Thinking critically about cross-cultural implementation—Swedish social workers’ experiences of testing the Kids’ Club method for helping child and mother victims of intimate partner violence

ABSTRACT

There are calls for evidence-based methods for helping children to deal with experiences of Intimate Partner Violence (IPV) in many countries. Therefore, it has been commonplace to implement such methods from outside of their home country. The aim of this study is to examine Swedish social workers’ experiences of testing the American Kids’ Club method for child and mother victims of IPV. After having tested leading Kids’ Club groups, seventeen social workers at four different locations were interviewed using a semi-structured interview guide. The results indicate that the social workers generally accepted the method. This was related both to some general features of the method and to their perceiving it as somewhat flexible. According to the social workers, the method needs some cultural adaptation to better suit the Swedish social services setting, otherwise it cannot be fully accepted. Finally, they thought that successful implementation depended on an organizational structure that enabled enough children to be referred to the programme as well as either high personal commitment or an organization that prioritized the method. Based on these results, we conclude that importing an American evidence-based group method to help children exposed to IPV to Sweden demands attention to issues of cultural adaption.

ABSTRAKT

I många länder har röster höjts för att hjälpa barn att hantera erfarenheter av våld i nära relation med evidensbaserade metoder. Därför har det blivit vanligt att sådana metoder sprids utanför det land de utvecklades i. Syftet med denna studie är att undersöka svenska socialarbetares erfarenheter av att testa den amerikanska Kids’ Club-metoden för barn och mammor som utsatts för våld i nära relation. Efter att ha lett Kids’ Club-grupper intervjuades sjutton socialarbetare på fyra olika platser med hjälp av en halvstrukturerad intervjuguide. Resultaten indikerar att socialarbetarna i allmänhet accepterade metoden. Detta var relaterat både till några allmänna egenskaper hos metoden och till att de uppfattade den som något flexibel. Enligt socialarbetarna behöver metoden lite kulturell anpassning för att bättre passa svensk socialtjänst innan den kan bli fullt accepterad. Slutligen trodde de att framgångsrik implementering är beroende av en organisatorisk struktur som gör det möjligt att tillräckligt många barn att hänvisas till programmet såväl som högt personligt engagemang eller att organisationen prioriterar metoden. Baserat på dessa resultat drar vi slutsatsen att importera en amerikansk evidensbaserad gruppmetod för att hjälpa barn utsatt för våld i nära relation till Sverige kräver uppmärksamhet på frågor om kulturell anpassning.

KEYWORDS:

• Support
• adaptation
• children
• intimate partner violence
• domestic violence

NYCKELORD:

• stöd
• anpassning
• barn
• våld i nära relation
• våld i hemmet

Chan, Hollingsworth, Espelage, and Mitchell (2016) argue that the context of culture is important for successful violence prevention. However, although implementation and testing of evidence-based interventions from outside of their home country are increasingly commonplace, implementing interventions in a different cultural context is often paired with challenges (Ferrer-Wreder, Sundell, & Mansoory, 2012). Ferrer-Wreder et al. (2012) suggest that studies of how well a method is suitable for use in the new context should include analyses of various aspects of the method, such as acceptability among professionals and the need for adaptations for the conditions of the new context.

Imported intervention methods are commonly adapted to some degree (Skärstrand, Larsson, & Andréasson, 2008). Adaptation may consist of planned or unplanned changes to any aspect of an intervention and its support structures including omissions, additions (or add-ons), and modifications (cf. Berkel, Mauricio, Schoenfelder, & Sandler, 2011). Although adaptation might be necessary in order to implement an evidence-based intervention, its value is debated, as it is often conceived as the opposite of fidelity (Ferrer-Wreder et al., 2012). Fidelity has been conceptualized as the actual delivery of the ‘driving elements of a program’ (Berkel et al., 2011, p. 25). Adaptation is thus often seen as a risk to these ‘driving elements’. However, complete fidelity rarely occurs in intervention research studies, thereby leaving open the possibility that adaptation can co-exist with high levels of fidelity and dosage (i.e. ‘finding the right mix of fidelity and adaptation’), and that these markers of implementation are not necessarily mutually exclusive (Durlak & DuPre, 2008).

In addition, changes to surface structure appear less controversial than deep structure changes. As an example, Bauman, Stein, and Ireys (1991) argue that it is important to maintain a programme's mechanism of operation while simultaneously reinvention may be needed in implementation in new sites if the mechanism leading to change is preserved. Therefore, Ferrer-Wreder et al. (2012) argue that processes of adaptation need to be studied to enable researchers to empirically test degrees of intervention adaptation in relation to intervention effectiveness, and thereby to learn from both successes and failures. Although this study does not test different degrees of adaptation, it seeks to provide insight into adaptation processes and enhance understanding of adaptation of interventions for children and mothers exposed to Intimate Partner Violence (IPV).

The call for effective methods for helping children exposed to IPV

Childhood exposure to IPV entails a heightened risk of the child developing problems such as post-traumatic stress, anxiety, depression, and other emotional or behavioural problems, as well as difficulties in school, or with social relationships (e.g. Kitzmann, Gaylord, Holt, & Kenny, 2003; Wolfe, Crooks, Lee, McIntyre-Smith, & Jaffe, 2003). Hence, limiting the consequences of such exposure is of utmost importance. Interventions have so far mainly been developed in the US and Canada and include a significant variety in the goals they aim to achieve, such as improved coping with stress and conflicts, treatment of symptoms of traumatic stress and behavioural disorders, support of the child–mother relationship or practical support to mothers and children (e.g. Graham-Bermann, Lynch, Banyard, Devoe, & Halabu, 2007; Jaffe, Wolfe, & Wilson, 1990; Jouriles et al., 2001). Although some methods have been developed in Europe (cf. Broberg et al., 2011), evidence-based methods for helping children to deal with experiences of IPV are still being called for in many countries. As a result, implementation of methods from outside of their home country has become increasingly commonplace. This study aims to examine Swedish social workers’ experiences of testing the Kids’ Club method for helping children exposed to IPV.

According to the 2007 Swedish Social Services Act, the social services are required to ensure that children who have witnessed violence receive the support and help they need (5 kap. 11 § SoL Lag 2007:225). However, a national evaluation of methods for helping children exposed to IPV showed that the interventions used gave only moderate results in terms of child health and well-being (Broberg et al., 2011). Based on the results of that evaluation, the increasing pressure on the public sector services to offer evidence-supported interventions (Berger, 2010), and the Kids' Club method having showed promising results in evaluations in USA (see below), the Kids' Club-program has recently been tested in Sweden.

The Kids’ Club method was developed in the USA and has been successful in reducing children's externalizing and internalizing of problems, particularly when the child programme is combined with parallel sessions for the victimized mother (e.g. Graham-Bermann & Hughes, 2003; Graham-Bermann et al., 2007). The programme consists of 10 weekly, 60-minute sessions for groups of children 6–12 years of age and their mothers. The child intervention is designed to strengthen the children's sense of safety and help them manage emotions and conflicts. The mother programme focuses on building empowerment and safety by educating the mothers about power and control and discussing ways to break cycles of domination.

The present study

This study examines experiences of the first implementation outside the USA of the Kids’ Club method for supporting children exposed to parental IPV and their mothers (at least the first approved by the developer). The aim of the study is to examine Swedish social workers’ experiences of testing the Kids’ Club intervention for child and mother victims of IPV. The aim is specified in the following research questions: What aspects of the method hindered and favoured acceptance? Did perceived needs for adaptation constitute barriers to acceptance of the method? What conditions for implementation did the group leaders describe? By answering these questions, this article seeks to provide a basis for researchers to reflect upon the interface of acceptance, adaptation needs, and conditions for implementation, and for social workers to reflect upon how challenges in dealing with method fidelity and adaptation can be dealt with when developing support for victimized children and their mothers.

Method

In a project commissioned by the Swedish National Board of Health and Welfare, four methods for supporting children exposed to IPV that had showed promising results in other countries were tested in Sweden during 2012–2015 (reference omitted for blinded review). One of these was the Kids’ Club group method (see also reference omitted for blinded review). In the project, social workers in five Swedish municipalities were trained in leading Kids’ Club groups.

Participants

Of the five municipalities, one was not able to offer Kids’ Club groups during the time frame of the project. After having led Kids’ Club groups with children exposed to IPV or parallel groups with their mothers in the remaining four municipalities, the group leaders were interviewed individually. The method was provided by the social services at each location and was offered as a voluntary intervention for the children and mothers. Some were recommended it by their social worker, others came on their own initiative. One location (5 group leaders) had run Kids’ Club groups three times; two locations (4 group leaders at each) had run Kids’ Club groups twice; and one location (4 group leaders) had run Kids’ Club groups once, at time of interviews. Thus, participants in the current study were all seventeen Kids’ Club group-leaders at four different locations. Fifteen were trained social workers, one was a retired midwife working as a volunteer at the Swedish church, and one was a lay worker at the Swedish church, the two latter working for the social services in their municipality. All group leaders were female.

Procedure

Contact was established in 2011 with the developer of the Kids’ Club intervention. The manual was translated into Swedish and back-translated and approved by the developer. The researchers and some of the group leaders met with the Kids’ Club research team in Ann Arbor, Michigan. Group leaders received two days of training either from the programme developers at the time, or later in Sweden from a certified Swedish teacher of Kids’ Club. Approval for the study was granted by the Regional Ethics Committee in Uppsala (Dnr: 2012/218). The study was conducted between 2012 and 2014 and the group leaders were all interviewed in 2014.

Following the ethical review and approval, and having run the 10-session Kids’ Club intervention in the project, all group leaders were asked about participation in individual interviews. They were given oral information about the study and, upon request, received the interview guide in advance of the interview. An appointment was made for the interviewer to meet the group leader. Interviews took place at a time convenient for the participants at their work-place or at the social services office offering the intervention. One interview was conducted by telephone. The interviewers were the authors of this article—a trained social worker and a trained child psychologist—both with experience of clinical youth work and in particular with experience of research about children in difficult life situations.

Interview format

Following the receipt of informed consent, the interviewer used a semi-structured interview guide designed to elicit talk about experiences and thoughts. The interview guide included five themes (Acceptance, Training, Conditions for Implementation, Practical Realization of the Programme and Adaptation Needs), each with a set of 4–10 specific questions to be asked to generate more nuanced descriptions of their experiences. Questions included for example ‘Do you think the Kids’ Club method meets the needs of your clients?’ ‘Is there anything about the Kids’ Club method that you feel hesitant about?’ ‘Do you think the Kids’ Club method is suitable for most parents and children in this situation?’ and ‘Do you see any obstacles to continuing to work with the method?’ The questions were individually formulated in communication with the individual group leader, and whether and in what order they were asked depended on how the mutual conversation developed. In addition, follow-up questions were formulated on the basis of what the individual group leader described. The interviews took 28–65 min. All interviews were recorded and later transcribed.

Process of analysis

The first step of the analysis was to code the entire interview material into the categories of (1) what aspects of the method hindered and favoured acceptance, (2) whether perceived needs for adaptation constitute a barrier to acceptance of the method, and (3) the conditions for implementation. In practice, this meant identifying all parts of interviews that on first impression appeared to represent different aspects of implementation experiences. The second step was to identify patterns within and connections between the content of these categories. This included reading through the entire interview material several times to identify and understand variations in the group leaders’ descriptions within each category and understand what signified the group leaders’ experiences of testing the Kids’ Club intervention. To do so, the interview material was divided into meaning units, which were condensed to abstract their underlying meaning in line with the process of directed content analysis (Hsieh & Shannon, 2005). One author did each step of the analysis and the other then verified the categories, patterns and findings.

The validity of the process and the outcome of the interpretation were strengthened by explicitly, frequently, and actively seeking out and addressing contradictions in each group leader's account so as to avoid, if possible, interpreting any account from a group leader in a way that contradicts what the same group leader had expressed elsewhere in the interview. Accounts contradicting the proposed interpretations and conclusions were used to stimulate alternative and more comprehensive interpretations (cf. Silverman, 2000).

In the results section of this paper, the findings of the analysis of the material as a whole are presented and illustrated with excerpts from the interviews.

Results

The analysis revealed that implementation relied on perceiving the method as somewhat flexible, certain cultural adaptations, and either high personal commitment or certain organizational requirements.

Acceptance of the method: its general features and flexibility

The interviewed Kids’ Club group leaders described their experience of working with the method in terms ranging from overwhelmingly positive to mainly positive, but also made concrete requests for modifications. All group leaders said that they believe the Kids’ Club to be a suitable method for most children who have experienced violence, but because children with certain types of neuropsychiatric difficulties, traumatization, violent behaviours or other issues can be difficult to assimilate into the group format, careful consideration should be given to whether Kids’ Club is what these children should be offered. Several group leaders emphasized, however, that these limitations are probably more related to the group format than to this specific method. On the other hand, the group format itself was believed by many of the group leaders to benefit the healing process of children and mothers, as it concretized for them that they are not alone in their experiences and feelings:

What permeates it somehow is ‘You’re not alone. Many of us here have gone through this and recognize this. And we all have our dilemmas and we’re all carrying this!’ (group leader 14)

An aspect of the Kids’ Club method that most group leaders said they particularly appreciated was that a common meal is followed by parallel groups for children and mothers:

I think there's an enormous benefit to meeting both the parent and child. (group leader 7)

Another trait that was perceived as a distinctive feature of the method and was much appreciated was that it was made clear that the reason for the group is violence, and that the violence was not the child's fault:

A particularly positive thing is that it’s the one who hits that is responsible […] that it’s never the child’s fault if adults use violence. (group leader 4)

The group leaders also thought that because the problem is violence, special attention should be given when putting a group together to the child's living situation, including how long ago in time the violence occurred and the child's relationship and amount of contact with the perpetrator.

Several group-leaders also indicated that violence can be particularly difficult to talk about and appreciated that the method gives mothers and children an opportunity to share their experiences if and how they want to, as well as making it possible for them to express their experiences and feelings in several ways, either verbally or for example by drawing:

You always have the option to say ‘pass’! You don't have to answer; you don't have to participate in the activities and do [things] if you don't want to. […] And I appreciate that! (group leader 5)

In addition, the fact that many group leaders had seen mothers and children appreciating the Kids’ Club groups also seemed to affect their own positive perceptions of the method:

Yes, we’ve been surprised; the children, have been positive, happy, they’ve come, except when they were ill, it’s happened that they were absent, but otherwise they’ve come, and have been proud [to be able to say]: ‘I’ve come every time!’ (group leader 11)

Altogether, the group leaders seemed generally willing to work according to the method in the Kids’ Club manuals: in groups, with parallel groups for children and mothers, and following the themes described in the manuals. However, the high acceptance also seemed linked to their perceiving the method as flexible to some degree. More precisely, the group leaders seemed to consider it positive that a specific methodology was described in the manual, but that it allowed for some flexibility:

You have the manual to work from, but things can turn out a bit different depending on the kids you get! […] Sometimes it was like a circus, but we managed somehow to stick to what we should do, or maybe not … Sometimes one might choose a new topic next time! And that's important, I think … I think it's important to have some flexibility with the kids, otherwise they’ll feel like: ‘Oh! Now we’re being forced to do this … ’ Discipline is a difficult issue! But I still think it's good to have the method and to stick to it more or less—the way the method is designed! (group leader 6)

Thus, the group leaders described a generally high acceptance of the method. This seems related both to some general features of the method and to its being perceived as somewhat flexible. The fact that many group leaders saw the method as flexible was also highly relevant for the findings related to the described needs for cultural adaptation of the method.

Needs for cultural adaptation: barriers and solutions related to time and time-outs

There are several aspects of the Kids’ Club method that group leaders emphasized they would like to change—or in fact had changed. Several felt that the session time was too short and that they were stressed by the need to keep up:

When you’ve had the manual and felt like ‘This is something we need to do. We really need to get to it today … ’, for example: ‘What tools do you have to use instead of fighting?’ And when you can’t make it work in the group because it’s too chaotic. You don’t have time to talk, you don’t have time to give them the tools that you should. It can be frustrating! And it’s hard! But then I think, it’s good that I have experience, and can fit it in another time when it’s calmer …  (group leader 17)

Other group leaders highlighted the positives of having limited time, both because it sticks to the method's ‘level’ of processing violent experiences and because the children probably could not cope with longer sessions. The original American version of the method allows 45 min for a session, not counting the initial group meal. One municipality has stuck to the manual fairly strictly, while the others have made some changes. One municipality received permission from the developer of the method to extend the group sessions by 15 min. However, variants with up to 90 min for the group session plus meal have been tried. In the interviews, the more experienced group leaders seem to experience less time pressure, and the time pressure appears to be more evident in the mother groups than the children groups.

Some specific contents of the method were also described as unsatisfactory. One group leader said that the manual should be supplemented by newer research and Swedish studies, others that up-to-date Swedish views on developmental psychology, safety, stress and gender roles should be included in the manual. Some also believed that security planning is not needed for some mothers, while others thought it requires considerably more time than is provided for in the manual. Thus, in these respects, the group leaders differed considerably in their wishes. Several highlighted however that clarifications in the manual would help them to prioritize, and would prevent pedagogical exercises from taking precedence over the group process.

One particular aspect of the method that many of the group leaders brought up as being unsatisfactory in the interviews is its view on child rearing. Several group leaders did not want to use the ‘time-outs’ suggested in the manual, but instead introduced a related theme, which they consider more in line with the Swedish approach to child rearing and child–parent relationships:

It’s about the time-outs, and about … […] And when it talks about child development, it felt quite square to me, the developmental psychology that’s presented …  (group leader 7)

They argue that the Swedish approach is characterized by a more equal child–parent relationship, in which the responsibility for children's behaviour to a large extent lies with the parent, and where ‘rewards’ for good behaviour should not be material, but should take the form of joint activities that demonstrate that the child and parent are mutually responsible for change and also that both can enjoy the improvement that has taken place.

In the mother groups in particular, the interviews revealed examples of both themes and elements that the group leaders said they had not taken up, such as the theme of child behavioural problems. Others had been modified, such as replacing the recommended time-outs with attachment theory, limiting the session about child development to the children's ages in the current group, and giving other examples of dangerous things than weapons and hurricanes.

Altogether, the interviews thus revealed a need and wish for cultural adaptation of the method to better suit Swedish social services settings. In some municipalities, these needs seemed to constitute barriers to full acceptance of the method, while in others, the perceived flexibility of the method had led to modifications in how it was implemented.

Conditions for implementation: organizational support and personal commitment

As previously mentioned, the Kids’ Club method was never implemented in one of the municipalities where group leaders had trained within the project. Thus, although the introduction of the method to the participating municipalities generally worked well and the method was well received, there were some difficulties with the practical implementation.

Some aspects of implementation mentioned in the interviews seem mainly related to the nature of the problem (i.e. violence) or the type of method (i.e. group-based with parallel groups for children and mothers) and hence are difficult to do anything about. For example, it was mentioned that sometimes a mother did not think her child needed an intervention, because the mother herself was too traumatized or exhausted to accurately judge her child's need for support. In other cases, parents thought they had protected the child, who therefore did not need support. Some also addressed the problem that according to the then-applicable Swedish law, treatment could only be given to a child if both custodians agreed to it, and some abused mothers would not bring the matter up with the child's father, who was the abuser. One concern that has to do with Kids’ Club's specific approach of parallel groups for children and mothers is that mothers who do not want to talk about their experiences thereby prevent the child from getting the group support. However, all of these conditions have to do mainly with decisions by the child's parents.

There were also examples of how the group format as such could be a barrier to implementation:

It can be difficult to arrange things so that families can participate, because they have other things going on. They have their handball training that day or soccer practice or dance. (group leader 5)

Scheduling conflicts between group sessions and children's activities are an example of the difficulties the group leaders faced when trying to put a group together. This appears to be a general kind of obstacle that would affect all types of group-based supportive interventions for children.

In the interviews, several group leaders pointed out that the age range in the children's group cannot be too large, and that it is challenging to put together a manageable group. Actually, recruiting enough children to get groups together was described as often dependent on contacts mediated by other units within the municipal social services:

We’re dependent on those in the building here, the investigators. Because I think it's, we can probably mostly recruit from our own organization, I think, because, alright the child psychiatry unit may find some, but they have to report it anyway, so you see, somehow when violence is involved it will go through the social services and be revealed …  (group leader 4)

The need to rely on other units to get in contact with enough families to put together manageable groups was thus obvious in the interviews.

In interviews several leaders also reflect on the criteria to use when putting together a group to talk about violence and the importance of having the right composition of children:

Something else I’ve thought about is recruitment and how to put the groups together as optimally as possible. Issues like this, which we might not have really solved yet, include at what point in the break-up process should people be, and how should visitation be organized and all that? It is a bit tricky, actually. (group leader 14)

Furthermore, although the descriptions of testing, offering and managing Kids’ Club support groups were positive overall, in the interview theme regarding the future of the method in the municipality it became obvious that specific conditions were important when implementing the method in the different municipalities. These conditions were described quite differently depending on how and by whom the method was first introduced in the municipality. Two of the municipalities in the study had already trained group leaders and started Kids’ Club groups before the research began, while the group leaders in the other two municipalities were introduced to the method and trained by the research team. In two of the municipalities, the intention expressed in the interviews at the end of the project was clearly to continue to provide the Kids’ Club after the research was completed. These were the same two municipalities that had begun offering Kids’ Club before the research started and that were instrumental in initially testing the method in Sweden. They consistently described receiving adequate support from their respective organizations. In addition, several group leaders gave the impression of having extraordinary personal commitment:

Of course it's always a bit problematic, how they should get here and how much to do, but maybe you just have to decide to do it, because they’ve been victimized, and they may have difficulties, and there's the question of money, and there are many such things … But you just have to make a decision … […] So I think it's good that it's been possible and has to be possible; that you might drive around gathering … […] There's been the church car, and there's been the social services’ car, and I’ve taken my own car. So, yes … I am a volunteer, you know! [Laughs]. (group leader 8)

In the other two municipalities, a condition for being able to train personnel in Kids’ Club and test it was that they were able to receive funds from the National Board of Health and Welfare to participate in the study. In these municipalities, group leaders expressed their personal readiness to lead more groups, but stressed that this depended on room being made for it within their job duties:

I can very well imagine continuing! But then when it comes to the practicalities, how it will be carried out in terms of work, and the tasks assigned to my unit, and if there’s a possibility …  (group leader 17)

Several group leaders also address the problem that many parent groups must be held in the evening, but they are not able to work any night of the week, and providing the groups means less time for them to do other things:

It always feels like you have to steal the time for children's activities somehow. None of us work solely with this; we have other tasks as well. I work as a family counselor for the most part and I have individual counseling using the Staircase-method,¹ uh, now we did this instead of individual counseling, so the kids we had who would have been offered individual counseling were offered Kids’ Club instead. (group leader 10)

Several group leaders in these municipalities explicitly believed that the question of whether to have more groups and how to prioritize what will be offered is a managerial issue:

We’ve actually asked that question of our managers here: is it possible for us to continue, and if it is possible, I can very well imagine doing so. (group leader 13)

In terms of barriers to practical implementation, everything seems to depend on other units—primarily within their organizational structure—being able to recruit groups of children exposed to violence. In addition, the high level of commitment of the previously trained group leaders seemed to outweigh most challenges, while the project-trained group leaders put forward some conditions for their continued participation. For them it was necessary that Kids’ Club groups were assigned to them by their manager, and that the obstacle of recruiting enough suitable children should be solved. This would ensure the groups are manageable and that management would not be able to criticize them for spending time on groups that obviously are not so desperately needed.

Discussion

The aim of the study was to examine Swedish social workers’ experiences of testing the Kids’ Club intervention for child and mother victims of IPV. The results indicate that (1) the social workers generally accepted the method, which was related both to some general features of the method and to their perceiving it as somewhat flexible; (2) according to the social workers, the method needs some cultural adaptation to better suit the Swedish social services setting and be fully accepted; and (3) they thought that implementation depended on an organizational structure that enabled enough children to be referred, as well as either high personal commitment or an organization that prioritized the method. Taken together, the results also indicate that if the municipality has not been self-driven in implementing the method and the group leaders are confident about making surface-structure adaptations, for groups to be formed the organization must prioritize the method and include the entire municipal social services in the implementation. One municipality not running the groups after staff being trained could also be a signal of the challenges of running groups that are not mandatory to the organization. One way in which researchers may address these challenges to help reduce the impact of IPV on children and mothers is to work with stakeholders to understand which outcomes are important to them (cf. Howarth et al., 2015).

On a general level, our results are in line with previous research that suggests that transferring interventions across cultural contexts is often paired with challenges and may require cultural adaptation to be fully accepted (cf. Ferrer-Wreder et al., 2012). In this respect, our results add to this field of research by indicating that this is true also when it comes to methods for helping child and mother victims of IPV.

Our finding that the social workers accepted the method because they perceived it as somewhat flexible constitutes a more novel contribution to the knowledge about implementation and raises questions about how structured manuals for intervention programmes aiming at helping victims of violence are, and how they should be, and about who is to judge what is a reasonable level of adaptation. Ferrer-Wreder et al. (2012) point out that while some models explicitly advocate that adaptation by definition involves changes to the surface structure of an intervention and not its deep structure, other models appear more open to changing the deep structure of an intervention, if empirical evidence indicates such a need. Thus, future studies of the Kids’ Club method in Sweden could benefit from combining exploration of different levels of adaptation with programme outcome. However, Petersén and Olsson (2015) caution against prioritizing a too narrow view of evidence at the cost of relevance to social work when aiming for relevant applied knowledge in social work and call this an evidence–relevance dilemma. Therefore, and because methods and techniques do not help people, but people help people, future studies of the Kids’ Club method could benefit from also exploring the value of the specific method's characteristics in relation to the group leaders’ warmth, empathy and judgment of specific situations in which the method's suggested content and process might need to be altered for the benefit of the individual child or mother. Future studies should also include the method's value-base and power relations (cf. Petersén & Olsson, 2015).

Limitations

Like many qualitative studies focussing on social work practice, this study has some methodological shortcomings. First, the sample was small, which limits the generalizability of the results. Second, the results rest on what the social workers expressed in the interviews. It is possible that they had forgotten some adaptations they made early in the process and/or did not want to convey to the researchers how they had dealt with method fidelity. Third, this study sheds no light on how the children or mothers experienced the programme and how it was put in practice by the Swedish social workers in the project. In particular, the results only reflect the group leaders’ descriptions of the intervention and its implementation, which say very little about whether children and mothers were helped by the groups. Fourth, in retrospect, it would have been valuable also to have interviewed the social workers in the municipality that was not able to organize groups. They could have provided important alternative information on the prerequisites for implementation. However, after taking these limitations into consideration, the study sheds light on an important and often neglected aspect of developing and spreading evidence-based methods, thereby raising important questions for future research and enabling social workers and administrators to more comprehensively understand the demands of providing evidence-based help to victims of violence.

Implications for social work and policy

One strength of the study lies in its possible value for the future development of support for children and mothers exposed to IPV. In particular, the results have some implications for social work practice with children exposed to IPV. Since participation in group work programmes have been found to impact positively on the relationship between mothers and their children who have experienced domestic abuse (Holt, Kirwan, & Ngo, 2015), and the programme studied here combines help for the parent with help for the child witness in such a way that have been found to enhance efficacy (cf. Rivett, Howarth, & Harold, 2006), it seems important to develop such programmes for best possible implementation. However, research is needed about the effectiveness of group work when compared to work with individuals, including which practice approach is the most suitable and effective when working with certain groups of people or specific types of problems after experiencing IPV (cf. Trevithick, 2005).

Based on the findings presented above, it appears that the manual may need some clarification to facilitate the continued implementation of the Kids’ Club programme in Sweden. First, the manual may need some general clarifications concerning cases where one should consider whether or not the method is suitable, the method's level of processing, and what things are necessary (e.g. the overriding goal) and what ones are optional (e.g. different techniques and handicraft activities). Clarification is also needed about how certain elements of the programme are supposed to help the children move towards a certain goal. Thus group leaders seem to find the Kids’ Club's overall aims and objectives, as well as the aims and objectives of each group session, to be good, but believe that the manual needs to be clarified regarding how the objectives will be achieved. They describe this as a mismatch between the target towards which the group is currently striving and the practical tasks that the manual describes; how the tasks are supposed to contribute to the goal remains unclear to them. The group leaders request more transparency in how the different optional exercises can contribute to the achieving the objectives of the group. In particular, they wanted some clarification of what exercises may be appropriate in group work with children of different ages. Group leaders seem to think that this would help them prioritize exercises in the manual in order to get the most important things done. Related to this, many also experienced difficulty keeping up with what the manual prescribes, but also claimed it becomes easier to prioritize as you become more experienced with the materials, themes and method.

Considering the difficulty of putting groups together revealed in this project, complementing the manual with some advice on how to put together groups that favour group processes, with particular focus on assembling a group of children who have experienced violence, may be helpful for group leaders. The manual could also better specify to what extent one may add collaborative exercises, the extent to which sessions can be extended and suggest alternative follow-up in case they want to continue the groups in some form after the Kids’ Club mission is completed.

When it comes to security planning, the developers of the programme and experienced group leaders in Sweden may need to discuss how to carry out such planning in accordance with current Swedish procedures and recommendations. Discussion may also be needed about the themes of behavioural problems, timeouts, and children's development and appropriate other examples of dangerous situations, snacks and relaxation exercises proposed. Thus, despite its limitations, the current study is important because it can stimulate further development of the method.

On a more general note, the results of the study indicate that American programmes cannot easily be imported to European settings without adaption, and that importing evidence-based group methods for helping children exposed to IPV to Sweden demands that consideration be given to the need for cultural adaption.

Finally, the study raises issues regarding who should ‘own’ the question of balancing method fidelity and cultural adaptation. For two of the municipalities, everything, including adaption, seemed easy; this may be because they took the original initiative themselves or because they had more experience of working with the method, or both. Either way, practitioners may benefit from dialogue and collaboration with researchers to jointly analyze what modifications can be made in the method and how extensive they can be, and to find an adequate balance between method fidelity and adaptation. This is because, even though this method was tested within the municipal social services with well-educated staff, when testing a method developed elsewhere it may be unclear what aspects of a particular method pertain to surface and deep structure respectively. It is therefore necessary that both researchers and practitioners recognize the benefits of collaboration and find well-functioning forms for it to take place.

Acknowledgements

This work was supported by the National Board of Health and Welfare in Sweden.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes on contributors

Åsa Källström is a Professor of Social Work at Örebro University, Sweden. She researches exposure to and experiences of victimization to violence and other forms of violations among children and young people and how family, friends and society can meet the children's and young people's needs of support.

Karin Grip has a PhD in psychology and is a licensed psychologist and psychotherapist at the department of psychology at the University of Gothenburg, Sweden. She has been involved in several projects concerning children exposed to Intimate partner violence and is also running a project concerning children to parents with psychosis.

ORCID

Åsa Källström http://orcid.org/0000-0002-4700-1452

Additional information

Funding

This work was supported by the National Board of Health and Welfare in Sweden.

Notes

1. The Staircase-method is a community-based intervention model for children exposed to IPV. In Sweden, individual counselling based on the Staircase model is the most common kind of intervention for children exposed to IPV. The model is described in a handbook and the intervention consists of individual sessions.