Feasibility of the Strengthening Families Program for Brazilian Families: A Mixed Method Study^*

Viabilidade do Strengthening Families Program para Famílias Brasileiras: Um Estudo com Métodos Mistos

Abstract

The objective of this study was to examine the feasibility (limited effectiveness, acceptability and practicality) of the Strengthening Families Program, a universal preventive intervention, for Brazilian families. A pre-experimental study was carried out, with pre-test, post-test, 6- and 10-12-month follow-ups. 74 adolescents and their parents participated. Scales on academic, parenting, and health outcomes were applied to adolescents at the four assessment times. Direct observation of implementation fidelity and families engagement in the intervention and telephone interviews with facilitators were used to investigate acceptability and practicality. The results show significant increase in parental supervision and learning self-efficacy. High levels of fidelity and parent/guardian engagement as well as moderate levels of adolescent engagement were found. The facilitators found the intervention had acceptable goals, but procedures excessively structured and unsuitable for families with low educational level. Practical implications are discussed.

Keywords:
prevention; parenting; substance abuse; family intervention

Resumo

Este estudo teve por objetivo examinar a viabilidade (efetividade limitada, aceitabilidade e praticidade) do Strengthening Families Program, uma intervenção preventiva universal, para famílias brasileiras. Conduziu-se um estudo pré-experimental, com pré-teste, pós-teste, 6 e 10-12 meses de follow-up. Participaram 74 adolescentes e seus pais. Escalas sobre desfechos acadêmicos, parentais e saúde foram aplicadas nos adolescentes nos quatro tempos de avaliação. Observação direta da fidelidade da implementação e do engajamento familiar na intervenção e entrevistas por telefone com facilitadores foram usadas para investigar aceitabilidade e praticidade. Identificou-se aumento significativo em supervisão parental e autoeficácia para a aprendizagem. Altos níveis de fidelidade e engajamento parental foram encontrados, bem como engajamento moderado dos adolescentes. Os facilitadores consideraram a intervenção aceitável em suas metas, mas com procedimentos excessivamente estruturados e inadequados para famílias com baixo grau de instrução. Implicações práticas são discutidas.

Palavras-chave:
prevenção; parentalidade; abuso de substâncias; intervenção familiar

Intrafamily violence (Avanci et al., 2017), sexual violence (Souto et al., 2017), and bullying (Nobre et al., 2018) are among the main types of violence afflicting Brazilian children and adolescents. Cumulative evidence indicates that parents and the family environment are the primary perpetrators of violence against children and adolescents (Macedo et al., 2019; Nunes & Sales, 2016). The deprivation of rights, unemployment, and lack of access to services and information to which many Brazilian families are exposed are social determinants of intrafamily violence (Macedo et al., 2019). Specific social groups are victims of multiple types of violence, for example indigenous children (Nascimento, 2014) and black girls (Souto et al., 2017), corroborating the social determinants of violence. There are initiatives to enable professionals to focus on the prevention of violence during childhood and adolescence in Brazil, particularly in the health care sector, but these do not address the issue specifically enough, particularly regarding prevention and the strengthening of protective ties (Vieira et al., 2015).

One of the evidence-based alternatives used in middle- and low-income countries to improve the quality of family relationships with the aim of preventing violence is the Strengthening Families Program (SFP 10-14) (Maalouf & Campello, 2014). In 2013, the Ministry of Health adopted SFP 10-14 for implementation in the basic social protection services of the National Policies of Social Assistance (Brasil, 2004) to strengthen family ties and prevent various harms to adolescent health such as substance abuse and intrafamily violence. In addition, it was expected to positively affect academic success and school engagement in the long-term, as there had been evidence hinting at this (Spoth et al. 2008). This, along with additional evidence related to the program’s positive impact on the improvement of family environment (Coatsworth et al., 2015; Mejía et al., 2015), long-term reduction of antisocial behavior (Spoth et al., 2000), decrease of risky sexual behavior (Spoth et al., 2014), and long-term delay of use or reduction in substance abuse (Foxcroftet al., 2003; Gates et al., 2006), indicated SFP 10-14 was a beneficial preventive alternative for families with adolescents.

SFP 10-14 is an American program, developed in the 1980s at University of Utah as an intervention of selective prevention (Kumpfer et al., 1989). Later its content and format were redesigned for universal prevention at Iowa State University (Kumpfer et al., 1996). SFP 10-14 consists of seven regular sessions, followed by four booster meetings, where the participants are parents/guardians and their children between 10 and 14 years of age participated in two-hour-long sessions. In the first hour, parents and children participate in separate sessions. In these, parents work on parenting practices combining synchrony and demand while the children practice assertive social skills to deal with peer pressure, emotion regulation skills, and life projects. In the second hour, parents and children participate jointly in family sessions with the aim of strengthening family cohesion, communication, values, and resources for problem resolution. The protective processes addressed in this intervention derive their theoretical basis from family systems theory, social cognitive theory, resilience models, and socio-ecologic models (Kumpfer, 2014).

In Latin America, this is the most-implemented family-focused prevention program known, having already been conducted in Mexico, Honduras, Costa Rica, Colombia, Bolivia, Ecuador, and Panama as well as Brazil (Mejía et al., 2019). SFP 10-14 studies with Latin American samples have demonstrated strengthening of family ties and reduction of stress in Porto Rican families (Chartier et al., 2010), reduction of coercive and permissive parenting practices in Chile (Correa et al., 2012), and improvement in communication and emotional regulation in Panamanian families (Mejía et al., 2015). Positive effects on adolescents were also identified, including an increase in social skills for handling peer pressure in Peruvian adolescents (Secretaría General de la Comunidad Andina, 2013) and a decrease in aggressiveness and antisocial behavior in Porto Rican adolescents (Chartier et al., 2010).

Given that the greater part of the available evidence for the effectiveness of preventive parenting interventions in general (Knerr et al., 2013), and SFP 10-14 (Gorman, 2017) in particular, derives from Northern Hemisphere studies, studies of the feasibility and effectiveness of this program in low- and middle-income countries are still needed (Maalouf & Campello, 2014; Mejía et al., 2019). The elevated levels of inequity which have historically plagued Brazil and the concentration of poverty in various regions have been further exacerbated since the beginning of this decade by the implementation of fiscal austerity policies (Malta et al., 2018), making it an appropriate context for investigating if and how SFP 10-14 works for economically disadvantaged families. Additionally, in Brazil, there is an urgent need for the implementation of already-available internationally psychosocial interventions or locally developed innovations capable of focusing on parental violence and stress in poor families (Silva et al., 2019), be it in the macrosocial sphere (e.g., poverty reduction policies), mesosocial (such as community social strengthening programs), or microsocial (for example, programs seeking to strengthen family ties).

In this context, a feasibility study (Bowen et al., 2009) was designed to investigate the limited effectiveness, acceptability, and implementation practicality of SFP 10-14 for vulnerable Brazilian families. SFP 10-14 feasibility analyses in Brazil may result in several contributions. First, it may provide inputs to optimize the intervention and prepare subsequent effectiveness studies, by indicating areas for improvement in the implementation process. Second, on the one hand, it may generate initial insights into its scalability or, on the other, its de-implementation if the intervention proves to be unfeasible as a tool of public policies aimed at the strengthening of family ties and health promotion to the child-adolescent public. Third, it may inform about the feasibility of SFP1-14 in a context of scarce resources, as well as the need for new waves of cultural adaptation or local production of preventive programs focused on the family (Mejía et al., 2019).

Specifically, the objective of this study was to assess the effects of the intervention on the use of alcohol, binge drinking, tobacco, marijuana, inhalants, cocaine, and crack in the last month; antisocial behavior; parenting skills; learning self-efficacy; school dropout; school engagement; school performance; and future perspective in the pre-test, post-test, and 6- and 10-12-month follow-ups. Secondary objectives were to describe the acceptability of the intervention by analyzing the engagement of parents/guardians and adolescents in the intervention and to examine the practicality of the intervention through the perceptions of the facilitators who implemented it and observations of the implementation’s fidelity.

Method

Design

A mixed-method study was carried out. A longitudinal pre-experimental design with quantitative measures at pre-test, post-test, and follow-up evaluations at 6 and 10-12 months was adopted. A complementary qualitative study focused on implementation quality was conducted, specifically on the participants' engagement in the intervention, the intervention’s implementation fidelity, and the implementation practicality in the services that adopted it. While the first two dimensions were investigated by direct observation, the latter were through telephone interviews.

Participants

Three hundred and sixty-one children and adolescents participated in the pre-test. However, significant parts of this sample were not evaluated in subsequent evaluation steps: 148 were not evaluated in the post-test, 122 in the 6-month follow-up, and 126 in the 10-12-month follow-up, which corresponds to 41%, 34%, and 35% respectively of the total initially selected for the study. Part of this loss resulted from the canceling or suspension of the implementation of the intervention at the service, which led to a loss of 18% (64) of the initial number adolescents evaluated as they had been placed in groups that ended up not receiving the intervention. The remainder of the participants were not present at one or more of the three post-test and follow-up measurement dates.

The comparative study sample consists of the 74 adolescents who were present at all of the pre-test, post-test, and 6- and 12-month follow-ups. This sample consisted of 52% boys and 48% girls, and the participants averaged 11.4 years of age (SD = 1.4). A number of the participants did not know their mother’s or female guardian’s education level (36%) and, among those who did, most reported that their mothers had studied until elementary school (75%). Most participants (73%) were beneficiaries of Bolsa Família (in Portuguese), a conditional cash transfer program for families who live in extreme poverty, and lived with two caregivers (65%).

The observation data for fidelity and engagement analysis came from 13 intervention groups in the states of Sergipe (2 groups), Ceará (1 group), Rio Grande do Norte (8 groups), and Pernambuco (2 groups). Groups of adolescents, parents/guardians, and families were observed. Two hundred and sixty-seven sessions were analyzed in total, comprising 89 adolescents, 88 parents/guardians, and 90 families.

Intervention facilitators from Ceará (N = 28), Rio Grande do Norte (N = 10), and Sergipe (N = 4) participated in the telephone interviews for the SFP 10-14 implementation practicality analysis.

Instruments

Use of Alcohol, Tobacco, Marijuana, Cnhalants, Cocaine, and Crack

The pattern of drug use was assessed through a questionnaire created by the World Health Organization (Smart et al., 1980) used in previous national epidemiological studies of drug use in adolescents (Carlini et al., 2010). Seven questions about drug use (alcohol, tobacco, marijuana, cocaine, inhalants, and crack) in the last month and heavy alcohol use were employed. The questions are presented in a multiple-choice format. For example: “In the last month, that is, in the last 30 days, have you had any alcoholic beverages?”, with the following answer options: (a) no; (b) yes, I drank 1 to 5 days in the month; (c) yes, I drank 6 to 19 days in the month; (d) yes, I drank 20 days or more in the month.

Antisocial Behavior

The Inventory of Aggressive or Destructive Behavior Reported by the Adolescent (Bringas, et al., 2006) was adapted to the present study and used to assess the frequency of antisocial behaviors presented by the adolescents in the last six months. It consists of ten items (e.g., “took things that were not yours without permission”) grouped into a single factor. The adolescent is asked to indicate the frequency on a five-point Likert scale varying from “never” to “often” (α = 0.78).

Parenting Practices

Parenting practices were assessed using the Parenting Practices Scale (PPS) of Teixeira et al. (2006). A version adapted for this study was used after semantic validation with children and adolescents in vulnerable contexts. It consists of 16 items in three factors: behavior supervision (α = 0.65; for instance, “My parents try to find out where go when I leave home”), intrusiveness (α = 0.64; for instance, “My parents have a say in everything I do”), and emotional support (α = 0.82; for instance, “My parents find time to spend with me and we do something nice together”).

Self-efficacy for Learning

The self-efficacy for self-regulated learning factor of the Children’s Self-Efficacy Scale-CSES-Br (Bandura, 2006), adapted to Brazil by Freitas (2011), was used. It has nine items (α = 0.74; for example, “studying even when there are other more interesting things to do”). An alteration was made to the response scale for this study, a 5-point scale, varying from “I definitely can't do it” to “I can definitely do it” was used.

Future Time Perspective

Future perspective was assessed with a question extracted from the Permanent System of Evaluation of Basic Education questionnaire from the state of Ceará (Secretaria da Educação do Ceará, 2010). The child/adolescent was requested to indicate post-high school intentions via a multiple-choice question with the options: (a) “enter university”, (b) “take a technical course”, (c) “just work”, or (d) “do not know yet”.

School Engagement

School engagement was assessed with three questions: (a) has the child/adolescent skipped classes or school days in the last 30 days, without parent/guardian permission? If so, how many times? (response options: from “no” to “more than 5 days”) (Instituto Brasileiro de Geografia e Estatística [IBGE], 2012); (b) engagement in school tasks (response options vary from “never” to “always”) (Instituto Nacional de Estudos e Pesquisas Educacionais Anísio Teixeira [INEP], 2009); and (c) satisfaction with school (response options: from “hate it” to “love it”) (created for this study).

Academic Performance

School performance was assessed with two questions: “In general, how are your grades in school currently?” (Answer options: low, average, high) and “Did you fail last year?” (Answer options: no; yes). These questions were adapted from the System of Evaluation of Basic Education (INEP, 2009).

School Dropout

A question extracted from the System of Evaluation of Basic Education was used (INEP, 2009). The child/adolescent was invited to say if the youth had dropped out of school during the academic year and stayed out of school for the remainder of it, with answer options of (a) yes, (b) no, (c) no, school was not in session.

Parent, Adolescent, and Family Engagement

The Parent, Adolescent, and Family Engagement Observation Script, developed for this study, in which the researchers recorded descriptive observations of verbal and non-verbal behaviors that were indicators of acceptability by the adolescents, parents/guardians, and families in that day’s session was used. The instrument included indicators of interest, confidence, transference to life, change, social support, and satisfaction along with a question about the observer’s impressions of the participants' adherence to the day’s session.

Implementation Fidelity

The Direct Observation Checklist for Implementation Fidelity was used in the adolescent, parent/guardian, and family sessions. The researchers observed the conduct of sessions and afterward recorded whether the adolescent, parent/guardian, and family sessions had been held; the meeting’s planned topic had been worked; materials other than those provided in the manual had been used; and the facilitators had the necessary material for the meeting (answers: yes or no). Furthermore, they made descriptive notes of relevant events demonstrating fidelity or infidelity in the implementation, using the topics and procedures described in the intervention manual as a guide (Brasil, 2014).

Implementation Practicality

A Semi-Structured Interview Script for Facilitators was used via telephone with the facilitators to examine implementation practicality and local adaptations to the intervention. The interview script contained eight open questions. The first two investigated the facilitator’s perception of the intervention (“What do you think of the Strengthening Families Program?” and “How did you feel about facilitating Strengthening Families Program meetings?”), while the remaining six questions addressed local adaptations. In this study, only data derived from the first two questions was used.

Procedures

The intervention was conducted at basic social protection service facilities serving vulnerable families. The existing Comprehensive Family Care Program was used as a launchpad for implementing the intervention. The intervention was facilitated by psychologists and social workers with ties to those services together with professionals from basic public health care services and educators from public schools. The intervention consisted of seven meetings of two hours length in which parents and children participated in separate meetings for the first hour, and in a joint meeting for the second. A single facilitator coordinated the parents’ meeting, two facilitators coordinated the adolescents’ one, and all three facilitated the joint family session. The facilitators were trained and supervised in advance during the implementation by Oswaldo Cruz Foundation and were instructed to implement the meetings according to the intervention manual, previously translated and adapted to Brazil (Brasil, 2014).

The participating families were recruited from the families using the basic social protection services for vulnerable families. The assessment of use of alcohol (including binge drinking), tobacco, marijuana, inhalants, cocaine and crack in the last month; antisocial behavior; parenting skills; learning self-efficacy; school dropout; school engagement; and future perspective was carried out in the pre-test, post-test, and 6- and 10-12-month follow-ups. All the instruments for the evaluation of these outcomes were answered by the adolescents. The pre-test, post-test, and 6- and 10-12-month follow-ups were done at the services where the intervention had been applied, while the follow-up assessments were carried out in set of settings , including the aforementioned services as well as schools and the participants’ homes.

The direct observation of groups to assess implementation fidelity and family engagement, was performed by two researchers, one of them observed sessions for parents/ guardians, while the other followed the session for adolescents, and both observed the family sessions. The observations were recorded during the sessions. The interviews with the facilitators were conducted by telephone and recorded for later transcription.

Data Analysis

Quantitative data regarding the comparative study was analyzed using inferential and descriptive statistical techniques. For the outcomes related to antisocial behavior, parenting practices, and learning self-efficacy, in addition to the means and standard deviations of the four evaluation points, linear growth models were adjusted (Raudenbush & Bryk, 2002) using gender, the number of intervention sessions attended by the adolescent, age, and family composition as covariables. The comparison between alcohol use in the pre-test and in the post-intervention evaluations used McNemar’s test, using the answers given by the participants. Finally, for the academic outcomes (assessed through items with ordinal responses), the comparison was performed using the Wilcoxon signed-rank test using the pre-test as a reference. The analyses were performed with the R statistical package (https://cran.r-project.org/) and adopted a significance level of 5%.

Occurrence frequency for the observational data for indicators of engagement and fidelity was summed by session. Thematic analysis was used for analysis of the behavioral data that had been recorded descriptively in the engagement and fidelity instruments as well as for the analysis of verbal data from the facilitators’ interviews.

Results

Health, Parenting, and Academic Outcomes

Table 1 presents the results related to alcohol and other drug consumption. The low consumption of cigarettes, inhalants, marijuana, cocaine, and crack in the month before each of the studies evaluations can be seen. Cigarette use was reported by only one participant in post-test and by one other in the 10-12-month follow-up. As for inhalant use, only one incident in each of the first three evaluations and two in the last were reported. It should be noted that only one participant, who reported using some type of inhalant in the post-test and follow-ups, was responsible for this result. Only two adolescents reported having consumed marijuana on 1 to 5 days of the month prior to data collection in the 10-12-month follow-up; no marijuana use was reported otherwise. Cocaine use was recorded by only one participant, in the pre-test. This participant confirmed having used cocaine 20 days or more before the beginning of the study, though did not report further use in the subsequent evaluations. As for crack consumption, only one use was reported - in the month prior to the 6-month follow-up.

Table 1
Use of alcohol and other drugs in the month before each evaluation (n = 74)

	Pre-teste		Post-teste		6 months		10-12 months
Alcohol	N	%	N	%	n	%	N	%
No	69	94.5%	71	95.9%	72	97.3%	70	94.6%
Yes, 1 to 5 days	4	5.5%	3	4.1%	2	2.7%	3	4.1%
Yes, 6 to 19 days	0	0.0%	0	0.0%	0	0.0%	1	1.4%
Yes, ≥ 20 days	0	0.0%	0	0.0%	0	0.0%	0	0.0%
Total	73		74		74		74
Binge drinking	n	%	N	%	n	%	N	%
None	69	93.2%	71	95.9%	73	98.6%	70	94.6%
1 time	3	4.1%	2	2.7%	0	0.0%	1	1.4%
2 times	1	1.4%	1	1.4%	1	1.4%	1	1.4%
3 to 5 times	1	1.4%	0	0.0%	0	0.0%	0	0.0%
≥ 6 times	0	0.0%	0	0.0%	0	0.0%	2	2.7%
Total	74		74		74		74
Cigarettes	n	%	N	%	n	%	N	%
No	74	100.0%	73	98.6%	74	100.0%	72	98.6%
Yes, 1 to 5 days	0	0.0%	0	0.0%	0	0.0%	1	1.4%
Yes, 6 to 19 days	0	0.0%	0	0.0%	0	0.0%	0	0.0%
Yes, ≥ 20 days	0	0.0%	1	1.4%	0	0.0%	0	0.0%
Total	74		74		74		73
Inhalants	n	%	N	%	n	%	N	%
No	73	98.6%	73	98.6%	73	98.6%	71	97.3%
Yes, 1 to 5 days	1	1.4%	0	0.0%	1	1.4%	1	1.4%
Yes, 6 to 19 days	0	0.0%	0	0.0%	0	0.0%	1	1.4%
Yes, ≥ 20 days	0	0.0%	1	1.4%	0	0.0%	0	0.0%
Total	74		74		74		73
Marijuana	n	%	N	%	n	%	N	%
No	74	100.0%	74	100.0%	74	100.0%	71	97.3%
Yes, 1 to 5 days	0	0.0%	0	0.0%	0	0.0%	2	2.7%
Yes, 6 to 19 days	0	0.0%	0	0.0%	0	0.0%	0	0.0%
Yes, ≥ 20 days	0	0.0%	0	0.0%	0	0.0%	0	0.0%
Total	74		74		74		73
Cocaine	n	%	N	%	n	%	N	%
No	72	98.6%	74	100.0%	74	100.0%	73	100.0%
Yes, 1 to 5 days	0	0.0%	0	0.0%	0	0.0%	0	0.0%
Yes, 6 to 19 days	0	0.0%	0	0.0%	0	0.0%	0	0.0%
Yes, ≥ 20 days	1	1.4%	0	0.0%	0	0.0%	0	0.0%
Total	73		74		74		73
Crack	n	%	N	%	n	%	N	%
No	74	100.0%	74	100.0%	73	98.6%	74	100.0%
Yes, 1 to 5 days	0	0.0%	0	0.0%	1	1.4%	0	0.0%
Yes, 6 to 19 days	0	0.0%	0	0.0%	0	0.0%	0	0.0%
Yes, ≥ 20 days	0	0.0%	0	0.0%	0	0.0%	0	0.0%
Total	74		74		74		74

A greater frequency of alcohol consumption and binge-drinking can be seen in the months prior to each evaluation time (Table 1). In Table 2 the results are reported in a dichotomous form; in it, the answer “yes” is independent of the number of times or days of consumption. In this sample, it turned out that the percentages consuming alcohol and engaging in binge-drinking diminished in the post-test and the 6-month follow-up but returned to their initial levels in the 10-12-month follow-up. However, the differences between the pre-test and the subsequent evaluations were not significant.

Table 2
Consumption of alcohol and binge drinking in the month before each evaluation (n = 74) and p-value relative to the McNemar test.

	Pre-test		Post-test		6 months		10-12 months
Alcohol	N	%	N	%	N	%	N	%
No	69	94.5%	71	95.9%	72	97.3%	70	94.6%
Yes	4	5.5%	3	4.1%	2	2.7%	4	5.4%
Total	73		74		74		74
			p= 0.617	p= 0.683	p= 1.00
	Pre-test		Post-test		6 months		10-12 months
Binge drinking	N	%	N	%	N	%	N	%
None	69	93.2%	71	95.9%	73	98.6%	70	94.6%
At least 1 time	5	6.8%	3	4.1%	1	1.4%	4	6.4%
Total	74		74		74		74
			p= 0.617	p= 0.134	p= 1.00

• * p-value relative to the McNemar test.

The results from the antisocial behavior, parenting practices, and learning self-efficacy scales are presented in Tables 3 and 4. For the outcome of antisocial behavior, a small increase can be seen on average over the evaluation period (Table 3). However, in the adjusted model, no significant increase in this variable over the four evaluations can be identified (Table 4). In the proposed model, a significant effect was found only for the age variable, that is, antisocial behavior is greater for the older participants on average.

The analysis of the effect of SFP 10-14 on parenting practices reveals that emotional support and intrusiveness present small variations from evaluation to evaluation (Table 3); though, no significant change was identified (Table 4). The data indicates that the older the adolescent, the lower the perception of emotional support from the parents. On the other hand, behavior supervision presented a significant increase over the analyzed period. This result can be seen in the boost to this variable’s average (Table 3) and confirmed via the significant linear affect indicated by the model (Table 4).

Table 3
Averages and standard deviations for antisocial behavior, parenting practices, and learning self-efficacy at each evaluation (n = 74)

Outcome	Pre-test	Post-test	6 months	10-12 months
Antisocial behavior	1.42 (0.64)	1.47 (0.69)	1.49 (0.78)	1.47 (0.62)
Parenting practices
Social support	3.85 (1.13)	4.14 (1.08)	3.98 (0.75)	4.03 (0.85)
Intrusiveness	2.51 (1.02)	2.58 (1.16)	2.30 (1.05)	2.55 (1.20)
Behavior supervision	3.92 (1.22)	4.03 (1.11)	4.14 (0.98)	4.22 (0.94)
Learning self-efficacy	3.54 (1.07)	3.68 (0.90)	3.86 (0.74)	4.02 (0.59)

The outcome of learning self-efficacy variable presented a significant increase over the four evaluations, beyond the differences related to age and family composition (Table 4). These findings reveal linear growth of self-efficacy when all four evaluation points are considered. According to the model, self-efficacy tends to be greater for younger participants. Furthermore, the presence of two parents/guardians at home is associated with a greater level of self-efficacy.

Table 4
Linear growth model adjustment for antisocial behavior, parenting practices, and learning self-efficacy (n = 74)

	Antisocial behavior	Parenting practices			Learning self-efficacy
		Emotional support	Intrusiveness	Behavior supervision
Time	0.006	0.006	0.004	0.023*	0.037**
Number of meetings	-0.004	0.009	0.050	-0.059	0.012
Male	0.021	0.123	0.199	-0.080	0.107
Age	0.052*	-0.121**	0.045	-0.063	-0.062*
Family composition	-0.062	0.141	-0.244	0.263	0.282*

• * p< 0.05, **p< 0.01.

No significant differences for variables related to school education were identified from pre-test to later periods (Table 5). A descriptive analysis of the academic data presented in Table 5 indicates that, regarding the non-parental-approved absences, there was an initial reduction in the post-test, however the number of absences regressed to the initial level in the follow-ups. An increase in performance and engagement, according to the sample participants’ reports, was observed, with an improvement in the percentage receiving average or high grades over the period and in the percentage of individuals asserting having done their homework most of the time or always. School satisfaction was the variable presenting the least variation in the period analyzed.

The results pertaining to future time perspective are described in Table 5. These results, obtained by means of a closed question, do not permit identification of tendencies, but some points may be highlighted. There is a reduction in the intention to enter higher education (9.4%) and to just work (6.7%) between the 10-12-month follow-up and the pre-test and an jump of 8.1% in the percentage of participants who say they do not know what they intend to do when they finish high school.

Intervention Engagement

Figure 1 describes the incidence of adolescent, parent/guardian, and family engagement over the intervention, according to the observed behavior indicators of interest, confidence, transference to life, change, social support, and satisfaction. The observational data analyses of the occurrence of engagement indicators over the course of the intervention indicated a greater incidence of engagement behaviors in the parent/guardian sessions, followed by the family ones. The incidence of confidence indicators (for example, sharing personal stories, exchanging information with each other and the facilitators), interest (demonstrating curiosity in the facilitators’ talks, undertaking activities with enthusiasm, showing a desire to learn), social support (showing empathy toward each other, encouraging peer talk, reacting with peer solidarity, giving advice to peers), and satisfaction (commending the program and the facilitators) were observed even in the first parent/guardian session and kept up over the other sessions. Comparatively, a lower occurrence of these indicators was observed in the youth sessions than in the family and parent/guardian ones.

Figure 1.
Engagement indicators for families, adolescents, and parents/guardians observed in the intervention (N = 13 groups).

Table 5
Comparison between pre-test, post-test, and 6- and 10-12-month follow-ups for the outcomes related to school life and plans for the future

	Pre-test		Post-text		6 months		10-12 months
Absences	n	%	n	%	n	%	n	%
None	58	78.4%	61	82.4%	57	77.0%	54	73.0%
1 or 2	12	16.2%	11	14.9%	14	18.9%	8	10.8%
3 to 5	3	4.1%	1	1.4%	1	1.4%	9	12.2%
≥ 6	1	1.4%	0	0.0%	2	2.7%	3	4.1%
	74		73		74		74
		p= 0.159	p= 0.901	p= 0.084
Does homework	n	%	n	%	n	%	n	%
Never	1	1.4%	3	4.1%	0	0.0%	0	0.0%
Rarely	8	10.8%	4	5.4%	5	6.8%	3	4.1%
Sometimes	16	21.6%	12	16.2%	13	17.6%	17	23.0%
Often	10	13.5%	12	16.2%	10	13.5%	12	16.2%
Always	38	51.4%	42	56.8%	45	60.8%	42	56.8%
	73		73		73		74
		p= 0.478	p= 0.104	p= 0.138
School satisfaction	n	%	n	%	n	%	n	%
Hate	3	4.1%	2	2.7%	2	2.7%	1	1.4%
Dislike	1	1.4%	2	2.7%	1	1.4%	2	2.7%
Like a little	19	25.7%	19	25.7%	20	27.0%	17	23.0%
Like a lot	27	36.5%	24	32.4%	29	39.2%	26	35.1%
Love	24	32.4%	27	36.5%	22	29.7%	27	36.5%
	74		74		74		73
		p= 0.645	p= 0.877	p= 0.596
Grades	n	%	n	%	n	%	n	%
Low	7	9.5%	8	10.8%	3	4.1%	4	5.4%
Average	28	37.8%	32	43.2%	36	48.6%	33	44.6%
High	35	47.3%	34	45.9%	33	44.6%	36	48.6%
	70		74		72		73
		p= 0.544	p= 0.535	p= 0.195
Future plans	n	%	n	%	n	%	n	%
College	36	48.6%	34	45.9%	30	40.5%	29	39.2%
Technical school	6	8.1%	9	12.2%	6	8.1%	10	13.5%
Just work	10	13.5%	11	14.9%	10	13.5%	5	6.8%
Other plans	5	6.8%	6	8.1%	9	12.2%	8	10.8%
Still don’t know	14	18.9%	12	16.2%	17	23.0%	20	27.0%
	71		72		72		72

Behavior indicators for transference to life and change due to the intervention were seen starting in the second session, having their highest incidence in the parent/guardian session followed by the adolescent and family sessions. For the transference to life category, applying the strategies or skills learned in the intervention to day-to-day interactions, such as using a point/scoring system to teach rule and limits, doing household chores, helping parents around the house, and giving advice to classmates and other parents based on what they learned in the program were reported. As for changes, reports of behavior changes noticed by the participants promoted by the intervention, such as talking instead of fighting (parents and children), stepping out to control anger and later solving problems (parents and children), and stopping drinking and finding a job after participating in the program (parents) were recorded.

Intervention Implementation Fidelity

The implementation fidelity analyses reveal that the family, parent/guardian, and adolescent meetings were held at all observed opportunities (Figure 2). Furthermore, at almost all the observed meetings, the scheduled subject was addressed and the correct materials and DVD for the session were used. The use of materials foreign to the program was rare, having been most frequent in the last family session, where photographs and small gifts and keepsakes were exchanged to say goodbye to the families and to celebrate the end of the intervention.

Figure 2.
SFP 10-14 implementation fidelity indicators observed in parent/guardian, adolescent, and family meetings (N = 13 groups).

Intervention Practicality

The positive aspects noted by the facilitators were related to the intervention’s intended goals, its methodological quality, and its impacts on the families, the community, and the facilitators themselves. The facilitators stressed how relevant the intervention’s objectives were, namely, the strengthening of bonds and prevention of harm to the health of the adolescent. They perceived the methodology as valid, attractive, creative, and dynamic. They emphasized that the intervention brings families and the community together and that parents reported learning over the course of the intervention. Finally, they said the offering of the intervention brought new meaning to their work and they felt useful, gratified, and fulfilled in their family interactions.

On the other hand, negative aspects noted by the facilitators included insufficient retention of families, an intervention decontextualized for impoverished families, comprehensibility impaired for families with low educational levels, and the intervention format causing distress and anxiety in facilitators by virtue of being highly structured and having timed procedures. Additionally, they reported having experienced insecurity, confusion, and difficulties in managing the intervention groups, especially in the initial sessions.

The interviewees recommended improvements aimed at the implementation process and at the intervention itself. Under implementation process, they recommended augmenting support from municipal management and local services, increasing the facilitator training time, and adopting implementation strategies capable of reaching and retaining a greater number of families. Regarding the intervention proper, the facilitators suggested adapting the videos to Brazilian families in vulnerable socioeconomic situations, adapting the intervention more specifically to a given region, and boosting the intervention’s attractiveness with the aim of doing away with the need for snacks and gifts thereby decreasing the implementation cost.

Discussion

This study sought to analyze the feasibility of SFP 10-14 in a sample of Brazilian families by investigating the intervention’s limited effectiveness, acceptability, and implementation practicality. The comparative analyses between pre-test, post-test, and 6- and 10-to-12-month follow-ups revealed a significant increase in parental supervision and learning self-efficacy over time, while other outcomes lacked significant changes. Parents/guardians showed themselves to have found the intervention highly acceptable, whereas the adolescents found it moderately so, and facilitators presented conflicting acceptability views. The facilitators considered the intervention to have relevant subject matter and acceptable procedures, but had problems with the excessively structured format and material that was barely understandable to families with low educational level. They pointed to the involvement of managers in the implementation process, the training of facilitators, and the reach and retention of families as crucial goals for implementation practicality.

Similar findings of a boost to parental supervision were found in other Latin American studies (Orpinas et al., 2014). Likewise, the parental supervision improvement results are coherent with the reports of this study’s parents/guardians and adolescents regarding the use of skills aimed at improving the family learned in the intervention in their daily interactions, especially communication and emotion regulation. Such findings on improvement in parental supervision, communication and emotional regulation gain relevance when considering the context of poverty experienced by the families participating in this study. There is ample evidence that the condition of poverty emphasizes parental stress and reduces the readiness of parents to engage in interactions receptive to the developmental needs of children and adolescents (Silva et al., 2019). In this regard, access to tools that increase parental competence made available in SFP 10-14 and related interventions can represent a gain for families that are deprived of resources, such as education and knowledge. It is, therefore, a microsocial intervention that mitigates a condition of scarce resources, to which other meso and macrosocial interventions must be added, especially vital for a generation victimized by austerity policies that emphasize inequities (Malta et al., 2018).

Equally relevant were the findings on academic self-efficacy, which improved over time at each evaluation. No previous studies evaluated the impact of this intervention on learning self-efficacy, which prevents comparisons. However, the results of the present study are consistent with previous findings of the positive impact of SFP 10-14 on academic success and school engagement (Spoth et al., 2008). Nonetheless, in the present study, which analyzed effects in the short term, other scholastic mastery skills did not change significantly. This being the case, it should be noted that evidence for SFP 10-14’s effectiveness on scholastic and health outcomes, such as antisocial behavior, substance abuse, and risky sexual behavior, derives from studies with medium- and long-term follow-ups (Spoth et al., 2000, 2008, 2014). As for drug abuse, it is noteworthy that this study’s findings show a very low prevalence of alcohol and other substance abuse both before and after the intervention. Substance abuse was not a baseline problem and remained so across the three evaluation points. In this sense, the absence of change may be interpreted as desirable result, compatible with the expectations for universal preventive interventions.

The parents/guardians found the intervention to be highly acceptable and adolescents, moderately so. Parents demonstrated greater interest, trust, social support exchange, satisfaction, and daily application of skills learned in the intervention than adolescents. It is possible that the lower adolescent engagement is due to the minimal attractiveness of the intervention in the face of their developmental needs (for example: the excessive use of written activities in detriment of participative strategies) and/or the facilitators’ weak skills for managing groups of adolescents. The findings gleaned from the interviews with the facilitators suggest, on the one hand, high acceptability for having a theoretically well-founded methodology, with creative procedures and goals compatible with the needs of families using basic protection services. However, on the other, the facilitators noted the low ease of intervention implementation versus contextual restrictions, such as offering snacks and gifts and its incompatibility with the deficient reading and writing skills of the target audience. Similarly, contextual barriers influenced the feasibility of SFP 10-14 in Europe as well, as indicated by Burkhart (2015).

Various practical implications derive from this data. Given the low implementation practicality reported by the facilitators, one alternative solution could be the adaptation or development of new, less onerous interventions for scarce resource contexts (United Nations Office on Drugs and Crime, n.d.). As such, the offering of adapted interventions derived from SFP 10-14 by non-professional, specialist providers should be considered, for example home visits as a part of existing service routines, which has already been shown to be viable in low- and middle-income countries (Healy et al., 2018). Furthermore, greater attention needs to be placed on the poverty of the families’ neighborhoods and the low educational level of the parents in the next wave of cultural adaptation. Such aspects are admittedly relevant to the transportability and adaptation of interventions developed in high-income countries to low and middle income ones (Knerr et al., 2013). Additionally, strategies for boosting the recruitment and adherence of families are fundamental to the implementation process, as noted in other Latin American countries (Mejía et al., 2019) and European ones (Segrott, 2013). Finally, this concerns not improving the intervention and family engagement, but also the delivery system. Clinical skills training for managing the facilitator groups is crucial, as has been the case in similar experiences of offering family and parent interventions to promote the mental health of children and adolescents in low- and middle-income countries (Pederson et al., 2019).

The findings on the practicality of SFP 10-14 for Brazilian families point to ways for the design of local interventions. The strengthening of family and community bonds should be considered as part of the theory of new interventions. The mechanisms of change foreseen in the intervention theory must be converted into clear objectives, while the procedures must be flexible (Isaacs et al., 2017). To this end, facilitators should receive training that enables them to adapt to the procedures, in a way that is sensitive to the needs of families, while remaining loyal to the objectives of the intervention. In addition, the bases, objectives and content of new interventions must be perceived as significant by the facilitators, in order to promote their engagement in the process of implementing and incorporating the intervention in the services. In this regard, we suggest designs based on collaborative frameworks, such as the co-production of interventions (Hawkins et al., 2017), a process that involves multiple stakeholders, such as community leaders, researchers, users, facilitators and managers. This would facilitate the customization of new interventions in the resources, peculiarities and needs of the context and target families and, therefore, their viability (Bowen et al., 2009).

The evidence of SFP 10-14 effectiveness identified in this study should be interpreted cautiously in light of the capabilities and limitations of a feasibility study. The pre-experimental design adopted does not permit safely making causal inferences about the intervention’s impact on the outcomes analyzed. The small sample size, the loss of participants between the pre-test and follow-ups, and the absence of a control group impair conclusive answers on the impact and point to the need for further effectiveness studies. It is also worth noting the low reliability index of the Parenting Practices Scale identified in the sample of this study, which may have affected the quality measurement of the emotional support, behavior supervision and parental intrusiveness. In addition, the use of fidelity criteria strictly related to the structure and content of the invention constitutes another limitation. Such criteria omit information about how the intervention was carried out, which protective processes were promoted, and to what extent the session objectives were covered.

Future effectiveness studies should be performed after new SFP 10-14 cultural adaptation waves, with the aim of making it less onerous, more flexible, and more compatible with the opportunities and restrictions of basic social protection services for economically disadvantaged Brazilian families. The mixed findings around the implementation’s practicality and acceptability highlight the need for improvements in the intervention itself and its support and delivery system to augment its feasibility, which should be incorporated into new versions of the intervention and then tested (Mejía et al., 2019). In conclusion, the scalability of SFP 10-14 in Brazil as an instrument of public policy related to preventing harm to adolescent health and strengthening family bonds depends, in short, on refining the intervention, correcting gaps in the implementation process, and cumulative evidence for its effectiveness.

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  Apoio: SENAD

• Erratum

  Erratum of article: Murta, Sheila Giardini, Vinha, Luís Gustavo do Amaral, Nobre-Sandoval, Larissa de Almeida, Miranda, Ana Aparecida Vilela, Menezes, Jordana Calil Lopes de, & Rocha, Viviane Paula Santos. (2020). Feasibility of the Strengthening Families Program for Brazilian Families: A Mixed Method Study. Psicologia: Teoria e Pesquisa, 36(spe), e36nspe16. https://doi.org/10.1590/0102.3772e36nspe16
  On page 3, in the title of the subsection Instruments, should be included the footnote:
  * Part of the instruments was described by Murta, S. G., Vinha, L. G. A., Nobre-Sandoval, L. A., Rocha, V. P. S., Duailibe, K. A., Gomes, M. S. M., Farias, D. A., & Foxcroft, D. R. (2020). Exploring the short-term effects of the Strengthening Families Program on Brazilian adolescents: a pre-experimental study. Drugs, Education, Prevention and Policy. https://doi.org/10.1080/09687637.2020.1769030

Publication Dates

• Publication in this collection
  02 Dec 2020
• Date of issue
  2020

History

• Received
  10 Oct 2019
• Reviewed
  22 Jan 2020
• Accepted
  26 Mar 2020