Key implementation considerations

Matthew R Sanders, Ph.D

Parenting and Family Support Centre

The University of Queensland

Overview

• Lessons learned from the planning phase• Lessons learned about engaging parents• Lessons about training• Lessons learned about program management• Lessons learned about aids and obstacles to

program use• Lessons learned about working together

Determine the desired level of population reach

Use available epidemiological data to estimate required population reach

• Number of eligible children in catchment area

• Current population prevalence of target child problem/s

• Proportion of parents completing the program whose children have clinically elevated emotional and behavioural problems (P)

• From trial data the proportion of children with clinical emotional and behavioural problems who move to non-clinical after the intervention (M)

• Desired reduction in population prevalence (R)

PxM

R=

Importance of establishing clear population targets for parental participation

0

16.5

33

49.5

66

82.5

99

010

2030

4050

6070

8090

100

0 2.5 5 7.5 10 12.5 15

Desired reduction in population prevalence (%)

Nece

ssar

y po

pula

tion

reac

h (%

)

Lessons learned from the planning phase

• The need for an evaluation plan that informs the delivery and also reports on outcomes

• Recruitment of agencies and settings involved in service delivery

• Availability of trained providers to deliver programs

• The need to address organizational barriers such as perceptions of “core business” and where parenting programs fit within the framework of agencies agendas and priorities

• Ensuring sufficient personnel to plan and organise parenting seminars and groups

• The importance of group-based delivery• Importance of primary care

Lessons learned about engaging parents

• Creating a “new” tradition of preparation for parenthood

• The use of the media to increase public awareness of Triple P

• The importance of timing outreach efforts• Understanding the priorities and competing

demands of parents

Strongest predictors of participation in any parenting programN=4500

• Emotional or behavioural problems during last 6 months (OR = 1.75)

• Talked to a professional in past 12 months (OR = 2.46)

• Heard about Triple P (OR = 2.86)

How can reach be improved?

• Be inclusive, normalize and destigmatize parenting programs

• Listen to what parents say they want

• Use multiple access points and delivery contexts

• Adopt an ecological model to support parenting throughout the lifespan

How do parents prefer to receive parenting information

Lessons about training

Australia

New Zealand

Scotland

England

USA

Canada

Germany

The Netherlands

Switzerland

Iran

Hong Kong

Singapore

Japan

Importance of effective dissemination

• Substantial evidence that practitioners undertaking Triple P training courses report (Sanders et al, 2003a, 2003b; 2005; Shapiro et al, 2006)– High overall participant satisfaction – Increased practitioner self efficacy– Improved independently observed and self reported

parent consultation skills (Sanders et al, 2003).– Majority of practitioners regularly use the intervention

What do we know about these differences?

• Some practitioners fail to complete training or do not implement program after initial training

• Subsequent users are more likely to:– Have completed accreditation (Seng, Prinz &

Sanders, 2006)– Have greater line management support (Turner,

Nicholson & Sanders, 2005)– Identify fewer barriers to program implementation

(Seng et al, 2006)– Have higher self efficacy post training (Turner et al,

2006)

Lessons learned

• Program use and therefore population exposure is influenced by both workplace support and practitioner self efficacy and (Turner et al, under review)

• Organisational commitment appear to be essential (Not all organisations have the capacity to implement Triple P)

• Web based strategies are needed to provide further support to agencies and services using Triple P

Deliver some evidence based programs through the primary care sector

Professionals Trained

Education, 13%

Medical Profession ,

5%

Social Services, 9%

Mental Health, 20%

Primary Care, 49%

Allied Health, 4%

Level 4: Group Triple P

• Groups of 10-12 parents • Active skills training in small groups

• 8 session group program– 4 x 2 hour group sessions– 3 x 15-30 minute telephone sessions– Final group / telephone session options

• Supportive environment• Normalise parenting experiences

Effects of Group Triple P -Intervention community Zubrick, et al (2005)

0

10

20

30

40

50

60

EBCI PPC Marital

% i

n C

LIN

IAL

RA

NG

E

Pre Post FU-1YR FU-2YR (n=803)

Effects of Group Triple P-Control Community

0

5

10

15

20

25

30

35

ECBI PPC Marital

% I

N C

LIN

ICA

L R

AN

GE

Pre- Post- FU 1yr FU 2YR

(n=807)

0

5

10

15

20

Depression Stress

% in

Clin

ical

Ran

ge

PRE POST FU 1YR F 2YR

N=596

MOTHER ADJUSTMENT Intervention CommunityZubrick, et al (2005)

0

2

4

6

8

10

Depression Stress

% in

Clin

ical

Ran

ge

PRE POST FU 1YR FU 2YR

MOTHERS ADJUSTMENT Control Community

Effects of Group Triple P on child behavior-ECBI Intensity Scores

0

10

20

30

40

50

60

Original trial Replication trial

% i

n C

LIN

IAL

RA

NG

E

Pre Post FU-1YR FU-2YR

n=803

WA Trial South East Sydney trial

n=277

Lessons learned

• Trained primary care providers can achieve meaningful clinical outcomes with both group and individually administered parenting interventions

• Provide adequate pre-training preparation practitioners and managers

• Importance of post training support• Mainstream services so they become a core part

of the practitioners work

Dealing with cultural differences

What languages?

• Culturally sensitive translation of core materials

• Customise materials as needed (types of examples used, video models, images used to represent culture)

• Albanian• English • Portuguese• Dutch• German• Turkish• Farsi• Vietnamese• Mandarin• Japanese• Urdu (in progress)• French (in progress)• Malay (in progress)• Spanish (in progress)

Lessons learned

• Be respectful of cultural difference • Avoid assumptions of cultural homogeneity • Avoid subtle endorsement of cultural stereotypes• Look for shared cultural experiences relating to

raising children as well as differences• Allow clients to educate us about issues that

need to be attended to in their community

Indigenous Triple P

• Participation of Indigenous people at all levels of program development from beginning to completion

• Reducing barriers to accessing services

• Culturally informed practice• Culturally tailored version of Group

Triple P – 6 group sessions– 2 home sessions– Longer session length

Indigenous Triple P

60

70

80

90

100

110

120

130

140

150

160

Indigenous Triple P Controls

EC

BI

Sco

res

Pre Post Follow Up

Lessons learned about program management

• Having sufficient staff to manage a large scale roll out of Triple P

• Flexible provision of training• Managing differences in parental uptake across

catchment areas• The importance of support for trained service

providers• Building a local website

Lessons learned about aids and obstacles to program use

• Make training ongoing• Involve a wider range of community

organisations

Lessons learned about working together

• Determining who to involve • Developing a shared understanding between

key agencies

Conclusions

• Triple P requires a systems-contextual approach to work effectively

• Over time parent consumers voice becomes increasingly important