Improving access to mental health services for mothers involved in the child welfare system by closing the post-referral gap - Only about two-thirds of people who have mental health (MH) concerns initiate care after a referral is made, and less than a third attend enough sessions to see minimally adequate benefits. For mothers in the child welfare (CW) system living with serious MH conditions, this gap is particularly pronounced. Diminished access to MH services places CW-involved mothers at increased risk for poor functioning and their children at increased risk for child maltreatment. Improving access for CW-involved mothers improves their well-being and reduces risk for their children, thus, the proposed project is of great public health significance. The present study asserts that lack of access occurs for two key reasons – first, the majority of CW-involved mothers who need MH services are not referred for care and, second, even when they are referred, few actually begin services. In CW contexts, referral by a caseworker sets off a chain of events that should end in mothers’ initial use of MH services (hereafter known as the referral-access pipeline). The present application explores determinants of caseworker-driven referral as well as factors that impact the post-referral gap (i.e., the discontinuity in the referral access pipeline between referral and initial use of services). The proposed study is embedded within an ongoing two-arm randomized controlled trial (R01HD102528) that is testing the delivery of a MH intervention, Parenting-STAIR (PSTAIR), within 10 sites providing CW preventive services in New York City. The parent study offers an ideal venue within which mothers’ access to care can be studied, as the gulf between referral and initial use of MH services (the boundaries of the referral-access pipeline) is well-documented in this context. The referral-access pipeline will be explored from two vantage points: the perspectives of caseworkers (N=30) at each of the 10 preventive agency sites and the perspectives of mothers (N=32). The proposed study will utilize convergent mixed methods, including primary qualitative interview data and secondary quantitative data, to identify the individual and contextual factors that facilitate or impede progress along the referral-access pipeline for mothers in the context of the CW system. Coincidence analysis will be used for analyses and is a configurational comparative method that can be used for purposively sampled, small sample sizes. Data from primary semi- structured interviews and secondary survey data from the parent study will be analyzed. The outcomes in the proposed study are referral and initial use. The CNA approach integrates qualitative and quantitative data to understand how combinations of one or more factors may be needed for an outcome (here, referral rate and initial use) across cases. The proposed study answers a call put forward by the National Institute of Mental Health to engage stakeholders to better understand persistent issues related to accessing MH services. The applicant will complete advanced methods training, develop connections with MH services researchers, and build on a research agenda focused on transforming access to quality MH services for mothers affected by mental illnesses and their children who are at risk, promoting optimal outcomes across generations.
