Kerry Littlewood. University of South Florida ... best way to adapt EBP to fit their needs. In this article, the ... East Carolina University, Greenville, NC 27858 (bal-.
Sharon M. Ballard, Lisa E. Tyndall, Eboni J. Baugh, and Carrie Bumgarner Bergeson East Carolina University Kerry Littlewood
University of South Florida
Framework for Best Practices in Family Life Education: A Case Example
Evidence-based programming (EBP) in family life education is in high demand because it has a higher likelihood of achieving desired outcomes than non-evidence-based programming. Although EBP can promote program sustainability and fidelity, the implementation of EBP in real-world settings can be challenging. Practitioners sometimes struggle with identifying the best way to adapt EBP to fit their needs. In this article, the Positive Parenting Program (Triple P) is used to provide an in-depth case example of adapting and implementing EBP through the lens of Ballard and Taylor’s (2012) Framework for Best Practices in Family Life Education. The authors outline framework elements that guided this adaptation, such as consideration of context and culture, program content and format, program design, and the role of the family life educator. Suggestions are provided for employing this framework to overcome barriers to implementation and ultimately increase program sustainability to improve the lives of families. Family life education is programming designed to enrich and strengthen family well-being (Arcus, Department of Human Development and Family Science, East Carolina University, Greenville, NC 27858 (ballards@ecu.edu). Key Words: Best practices in family life education, evidencebased programming, family life education, implementation science, program adaptation, Triple P Positive Parenting Program.
1992). As such, family life educators have a primary goal of helping families build knowledge and skills to facilitate optimal family functioning (Myers-Walls, Ballard, Darling, & Myers-Bowman, 2011). Like other domains of family practice, there is increasing demand for the use of evidence-based family life education programs (Small, Cooney, & O’Connor, 2009). Evidence-based programming (EBP) has been shown through rigorous, peer-reviewed evaluation to be effective in achieving desired outcomes (Small et al., 2009). EBP includes core components that are necessary for a program to effectively achieve its intended outcomes (Blase & Fixsen, 2013). These core components, which are based in theory and research, can include learning strategies, activities, content, or other programming features such as dosage (e.g., number and length of sessions). Program fidelity is often determined by assessing adherence to the core components established for a particular program. There are various ways of identifying and indexing EBP. One example is the Substance Abuse and Mental Health Services Administration’s (SAMHSA, 2015) National Registry of Evidence-Based Programs and Practices, which has outlined four dimensions by which programs are rated in order to be considered evidence based: methodological rigor, effect size, program fidelity, and conceptual framework. Family life educators and other practitioners often feel pressure to use EBP (Fratello, Kapur,
Family Relations (2016) DOI:10.1111/fare.12200
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2 & Chasan, 2013), and they recognize that selecting EBP rather than developing or selecting a program with minimal evidence reduces the risk of the program failing. There is an assumption that if the EBP is implemented as it was designed (i.e., with fidelity), it will achieve the desired results. Although this increased chance of success and credibility is attractive to funders and other stakeholders (Small et al., 2009), available EBP may not meet the needs of the audience, be a philosophical fit for the educator, or align with the mission of the educator’s agency or organization. There can also be variability in the implementation of EBP, which may compromise fidelity and, in turn, program outcomes (Fagan, Hanson, Hawkins, & Arthur, 2008; Moore, Bumbarger, & Cooper, 2013). Several dynamic factors affect program implementation. One primary factor affecting implementation is the program facilitator. Despite the ill-informed perception that anyone can be trained to implement EBP effectively, implementation with a skilled family life educator or practitioner is important. Berkel, Mauricio, Schoenfelder, and Sandler (2011) identified quality of delivery, fidelity, participant responsiveness, and program adaptation as four additional factors that affect implementation. Three of these are directly related to the practitioner, and it could be argued that participant responsiveness is related to quality of delivery as well (e.g., how well the activities are carried out, how well the material is conveyed to the participants). Practitioners must be able to gain the trust of their audiences, effectively recruit participants to attend program sessions, and negotiate other implementation factors such as organizational capacity (Durlak & DuPre, 2008) for the program to have the most impact. Implementation science is a growing area of research that focuses on the processes and contextual factors that affect the implementation of evidence-based programs (Berwick, 2003; Fixsen, Naoom, Blase, Friedman, & Wallace, 2005; Moore et al., 2013). Specifically, implementation science is the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and hence, to improve the quality and effectiveness of services (Eccles & Mittman, 2006). Implementation science includes many factors of effective programming, such as fidelity and program delivery (see
Family Relations Durlak & DuPre, 2008, for a review of research on implementation). A key area of implementation science that is important to this article is program adaptation. Adaptation of EBP is very common, and it is important that adaptations maximize the benefits of using EBP and maintain a high level of fidelity (Moore et al., 2013). Practitioners often need to balance reactive and proactive adaptations. Reactive adaptations (changes made to the program during implementation to accommodate any challenges that arise) are more common than proactive adaptation (planned and intentional changes made before implementation; Moore et al., 2013). Proactive, intentional, and well-planned adaptations may ensure cultural relevance or increase attendance and thereby improve program effectiveness (Moore et al., 2013). Yet reactive adaptations may be necessary to ensure that participant needs are being met or that program fidelity is being maintained when unexpected situations arise. Ballard and Taylor’s (2012) Framework for Best Practices in Family Life Education provides a comprehensive view of programs, including the various implementation factors, and is a useful tool for making proactive program adaptations. The purpose of the present article is to provide a case example in which we illustrate the process of adapting and implementing EBP using the Framework for Best Practices in Family Life Education as a guide. The EBP used in this case example is the Triple P—Positive Parenting Program (Triple P; Sanders, 1999). We adapted, implemented, and evaluated Level 3 of Triple P (see Baugh, Ballard, Tyndall, Littlewood, & Nolan, 2015, for a full description of the implementation evaluation). We first describe each component of the Framework for Best Practices in Family Life Education. Second, we describe the basic components of Triple P. Third, we provide detail on how we adapted Triple P for use in a university workplace setting using the framework as a guide. Finally, we discuss implications and lessons learned to offer ideas for future directions and application of this work to other evidence-based child and family programs. Framework for Best Practices in Family Life Education Ballard and Taylor’s (2012) Framework for Best Practices in Family Life Education includes
Framework for Best Practices FIGURE 1. Framework for Best Practices in Family Life Education.
Culture
The Family Life Educator
Program Content
Program Design
Strengths and Needs of Population
three primary components: (a) program content, (b) program design, and (c) the family life educator—all of which are set in the context of culture and the strengths and needs of the population (see Figure 1). The framework was designed to illustrate the idea of best practices as a “combination of empirically supported content and program design along with experiences and skills of the family life educator” (Ballard & Taylor, 2012, p. 5) and was originally applied to family life education programming with diverse populations. The purpose of the framework is to illustrate the key components of family life education programs and to allow family life educators the opportunity to identify best practices for use in their own programming within each of these components. Overview of Triple P Parenting Program Triple P is an evidence-based parenting intervention to prevent child behavior problems through increasing parental knowledge, ability, and self-efficacy (Sanders, 1999). Developed in Australia, Triple P has been tested using randomized control trials and was developed as an evidence-based program using more than 30 years of research (Sanders, 2012). In an effort to address the diverse needs of parents and children, Triple P uses a systemic information dissemination approach, consisting of five levels of intervention with increasing intensity: Level 1 (universal) is a media and promotional
3 information strategy, Level 2 (selected) provides brief guidance for parents through a series of three seminars, Level 3 (primary care) is appropriate for mild to moderate child behavior problems and is typically delivered one-on-one with parents, Level 4 (standard) is intense parent training for severe behavioral difficulties and can be delivered in a group format, and Level 5 (enhanced) is an intense intervention to address parenting difficulties accompanied by other areas of family distress (Sanders, 2012). Regardless of the level, there are a variety of Triple P materials available to assist in implementation, including “tip sheets,” which are concise information sheets providing key information to parents on a single parenting challenge (e.g., temper tantrums). Researchers have demonstrated that Triple P reduces child behavioral problems at home and at school by increasing parental confidence and efficacy and by decreasing perceived stress in the parental role (Sanders, Turner, & Markie-Dadds, 2002). In a meta-analysis of studies evaluating Triple P, Nowak and Heinrichs (2008) found that the comprehensive nature and flexibility of the intervention provided a statistically positive influence on the parent–child relationship for families from a wide variety of socioeconomic and cultural backgrounds and dealing with a range of behavioral problems. In addition, Triple P has demonstrated effectiveness in the larger community by reducing the rate of authenticated cases of child maltreatment, foster care placements, and maltreatment-related injuries (Prinz, Sanders, Shapiro, Whitaker, & Lutzker, 2009). For the purpose of this case example, Level 3 of Triple P was delivered in a university workplace setting to illustrate the utility of the framework in adapting and implementing an evidence-based program. Level 3, also known as Primary Care Triple P, is a brief intervention designed to help parents with specific parenting concerns regarding distinct child behavior problems using at least three face-to-face sessions and a follow-up session conducted either face-to-face or via telephone (Sanders, 2012). This level was chosen because it can be delivered within a short time period, which is highly applicable for working parents when delivered in the workplace. During the program, the practitioner clarifies the particular parenting concern in the first session and works with the parent to identify an appropriate monitoring technique with which to track the
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behavior. In subsequent sessions, behavior monitoring data are shared, and factors that might affect the child’s behavior are gleaned from the data, which leads to the development of a parenting plan. The parenting plan is assessed and revised if needed in the third session, and the fourth session is a final follow-up. Case Example Adaptations are most often made because of feasibility issues rather than philosophical issues, with the most common adaptations being made to content, procedures (way that the program is delivered), or dosage (e.g., number of sessions; Moore et al., 2013). The Framework for Best Practices in Family Life Education provides a holistic view of programming that encompasses these logistical issues along with other aspects of programming, such as contextual issues. This section describes how each component of the framework was applied to adapt Level 3 of Triple P, including (a) context (strengths and needs of the population, as well as culture), (b) program content, (c) program design, and (d) the family life educator. As we address each component, we describe the specific adaptations that were made and how the framework was used in this process. Table 1 outlines content that was covered in each of the five sessions of the adapted program. Context for Program Adaptation Context includes cultural factors, such as race, ethnicity, gender, socioeconomic status, and community, as well as the strengths and needs of the individuals for whom the program is designed. These contextual factors (i.e., culture and strengths and needs of the population) form the outer circle of the framework (Figure 1), which indicates that they are foundational for the program itself. Contextual factors such as socioeconomic status, community support, and specific information needs of the population may influence all aspects of the program; assessment of these factors is therefore essential. This assessment, often called a needs assessment, can occur using informal or formal methods and should include a variety of stakeholders, such as community members and potential participants. First and foremost, the program must be available and supported within the larger community; then as program planning begins, the interest and likelihood of attendance must
Table 1. Adapted Triple P Intervention Session Session 1: Balancing work and family
Session 2: Behavior monitoring
Session 3: Parenting plans
Session 4: Managing misbehavior Session 5: Planning ahead; self and partner care
Topics Covered Being a parent Work–family life balance Parenting strengths and challenges Positive parenting Causes of behavior problems Child development ages and stages Goals for behavior change Balancing positive and problem behavior Developing a positive relationship with child Teaching new skills and/or behavior Parent traps and solutions Dealing with misbehavior Behavior interventions Planning activities training Supporting partners and coparents Managing stress
be assessed. In this section, we describe our needs assessment, in which we assessed culture and the strengths and needs of the population in relation to our adaptation and implementation of Triple P. Culture. Guerra and Knox (2008) defined culture as “a collection of social norms, beliefs, and values that are learned over time and that provide both a worldview and a way of living” (p. 305). In addition to the culture of the individual who will be receiving the programming, culture can refer to the agency and community in which the programming occurs. The factors in the community or culture that might affect implementation are wide reaching. Factors such as funding, politics and policy, the culture of the organization, and the capacity of the organization to deliver the program effectively have all been identified as essential for successful implementation (Durlak & DuPre, 2008; Guerra & Knox, 2008). Therefore, it is critical to identify those cultural factors that will be relevant to the particular agency and program of interest. This may involve mapping cultural assets that can facilitate programming, as well as identifying factors that have the potential to inhibit the program.
Framework for Best Practices In this case example, the larger community context played a positive role in the adaptation process. As part of the introduction of Triple P within Pitt County, training and ongoing support were made available to interested child and family practitioners. Following this countywide Triple P implementation, the state of North Carolina began implementing Triple P at a population level. To date, a total of 33 counties across the state have adopted Triple P. Funding sources to support the statewide implementation have included Title IV Division of Public Health block grants, Race to the Top—Early Learning Challenge Federal Grants, SAMHSA LAUNCH Grants, Centers for Disease Control and Prevention, and the John Rex Foundation. In support of ensuring an effective statewide implementation, the North Carolina Triple P Learning Collaborative (NCTPLC) was formed to connect coordinators in each county, evaluation specialists, and Triple P implementation consultants (NCTPLC, 2014). This countywide and statewide implementation of Triple P provided an important cultural context for our implementation at the university level. Specifically, the authors obtained training and ongoing support (e.g., materials, peer support) through the county initiative and then decided to implement the program within the university setting. Other cultural assets specific to the university setting included flexible schedules of the practitioners, educated and motivated participants, and the university’s mission of service to the community. Additionally, the University Wellness Committee endorsed Triple P programming for the university community, which may have increased supervisors’ willingness to allow their employees time to participate in the program; however, the actual effect of this endorsement was not measured. The influence of the university was bidirectional in that adaptations, such as time of day and length of the sessions, were made to accommodate the norms of the workplace and university culture. Strengths and Needs of the Population. The university workplace provided access to a diverse group of parents who varied in their socioeconomic status (SES) and were employed in a wide range of job classifications (e.g., hourly staff, contracted faculty, shift workers). All parents, regardless of SES or occupation, are in need of parent information and can relate to others who share similar parenting challenges.
5 Additionally, a core principle of parent education is that all parents deserve the opportunity to participate in parent education and can benefit from this participation (National Parenting Education Network, n.d.). The Triple P parenting system was therefore designed to be a universal (i.e., designed for everyone) parenting education program, although some levels are better suited for particular audiences (Sanders, 2012). With both community and university support in place, an initial needs assessment using an online survey was administered to a university-sponsored Listserv of faculty and staff. The total number of subscribers to this Listserv is approximately 4,000 faculty and staff, and 50 responded to the survey. Although we achieved only about a 1% response from Listserv subscribers, it is unknown how many of the subscribers were parents of children between 2 and 12 years of age. The specific parameters of the population increases the likelihood that our 50 responses were a more meaningful representation of this population’s needs than one may initially assume on the basis of the low overall response rate. This initial needs assessment of potential participants consisted of a five-item survey to assess faculty and staff interest in participating in a parent education program and the feasibility of delivery on weekdays during typical work hours. Among those who responded, 94% (n = 47) indicated that they thought other faculty, staff, and students would be interested in a free parenting program offered on campus. Most (n = 49) also indicated that they would participate in the program themselves, if offered. The majority indicated that summer (74%) was the preferred season for the program, followed by fall (62%) and spring (40%). There was no clear preference for day of the week on which the program should be held, but time of day preferred by the most respondents (37%) was during the lunch hour. Following these needs assessment results, this intervention was designed to meet weekly in 1-hour sessions during the Wednesday lunch hour, for a total of five consecutive weeks. Additionally, 28 respondents (56%) answered an open-ended question regarding barriers to participation; the most common barriers mentioned were related to family responsibilities, parking and commuting issues, child care, and work demands, with the majority of responses focused on time of day and conflicts with other responsibilities.
6 Although demographic data were not collected from the respondents, this initial needs assessment guided the implementation model by assessing receptiveness toward the program among potential participants on this university campus. However, it was then important to assess the strengths and needs of the actual program participants to ensure program fit. Family life education takes a strengths-based perspective by “developing potentials” in people rather than merely addressing problems (Arcus, Schvaneveldt, & Moss, 1993; Myers-Walls et al., 2011). Therefore, at the beginning of program delivery, participant attitudes toward workplace parenting interventions were assessed using the Employee Preferences for Parenting Support (EPPS; Sanders, Haslam, Calam, Southwell, & Stallman, 2011). The EPPS is a 19-item self-report measure divided into three parts. Part 1 assesses previous experience with parenting programs, decisions to attend a parenting program, and perception of child behavior problems. Part 2 measures participant agreement with statements about work–family balance, such as “Balancing work and family is stressful” and “I am more likely to attend a parenting program sponsored by my workplace than one at a clinic,” with five-point Likert-type response options ranging from strongly agree (1) to strongly disagree (5). Part 3 examines preference for certain characteristics of parenting programs using five-point response options anchored by very important (5) and not important at all (1) on items such as “How important an issue is balancing work and family for you as a working parent?” and “How important is it that the program has been demonstrated to be effective?” Sanders et al. (2011) reported that the EPPS is not to be used as a quantitative measure, and each item should be assessed individually, with no total scale or subscale scores. The results of the EPPS survey revealed that the majority of program participants (69%) had not previously attended a parenting program. Most reported a preference for group (58%), individual (27%), or seminar (24%) formats; fewer preferred self-help (11.1%) or Internet (6.7%) formats. The majority of participants reported that balancing work and family was stressful (69%) and difficult (65%), that work–family balance was an important issue (67%), and that parenting programs should be made available at work and be open to partners (67%) (see Tables 2 & 3).
Family Relations The characteristics of an employee parenting program deemed most important by participants were having trained practitioners, addressing personally relevant issues, being available in the workplace rather than at a clinic, and offering demonstrated program effectiveness. Additional results from this survey are included in Tables 2 and 3. The results of this survey validated and confirmed that, for the population we were serving, balancing work and family was stressful and these parents were receptive to receiving help through a parenting program. The results further strengthened the rationale for proceeding with the program being offered at the workplace. Program Content and Design Program fidelity (i.e., implementing a curriculum as it was developed) involves both program content and program design, and is a central component of EBP. The idea is that if a program that has been deemed to be effective (i.e., evidence-based) is offered with fidelity, then it will achieve the desired outcomes. Many specific evidence-based programs have core components that are considered integral to the effectiveness of the program and cannot be altered if fidelity is to be maintained. Generally, adaptations at the surface level, such as adding relevant examples or replacing images to reflect the audience, are acceptable revisions and do not threaten program fidelity (Mazzucchelli & Sanders, 2010; O’Connor, Small, & Cooney, 2007). The developers of Triple P have encouraged low-risk context- and audience-appropriate adaptations, such as those related to number of sessions, session length, or individual versus group sessions, which allow for flexibility while maintaining program fidelity (Mazzucchelli & Sanders, 2010). These types of low-risk adaptations may be beneficial for meeting the needs of the audience (Mazzucchelli & Sanders, 2010). Measuring fidelity can be challenging, and there is no consensus on the best way to operationalize it (Berkel et al., 2011). A common method of measuring fidelity is through the use of a fidelity checklist, which outlines the core components and features of program content and design that must be present for each session of a particular program. A checklist, which can be completed by a third party via observation or completed as a self-report measure by the practitioner, can be used to calculate a percentage of
Framework for Best Practices
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Table 2. Employee Preferences for Parenting Support: Balancing Work and Family and the Role of the Organization
I am more likely to attend a parenting program sponsored by my workplace than one at a clinic. Organizations that support employees to better balance work and family issues are demonstrating they value the individual employee and understand the importance of families. Organization work–family balance programs should be open to partners of employees so parents can support each other in reducing work–family conflict. My organization supports me in managing my work and family commitments. Programs addressing work and family balance should be delivered in work hours.
Strongly Disagree % (n)
Disagree % (n)
Neither % (n)
Agree % (n)
Strongly Agree % (n)
10.2 (5)
10.2 (5)
18.4 (9)
34.7 (17)
26.5 (13)
12.2 (6)
10.2 (5)
4.1 (2)
28.6 (14)
44.9 (22)
8.2 (4)
12.2 (6)
12.2 (6)
26.5 (13)
38.8 (19)
12.2 (6)
14.3 (7)
14.3 (7)
34.7 (17)
24.5 (12)
12.2 (6)
10.2 (5)
26.5 (13)
32.7 (16)
18.4 (9)
the core components delivered or the amount of time spent on them. In this case example, after programming was complete, the four authors who facilitated the program completed the fidelity checklist designed for Level 3 Triple P practitioners. This checklist followed the original Triple P four-session format and was adjusted for our five-session format. Each author completed the checklist independently, and any discrepancies were discussed until consensus reached. We had 93% fidelity, which was calculated by using the total number of program components and the number of components we included. Areas in which we deviated from the program as designed included altered dosage (five sessions instead of four) and the overall delivery of the program (group instead of individual). However, we maintained the sequence of content as well as the five core principles of Triple P: (a) ensuring a safe, interesting environment; (b) creating a positive learning environment; (c) using assertive discipline; (d) setting realistic expectations; and (e) increasing parental self-care (Sanders, 2012). Program Content. Practitioners must give careful consideration to additional content or skills— based on best practices—needed to successfully implement the program and be most effective for their audience. Following the guidelines set forth by Triple P and best practices from other evidence-based program adaptations,
the program used in this case example was adapted within a framework of flexibility while maintaining fidelity (Domenech Rodriguez, Baumann, & Schwartz, 2011; Lee, Altschul, & Mowbray, 2008; Sanders, 2012). On the basis of participant needs and a review of literature on best practices in parent education (Cooke, Potter, Stoner, & Yokom, 2011; National Parenting Education Network, n.d.), we incorporated work–family balance, stress reduction, and information about age-appropriate behavior into the program content. Although content on work–family balance and stress reduction was provided through Triple P tip sheets, this content is not routinely provided in Level 3 primary care. In addition, our participants reported that it was important for a parent education program to address personally relevant issues, and they requested information on developmentally appropriate child behaviors. An understanding of child development is a central part of parenting knowledge and has been linked to myriad benefits, including effective parenting (Bornstein, Cote, Haynes, Hahn, & Park, 2010), increased parental self-efficacy and competence (Hess, Teti, & Hussey-Gardner, 2004), and fewer problematic parenting behaviors (Morawska, Winter, & Sanders, 2009). Therefore, information about appropriate behavior at various ages (often known as “ages and stages”) was prepared by the practitioners and disseminated to participants. When a participant requests
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Family Relations Table 3. Employee Preferences for Parenting Support: Aspects of Work–Family Balance Program Delivery M (SD)
How important an issue is balancing work and family for you as a working parent? How important is it that the program is conducted by trained practitioners? How important is it that programs address personally relevant issues? How important is it that support or programs to help parents balance work and family more effectively are made available to working parents? How important is it that the program has been demonstrated to be effective? How important is it that participants are encouraged to set and achieve their own goals? How important is it that parenting programs have flexible delivery formats? How important is it that different levels of programs are available according to the needs of the individual parent? How important is it that resources are professionally produced and presented?
5.59 (7.10)
4.61 (0.53) 4.51 (0.61) 4.38 (0.67)
4.38 (0.67) 4.18 (0.72)
4.16 (0.77)
4.14 (0.73)
4.12 (0.88)
Note. Higher mean scores indicate higher level of importance.
additional information, practitioners should remain flexible enough to consider its utility and consulting the best practices literature regarding integration of the information can help provide the balance of flexibility with fidelity. Program Design. Content often is the primary emphasis within a program, but program design —that is, format, features, and method—is important too. Aside from the content additions mentioned earlier, the majority of our adaptations focused on process or design as suggested for the Triple P parenting system (Mazzucchelli & Sanders, 2010). The process adaptations were designed to better meet the needs of our participants (e.g., group rather than individual format) and to reduce the barriers to participation identified in the initial needs assessment. Conducting the program during a culturally acceptable time to be away from work (i.e., the lunch hour) reduced some of the burden
on the employee and the employer and made the program more easily accessible to a wider range of employees. Given the results from the work measure, these program features (along with holding it within the actual workplace) may have increased participation. Additional program design elements that were maintained included a strengths-based perspective and a self-regulatory framework. We focused on what parents were doing well and asked them to start out each session with positive statements. As we got to know the participants, we were able to point out things they shared as strengths or help them to reframe seemingly negative situations. Helping parents to see the strengths they do have can be empowering and help increase their confidence and self-efficacy. This strengths approach fit well with Triple P’s self-regulatory framework. Self-regulation (i.e., in which practitioners follow the lead of the parents and empower them to identify strategies that will work for them) is a core component of Triple P, and it was followed in this adaptation. For example, during group sessions, participants created a parenting plan that allowed them to monitor their child’s behavior and make adjustments as needed. As facilitators, we offered assistance and strategies, but the parents guided the decision-making process and identified any changes that needed to be made to their parenting plan. Additionally, to further personalize the program design, we followed up with each participant via e-mail to facilitate follow-through on implementation of the behavior tracking and parenting strategies discussed in the program. This follow-up e-mail allowed for the more individual interaction that is present in traditional Level 3 programming but was not possible with our group format. The Family Life Educator The person who actually implements an evidence-based program might be called a practitioner, provider, educator, facilitator, family life educator, or some other term. Regardless of the title, the role of the person conducting the program is crucial to its success. Lize, Andrews, Whitaker, Shapiro, and Nelson (2014) suggested that educator skill level is vital to program quality and could influence parental engagement and the ability to modify behaviors and attitudes. Some researchers have stated that educator competence may be more important for participant
Framework for Best Practices outcomes than program content or design are (Duncan & Goddard, 2011). Specific educator characteristics that have been deemed most likely to ensure high-quality implementation are the perception of the need for and benefit of the program, self-efficacy, and expertise (Durlak & DuPre, 2008). Resulting from rigorous evaluation of their training process, the Triple P program incorporates competency-based training methods for practitioners that increase self-efficacy and self-direction but encourage a culture of support designed to strengthen the perceived need for and benefit of the program (Turner, Nicholson, & Sanders, 2011). This training also aims to ensure that practitioners will be able to maintain program fidelity. To be qualified to deliver Triple P services, a practitioner must attend a brief training (2 to 5 days), preaccreditation (1 day), and an accreditation process (1 to 2 days) that includes successful completion of both an oral and a written exam (Sanders, 2012). Separate training and accreditation are required for each level of Triple P, and they consist of a multidisciplinary approach to active skills training conducted by accredited Triple P trainers and delivered using standardized materials (Turner & Sanders, 2006). Studies on the impact of Triple P training indicate that trained and accredited practitioners had better parent consultation skills, higher confidence in those skills, and more satisfaction with this training model than their untrained peers (Seng, Prinz, & Sanders, 2006). The program for this case example was implemented by a multidisciplinary team consisting of two certified family life educators, one licensed marriage and family therapist, and one social worker who possessed a background and experience in family science and training in program implementation and delivery. All four team members were accredited Triple P practitioners (three in Level 3—two of whom were also accredited in Level 2—and one in Level 4) and each participated in the implementation using a tag-team approach. Although program-specific training of the practitioner is vital, entry-level knowledge and experience are also important to the success of the program. Triple P dissemination strategies encourage the training of practitioners from a wide variety of professions (e.g., psychology, social work, nursing, counseling, medicine) who have experience with child and family development to ensure that programs are delivered
9 by competent professionals (Sanders, 2012). Although they may have sufficient content-area expertise, not all of these professionals are trained in implementation science or have sufficient experience in program delivery. In addition to child and family content, practitioners who implement EBP ideally need skills in program development and evaluation as well as interpersonal skills, which are important for connecting with participants and creating a supportive environment conducive to learning. Developers of EBP and those who are choosing an evidence-based program for their agency or community should consider the educational background and skills of those available to implement the program to ensure successful implementation. Family life educators are one group of professionals who are well suited to deliver EBP. Those who are certified family life educators (CFLEs) through the National Council on Family Relations hold a 4-year degree and are trained in 10 family-science content areas, such as internal dynamics of families and human sexuality (see National Council on Family Relations, 2016, for more information on certification). CFLEs also have training in family life education methodology, and therefore understand the need for EBP and have the ability to adapt it for diverse populations. Implications and Lessons Learned In the field of implementation science, many barriers to the quality implementation of EBP have been noted (Aarons & Palinkas; 2007; Breitkreuz, McConnell, Savage, & Hamilton, 2011; Sanders et al., 2002). Evaluations specific to Triple P suggest that lack of political or government support, practitioner turnover, and criticism of program effectiveness are common obstacles to successful implementation (Sanders et al., 2002). Competing work demands for practitioners, knowledge of multiple interventions, attitudes toward the intervention, and diversity of facilitator experience or training have also been noted as barriers to effectively implementing EBP (Aarons & Palinkas, 2007). By adapting EBP to fit specific populations, practitioners can increase the quality of their implementation efforts and reduce barriers. In addition to benefiting the intended population, adapting a program also links science and practice, allowing practitioners and researchers to
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examine change and outcomes in a wide variety of contexts, thereby advancing the efficacy of prevention science (Lee et al., 2008). While adaptation of EBP might reduce barriers to implementation (Berwick, 2003; Moore et al., 2013), this alone is not enough, as practitioners who neglect to record changes in program delivery preclude replication and methodical evaluation of program outcomes (Domenech Rodriguez et al., 2011). Botvin (2004) suggested that prevention science research should examine whether adaptation is needed to tailor programs to specific populations and how EBP can be adapted in ways that do not decrease effectiveness. The adapted program illustrated in this case example followed the Framework for Best Practices in Family Life Education (Ballard & Taylor, 2012), which highlighted the importance of contextual factors such as community and institutional or administrative support, as well as the key factors for program implementation: (a) context (strengths and needs of the population, and culture), (b) program content, (c) program design, and (d) the family life educator. Implications and lessons learned for each of these components are outlined in the following section.
these factors might provide rationale and guidance for adapting EBP to maximize the potential for achieving desired outcomes within the existing structure. A trained educator may see the importance of a program and its relevance for the population, but administrative buy-in is also a critical component of the environmental context of implementation (Durlak & DuPre, 2008). For practitioners without sufficient contextual support, contacting the program developer or other practitioners currently implementing the program might be fruitful strategies for gaining support. Assessing the cultural context before adopting EBP might ensure a good alignment between EBP and the culture. If a specific program has been selected before this assessment, a proactive adaptation might alleviate some of the contextual barriers to implementation. In addition, community engagement has been noted as one of the most vital components of adaptation (Domenech Rodriguez et al., 2011), and practitioners should therefore consult with community leaders and stakeholders (i.e., those with a vested interest in the population and those with decision-making ability in the organization) to foster additional contextual support. Program Content
Context and Culture Conducting a needs assessment, as demonstrated in this article, can add support and credence to a practitioner’s plan to implement EBP. A primary focus for many practitioners is the fit of EBP with the needs of their participants (Aarons & Palinkas, 2007), with the understanding that emphasizing participant needs is one way to increase acceptability and buy-in from administrators and supervisors (Elliott & Mihalic, 2004). However, in addition to needs, which often reflect a deficit model, assets or strengths of participants should be considered. Relative to parent education, this strength-based perspective starts with an assumption that all parents have good qualities as a parent and that appropriate education can help highlight or strengthen these qualities. In addition to identifying strengths of participants, it is important to identify strengths in the context of implementation. Equally important is recognizing that the culture and climate of an organization have direct influences on the implementation and delivery of EBP (Aarons, Hulburt, & McCue Horowitz, 2011). Examination of
Determining the modifications or adaptations to program content that are needed to best suit a specific population is a critical decision that requires a specific skill set. Most adaptations to parent education programs occur on the basis of practitioner response to the current needs of parents, or from attempts to engage parents by making programming fit their cultural and social background (Lize et al., 2014). In our case, maintaining the core elements of the Triple P curriculum was crucial to the success of the example program, but listening to the needs of participants for additional content was also important. Whenever possible, practitioners should follow the guidance of the program developers to ensure that they are safeguarding program fidelity when adapting EBP. Program Design The design of a program can greatly affect the willingness and ability of a practitioner or an agency to implement the program, as well as affect parent attendance and participation in the program. An understanding of potential barriers
Framework for Best Practices specific to the audience is critical when planning program design and delivery. Evaluation must also be a component of quality program implementation, as it can lead to increased understanding of these barriers and ways to overcome them. In addition to this understanding, when adapting EBP, both formative and summative evaluations are important for determining the effect of these adaptations on program effectiveness (Elliott & Mihalic, 2004). Evaluation of the case example program noted design factors such as preferred time of the program, a convenient location, strengths-based focus, attention to contextual factors affecting parenting, and the use of accredited practitioners as evidence of effectiveness (Baugh et al., 2015). One additional aspect of program design and evaluation is reflection. Reflection is an important skill when conducting family life education programming and can be an opportunity to capture less tangible aspects of programming that might not be revealed in formal evaluations (Small & Kupisk, 2015). Reflecting on what went well and what could be changed in the future leads to improved implementation outcomes such as program delivery and participant responsiveness. The Role of the Educator It is evident that a key to successful implementation is having the ability to be flexible and competent while also working in a systemic partnership with those involved in implementation: families, practitioners, and agencies (Aarons & Palinkas, 2007). Therefore, the role of the family life educator or of other practitioners with family life education training is of primary importance in implementing adapted EBP, as they will be equipped with the knowledge and ability to adapt programs to fit a specific population. Practitioner skills and qualifications are often overlooked in implementation science literature; a qualified practitioner such as a certified family life educator is a key ingredient for all aspects of successful program implementation. For example, consideration should be given to participant characteristics, age of parents and children, and complexity of family issues because “lack of fit between the EBP and the family could cause ambiguity and discomfort in . . . services” (Aarons & Palinkas, 2007, p. 414). The skills to conduct a needs assessment and solicit participant input during the planning
11 stages of delivery are necessary to provide appropriate services and ensure program fit. Utilizing EBP and employing content based on research is effective only if that information can be disseminated in a manner that participants understand (Ballard & Taylor, 2012). Additionally, Small and Kupisk (2015) indicated that practitioners should possess practical wisdom, which encompasses problem solving and prudent decision making when reactive adaptations to a program are needed because of unexpected challenges or complex situations that arise during programming. The practitioners in this case example had extensive experience in developing, implementing, and evaluating family life education programs. This experience, along with our collaborative approach, aided in the successful adaptation and implementation of Triple P. Practitioners should continually seek information, support from colleagues, and additional training to increase their self-efficacy and understanding of the value of their intended program. Conclusion EBP is a great source of education and support for families when delivered properly. However, often what works during the development of these programs is not directly transferable to real-world agencies and practitioners. Those who work to implement these programs can get discouraged and encounter barriers that cause them to stop implementation completely. The Framework for Best Practices in Family Life Education is a tool that assists practitioners in making EBP work for their agency and population. This case example demonstrates the steps involved in utilizing this framework for adapting EBP to overcome several potential barriers to implementation while still maintaining a high level of program fidelity. Implementing EBP with fidelity is important for achieving desired outcomes; however, strict fidelity can also limit program effectiveness (Mazzucchelli & Sanders, 2010). Program adaptation involves a balance of gains and losses that the practitioner must carefully consider. The questions to consider (see Table 4) can guide practitioners as they weigh the gains and losses that result from their program adaptations. In this case example, adaptation of the program resulted in greater accessibility (offered in the workplace at lunchtime), a high number
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Table 4. Considerations in Applying the Framework for Best Practices in Family Life Education to Program Adaptation Framework Component
Adaptation Activities
Questions to Consider
Context: Culture and strengths and needs of the population
Conduct a needs assessment
Program content
Revise content as necessary according to participant needs and best practices Monitor fidelity
Program design
Make needed process adaptations (e.g., length of program, format, time of day) Incorporate strengths-based elements Develop an evaluation plan
Who is the intended audience for my program? What are their most relevant characteristics (e.g., SES, education, age)? How does the program relate to other community groups, organizations, and agencies? What support do I have for this program, and who are the community stakeholders? What participant preexisting knowledge, skills, and attitudes might influence the program? Is this program a good fit for my audience? Can I maintain the core elements of the program if I make adaptations? How will I measure program fidelity? What barriers exist for participant recruitment and retention? Can modifying length of program or sessions address these barriers? What dosage is needed to maximize results? What strengths do participants have? How can I incorporate and build on them? Does the evaluation plan include both summative and formative components?
The family life educator
Assess one’s knowledge and skills relative to the program Obtain program-specific training Build collaborations and support systems
of participants exposed to the program (group format vs. individual), normalization of parenting challenges and social support (group format), and relevance to work environment (incorporation of a focus on work–family balance). However, we lost the one-on-one interaction with parents and individualized feedback that are design features of the traditional Level 3 format, along with a loss of some in-session practice time in which parents practice the skills learned. The skill set and knowledge base of the family life education practitioners allowed for successful implementation of this evidence-based program without losing the core elements of the program that are the foundation of its effectiveness. Although a variety of professionals can be
Do I have the knowledge base needed to successfully implement this program? Is there any training required for this program? Is this program a good fit for me as a practitioner? Do I have the skills needed to implement, adapt, and evaluate the program, or should I consult someone with a different skill set? What type of support will I need to implement and evaluate this program effectively?
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