Original Article
Developing the eCPP: Adapting an Evidence-Based Parent Training Program for Digital Delivery in Primary Care Settings Susan M. Breitenstein, RN, PhD, PMHCNS-BC • James Shane, BS • Wrenetha Julion, RN, PhD • Deborah Gross, RN, DNSc, FAAN
ABSTRACT Keywords health promotion, health education, parenting, intervention adaptation, digital delivery, technology, intervention research
Background: Developing innovative delivery methods is needed to overcome time and logistic barriers to in-person participation in evidence-based parent training (PT) programs. Purpose: The purpose of this paper is to (a) describe the systematic process for adapting an evidence-based group PT program (the Chicago Parent Program) to a tablet-based delivery format, (b) present the adapted program, and (c) discuss opportunities and challenges of adapting evidence-based programs for alternative delivery methods. Methods: To ensure consistency with the original program and relevance to the intended program recipients, three groups—parents (n = 10), CPP developers (n = 3), and digital delivery experts—were engaged throughout the systematic steps of the delivery adaptation of the Chicago Parent Program (eCPP). Group meetings were used to identify the program’s core components, develop the adaptation program model, assess potential mismatches for the new delivery context, and adapt the original program model and materials. Results: The final eCPP is a six-module Internet-based intervention that includes: interactive activities, video examples and explanations of parenting strategies, reflection questions, assessment of parent knowledge with feedback, and module practice assignments. Linking Evidence to Action: Developing innovative delivery approaches for evidenced-based interventions are promising to increase intervention sustainability and participant access and engagement. It is critical that these adaptations are systematic and developed with expert consultation and community input.
BACKGROUND Emotional and behavioral problems affect 10–20% of children worldwide, are a common parental concern in primary care settings, and account for a large portion of children’s healthcare costs (Kieling et al., 2011; O’Connell, Boat, & Warner, 2009). Preventing these problems in children is a key initiative of the National Prevention Strategy of the United States Patient Protection and Affordable Care Act (ACA; 2010). For example, provisions in the ACA include expanded funding and integration of mental illness prevention in primary care settings. Evidence-based parent training (PT) programs aimed at improving emotional well-being by promoting early childhood development via positive parenting would now be supported or eligible for funding through the prevention and public health fund under the ACA. Parent training is a systematic approach to help parents change their behavior and communication with their children with the goal of increasing desirable child behaviors. Successful PT programs have been developed for delivery in face-to-face
Worldviews on Evidence-Based Nursing, 2015; 12:1, 31–40. C 2015 Sigma Theta Tau International
formats typically in eight to 14 sessions (Barlow, Smailagic, Ferriter, Bennett, & Jones 2010). These formats, however, are not compatible with structures and resources in primary care settings, where parents are likely to seek assistance. For example, routine well-child visits in primary care settings last an average of 8 min to 20 min (Halfon, Stevens, Larson, & Olson, 2011; Meadows, Valleley, Haack, Thorson, & Evans, 2011). Thus, providing parenting guidance to families struggling with their children’s emotional or behavioral problems is often not feasible for practitioners needing to address other issues (Meadows et al., 2011; Olson et al., 2004). Even basic parent education and counseling topics recommended by the American Pediatric Association (e.g., reading to children, nutrition, and injury prevention) are provided to only 25% of parents (Johnson & Millstein, 2003; Young & Boltri, 2005). Integrating a PT program within the set of provider responsibilities is a major challenge. Evidence-based PT interventions must be adapted for practical use in the primary care setting to efficiently and effectively help parents and promoting emotional and behavioral
31
Digital Adaption of a Parent Training Program
health in children. In this paper, we describe the systematic process for adapting a face-to-face evidence-based PT program, the Chicago Parent Program (CPP), to an Internet-based delivery model designed as an Android tablet application (we will refer to this deliver method as digital delivery) to make this PT program more accessible in primary care settings.
THE CHICAGO PARENT PROGRAM The CPP—designed to promote parenting competence and prevent behavioral problems—is a manualized communitybased program for parents of preschoolers (Gross, Garvey, Julion, & Fogg, 2007). The CPP was developed for ethnically diverse families with young children and is listed on the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry for Evidence-based Programs and Practices. We chose the CPP because it is effective with lowincome, ethnically diverse families (Breitenstein et al., 2012). This is a vulnerable population who have had less access to evidence-based mental health promotion programs and lower rates of participation (Garvey, Julion, Fogg, Kratovil, & Gross, 2006; Ingoldsby, 2010; Lyon & Budd, 2010). The CPP was designed using a face-to-face, group delivery method. Two-hour weekly sessions are led by two group leaders over 11 weeks, followed by a booster session (to support skill maintenance) approximately 4 to 6 weeks later (Gross et al., 2007). The CPP is organized by principles of Social Cognitive Theory (Bandura, 1997) and Coercion Theory (Patterson, 1982). Parents learn a range of strategies for using their behavior, words, affect, and attention for guiding and selectively reinforcing children’s behavior. The CPP is suitable for adaptation into a digital format because it uses multiple strategies to promote learning in parents that are amenable to digital media. The program materials are fully developed, including detailed manuals with session content, videos of narrator and parent-child interactions, and practice assignments. Preliminary tests using a two-session digital prototype of the CPP supported feasibility (Breitenstein & Gross, 2013).
ADAPTATION PROCESS Digital applications of evidence-based programs (EBPs) are feasible, innovative, and potentially cost-effective approaches to addressing the challenges of delivering PT in primary care settings (Breitenstein, Gross, & Christophersen, 2014). However, systematic and rigorous processes are needed to achieve equivalence. An adaptation of an EBP has been defined as “the process of modifying key characteristics of an intervention, recommended activities and delivery methods, without competing with or contradicting the core elements, theory, and internal logic of the intervention” (McKleroy et al., 2006 p. 62). Our adaptation was guided by the approach described by Card, Solomon, and Cunningham (2011). Steps included (a) identification of the program’s core components, (b) development of the model for delivery adaptation, (c) assessment of
32
potential mismatches between the original program delivery and materials and the new delivery context, and (d) adaptation of the original program delivery strategy and materials. Core components (sometimes called key or active ingredients) are the elements thought to be responsible for program effectiveness (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005). These components are considered essential for the program to work. Therefore, it is important that an adaptation from face-toface to digital delivery be consistent with the underlying theory of the original program, honor the core components of the program, and address the needs of the target population. The purpose of this paper is to (a) describe the systematic process for adapting an evidence-based group PT program (the CPP) for digital delivery, (b) present the adapted program, and (c) discuss opportunities and challenges of adapting EBPs for alternative delivery methods.
METHODS Design Three key stakeholder advisory groups were formed to elicit expert and community input to inform each step in the adaptation process (e.g., identification, development, assessment, and adaptation). The work of these advisory groups that included parents, CPP content experts, and multimedia experts is described below.
Advisory Group Members and Procedures Parent advisory group. Six African American and four Latino parent advisors were recruited from local Head Start centers. Because the CPP was developed and tested in low income, ethnic minority populations (Breitenstein et al., 2012; Gross et al., 2007), it was important to engage a group of parents from this population to ensure that the adaptation remained culturally and contextually relevant. Two-hour advisory meetings were conducted at a local Head Start center. Parents were provided dinner, free childcare, and a $20 gift card to compensate them for their time and expertise. Ten mothers participated; eight reported annual family incomes
Developing the eCPP: Adapting an Evidence-Based Parent Training Program for Digital Delivery in Primary Care Settings Susan M. Breitenstein, RN, PhD, PMHCNS-BC • James Shane, BS • Wrenetha Julion, RN, PhD • Deborah Gross, RN, DNSc, FAAN
ABSTRACT Keywords health promotion, health education, parenting, intervention adaptation, digital delivery, technology, intervention research
Background: Developing innovative delivery methods is needed to overcome time and logistic barriers to in-person participation in evidence-based parent training (PT) programs. Purpose: The purpose of this paper is to (a) describe the systematic process for adapting an evidence-based group PT program (the Chicago Parent Program) to a tablet-based delivery format, (b) present the adapted program, and (c) discuss opportunities and challenges of adapting evidence-based programs for alternative delivery methods. Methods: To ensure consistency with the original program and relevance to the intended program recipients, three groups—parents (n = 10), CPP developers (n = 3), and digital delivery experts—were engaged throughout the systematic steps of the delivery adaptation of the Chicago Parent Program (eCPP). Group meetings were used to identify the program’s core components, develop the adaptation program model, assess potential mismatches for the new delivery context, and adapt the original program model and materials. Results: The final eCPP is a six-module Internet-based intervention that includes: interactive activities, video examples and explanations of parenting strategies, reflection questions, assessment of parent knowledge with feedback, and module practice assignments. Linking Evidence to Action: Developing innovative delivery approaches for evidenced-based interventions are promising to increase intervention sustainability and participant access and engagement. It is critical that these adaptations are systematic and developed with expert consultation and community input.
BACKGROUND Emotional and behavioral problems affect 10–20% of children worldwide, are a common parental concern in primary care settings, and account for a large portion of children’s healthcare costs (Kieling et al., 2011; O’Connell, Boat, & Warner, 2009). Preventing these problems in children is a key initiative of the National Prevention Strategy of the United States Patient Protection and Affordable Care Act (ACA; 2010). For example, provisions in the ACA include expanded funding and integration of mental illness prevention in primary care settings. Evidence-based parent training (PT) programs aimed at improving emotional well-being by promoting early childhood development via positive parenting would now be supported or eligible for funding through the prevention and public health fund under the ACA. Parent training is a systematic approach to help parents change their behavior and communication with their children with the goal of increasing desirable child behaviors. Successful PT programs have been developed for delivery in face-to-face
Worldviews on Evidence-Based Nursing, 2015; 12:1, 31–40. C 2015 Sigma Theta Tau International
formats typically in eight to 14 sessions (Barlow, Smailagic, Ferriter, Bennett, & Jones 2010). These formats, however, are not compatible with structures and resources in primary care settings, where parents are likely to seek assistance. For example, routine well-child visits in primary care settings last an average of 8 min to 20 min (Halfon, Stevens, Larson, & Olson, 2011; Meadows, Valleley, Haack, Thorson, & Evans, 2011). Thus, providing parenting guidance to families struggling with their children’s emotional or behavioral problems is often not feasible for practitioners needing to address other issues (Meadows et al., 2011; Olson et al., 2004). Even basic parent education and counseling topics recommended by the American Pediatric Association (e.g., reading to children, nutrition, and injury prevention) are provided to only 25% of parents (Johnson & Millstein, 2003; Young & Boltri, 2005). Integrating a PT program within the set of provider responsibilities is a major challenge. Evidence-based PT interventions must be adapted for practical use in the primary care setting to efficiently and effectively help parents and promoting emotional and behavioral
31
Digital Adaption of a Parent Training Program
health in children. In this paper, we describe the systematic process for adapting a face-to-face evidence-based PT program, the Chicago Parent Program (CPP), to an Internet-based delivery model designed as an Android tablet application (we will refer to this deliver method as digital delivery) to make this PT program more accessible in primary care settings.
THE CHICAGO PARENT PROGRAM The CPP—designed to promote parenting competence and prevent behavioral problems—is a manualized communitybased program for parents of preschoolers (Gross, Garvey, Julion, & Fogg, 2007). The CPP was developed for ethnically diverse families with young children and is listed on the Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry for Evidence-based Programs and Practices. We chose the CPP because it is effective with lowincome, ethnically diverse families (Breitenstein et al., 2012). This is a vulnerable population who have had less access to evidence-based mental health promotion programs and lower rates of participation (Garvey, Julion, Fogg, Kratovil, & Gross, 2006; Ingoldsby, 2010; Lyon & Budd, 2010). The CPP was designed using a face-to-face, group delivery method. Two-hour weekly sessions are led by two group leaders over 11 weeks, followed by a booster session (to support skill maintenance) approximately 4 to 6 weeks later (Gross et al., 2007). The CPP is organized by principles of Social Cognitive Theory (Bandura, 1997) and Coercion Theory (Patterson, 1982). Parents learn a range of strategies for using their behavior, words, affect, and attention for guiding and selectively reinforcing children’s behavior. The CPP is suitable for adaptation into a digital format because it uses multiple strategies to promote learning in parents that are amenable to digital media. The program materials are fully developed, including detailed manuals with session content, videos of narrator and parent-child interactions, and practice assignments. Preliminary tests using a two-session digital prototype of the CPP supported feasibility (Breitenstein & Gross, 2013).
ADAPTATION PROCESS Digital applications of evidence-based programs (EBPs) are feasible, innovative, and potentially cost-effective approaches to addressing the challenges of delivering PT in primary care settings (Breitenstein, Gross, & Christophersen, 2014). However, systematic and rigorous processes are needed to achieve equivalence. An adaptation of an EBP has been defined as “the process of modifying key characteristics of an intervention, recommended activities and delivery methods, without competing with or contradicting the core elements, theory, and internal logic of the intervention” (McKleroy et al., 2006 p. 62). Our adaptation was guided by the approach described by Card, Solomon, and Cunningham (2011). Steps included (a) identification of the program’s core components, (b) development of the model for delivery adaptation, (c) assessment of
32
potential mismatches between the original program delivery and materials and the new delivery context, and (d) adaptation of the original program delivery strategy and materials. Core components (sometimes called key or active ingredients) are the elements thought to be responsible for program effectiveness (Fixsen, Naoom, Blase, Friedman, & Wallace, 2005). These components are considered essential for the program to work. Therefore, it is important that an adaptation from face-toface to digital delivery be consistent with the underlying theory of the original program, honor the core components of the program, and address the needs of the target population. The purpose of this paper is to (a) describe the systematic process for adapting an evidence-based group PT program (the CPP) for digital delivery, (b) present the adapted program, and (c) discuss opportunities and challenges of adapting EBPs for alternative delivery methods.
METHODS Design Three key stakeholder advisory groups were formed to elicit expert and community input to inform each step in the adaptation process (e.g., identification, development, assessment, and adaptation). The work of these advisory groups that included parents, CPP content experts, and multimedia experts is described below.
Advisory Group Members and Procedures Parent advisory group. Six African American and four Latino parent advisors were recruited from local Head Start centers. Because the CPP was developed and tested in low income, ethnic minority populations (Breitenstein et al., 2012; Gross et al., 2007), it was important to engage a group of parents from this population to ensure that the adaptation remained culturally and contextually relevant. Two-hour advisory meetings were conducted at a local Head Start center. Parents were provided dinner, free childcare, and a $20 gift card to compensate them for their time and expertise. Ten mothers participated; eight reported annual family incomes
