Parenting-Skills Program for HIV Prevention Among Thai Early Adolescents Warunee Fongkaew, RN, PhD Sue Turale, RN, DEd, FCNA, FACMHN Chutima Meechamnan, RN, PhD Key words: early adolescents, HIV prevention, parenting-skills program, participatory action research, Thailand
A
s in a number of other countries, Thailand continues to be confronted with concerning trends regarding the HIV epidemic among youth, due to a dramatic rise in adolescent sexual activity and high rates of risky sexual behavior over recent decades. For example, according to the Thailand AIDS Response Progress Report (Joint United Nations Programme on HIV/AIDS, 2012), data for 2010– 2011, compared to 2008–2009, indicated that young people had increased risky behaviors such as low condom use, having more than one sex partner, and initiating sexual intercourse at a younger age. Additionally, the number of young people ages 15– 24 years who were patients with sexually transmitted infections increased from 41.5 cases/100,000 population in 2005 to 79.8 cases/100,000 population in 2010 (Bureau of Epidemiology, 2012). This evidence indicates growing risk of HIV transmission among this population, and thus, prevention interventions are a priority to reduce HIV risk taking in Thai youth. Growing evidence highlights the importance of parents in prevention of HIV; however, few programs have been developed to increase parental monitoring regarding high-risk and protective behaviors. Most parental interventions have focused on parent–child communication about sexual topics and safer-sex behavior, which provide positive outcomes for sexual risk behaviors (Miller et al., 2010; Prado et al., 2007). Parents have reported having experiences of embarrassment, lack of accurate information, and poor communication skills contributing to their
difficulties in effective discussions about sexuality with their adolescent children (Ballard & Gross, 2009; Gallegos, Villarruel, Gomez, Onofre, & Zhou, 2007). Thai parents are expected to take responsibility for monitoring and providing sexual reproductive health education, despite the fact that few parents know how to handle these roles (Fongkaew et al., 2012), and even though some sexual education is provided in schools. Culturally, discussion of sexual issues between parents and children is rare, and Thai families cannot be seen as the primary resource of sexual information for adolescents (Sridawruang, Pfeil, & Crozier, 2010). Additionally, Thai parents may not be aware of adolescent sexual risk behaviors because children keep their sexual stories secret due to fear of being scolded, blamed, or punished by parents (Fongkaew et al., 2012). Parents need to overcome any barriers to talking about sexual issues and risky behaviors. They require assistance, training, and practice in communication skills to gain more understanding and skills; this will result in more effective protection from problem behaviors for their children (Rhucharoenpornpanich et al., 2010). However, it is essential that HIV prevention programs be structured on the basis of Thai cultural characteristics. In a previous article (Meechamnan, Warunee Fongkaew, RN, PhD, is a Professor, Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand. Sue Turale, RN, DEd, FCNA, FACMHN, is a Professor of International Nursing, Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand. Chutima Meechamnan, RN, PhD, is an Instructor, Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand.
JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 25, No. 6, November/December 2014, 664-669 http://dx.doi.org/10.1016/j.jana.2014.07.006 Copyright Ó 2014 Association of Nurses in AIDS Care
Fongkaew et al. / Parenting Skills for HIV Prevention Among Thai Adolescents
Fongkaew, Chotibang, & McGrath, 2014), findings from a Thai needs assessment indicated that adolescents did not dare to communicate about sex with their parents for fear of negative judgement, while parents (a) believed their children were too young to learn about sexual issues and HIV infection, and (b) required support to overcome communication barriers. Our aim here is to describe the development phase of the Collaborative Thai Parenting Program (CTPP) for HIV prevention in the Thai context and the feasibility of program implementation through pilot testing to strengthen parents’ capacities in parenting and communication skills with their children.
Method Our study used a qualitative approach and participatory action research (PAR). PAR is different from other public health research approaches because it is based on a cycle of reflection, data collection, and actions, and can be used to improve health and reduce health inequities (Baum, McDougall, & Smith, 2006). PAR was thought to be very appropriate for our study because it empowers people and involves them as research partners in actions to improve health and some other phenomena (Turale & Fongaew, 2014). In our
665
study, the research partners were parents who were empowered to develop skills to reduce HIV risk in their children. Research ethics approval was obtained from the Faculty of Nursing, Chiang Mai University, Thailand, and the high school where the study took place. Throughout all study processes, the participants’ rights were protected and we obtained informed consent. Program Development The CTPP was developed and pilot tested through five phases of a PAR process because PAR encourages participants to undertake actions to improve a situation (Stringer, 2007; see Figure 1). A core working group of nine parents, members of the Youth Family and School Network of a public school in Chiang Mai, committed themselves to program development with support from two teachers, school administrators, and the principal investigator. Through empowerment and raising awareness, PAR engaged parents in the CTPP processes of problem identification, planning, development, and finally, implementing the program. Moreover, PAR had the potential to create a sense of belonging among parent leaders so that they could sustain the program by disseminating it to other parents.
Figure 1. Participatory action research process for collaborative Thai parenting program.
666 JANAC Vol. 25, No. 6, November/December 2014
The Collaborative Thai Parenting Program (CTPP) The innovative CTPP aimed to support parental communication, supervision, and monitoring of adolescent children. Content was based on needs assessments of key stakeholders (30 parents, 10 teachers, and 67 early adolescents in the school community) using focus group discussions and group discussion using participatory activites. Four modules were delivered emphasizing parents’ understandings of: adolescent development; effective and appropriate parenting styles and practices, and positive parent-child relationships; the importance and quality of parent-adolescent communication; and their roles in HIV prevention through improved ability to effectively communicate with their adolescent children about sexual risk behaviors and HIV and AIDS, parent-child relationships, and parental monitoring. Specific content of the eight sessions is summarized in Table 1. The CTPP used participatory learning experiences and skills-building strategies to enhance parents’ capacities. Program activities included group discussions, skills building, games, and role playing. Parent leaders undertook teaching practice sessions in content development, learning the content, and sequencing program delivery to build confidence and skills in conducting effective interactive sessions. Table 1. Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8
Outline of Collaborative Thai Parenting Program Understanding adolescent development Understanding parenting styles Parent-adolescent communication: Being a good listener Parent-adolescent communication: Warning about the dangers Let’s talk about sex issues Growing up: A chaotic teenager Shielding to protect adolescents from HIV or AIDS How to keep track of teens: The great detection
Piloting of CTPP Twenty parents volunteered to participate in a pilot 1-day parent-training session in a school meeting room. Parent leaders obtained preintervention data and used participatory learning experiences and skills-building strategies to enhance parents’ capacities, such as group discussions, skill building, games, role playing, and video clips. The principal investigator assisted in group facilitation and process, and a booklet providing details about the content was distributed to parent participants after finishing the sessions. Postintervention data were obtained immediately after and 1 month after the intervention. Parents were asked to fill out the follow-up questionnaire and participate in focus group discussions to reflect on the parenting program. They suggested having a shorter booklet that was easier to read and understand, and making a series of short movies to deliver essential messages about adolescent HIV risk and parents’ roles in HIV prevention that could reach both parents and adolescents. These suggestions were accepted and added to the CTPP.
Results Refining and Revising the Program The booklet was revised by the parent leaders to be more precise, concise, and with attractive patterns. The content included: (a) basic knowledge of HIV, (b) why teens might engage in risky behavours, and (c) suggestions to protect teens from HIV (taking care of them with love and understanding, understanding adolescent development, initiating communication about HIV and prevention, and parent monitoring). Parent leaders initially wrote the video script and revised it after comments from a communication expert; they then participated in a series of workshops in video-making and received training to act in the video. The videos comprised a four-part series of three stories: (a) Teens are facing risk, aimed to increase parents’ awareness of sexual risks among teens; (b) It’s not too difficult to talk about sexual issues, aimed to improve parents’ abilities to effectively communicate with teens about sexual matters; (c) Teaching teens
Fongkaew et al. / Parenting Skills for HIV Prevention Among Thai Adolescents Table 2.
667
Comparisons of Mean Scores in the Knowledge about HIV, Parent-Adolescent Communication, and Parent Monitoring by Parents Before, Immediately After, and 1 Month After Using the Program (n 5 20) Mean Differences
Score on knowledge about HIV Before intervention Right after intervention At 1-month follow-up After implementing revised program Score on parent communication Before intervention Right after intervention At 1-month follow-up After implementing revised program Score on parent monitoring Before intervention Right after intervention At 1-month follow-up After implementing revised program
M
SD
Right After Intervention
1-Month Follow-up
After Implementing Revised Program
9.45 10.40 10.80 11.45
.55 .29 .26 .13
2.95 -
21.35 2.40 -
22.00* 21.05* 2.65* -
67.1 66.85 71.10 71.81
1.41 .77 1.18 .99
2.25 -
4.00* 4.25* -
4.70* 4.95* .70 -
35.05 36.25 39.25 40.45
.94 .92 .72 .59
1.20 -
4.20* 3.00* -
5.40* 4.20* 1.20* -
Note: *p , .01.
about HIV, presenting details of HIV prevention including parenting roles, styles, and monitoring; and (d) a television talk program, Small things can make a big difference, which recognized the influence of parents on risk behaviors and how they could play a critical role in HIV prevention. Piloting the Parenting Program The new version of the booklet and video clips were distributed to all 20 participants from the pilot parent-training session. One month later, they were asked to fill out the questionnaire and engage in two focus group discussions. We found that the mean score in knowledge of HIV, parent communication, and parent monitoring after implementing the revised program were higher than those at the baseline and right after intervention, at the statistical significance level of p 5 .01 (see Table 2). Findings from qualitative data also demonstrated changes among parents. Parents shared their experiences of being able to manage their emotions before initiating a conversation with their adolescents, using rational discussion, and setting rules regarding appropriate behaviors with their children. One mother said: Before joining the program, I got angry easily and always hit or kicked my son. After the pro-
gram, I calmed down, and can talk and discuss with reasons. I and my son make the rules together. If he breaks the rules, I can punish him. Some parents learned how to keep track of their children’s risky sexual behaviors. As one mother reported: ‘‘I check the condoms in his pocket or his wallet. If the condoms disappear, that means he used them.’’ In addition, parent trainers in the core working group mentioned they had to improve themselves before they passed on their knowledge and experiences to other parents. Moreover, they gained leadership development from conducting the parenting-skills program.
Discussion According to PAR, knowledge should be developed in collaboration with local expert knowledge and the voices of the ‘‘knowers.’’ Knowing is a product of people coming together to ‘‘share experiences through a dynamic process of action, reflection and collective investigation’’ (Gaventa & Cornwall, 2001, p. 70). PAR encourages those directly affected by the research problems to participate in the research process. In our study, the parent-skills program was developed in collaboration with parent leaders based on the needs
668 JANAC Vol. 25, No. 6, November/December 2014
and concerns of participants. The parenting-skills program developed was culturally appropriate and practical to the Thai family context and can help strengthen parenting skills, particularly communication and monitoring for HIV prevention among early adolescents. The details of each component of the program were adjusted according to the parent leaders’ reflections and suggestions through the process of program development and implementation. The details were similar to many studies designed to help parents become more confident and competent in communicating with and monitoring their children related to sex and sexuality (Lin, Chu, & Lin, 2006; Prado et al., 2007; Stanton et al., 2004). As a result of implementing the parent-skills program for HIV prevention with early adolescents, the parents joining the program implementation improved their knowledge of HIV, abilities to communicate with their children, and monitoring of teen behaviors. Our results were congruent with the parent training program developed by Lin et al. (2006), which trained parents about sex knowledge, self-efficacy in sexual education, communication effectiveness, and communication behavior. Other positive outcomes were changes in parent leaders in the core working group from program initation to evaluation. The parents improved their attitudes toward parenting skills, knowledge about HIV, leadership, and confidence in conducting the program. We believe these benefits came from the PAR approach, a research approach that acknowledges and ensures people’s equality of liberation, provision of freedom from oppressive conditions, life enhancement, and ensures the expression of people’s full human potential (Stringer, 2007). Parent leaders were encouraged to consider themselves as co-researchers, driving the study forward as a group of individuals with shared objectives and decision-making powers. They were empowered to create content and activities in the program by themselves and participated in training sessions to develop skills to become competent parent trainers, so they could disseminate the information and provide support and consultation to other parents. Providing an opportunity to be involved in program development, from the initial stages of planning through to the stages of evaluation, made this program successful and resulted in a sense of ownership of the program among the core working group.
Disclosures The authors report no real or perceived vested interests that relate to this article that could be construed as a conflict of interest. Study sponsors had no involvement in study designs, data collection/analysis, or manuscript preparation.
Acknowledgments We appreciate the contributions of all participants and the staff at KW school. The study was funded by the National Research University Project under Thailand’s Office of Higher Education Commission and Grant number wf62.
References Ballard, S. M., & Gross, K. H. (2009). Exploring parental perspectives on parent-child sexual communication. American Journal of Sexuality Education, 4, 40-57. http://dx.doi.org/ 10.1080/15546120902733141 Baum, F., MacDougal, C., & Smith, D. (2006). Participatory action research. Journal of Epidemiology & Community Health, 60(10), 854-857. http://dx.doi.org/10.1136/jech.2004.028662 Bureau of Epidemiology. (2012). HIV infection surveillance in Thailand 2011. Nonthaburi, Thailand: Division of Epidemiology, Ministry of Public Health. Fongkaew, W., Cupp, P. K., Miller, B. A., Atwood, K. A., Chamratrithirong, A., Rhucharoenpornpanich, O., . Byrnes, H. F. (2012). Do Thai parents really know about sexual risk-taking of their children: A qualitative study in Bangkok. Nursing and Health Sciences, 14, 391-397. http:// dx.doi.org/10.1111/j.1442-2018.2012.00703.x Gallegos, E. C., Villarruel, A. M., Gomez, M. V., Onofre, D. J., & Zhou, Y. (2007). Sexual communication and knowledge among Mexican parents and their adolescent children. Journal of the Association of Nurses in AIDS Care, 18(2), 28-34. http://dx.doi.org/10.1016/j.jana.2007.01.007 Gaventa, J., & Cornwall, A. (2001). Power and knowledge. In P. Reason, & H. Bradbury (Eds.), Handbook of action research: Participative inquiry and practice (pp. 70-80). London, England: Sage Publications. Joint United Nations Programme on HIV/AIDS. (2012). Report on the global AIDS epidemic. Retrieved from http://www. unaids.org/en/media/unaids/contentassets/documents/ epidemiology/2012/gr2012/20121120_UNAIDS_Global_ Report_2012_with_annexes_en.pdf Lin, Y., Chu, Y., & Lin, H. H. (2006). The study of the effectiveness on parental sexuality education. Education, 127(1), 16-30.
Fongkaew et al. / Parenting Skills for HIV Prevention Among Thai Adolescents Meechamnan, C., Fongkaew, W., Chotibang, J., & McGrath, B. B. (2014). Do Thai parents discuss sex and AIDS with young adolescents? A qualitative study. Nursing and Health Sciences, 16, 97-102. http://dx.doi.org/10.1111/ nhs.12072 Miller, K. S., Maxwell, K. D., Fasula, A. M., Parker, J. T., Zackery, S., & Wyckoff, S. C. (2010). Pre-risk HIVprevention paradigm shift: The feasibility and acceptability of the parents matter! Program in HIV risk communities. Public Health Reports, 125(Suppl. 1), 38-46. Prado, G., Pantin, H., Briones, E., Schwartz, S. J., Feaster, D., Huang, S., . Szapocznik, J. (2007). A randomized controlled trial of a parent-centered intervention in preventing substance use and HIV risk behaviors in Hispanic adolescents. Journal of Consulting and Clinical Psychology, 75(6), 914-926. http://dx.doi.org/10.1037/0022-006X.75.6.914 Rhucharoenpornpanich, O., Chamratrithirong, A., Fongkaew, W., Rosati, M. J., Miller, B. A., & Cupp, P. K. (2010). Parenting and child problem behaviors: A comparative study of sons and daughters in Thailand. Journal of the Medical Association of Thailand, 93(3), 293-300. Sridawruang, C., Pfeil, M., & Crozier, K. (2010). Why Thai parents do not discuss sex with their children: A qualitative study. Nursing and Health Sciences, 12, 437-443. http://dx. doi.org/10.1111/j.1442-2018.2010.00556.x Stanton, B., Cole, M., Galbraith, J., Li, X., Pendleton, S., Cottrel, L., . Kaljee, L. (2004). Randomized trial of a parent intervention: Parents can make a difference in long-term adolescent risk behaviors, perceptions, and knowledge. Archives of Pediatrics & Adolescent Medicine, 158, 947-955. http://dx.doi.org/10.1001/archpedi.158.10.947 Stringer, E. T. (2007). Action research (3rd ed.). Los Angeles, CA: Sage. Turale, S., & Fongkaew, W. (2014). Participatory action research: Some strategies for publication of findings. Pacific Rim Journal of International Nursing Research, 17(14), 304-307.
669
A
s in a number of other countries, Thailand continues to be confronted with concerning trends regarding the HIV epidemic among youth, due to a dramatic rise in adolescent sexual activity and high rates of risky sexual behavior over recent decades. For example, according to the Thailand AIDS Response Progress Report (Joint United Nations Programme on HIV/AIDS, 2012), data for 2010– 2011, compared to 2008–2009, indicated that young people had increased risky behaviors such as low condom use, having more than one sex partner, and initiating sexual intercourse at a younger age. Additionally, the number of young people ages 15– 24 years who were patients with sexually transmitted infections increased from 41.5 cases/100,000 population in 2005 to 79.8 cases/100,000 population in 2010 (Bureau of Epidemiology, 2012). This evidence indicates growing risk of HIV transmission among this population, and thus, prevention interventions are a priority to reduce HIV risk taking in Thai youth. Growing evidence highlights the importance of parents in prevention of HIV; however, few programs have been developed to increase parental monitoring regarding high-risk and protective behaviors. Most parental interventions have focused on parent–child communication about sexual topics and safer-sex behavior, which provide positive outcomes for sexual risk behaviors (Miller et al., 2010; Prado et al., 2007). Parents have reported having experiences of embarrassment, lack of accurate information, and poor communication skills contributing to their
difficulties in effective discussions about sexuality with their adolescent children (Ballard & Gross, 2009; Gallegos, Villarruel, Gomez, Onofre, & Zhou, 2007). Thai parents are expected to take responsibility for monitoring and providing sexual reproductive health education, despite the fact that few parents know how to handle these roles (Fongkaew et al., 2012), and even though some sexual education is provided in schools. Culturally, discussion of sexual issues between parents and children is rare, and Thai families cannot be seen as the primary resource of sexual information for adolescents (Sridawruang, Pfeil, & Crozier, 2010). Additionally, Thai parents may not be aware of adolescent sexual risk behaviors because children keep their sexual stories secret due to fear of being scolded, blamed, or punished by parents (Fongkaew et al., 2012). Parents need to overcome any barriers to talking about sexual issues and risky behaviors. They require assistance, training, and practice in communication skills to gain more understanding and skills; this will result in more effective protection from problem behaviors for their children (Rhucharoenpornpanich et al., 2010). However, it is essential that HIV prevention programs be structured on the basis of Thai cultural characteristics. In a previous article (Meechamnan, Warunee Fongkaew, RN, PhD, is a Professor, Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand. Sue Turale, RN, DEd, FCNA, FACMHN, is a Professor of International Nursing, Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand. Chutima Meechamnan, RN, PhD, is an Instructor, Faculty of Nursing, Chiang Mai University, Chiang Mai, Thailand.
JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 25, No. 6, November/December 2014, 664-669 http://dx.doi.org/10.1016/j.jana.2014.07.006 Copyright Ó 2014 Association of Nurses in AIDS Care
Fongkaew et al. / Parenting Skills for HIV Prevention Among Thai Adolescents
Fongkaew, Chotibang, & McGrath, 2014), findings from a Thai needs assessment indicated that adolescents did not dare to communicate about sex with their parents for fear of negative judgement, while parents (a) believed their children were too young to learn about sexual issues and HIV infection, and (b) required support to overcome communication barriers. Our aim here is to describe the development phase of the Collaborative Thai Parenting Program (CTPP) for HIV prevention in the Thai context and the feasibility of program implementation through pilot testing to strengthen parents’ capacities in parenting and communication skills with their children.
Method Our study used a qualitative approach and participatory action research (PAR). PAR is different from other public health research approaches because it is based on a cycle of reflection, data collection, and actions, and can be used to improve health and reduce health inequities (Baum, McDougall, & Smith, 2006). PAR was thought to be very appropriate for our study because it empowers people and involves them as research partners in actions to improve health and some other phenomena (Turale & Fongaew, 2014). In our
665
study, the research partners were parents who were empowered to develop skills to reduce HIV risk in their children. Research ethics approval was obtained from the Faculty of Nursing, Chiang Mai University, Thailand, and the high school where the study took place. Throughout all study processes, the participants’ rights were protected and we obtained informed consent. Program Development The CTPP was developed and pilot tested through five phases of a PAR process because PAR encourages participants to undertake actions to improve a situation (Stringer, 2007; see Figure 1). A core working group of nine parents, members of the Youth Family and School Network of a public school in Chiang Mai, committed themselves to program development with support from two teachers, school administrators, and the principal investigator. Through empowerment and raising awareness, PAR engaged parents in the CTPP processes of problem identification, planning, development, and finally, implementing the program. Moreover, PAR had the potential to create a sense of belonging among parent leaders so that they could sustain the program by disseminating it to other parents.
Figure 1. Participatory action research process for collaborative Thai parenting program.
666 JANAC Vol. 25, No. 6, November/December 2014
The Collaborative Thai Parenting Program (CTPP) The innovative CTPP aimed to support parental communication, supervision, and monitoring of adolescent children. Content was based on needs assessments of key stakeholders (30 parents, 10 teachers, and 67 early adolescents in the school community) using focus group discussions and group discussion using participatory activites. Four modules were delivered emphasizing parents’ understandings of: adolescent development; effective and appropriate parenting styles and practices, and positive parent-child relationships; the importance and quality of parent-adolescent communication; and their roles in HIV prevention through improved ability to effectively communicate with their adolescent children about sexual risk behaviors and HIV and AIDS, parent-child relationships, and parental monitoring. Specific content of the eight sessions is summarized in Table 1. The CTPP used participatory learning experiences and skills-building strategies to enhance parents’ capacities. Program activities included group discussions, skills building, games, and role playing. Parent leaders undertook teaching practice sessions in content development, learning the content, and sequencing program delivery to build confidence and skills in conducting effective interactive sessions. Table 1. Session 1 Session 2 Session 3 Session 4 Session 5 Session 6 Session 7 Session 8
Outline of Collaborative Thai Parenting Program Understanding adolescent development Understanding parenting styles Parent-adolescent communication: Being a good listener Parent-adolescent communication: Warning about the dangers Let’s talk about sex issues Growing up: A chaotic teenager Shielding to protect adolescents from HIV or AIDS How to keep track of teens: The great detection
Piloting of CTPP Twenty parents volunteered to participate in a pilot 1-day parent-training session in a school meeting room. Parent leaders obtained preintervention data and used participatory learning experiences and skills-building strategies to enhance parents’ capacities, such as group discussions, skill building, games, role playing, and video clips. The principal investigator assisted in group facilitation and process, and a booklet providing details about the content was distributed to parent participants after finishing the sessions. Postintervention data were obtained immediately after and 1 month after the intervention. Parents were asked to fill out the follow-up questionnaire and participate in focus group discussions to reflect on the parenting program. They suggested having a shorter booklet that was easier to read and understand, and making a series of short movies to deliver essential messages about adolescent HIV risk and parents’ roles in HIV prevention that could reach both parents and adolescents. These suggestions were accepted and added to the CTPP.
Results Refining and Revising the Program The booklet was revised by the parent leaders to be more precise, concise, and with attractive patterns. The content included: (a) basic knowledge of HIV, (b) why teens might engage in risky behavours, and (c) suggestions to protect teens from HIV (taking care of them with love and understanding, understanding adolescent development, initiating communication about HIV and prevention, and parent monitoring). Parent leaders initially wrote the video script and revised it after comments from a communication expert; they then participated in a series of workshops in video-making and received training to act in the video. The videos comprised a four-part series of three stories: (a) Teens are facing risk, aimed to increase parents’ awareness of sexual risks among teens; (b) It’s not too difficult to talk about sexual issues, aimed to improve parents’ abilities to effectively communicate with teens about sexual matters; (c) Teaching teens
Fongkaew et al. / Parenting Skills for HIV Prevention Among Thai Adolescents Table 2.
667
Comparisons of Mean Scores in the Knowledge about HIV, Parent-Adolescent Communication, and Parent Monitoring by Parents Before, Immediately After, and 1 Month After Using the Program (n 5 20) Mean Differences
Score on knowledge about HIV Before intervention Right after intervention At 1-month follow-up After implementing revised program Score on parent communication Before intervention Right after intervention At 1-month follow-up After implementing revised program Score on parent monitoring Before intervention Right after intervention At 1-month follow-up After implementing revised program
M
SD
Right After Intervention
1-Month Follow-up
After Implementing Revised Program
9.45 10.40 10.80 11.45
.55 .29 .26 .13
2.95 -
21.35 2.40 -
22.00* 21.05* 2.65* -
67.1 66.85 71.10 71.81
1.41 .77 1.18 .99
2.25 -
4.00* 4.25* -
4.70* 4.95* .70 -
35.05 36.25 39.25 40.45
.94 .92 .72 .59
1.20 -
4.20* 3.00* -
5.40* 4.20* 1.20* -
Note: *p , .01.
about HIV, presenting details of HIV prevention including parenting roles, styles, and monitoring; and (d) a television talk program, Small things can make a big difference, which recognized the influence of parents on risk behaviors and how they could play a critical role in HIV prevention. Piloting the Parenting Program The new version of the booklet and video clips were distributed to all 20 participants from the pilot parent-training session. One month later, they were asked to fill out the questionnaire and engage in two focus group discussions. We found that the mean score in knowledge of HIV, parent communication, and parent monitoring after implementing the revised program were higher than those at the baseline and right after intervention, at the statistical significance level of p 5 .01 (see Table 2). Findings from qualitative data also demonstrated changes among parents. Parents shared their experiences of being able to manage their emotions before initiating a conversation with their adolescents, using rational discussion, and setting rules regarding appropriate behaviors with their children. One mother said: Before joining the program, I got angry easily and always hit or kicked my son. After the pro-
gram, I calmed down, and can talk and discuss with reasons. I and my son make the rules together. If he breaks the rules, I can punish him. Some parents learned how to keep track of their children’s risky sexual behaviors. As one mother reported: ‘‘I check the condoms in his pocket or his wallet. If the condoms disappear, that means he used them.’’ In addition, parent trainers in the core working group mentioned they had to improve themselves before they passed on their knowledge and experiences to other parents. Moreover, they gained leadership development from conducting the parenting-skills program.
Discussion According to PAR, knowledge should be developed in collaboration with local expert knowledge and the voices of the ‘‘knowers.’’ Knowing is a product of people coming together to ‘‘share experiences through a dynamic process of action, reflection and collective investigation’’ (Gaventa & Cornwall, 2001, p. 70). PAR encourages those directly affected by the research problems to participate in the research process. In our study, the parent-skills program was developed in collaboration with parent leaders based on the needs
668 JANAC Vol. 25, No. 6, November/December 2014
and concerns of participants. The parenting-skills program developed was culturally appropriate and practical to the Thai family context and can help strengthen parenting skills, particularly communication and monitoring for HIV prevention among early adolescents. The details of each component of the program were adjusted according to the parent leaders’ reflections and suggestions through the process of program development and implementation. The details were similar to many studies designed to help parents become more confident and competent in communicating with and monitoring their children related to sex and sexuality (Lin, Chu, & Lin, 2006; Prado et al., 2007; Stanton et al., 2004). As a result of implementing the parent-skills program for HIV prevention with early adolescents, the parents joining the program implementation improved their knowledge of HIV, abilities to communicate with their children, and monitoring of teen behaviors. Our results were congruent with the parent training program developed by Lin et al. (2006), which trained parents about sex knowledge, self-efficacy in sexual education, communication effectiveness, and communication behavior. Other positive outcomes were changes in parent leaders in the core working group from program initation to evaluation. The parents improved their attitudes toward parenting skills, knowledge about HIV, leadership, and confidence in conducting the program. We believe these benefits came from the PAR approach, a research approach that acknowledges and ensures people’s equality of liberation, provision of freedom from oppressive conditions, life enhancement, and ensures the expression of people’s full human potential (Stringer, 2007). Parent leaders were encouraged to consider themselves as co-researchers, driving the study forward as a group of individuals with shared objectives and decision-making powers. They were empowered to create content and activities in the program by themselves and participated in training sessions to develop skills to become competent parent trainers, so they could disseminate the information and provide support and consultation to other parents. Providing an opportunity to be involved in program development, from the initial stages of planning through to the stages of evaluation, made this program successful and resulted in a sense of ownership of the program among the core working group.
Disclosures The authors report no real or perceived vested interests that relate to this article that could be construed as a conflict of interest. Study sponsors had no involvement in study designs, data collection/analysis, or manuscript preparation.
Acknowledgments We appreciate the contributions of all participants and the staff at KW school. The study was funded by the National Research University Project under Thailand’s Office of Higher Education Commission and Grant number wf62.
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