Background
Foster care children and youth are among the most vulnerable populations in the U.S. (Farruggia & Sorkin, 2009). Foster youth are at particularly high risk for sexual risk taking, adolescent pregnancy, and early childbearing (Carpenter et al., 2001; Courtney & Dworsky, 2006; Dworsky & Courtney, 2010; James et al., 2009; Risley-Curtiss, 1997). They lack connections to trusted and knowledgeable adults with whom they can discuss sexual health issues (Constantine et al., 2009; Haight et al., 2009; Love et al., 2005). Studies with child welfare staff, foster parents and caregivers, and foster youth increasingly suggest the importance of establishing clear and consistent policies and procedures (Boonstra, 2011; Collins et al., 2007; Constantine et al., 2009; Love et al., 2005). The applicability and feasibility of such policies has not been documented in the literature. The present study examines the content and context of sexual and reproductive health policies for foster youth in California to assess the potential applicability of policy implementation across the state.
Methods
Santa Clara County case study of policy formation and implementation: An in-depth case study of the policy formation process and history, implementation status and policy stakeholder experiences was conducted in Santa Clara County (SCC), a county with a known sexual and reproductive health policy for foster youth. Key informant interviews were conducted with county experts knowledgeable about health and social policies related to foster youth sexual and reproductive health. Snowball sampling was used to maximize the range of key perspectives and specialties. A theoretical framework for the policymaking was used to examine policy formation and implementation. A total of nine individuals participated in the interviews, representing six agencies and organizations. Supplemental documents relevant to the policy process were obtained from study participants and qualitatively analyzed along with the expert interviews.
Statewide assessment of existing policies and procedures: Child welfare professionals from a sample of counties participated in a web-based survey to assess current policies and procedures, and in brief expert interviews to examine policy practices. A document review of publically available policy documents was conducted for the sampled counties to identify and examine existing policies and procedures. Representatives from 17 counties participated in the survey and interviews; two formal policy documents were reviewed and summarized.
Qualitative analysis: Qualitative analysis was conducted using NVivo© software to input, organize and code data. Manual transcript-based theme analysis was subsequently conducted, using a process of inductive highlighting and coding of relevant themes for each broad topic area or general theme (Bertrand et al., 1992; Fonteyn et al., 2008; Krueger, 1994), and exemplary quotes identified.
Results
Santa Clara County case study
Participating stakeholders recognized the key issues and implications of early pregnancy and childbearing among foster youth. Stakeholders also identified attainable solutions to address youth needs. Solutions included 1) the judges‘ roles as leaders and conveners, 2) the active involvement of multiple stakeholders in developing and implementing a sexual and reproductive health policy for youth, and 3) the central role of child welfare staff and social workers in addressing the sexual and reproductive health issues and needs of foster youth. Finally, the political conditions were primed for addressing this issue as demonstrated by the involvement of key national organizations in increasing awareness about the unique needs of court involved youth and highlighting the unique role of juvenile court judges. The juvenile court judges functioned as highly influential policy entrepreneurs involved in the policy process. They brought legitimacy to this issue, and helped push this issue to a local policy agenda.
The implementation activities described in this case study demonstrate key aspects of both the top-down bottom-up approaches to policy implementation (Hjern, 1982; Sabatier, 1986). The early implementation process denotes strong top-down influence, as policy decision makers were influential in developing and mandating adherence to a new policy for foster youth. However, the implementation process described in this case study largely demonstrates a bottom-up approach. There was wide discretion in terms of how individual social workers interpreted and carried out the policy mandates, and there were no established measures to monitor and assess implementation.
Statewide assessment
This assessment demonstrates that while child health professionals are aware of multiple sources of information, support and services for foster youth, few counties have formal policies and procedures outlining and mandating the resources that youth receive. Referrals to external services and support and conversations with social workers were the most commonly cited resource for providing youth with sexual and reproductive health information. Several study participants noted that resources for foster youth are delivered on a case-by-case basis.
Across counties, there was widespread recognition that the issues associated with youth sexual and reproductive health were significant and problematic for youth and child welfare staff. Social workers were perceived to be uncomfortable and inadequately training to address these issues with foster youth. Possible identified policy solutions included: 1) collaborative partnerships with public health nurses to deliver resources and support to both youth and social workers; and 2) use of social workers from specialized adolescents units to address these needs. However, the presence of collaborations with public health nurses and specialized adolescent units were cited by few counties; leaving most counties to rely on optional and periodic involvement in ILP workshops, and infrequent and inconsistent discussions with social workers.
Several study participants cited the need for child welfare administrators to prioritize and mandate that social workers address youths‘ sexual and reproductive health needs. Given competing mandates and numerous work force demands, some child welfare staff believed that it would be difficult to make this a priority without administrative mandates. Furthermore, most study participants believed that the youth, social workers and foster parents/caregivers in their county would benefit from a formal policy. Nonetheless, policy formation had only occurred in one of the sampled counties (Los Angeles). The missing policy element may have been an unsuitable political context. Only two counties cited conditions or factors indicative of political support; involvement and influence from external advocacy organizations in raising awareness about foster youths‘ sexual and reproductive health needs.
Conclusion
The Santa Clara County (SCC) case study demonstrates the feasibility of policy reform given the presence and alignment of necessary policy streams. The policy process in SCC suggests the importance of sufficient problem recognition, identification of feasible policy solutions, and an amenable political environment. Two juvenile justice judges functioned as influential policy entrepreneurs, effectively bringing greater prioritization to this issue and promoting agenda setting. While the juvenile judges were key actors in the SCC policy process, there is evidence from the statewide assessment that actors from other policy venues can be influential in establishing problem definition and promoting agenda setting. However, this case study shows that formal policies cannot, by themselves, produce changes at the street level and that the implementation process is not easy and needs to be supported with ample resources and involvement of committed stakeholders. These findings are supported by the implementation literature that proposes that policy change is only a necessary first step in a longer process of creating new roles and practices.
However, the question remains as to whether or not policy formation is sufficient solution given the lack of evidence demonstrating the success policy implementation and a substantive impact on youth outcomes. Though there is evidence from this study indicating that child welfare staff need a policy mandate to change current practices, additional evidence is needed to substantiate the content of these policies and the degree to which they should be implemented across various county settings. As such, it is necessary to develop comprehensive data tracking and monitoring systems that will provide a greater understanding of the scope of unplanned pregnancies, live births, parenting, adoptions, abortions, and sexually transmitted infections among young women and men in foster care. The availability of outcome data also has the potential to provide additional evidence and new problem framing around this issue that can be helpful to future policy entrepreneurs interested in promoting agenda setting and policy change. Additionally, without such established monitoring systems it will be difficult for county stakeholders to critically assess youth needs, and evaluate the impact of specific policies and procedures.
