknowledgments

We wish to express our appreciation to the child welfare workers and state child welfare training system for their partnership in these research efforts.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by the Society of Family Planning Research Fund (SFPRF12-ES06) and by the Fahs-Beck Fund for Research and Experimentation. The content is solely the responsibility of the authors and does not represent the views or opinions of the SFPRF or the Fahs-Beck Fund for Research and Experimentation.

ORCID iD

Katie Massey Combs

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