Post on 10-Jan-2016
CDC-Funded Triple P System Population Trial
Presented by:
Ron Prinz, University of South Carolina
U.S. Triple P System Population Trial
Principal Investigators: Ron Prinz & Matt Sanders
Funding Agency: Centers for Disease Control and Prevention (CDC)
Project Director: Cheri Shapiro
CDC Collaborating Officials: Dan Whitaker, Kendell Cephas
Key points for this presentation
• Description of the population trial—which is midway towards completion
• Illustration of the range of service providers and agencies involved in Triple P delivery
• Reflections on feasibility, acceptability, benefits for workforce
• Indications of population penetration thus far
Primary aims of the trial
• Reduce risk for child maltreatment• Reduce risk for child behavioral/emotional
problems• Implement all levels of the Triple P system to
promote positive parenting principles and strategies population-wide
• Test population penetration of the system• Assess impact at population level, rather than
with individuals at a clinical level
Background context of trial
• South Carolina context backdrop for the trial:– Significant funding cuts to social services and family
mental health services– Multiple disciplines and agencies serving target
population with little cross-coordination– Services often disconnected, relying on conflicting
approaches, having poor referral pathways– Service providers usually experienced but often
inadequately trained – Little prior exposure to evidence-based parenting
programs
Research design
• 18 counties located in South Carolina:– Each between 50,000 and 175,000– None with prior exposure to Triple P – Random assignment of counties:
(1) Triple P System
(2) Comparison (services as usual)
• Counties were matched on child abuse rates, poverty, and population size
Intervention Counties
Comparison Counties
South Carolina counties
Target population
All families:• with children in the birth to 7-year-old range• residing in the nine Triple P counties (or the nine
comparison counties)
Child maltreatment; Childhood Injuries
• Child maltreatment (birth to 7 years)– 17.5 investigated cases per 1,000 children– 6.5 founded (substantiated) cases per 1,000 children
• Child out-of home placements:3.8 placements per 1,000 children
• Child injuries (hospitalization and ER visits):615 visits per 10,000 children
However, official records grossly underestimate the extent of detrimental parenting practices
Coercive parenting practices
0
10
20
30
40
50
60
70
Threatening and notfollowing through
Shouting or becomingangry
Single spank More than one spank Spanking with object
Parenting practices (likely or very likely)
% o
f Par
ents
.
Coercive parenting practices
0
5
10
15
20
25
30
0 1 2 3 4 5
Number of coercive parenting practices (likely or very likely)
% o
f Pare
nts
.
Strategies to de-compartmentalize
• Avoid narrow linkage to child abuse– With practitioners– With parents
• Promote adoption of key Triple P assumptions• Disseminate all levels of Triple P
Avoid narrow linkage to child abuse
• With practitioners:– NO: “Triple P is being disseminated to prevent child
abuse.”– YES: “Triple P benefits parents and children in many
different circumstances.”
• With parents:– NO: “We are providing this parenting and family
support so that you don’t abuse your child in the future.”
– YES: “Good parenting and family support is for every parent.”
Promote key assumptions of Triple P
• Principle of sufficiency• Parenthood preparation is about promoting
flexibility, adaptation and capacity to change• Promote parental self-regulation, family-driven
goal setting, flexible delivery modalities and program intensities
• Multidisciplinary:– Practitioners from many disciplines who serve families– No discipline “owns” or controls Triple P
• As a result:– Involve many settings and service providers– Create multiple access points for families
Key assumptions continued
Levels of intervention
Universal Triple PUniversal Triple PLevel OneLevel One
Primary Care Triple PLevel three
Selected Triple PLevel Two
Standard Triple PLevel four
Enhanced Triple PLevel five
Universal Triple P
Triple PMedia strategy
De-stigmatize Validate
EmpowerNormalize
Strategies to increase public awareness
• Multiple publicity strategies– Press releases– Reporter-initiated news stories– Positive Parenting articles (Sanders)– Radio public-service announcements (PSAs)– Community events– School newsletters, other mailings– Bumper stickers, memorabilia
• Involve larger numbers of parents in lower program levels (e.g., parenting seminars)
Constructive media coverage
Level 2: Triple P Seminar Series
Seminar 1
The Power of Positive Parenting
Seminar 2
Raisingconfident, competent children
Seminar 3
Raising resilient children
90 minute large groupparenting seminarsInvitation to return
Communications strategy: Cumulative view
0
10
20
30
40
50
60
Q4 2003 Q1 2004 Q2 2004 Q3 2004 Q4 2004 Q1 2005 Q2 2005 Q3 2005
Time
Num
ber
Sanders Articles Press Releases Run Seminars & Community Events
Training of service providers
Providers of Triple P: Settings
• Mental health centers• Health clinics• County child welfare departments• Elementary schools• Preschools and daycare centers• NGOs and non-profit organizations• Churches and other religious institutions• Private sector
Triple P providers: Mental health system
• Therapists• Counselors• Home-visiting staff• Case managers, supervisors• Disciplines: social work, psychology, marriage
and family therapy, counseling, nursing, parent educator, psychiatry
Triple P providers: Child welfare system
• TANFF workers• Outreach and home-visiting staff• Case managers, supervisors
Profile of providers
0 5 10 15 20 25 30 35
Counselors, therapists
parent educators
social workers
Child care staff
nurses
other
administrators
educators
Pro
vider
s
Percentage
Profile of Triple P providers
Number of providers trained (through 2005) 568
Mean age of providers 43.5 yrs
% in present position greater than 5 years 42%
Ethnic backgrounds
European Americans
African Americans
Other racial/ethnic
54%
40%
6%Mean # of years in parent consultation work
Greater than 5 years
Greater than 10 years81%
59%
Training impact on providers’ parent consultation skills
1
2
3
4
5
6
7
Adequacy of training Confidence in parentconsultation skills
Overall level of selfefficacy
Pre Training Post Training Follow up
How satisfied were providers?1=very dissatisfied; 7=extremely satisfied
Overall Satisfaction with Training Mean (SD)
Part 1 of Training 6.24 (1.12)
Part 2 of Training (when providers asked to demonstrate competencies)
6.47 (1.14)
0
100
200
300
400
500
600
700
800
Start 2003 Mid 2003 Start 2004 Mid 2004 Start 2005 Mid 2005
Intervention Counties Comparison Counties
Growth in Triple P providers
Population assessment
• Not feasible to assess individual families• Need to rely on available population indicators• Archival data, even with inherent limitations, can
be useful• Telephone surveys of random households
provide population snapshots• Practitioners can provide useful data• Cost effectiveness analysis
Archival data
• Child maltreatment– Rates of investigated CM– Rates of founded (substantiated) CM
• Child injuries (hospitalizations and ER visits)• Child out-of-home placements
Tracking key constructs
• Child maltreatment– Rates of investigated CM– Rates of founded (substantiated) CM
• Child injuries (hospitalizations and ER visits)• Child out-of-home placements• Growth in number of Triple P providers• Awareness of Triple P in the population• Population reach: Parent exposure to Triple P
interventions
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
1999 2000 2001 2002 2003
Year
Intervention Counties
Comparison Counties
Num
ber o
f Pla
cem
ents
per
100
0 C
hild
ren
(0-7
Yea
rs)
Child out-of-home placements
Baseline Years
Telephone surveys of households
• Random telephone survey of households (families with at least on child 6 mos. to 7 yrs. old)
• 1,800 households in intervention counties• 1,800 households in intervention counties• Gauge awareness of Triple P• Other variables:
– Parenting practices– Child behavioral/emotional problems– Parental accessing of services
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
2003 2004 2005
Intervention Counties Comparison Counties
Per
cent
age
of
Res
pond
ents
Parental awareness of Triple P
Population reach of Triple P to date
• Eligible population: 85,000 families with a child birth to 7 years old
• To date: 12,197 families have received direct services via Triple P programming
• 6.8-11.7% receiving Triple P interventions per year (excluding media exposure)
Some lessons learned thus far
• Front-line staff working in different agencies and settings want collaboration and cross-agency communications
• Triple P offered common terms, intervention methods, and system without requiring complex interagency agreements
• Building up a positive contagion effect takes:– Patience– Multiple strategies– Sustaining of community engagement
Conclusions thus far
Population trial has demonstrated:– Feasibility of disseminating the entire Triple P system
at one time– Substantial uptake despite community infrastructure
problems, fractured delivery systems– Growing awareness of Triple P among parents
throughout the population– Potential detectability of population impact through
archival data systems
Conclusions
• Biggest line item of service delivery is personnel:– Dissemination of the Triple P system is not requiring
the addition of service delivery personnel– Using the existing workforce– Training, parenting resource materials, consultation
and support
• The U.S. Triple P System Population Trial is providing a unique opportunity to examine long-term, cumulative impact on the population and on service providers.
Thank you for your attention
Longitudinal tracking of providers
• To assess numbers of families receiving Triple P• Telephone interview 6 months after Triple P training
– 526 providers interviewed to date– Participation rate: 94.3%
• Telephone interview 18 months after Triple P training– 325 providers interviewed to date– Participation rate: 88.3%
0
5
10
15
20
25
1999 2000 2001 2002 2003
Year
Intervention Counties
Comparison Counties
Rates of investigated cases of child maltreatment
Baseline Years
0
1
2
3
4
5
6
7
8
1999 2000 2001 2002 2003
Year
Intervention Counties
Comparison Counties
Num
ber
of Founded
Cas
es P
er 1
,000
Childre
n A
ges
0 - 7
Rates of founded cases of child maltreatment
Baseline Years
0
100
200
300
400
500
600
700
1999 2000 2001 2002 2003
Year
Visi
ts p
er 1
0,00
0 C
hild
ren
(0-7
Yea
rs)
Intervention Counties
Comparison Counties
Child injuries (hospitalizations and ER visits)
Baseline Years