Lessons learned in evaluating the Familias Fuertes program in three countries in Latin America

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Informe especial / Special report                                                                                                            Pan American Journal
                                                                                                                                                   of Public Health

Lessons learned in evaluating the
Familias Fuertes program in three countries
in Latin America
Pamela Orpinas,1 Ashley Ambrose,2 Matilde Maddaleno,3
Lauren Vulanovic ,2 Martha Mejia,4 Betzabé Butrón,2
Gonzalo Sosa Gutierrez,5 and Ismael Soriano 2

                            Suggested citation          Orpinas P, Ambrose A, Maddaleno M, Vulanovic L, Mejia M, Butrón B, et al. Lessons learned in
                                                        evaluating the Familias Fuertes program in three countries in Latin America. Rev Panam Salud Publica.
                                                        2014;36(6):383–90.

                                      abstract          This report describes 1) the evaluation of the Familias Fuertes primary prevention program
                                                        in three countries (Bolivia, Colombia, and Ecuador) and 2) the effect of program participation
                                                        on parenting practices. Familias Fuertes was implemented in Bolivia (10 groups, 96 parents),
                                                        Colombia (12 groups, 173 parents), and Ecuador (five groups, 42 parents) to prevent the
                                                        initiation and reduce the prevalence of health-compromising behaviors among adolescents by
                                                        strengthening family relationships and enhancing parenting skills. The program consists of
                                                        seven group sessions (for 6–12 families) designed for parents/caregivers and their 10–14-year-
                                                        old child. Parents/caregivers answered a survey before the first session and at the completion of
                                                        the program. The survey measured two important mediating constructs: “positive parenting”
                                                        and “parental hostility.” The Pan American Health Organization provided training for facili-
                                                        tators. After the program, parents/caregivers from all three countries reported significantly
                                                        higher mean scores for “positive parenting” and significantly lower mean scores for “parental
                                                        hostility” than at the pre-test. “Positive parenting” practices paired with low “parental hos-
                                                        tility” are fundamental to strengthening the relationship between parents/caregivers and the
                                                        children and reducing adolescents’ health-compromising behaviors. More research is needed to
                                                        examine the long-term impact of the program on adolescent behaviors.

                                      Key words         Parenting; adolescent; adolescent behavior; primary prevention; family; Bolivia;
                                                        Colombia; Ecuador; Latin America.

  Parents/caregivers play pivotal roles                 tional and physical well-being and pro-             at parenting have a warm and caring
in the lives of the children they raise.                tect them from harm and adverse cir-                relationship with the children (3); com-
They can promote the children’s emo-                    cumstances such as discrimination and               municate family values against high-risk
                                                        poverty. Quality of family relationships            behaviors (4); and maintain consistent
1	
  Department      of Health Promotion and Behavior,     is important in the parenting process.              discipline, supervision, and involvement
   University of Georgia, Athens, Georgia, United
   States of America. Send correspondence to:           Good parenting skills can protect chil-             (5–8). Parenting that reflects a combina-
   ­Pamela Orpinas, porpinas@uga.edu                    dren and adolescents from engaging in               tion of all of these characteristics may
2	 Department of Family, Gender and Life Course,
    Pan American Health Organization, Washington,
                                                        behaviors that compromise their health,             have the strongest positive effect on pre-
    District of Columbia, United States of America.     such as drug use, early sexual activ-               venting risk behaviors (9, 10). Strong pa-
3	Ministry of Health, Santiago, Chile.
4	Pan American Health Organization, La Paz, Bolivia.
                                                        ity, school dropout, and peer aggression            rental control may be particularly impor-
5	 Ministry of Health and Social Protection, Bogotá,   (1, 2). Decades of family research have             tant for children living in areas where
    Colombia.                                           determined that those most successful               drugs and violence abound (3, 11). Con-

Rev Panam Salud Publica 36(6), 2014                                                                                                                           383
Special report                                  Orpinas et al. • Lessons learned in evaluating the Familias Fuertes program in three countries

versely, researchers have consistently                   TABLE 1. Familias Fuertes program: session objectives
shown that harsh parental discipline and
lack of parenting skills can lead youth to                 Session                                Objectives
engage in numerous problem behaviors                          1       Parents/caregivers give love and set limits
(12, 13).                                                             Youth communicate goals and dreams
                                                                      Whole family supports goals and dreams
    Most parents/caregivers would like to
provide a good environment for the chil-                      2       Parents/caregivers establish home rules
                                                                      Youth learn to appreciate parents
dren to succeed, but some do not have
                                                                      Whole family promotes family communication
the knowledge and skills to create a posi-
                                                              3       Parents/caregivers stimulate good behavior
tive home environment that balances
                                                                      Youth deal with stress in healthy ways
affection with age-appropriate limits.                                Whole family appreciates family members
Programs designed to improve parent-
                                                              4       Parents/caregivers learn to set appropriate consequences
ing skills may be particularly important                              Youth learn to obey the rules
in low- and medium-income countries                                   Whole family uses family reunions
where parents/caregivers have limited                         5       Parents/caregivers practice listening and paying attention to feelings
resources (2).                                                        Youth deal with peer pressure
    In 2007, the Pan American Health                                  Whole family understands family values
Organization (PAHO) selected the                              6       Parents/caregivers help protect youth against high-risk behaviors
Strengthening Families Program (SFP)                                  Youth practice resisting peer pressure and choosing good friends
for parents and youth aged 10–14 years                                Whole family talks about peer pressure and establishing expectations
as the best model for prevention for Latin                    7       Parents/caregivers focus on connecting to community resources
American families (14). PAHO adapted                                  Youth learn ways to help others and interact with positive role models
                                                                      Whole family reviews program content and graduate
the program for Latin Americans by
modifying some of its strategies and cre-
ating videos with actors who reflected a
wide range of Latino racial groups but         based on the presence of behavioral or                success (25); and savings of US$ 9.60 for
used a standardized Spanish language           emotional problems. Second, as a family-              every dollar invested (26).
(15). The adapted version, known as Fa-        centered prevention program, the values                  The goal of this report was to describe
milias Fuertes (FF), has been implemented      promoted by FF are consistent with the                1) the evaluation of FF in three countries
in 13 countries in Latin America and the       strong ties of the Latino family (18). La-            in Latin America—Bolivia, Colombia,
Caribbean, as well as in the United States     tino parents/caregivers and adolescents               and Ecuador—and 2) the effect of FF on
(16). The program is designed for youth        have both emphasized the importance                   parenting skills of parents or caregiv-
living in any family configuration and         of the whole family participating in the              ers who participated in the program.
the videos portray different types of          program (16). Third, FF has the poten-                Parents/caregivers completed a survey
family structures. All adults who take         tial to bridge the gap between theory                 before and after participating in the
care of youth are invited to participate       (research) and practice (implementation)              seven-session program (“pre-test” and
as research conducted among traditional        because the program can be organized                  “post-test”). It was hypothesized that
family structures indicates family inter-      and administered by community mem-                    participating parents/caregivers’ “posi-
vention programs are more successful           bers without advanced degrees. Fourth,                tive parenting” skills would increase and
when they include both the father and          FF is relatively inexpensive to imple-                “parental hostility” would decrease.
mother (17). The long-term goal of FF          ment and only comprises seven short
is to prevent the initiation of high-risk      sessions. All of the materials—includ-                MATERIALS AND METHODS
behaviors among adolescents (e.g., use         ing videos, printable facilitator manuals,
of alcohol and other drugs, early sexual       and PAHO’s manual for measuring                       The intervention
intercourse, teen pregnancy, aggression,       behavior-mediating constructs (19)—are
and school dropout) and reduce their           free and can be downloaded from the                      FF consists of seven weekly two-hour
prevalence by strengthening relation-          PAHO website.6 Fifth, FF is based on the              sessions for parents/caregivers and chil-
ships among family members and pro-            SFP, which has been shown to be very ef-              dren in the family aged 10–14 years. The
moting self-regulation and positive con-       fective. In clinical trials conducted among           participants are divided into groups of
flict resolution strategies.                   a predominantly white student popula-                 6–12 families each. During the first hour
    FF has several characteristics that make   tion in Iowa, completion of the SFP was               of each session, parents/caregivers and
it ideal for prevention of high-risk behav-    associated with long-term reductions in               children work in separate groups; during
iors. First, FF is designed as a primary       the initiation and past-month use of al-              the second hour all family members work
prevention program for all families with       cohol and cigarettes (20); slower overall             together in the same group. Table 1 pro-
an adolescent aged 10–14 years. The goal       growth in substance use (21); reduced                 vides details about the objectives of each
of the program is to prevent initiation        use of methamphetamine (“meth”) and                   session by group (youth, parents/care-
of the “slippery slope” of trying drugs,       prescription drugs (22); reduced high-risk            givers, and whole family). The sessions
missing school, and becoming teen par-         sexual behaviors (23); reduced aggression             include videos, interactive exercises,
ents, and thus falling into a self-defeating   and hostility (24); increased academic                and discussions. Facilitators who have
process of cumulative disadvantage. Se-                                                              completed the FF program’s three-day
lection of adolescent participants is not      6	http://tinyurl.com/PAHO-ES-FF                      training workshop lead the sessions. FF

384                                                                                                                  Rev Panam Salud Publica 36(6), 2014
Orpinas et al. • Lessons learned in evaluating the Familias Fuertes program in three countries                                      Special report

facilitators do not require clinical training     behavior, and 3) increase their consis-         supervision. Figure 1 depicts the pro-
or advanced degrees but do need to have           tency in monitoring and supervising the         gram’s conceptual model, including the
good facilitation skills, enthusiasm, and         child’s whereabouts. Parents/caregivers         hypothesized mediators and outcomes,
the ability to maintain program fidelity.         also learn to communicate family values         and details about the specific behaviors
“Effective group leaders can be drawn             that do not support high-risk behaviors.        the program targets among parents/
from the following: family and youth ser-         Youth are encouraged to communicate             caregivers, youth, and the community.
vice workers, mental health staff, teach-         more effectively with their parents/care-
ers, school counselors, ministers, church         givers, share their goals, and understand       Study design and sample
youth staff, skilled parents/caregivers           and follow home rules.
who have previously attended the pro-                 In addition to teaching parents/               FF was implemented in the three
gram, and staff from [Iowa’s] Coopera-            ­caregivers how to express love and set         countries as a community service, not
tive Extension Service” (14). As a primary         limits within the family, FF is designed       as a research study. The purpose of the
prevention program, FF is designed for             to improve the children’s ability to make      subsequent evaluation described here
all families, not just those with children         decisions with their peers and to enhance      was to document change in behavior
with behavioral or emotional problems.             youth cognitions that have been shown to       among participants upon their comple-
   FF is guided by two principles of               be effective in preventing drug use. Most      tion of the program, under the auspices
effective child rearing. The first prin-           children are not “pulled” into groups          of PAHO and based on its ethical guide-
ciple is to express love. FF is designed           with values that conflict with their own.      lines, with the goal of improving parent-
to enhance parents/caregivers’ positive            Rather, they will choose friends with dis-     ing practices. Thus, none of the countries
relationship with the child by reinforc-           positions that match their own, which are      had a control group. In all countries, the
ing skills that better enable them to              influenced by parenting practices (27).        program was implemented in schools.
give compliments, show affection, ap-              Thus, parents/caregivers have an indirect      Participants completed the pre-test at
preciate the child’s goals and activities,         role in influencing the child to choose        the beginning of the first session and the
and be involved in the child’s world.              positive friendships. As a community-          post-test at the end of the seventh ses-
The second principle is to set limits.             based program, FF facilitates the interac-     sion. The surveys used in all three coun-
Parents/­caregivers learn to 1) establish          tion among the parents/caregivers who          tries measured the mediating constructs
home rules, and effective consequences             participate in the program, enhances so-       identified in the program’s theoretical
for breaking them, 2) reinforce positive           cial support, and provides community           model. Between September and Decem-

        FIGURE 1. Familias Fuertes program conceptual model

                    Activities                                        Mediators                                     Outcomes

                                                               PARENTS/CAREGIVERS
                                                     Improve positive parenting practices
                                                     – Enhance positive relationship with child
                                                       (compliments, affection, appreciation,
                                                       involvement)
                                                     – Communicate family values against
                                                       high-risk behaviors                                 Reduce health-compromising
                                                     – Increase consistent parental discipline             behaviors among youth:
                                                       and supervision
                                                                                                           1) Decrease initiation and/or
            Program Effects:                                                                                  delay onset of alcohol,
            Deliver 7 sessions of                                       YOUTH                                 tobacco, and other drug
            Familias Fuertes Program                 Enhance preventive cognitions                            use
                                                     – Increase negative attitudes toward                  2) Reduce prevalence of
                                                       high-risk behaviors                                    school dropout and
                                                     – Enhance goal-oriented decisions                        aggression
                                                     Improve decision-making with peers
                                                     – Increase resistance to peer pressure
                                                     – Increase appreciation of good friends
                                                     Improve family relationships
                                                     – Enhance positive relationship with
                                                       parents (compliments, affection,
                                                       appreciation, involvement)
                                                     – Understand and accept family values
                                                       against high-risk behaviors
                                                     – Follow parental rules

          Community Effects:
          Provide opportunities for                                 COMMUNITY
          interpersonal communication                Increase sense of empowerment
          in a safe and relaxed                      – Increase communication and social
          environment                                  support with other parents/neighbors

Rev Panam Salud Publica 36(6), 2014                                                                                                            385
Special report                                                     Orpinas et al. • Lessons learned in evaluating the Familias Fuertes program in three countries

ber 2012, PAHO trained local facilita-                          Quito. The mean age of parents/­caregivers                         Positive parenting. The “positive par-
tors in La Paz (Bolivia) (n = 35), Bogotá                       was 40.4 (SD = 6.9, range 27–52). Over half                        enting” construct refers to parental be-
(Colombia) (n = 31), and Quito (Ecua-                           of the participants were women (54%).                              haviors that show love, appreciation,
dor) (n = 21). All FF sessions were imple-                      Approximately 30% of the families had                              and interest in the child’s ideas and ac-
mented after the training. Participants                         finished high school, and another 30% had                          tivities. In Bolivia, “positive parenting”
included the parents/caregivers, mostly                         some college education. Three siblings                             was measured by six items (alpha = 0.79);
mothers, and one child per family. The                          participated but did not complete the pre-                         in Colombia, it was measured by only
children’s age ranged between 10 and 14                         test or the post-test.                                             three of those items (alpha = 0.71). In
years. In all countries, the sample of par-                                                                                        Ecuador, it was measured with two dif-
ticipating children was evenly divided                          Measures                                                           ferent scales: one determining the level
by gender (girls: 48%; boys: 52%).                                                                                                 of “parental appreciation” (seven items,
                                                                   All surveys measured the two main                               alpha = 0.80) from the Positive Parenting
Bolivia. In Bolivia, 10 FF groups were                          constructs that the program is designed                            Style Scale (28) and the other determin-
conducted with a total of 119 families.                         to influence: “positive parenting” and                             ing the level of “parental warmth” (five
The large majority of these families had                        “parental hostility.” However, because                             items, alpha = 0.82) based on the Behav-
an indigenous ethnic background (Ay-                            this was not a research study, there                               ioral Affect Rating Scale (19, 29).
mara). Participants lived in low-income                         were some differences in the instru-
areas in suburbs of the city of La Paz,                         ments selected in each country. In Bo-                             Parental hostility. The “parental hostil-
with high levels of insecurity and high                         livia and Colombia, parents/caregivers                             ity” construct refers to parental behav-
exposure to social risks. The mean age of                       completed a short survey, whereas in                               iors that can indicate anger, such as
parents/caregivers was 37.3 (standard                           Ecuador parents/caregivers completed                               losing control, shouting, or hitting. In
deviation (SD) = 8.7, range 18–68). The                         a longer survey. For Ecuador, four                                 Bolivia, “parental hostility” was mea-
majority of participants were women                             additional constructs were reported:                               sured by five items (alpha = 0.72); in
(86%). Three older siblings and a few                           “parental involvement,” “consistent                                Colombia, it was measured with three
grandparents also participated.                                 discipline,” “parental monitoring,” and                            of those items (alpha = 0.71). In Ecua-
                                                                “parental communication against high-                              dor, “parental hostility” was measured
Colombia. In Colombia, 12 FF groups                             risk behaviors.” All scale scores were                             using the hostility subscale (seven items,
were conducted with 182 families. The                           computed as the average of all the                                 alpha = 0.85) from the Behavioral Affect
program was implemented in four cit-                            items, with higher scores representing                             Rating Scale (19, 29).
ies: Barranquilla, Cúcuta, Manizales,                           stronger support for the construct. Re-
and Palmira. The mean age of parents/                           sponse categories are listed in Table 2.                           Parental involvement. “Parental in-
­caregivers was 40.6 (SD = 8.1, range 27–                       Completion of the survey was volun-                                volvement” in the child’s life was mea-
 71) and the majority were women (75%).                         tary and did not affect whether or not                             sured with 10 items (alpha = 0.79) based
                                                                families could participate in the pro-                             on scales used in previous studies (19)
Ecuador. In Ecuador, five FF groups were                        gram. Participants were informed that                              but modified to incorporate behaviors
implemented with 82 families. The pro-                          they could skip questions or refuse to                             reinforced by the FF program, such as
gram was conducted in three schools in                          answer.                                                            support for the child’s goals and dreams.

                  TABLE 2. Comparison of parent/caregiver responses before and after the implementation of the Familias Fuertes
                  program, Bolivia, Colombia, and Ecuador, 2012–2013

                                                                                             Pre-test               Post-test
                                  Behavior-mediating constructa                             mean (SDb)             mean (SD)              tc       df d        P
                  Bolivia
                    Positive parentinge                                                     3.10 (0.63)            3.30 (0.57)        –3.610        90        0.001
                    Parental hostilitye                                                     2.04 (0.54)            1.88 (0.51)         3.031        92        0.003
                  Colombia
                    Positive parentinge                                                     3.38 (0.65)            3.54 (0.52)        –3.069       172        0.002
                    Parental hostilitye                                                     2.07 (0.63)            1.90 (0.68)         2.803       172        0.006
                  Ecuador
                    Parental appreciationf                                                  3.80 (0.53)            4.15 (0.51)        –5.230        41     < 0.0001
                    Parental warmthf                                                        4.18 (0.63)            4.51 (0.44)        –4.386        41     < 0.0001
                    Parental hostilityf                                                     2.78 (0.67)            2.50 (0.53)         3.593        40        0.001
                    Parental involvementf                                                   4.12 (0.47)            4.33 (0.42)        –3.439        41        0.001
                    Consistent disciplinef                                                  3.23 (0.82)            3.69 (0.69)        –3.838        41     < 0.0001
                    Parental monitoringf                                                    4.15 (0.69)            4.42 (0.55)        –4.140        41     < 0.0001
                    Parental communication against high-risk behaviorsg                     2.04 (0.98)            2.38 (0.76)        –2.596        41        0.013
                  a   All scales were computed as the average of all items, with higher values indicating a stronger support for the construct.
                  b   SD: standard deviation.
                  c   t: Student’s t-test result for paired samples.
                  d   df = degrees of freedom.
                  e   Response categories ranged between “never” (1) and “always” (4).
                  f   Response categories ranged between “never” (1) and “always” (5).
                  g   Response categories ranged between 0 times (0) and 3 or more times (3).

386                                                                                                                                               Rev Panam Salud Publica 36(6), 2014
Orpinas et al. • Lessons learned in evaluating the Familias Fuertes program in three countries                                                                     Special report

Consistent discipline. “Consistent dis-            FIGURE 2. Proportion of sample that reported                                      Among those with lower room for im-
cipline” (consistency in applying conse-           an increase in “positive parenting,” by “room                                     provement, on average across countries,
quences for the child’s behaviors) was             for improvement” (“high” versus “low”)                                            21% increased their “positive parenting”
measured using three items (alpha = 0.84).         at baseline, after completing the ­   Familias                                    at post-test and 25% decreased their “pa-
                                                   Fuertes program, Bolivia, Colombia, and­                                          rental hostility.”
                                                   Ecuador, 2012–2013
Parental monitoring. “Parental monitor-
ing” (parents/caregivers’ solicitation of
                                                                                      90
                                                                                               High room for improvement             DISCUSSION
information from the child about his/her                                                       Low room for improvement
whereabouts and friendships) was mea-                                                 80                                                The design and content of the FF pro-

                                                  Percent of sample increasing mean
sured with 11 items (alpha = 0.92) (30).                                              70                                             gram is consistent with the evidence-
                                                                                                                                     based SFP, which was proven effective
Parental communication against high-                                                  60                                             through rigorous randomized control tri-

                                                           score at post-test
risk behaviors. “Parental communica-                                                  50                                             als, and is therefore expected to achieve
tion against high-risk behaviors” was                                                                                                similar results. The strict facilitator
measured with eight items (alpha = 0.93)                                              40                                             training guidelines and standardized
adapted from the “Parent-Child Com-                                                   30                                             materials guarantee the consistency of
munication About Smoking” measure                                                                                                    FF with the SFP. Although several stud-
                                                                                      20
to include alcohol, drugs, gangs, fights                                                                                             ies of the SFP have been conducted, the
at school, school dropout, and sexual                                                 10                                             literature on FF is nascent: one study in
behaviors (19).                                                                                                                      Honduras (31), an evaluation of the pro-
                                                                                       0
                                                                                           Bolivia       Colombia          Ecuador   gram in Chile (32), and a pilot evaluation
RESULTS                                                                                              Positive parenting
                                                                                                                                     with Latino families living in the United
                                                                                                                                     States (16). Given the importance of par-
   Of the 383 participants, 311 sets of                                                                                              enting programs, the World Health Or-
results for the pre-test and the post-test                                                                                           ganization (WHO) has called for more
were matched (Bolivia: n = 96, 81%; Co-            FIGURE 3. Proportion of sample that reported                                      evaluation of these types of programs
lombia: n = 173, 95%; Ecuador: n = 42,             an decrease in parental hostility, by “room for                                   (1). The current FF evaluation is useful
                                                   improvement” (“high” versus “low”) at base-                                       for increasing understanding of the ef-
51%). In Ecuador, 82 families started the
                                                   line, after completing the Familias Fuertes
first session, but only 51 completed all                                                                                             ficacy of FF in Latin America, but more
                                                   program, Bolivia, Colombia, and Ecuador,
sessions. Of these, 42 completed both a            2012–2013                                                                         research is needed.
pre-test and a post-test.                                                                                                               Parents/caregivers changed in two
   Table 2 provides details on the mean                                                        High room for improvement             dimensions that both theory and re-
scores of parents/caregivers before and                                               90       Low room for improvement              search highlight as key to positive child
after the implementation of the FF pro-                                               80                                             development (9, 12). First, they reported
                                                  Percent of sample decreasing mean

gram. The Student’s t-test was used to                                                                                               an increase in their “positive parenting”
assess whether changes in scores for                                                  70                                             skills in the form of showing more love,
paired samples were statistically dif-                                                60                                             appreciation, and interest. Second, they
                                                           score at post-test

ferent. After the program, parents/­                                                                                                 reported less hostility toward the chil-
                                                                                      50
caregivers from all three countries re-                                                                                              dren in the form of less shouting and in-
ported statistically significant higher                                               40                                             sulting. The literature shows that nurtur-
“positive parenting” and lower “pa-                                                                                                  ing and responsive parenting provides
                                                                                      30
rental hostility.” In Ecuador, parents/­                                                                                             a shell of protection and reduces ado-
caregivers reported statistically signifi-                                            20                                             lescent risk behaviors (33). The change
cant higher “parental involvement,”                                                   10                                             in the participating parents/caregivers’
“consistent discipline,” “parental moni-                                                                                             perceptions of these important dimen-
toring,” and “parental communication                                                   0                                             sions is promising, but the results do
about health-­compromising behaviors.”                                                     Bolivia       Colombia          Ecuador   not indicate if the changes will be sus-
   Parents/caregivers with very high                                                                  Parental hostility             tained over time. Theoretically, these
“positive parenting” and those with very                                                                                             changes should lead to reductions in the
low “parental hostility” at pre-test had                                                                                             initiation and frequency of adolescents’
very little possibility of improving their         reported an increase in “positive parent-                                         health-compromising behaviors. More
scores. Thus, to examine the proportion            ing” and Figure 3 shows the proportion                                            research is needed to examine the long-
of parents/caregivers that improved                that reported a decrease in “parental                                             term impact of this intervention.
their scores at post-test, the sample was          hostility,” by room for improvement in                                               The improvement of parenting skills
divided into the approximately one-                their scores. The more room for improve-                                          through participation in the program
third of the group with “low room for              ment, the larger the proportion that im-                                          can be attributed to several factors. First,
improvement” and those with higher                 proved their scores. Among those with                                             the evaluated program materials were
room for improvement (i.e., lower initial          “high room for improvement,” on aver-                                             consistent with the original program
scores in “positive parenting” and higher          age across countries, 75% increased their                                         materials with the exception of some
scores in “parental hostility”). Figure 2          “positive parenting” at post-test and                                             cultural adaptations for Latino fami-
shows the proportion of the sample that            68% decreased their “parental hostility.”                                         lies. In addition to being translated into

Rev Panam Salud Publica 36(6), 2014                                                                                                                                           387
Special report                                Orpinas et al. • Lessons learned in evaluating the Familias Fuertes program in three countries

Spanish and modified to fit the reality      conducted several weeks after the last           Personal Communication, 19 February
of some countries in Latin America, the      session. However, this best-case scenario        2014). Although it is expected that the
program was revised by PAHO experts          is not possible in most countries where          adapted FF program will achieve similar
in gender and health to eliminate pos-       the main focus is to provide a service,          results as the SFP, a rigorous impact
sible gender biases. PAHO has built a        not conduct a rigorous research study.           evaluation of FF in Latin America is
legacy around FF in the Americas, offer-     The training of facilitators should in-          integral to the continual improvement
ing technical cooperation to countries in    clude skills for data collection. As ac-         and growth of the program. A clustered
all aspects of program implementation.       cess to phones and computers increase,           randomized control trial measuring the
Second, using videos and practical ac-       online data collection and audio-assisted        impact of the FF program on alcohol and
tivities, the program provides a model       interviewing could help reduce literacy          drug use, school dropout, and aggres-
of the skills that parents/caregivers need   limitations and social desirability (34).        sion, using a control group as compari-
to learn, followed by practical exercises    In spite of these implementation prob-           son, would allow for the examination
to enhance learning. Third, the program      lems, results consistently showed posi-          of changes in drug use and other risk
addresses the fundamental parenting          tive changes. In addition, the comments          behaviors relative to the trajectories in
skills: showing love, reducing harsh par-    from parents/caregivers in this evalua-          the “normal” population. Many of the
enting, setting age-appropriate limits,      tion showed high levels of satisfaction          outcomes, such as adolescent alcohol
having consequences for the behavior,        with the program and positive changes.           use, will increase over time. Previous
communicating without negativity, and           Characteristics of the sample may also        research has shown that the growth of
supervising the child’s whereabouts.         affect the results. Factors such as qual-        increase was lower in the intervention
   The low response rate in Ecuador was      ity of the relationship between parents/         group than the control group but ado-
due to lack of support from the principal    caregivers or levels of stress may be            lescents in both groups increased their
of one of the schools, who limited access    influencing the results and should be            alcohol use (21). A longitudinal study
to the building during the weekends.         taken into account. Another limitation           with a control group will help ensure the
Meetings could not be held for a couple      was the low participation of fathers or          sustainability of the program as fund-
of weeks, after which parents/­caregivers    male caregivers. The predominance of             ing and commitment to the program
stopped attending. This problem high-        female caregivers is not uncommon in             by country governments increases with
lights the need for strong administra-       family programs. Part of the problem is          strong evidence.
tive support for successful program          that in families where parents are single,
implementation. Another problem that         divorced, or separated, the mother usu-          Conclusions
reduced participation in low-income          ally has custody of the children and is
communities was lack of transportation       the only parent to attend school events             Familias Fuertes is a primary pre-
and the cost of public transportation to     (32, 35). More research is needed on             vention program designed to prevent
the schools. Providing funds for trans-      recruitment strategies to increase partici-      health-compromising behaviors among
portation, or implementing the program       pation of male caregivers. Volunteer bias        adolescents by strengthening family
in the community instead of the schools,     should also be considered as a potential         relationships and enhancing parent-
may alleviate this problem.                  confounding factor in the analysis of            ing skills. In this evaluation, parents/­
   The process of evaluating FF revealed     the data. Invitations to participate in the      caregivers from Bolivia, Colombia,
a number of challenges and areas for im-     program were distributed to all parents/         and Ecuador who participated in FF
provement. Because this evaluation was       legal guardians at each school, and it is        increased their “positive parenting”
not a research study, in which rigorous      possible that families with greater moti-        practices and reduced hostile behav-
attention to measurement is paramount,       vation and resources chose to participate        iors. Expressing caring feelings, setting
facilitators from different countries did    in the program. Therefore, characteris-          clear and age-appropriate limits, and
not use the same scales. However, in         tics of participating families should also       being involved in the life of children
all three countries where the program        be measured carefully to account for             are fundamental to strengthening fam-
was evaluated, scales that measured the      these factors.                                   ily relationships. A strong and positive
expected changes in mediating the fam-          The scores did not follow a normal            parent/caregiver–child relationship has
ily variables were used. Facilitators sug-   distribution. Many parents/caregivers            been consistently linked to adolescents
gested that the scales should be short-      had high scores for “positive parenting”         exhibiting fewer health-compromising
ened and alternative ways of measuring       and low scores for “parental hostility,”         behaviors. More research is needed to
should be incorporated to accommodate        an expected outcome given that the pro-          determine the best strategies to measure
parents/caregivers with low literacy lev-    gram is designed for the general popula-         impact, the possible adaptations to local
els. In this evaluation, use of just three   tion, not for families with children with        cultures, and the long-term impact of the
items provided as good an estimate of        behavioral problems. In spite of this ceil-      program on adolescent behaviors.
the construct as the longer scales. Future   ing effect, scores did reflect change in the        To ensure the sustainability of the
evaluators should consider using short       expected direction.                              program in the Americas region, PAHO
scales and common instruments to fa-            The short-term evaluation and the lack        has streamlined the distribution and
cilitate the comparisons across countries.   of control group were also limitations.          availability of FF materials (including
To reduce social desirability, the persons   The evaluation of FF in Chile showed             manuals and videos), which are avail-
who facilitate the intervention should       changes in adolescent outcomes only              able online at no cost. An adaptation of
not be the same as those who assess          after the third year (T. Zubarew, Pon-           FF for Latinos living in the United States
the families and the post-test should be     tificia Universidad Católica de Chile,           is available from the lead author (PO).

388                                                                                                         Rev Panam Salud Publica 36(6), 2014
Orpinas et al. • Lessons learned in evaluating the Familias Fuertes program in three countries                                                        Special report

With program materials and evalua-                       dean Community Anti-Illicit Drug Pro-                 program; the families who participated
tion instruments defined and available,                  gram (PRADICAN), and the Pan Ameri-                   in it; and the European Union and the
PAHO has established strong commu-                       can Health Organization (PAHO) for                    Royal Norwegian Embassy, for their
nication networks with governments                       their leadership and technical support                financial contributions.
and communities to share knowledge,                      in the implementation and evaluation
including evaluation results and sugges-                 of the Familias Fuertes (FF) program. The
                                                                                                                 Funding. The European Union and
tions for program implementation and                     authors also thank the implementing
                                                                                                               the Royal Norwegian Embassy helped
adaptation.                                              partners, the trainers, and the facilitators
                                                                                                               fund this evaluation.
                                                         of FF in Bolivia, Colombia, and Ecuador,
  Acknowledgments. The authors thank                     for their dedicated commitment to the
the Andean Community (CAN), the An-                      implementation and evaluation of the                    Conflicts of interest. None.

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                                     resumen         Este informe describe 1) la evaluación del programa de prevención primaria Familias
                                                     Fuertes en tres países (Bolivia, Colombia y Ecuador) y 2) el efecto de la participación
                                                     en el programa sobre las prácticas de crianza. El programa Familias Fuertes se llevó a
       Lecciones aprendidas al                       cabo en Bolivia (10 grupos, 96 padres), Colombia (12 grupos, 173 padres) y Ecuador
           evaluar el programa                       (5 grupos, 42 padres) para prevenir el inicio y reducir la prevalencia de comporta-
           Familias Fuertes en                       mientos que constituyen un riesgo para la salud de los adolescentes, mediante el
                                                     fortalecimiento de las relaciones familiares y la mejora de las habilidades de crianza.
 tres países de América Latina                       El programa consta de siete sesiones de grupo (para 6 a 12 familias) dirigidas a padres
                                                     o cuidadores y sus hijos de 10 a 14 años de edad. Los padres o cuidadores respondie-
                                                     ron a una encuesta antes de la primera sesión y al término del programa. La encuesta
                                                     midió dos conceptos importantes: la “crianza positiva” y la “hostilidad parental”. La
                                                     Organización Panamericana de la Salud capacitó a los facilitadores. Después del pro-
                                                     grama, los padres o cuidadores de los tres países presentaron puntuaciones m    ­ edias
                                                     significativamente mayores en “crianza positiva” y significativamente menores en
                                                     “hostilidad parental” que en la encuesta previa. La prácticas de “crianza positiva”
                                                     asociadas con una baja “hostilidad parental” son fundamentales para fortalecer la
                                                     relación entre los padres o cuidadores y los niños, y reducen los comportamientos
                                                     que constituyen un riesgo para la salud de los adolescentes. Es necesaria una investi-
                                                     gación más amplia para analizar la repercusión a largo plazo del programa sobre los
                                                     comportamientos de los adolescentes.

                              Palabras clave         Responsabilidad parental; adolescente; conducta del adolescente; prevención primaria;
                                                     familia; Bolivia; Colombia; Ecuador; América Latina.

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