Background

Childhood adversity has been shown to be associated with several negative health outcomes (Anda et al., 2006; Gilbert et al., 2009; Hussey et al., 2006). Adverse childhood experiences (ACE) encompass key experiences within child maltreatment and broadly include exposure to abuse and household dysfunction. Initial research by Felitti and colleagues (1998) showed that ACE are common and that, as the number of ACE experienced increased, the number of negative physical and mental health outcomes reported also increased. Many children thrive and succeed despite having ACEs. Studies show that through the presence of protective factors, a child can develop the resilience needed to reduce the negative effects of ACEs (Afifi & MacMillan, 2011). Protective factors include nurturing caregivers or role models during childhood, individual intelligence, personal drive, and social connections, and access to concrete supports (DuMont et al., 2007; Luthar & Brown, 2007; Masten et al., 1990; Masten & Coatsworth, 1998). Protective factors emphasize the primary prevention of child maltreatment to promote child well-being.

Communities have a vital role in child well-being. While historic conceptualizations of child wellbeing focused more narrowly on child-level indicators (Ben-Arieh & Frones, 2011; Fernandes et al., 2012; OECD, 2009), contemporary definitions consistently identify child-wellbeing as being multi-dimensional and deeply influenced by relationships, parental support and community-level characteristics (Lippman et al., 2011; Jones et al., 2015; Gleason & Narvaez, 2019; Srivastav et al., 2020). Community-level child well-being is influenced by individual community members’ beliefs about parenting and broader community social norms related to parenting. A 2010 analysis of the Fragile Families and Child Wellbeing Study found five key pathways in which family structure may impact child well-being: parental resources, parental mental health, parental relationship quality, parenting quality, and father involvement (Waldfogel et al., 2010). Lippman et al.’s (2011) child well-being framework incorporates the role of community-level characteristics and identifies positive parenting; parental activities and enrichment; parent involvement in community; resources; social capital; and safe household as indicators of the family context contributing to well-being (Lippman et al., 2011). Taken together, both frameworks note the importance of multi-level influences on parenting behaviors, practices, and norms including interpersonal relationships, community contexts, and legislative policy.

Positive parenting and parental skill building lead to higher levels of child well-being (Newland. 2015) and can be enhanced through effective parenting programs (Sanders et al., 2014). Research by Sanders et al., (2014) and Chen et al., (2019) have found that positive parenting may have long-term positive impacts on families, including: balancing parental warmth and discipline, promoting safe and positive child-parent interactions, creating nurturing home environments that encourage prosocial behavior and providing consistent family routines. Positive parenting techniques may also be a protective factor for children who have experienced adversity (Yamaoka & Bard, 2018).

Parenting interventions such as the Positive Parenting Program (also known as Triple P), Parent-Child Interaction Therapy (PCIT) and Incredible Years (IY) are evidence-based and provide positive parental skill-building; however, the availability and accessibility of these programs are highly variable and underutilized (Sanders et al., 2015; Weisenmuller & Hilton, 2021). Moreover, many positive parenting interventions are not accessed unless families are already experiencing crisis.

Empirical studies have found a variety of facilitators and barriers caregiver help-seeking behaviors; however, many studies focus on individual help-seeking for services such as mental health or primary care and these factors cannot be extrapolated to help-seeking in the context of parenting as this dyad creates an additional complexity as care is being accessed on behalf of themselves and the child (Lanier et al., 2017). A 2020 American Psychological Association review of barriers to access, implementation, and utilization to parenting interventions found three individual barriers: misinformation about the techniques used in behavioral parenting therapy; parental cognitions and readiness to change; and stigma associated with treatment seeking (Weisenmuller & Hilton, 2021). These individual caregiver barriers are further influenced by an array of other community and societal factors including cultural factors, childhood experiences, intraindividual parent factors, religious factors, stigma, and mode of delivery (Weisenmuller & Hilton, 2021).

Although inconsistent across literature, parental help-seeking is higher in caregivers with higher socio-economic status; have few barriers to services; have a child with an externalizing behavior problem; parents are burdened by child’s symptoms; and perceive intervention as effective at decreasing burdensome symptoms (Demster et al., 2013). Social learning theory posits that behaviors are learned through observation, modeling, and cognitive processing (Bandura, 1977). Sometimes this learning is explicit (Reber et al., 1999), such as practicing the parenting skills learned by participating in home visiting programs. Other times, this learning is implicit, or gained through watching others (Bandura, 1997; Reber et al., 1999), such as exhibiting the same parenting skills that were used in their family of origin. It should also be noted that Bandura (1997) posits that behaviors can change over time based on reinforcement or punishments, which can include positive or negative, internal or external stimuli. Because (1) access and participation in parenting interventions is influenced by both individual, interpersonal, and community-level factors and (2) learning occurs in a social context (Bandura, 1997), it is important to further understand perceptions around parental and caregiver social norms around parenting to inform new strategies for increasing engagement in positive parenting skill-building through community-based parenting interventions.

Studies related to parental help-seeking consistently note the two types of stigma that influence behaviors: self-stigma, or the degree to which someone experiences a reduction in their self-esteem or self-worth because they label themselves as unacceptable, and public stigma, or an individual’s perception of public reaction toward a person who seeks treatment or has psycho-social problem (Dempster et al., 2013). Help-seeking stigma has primarily been explored in the context of a child behavioral problem, and there is a research void in the understanding of stigma and norms around positive parenting practices in the absence of a behavioral issue. Access to positive parenting interventions is inhibited by this public stigma, and this is further exacerbated by broader systemic barriers to parenting interventions such as the cost-effectiveness of interventions; available funds for service delivery; sustainment of services over time; under-resourced systems and professionals delivering these interventions; and consistent reimbursement through insurance (Weisenmuller & Hilton, 2021).

Positive social norms are important indicators for the passage of public policies and funding to support evidence-based parenting interventions (Burstein, 2003; Metzler et al., 2012). Social norms are defined as main stream attitudes, opinions, and behaviors of a group (Klika & Linkenbach, 2019). Actual norms refer to the behaviors and attitudes held by a majority of people within a group. Actual norms can influence the way people think and ultimately behave; however, they cannot be understood outside of the context they emerged (e.g. historical and social contexts; Bronfenbrenner 1979). Research on social norms around parenting warrants a deeper investigation, as it can inform strategies that decrease public stigma for parenting support and subsequently increase participation in positive parenting interventions and increase support for public policies and funding for parenting interventions. Ultimately, understanding norms around parenting can lead to normalization of help-seeking behaviors.

This exploratory study examines the extent to which opinions about help-seeking are related to support for parenting interventions using a sample of South Carolina adults. South Carolina child maltreatment rates are consistent with national numbers, with neglect being the most reported maltreatment type, and females and children of color reporting higher rates of maltreatment (Administration for Children and Families, 2020). We believe this study can provide important insight on how diverse states, particularly in the American South can shape attitudes and norms around child maltreatment and child well-being.

Methods

Study data was collected through phone surveys of adults age 18 and older living in the United States (US) state of South Carolina (n = 1,145). To achieve an adequate sample, researchers purchased a list of landline and cell phone numbers containing demographic information consistent with South Carolina census data. A random sample of phone numbers were selected between August 2019- December 2019. Every region of the state had an equal opportunity of being called and interviewed for the study.

A phone call protocol was used ensure data collection consistency. Three attempts were made on each phone number. In cases where the prospective participant’s phone was not answered or rang busy, three attempts were made to contact. When contact was made and consent was received verbally, trained interviewers read interview questions and response options verbatim. Response options were on a 5-point Likert scale: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree. Responses of “Don’t know” or “Refused” were not provided as response options, but if either response was given, the interviewer recorded the response. Responses of “Don’t know” and “Refused” were treated as missing. Interviewers re-read questions upon participant request. No additional information was provided to the participant. If participants asked questions or sought further clarification, the interviewer responded with the statement “Whatever that means to you.” The response rate was 11.5%. All interviews were conducted in English. The Heartland Institutional Review Board approved this study.

Dependent variables: opinions related to government intervention for parenting support

Opinions related to government intervention for parenting support were the dependent variables in this study. Participants were asked to rate their agreement with two statements: a) “All parents should have the option of no-cost, in home parenting support” and “All parents should receive tax credits for parenting classes” using a 5-point Likert scale. These statements were adapted from a study examining public perceptions on preventing adverse childhood experiences (ACEs) (Purtle et al., 2020, 2021).

Independent variables: beliefs related to help seeking for parenting

Three survey questions examined beliefs related to parenting support: (a) “I know where to go in my community to get parenting knowledge and skills,” (b) “The government and other organizations should help parents who don’t have support from family and friends,” (c) “Parents need support from family and friends when parenting gets hard.”

Covariates: demographics

Demographic variables, including gender (male, female), age (18–29, 30–49, 50–64 and over 56), race (non-Hispanic white, Hispanic, Black or African American, Native American/American Indian, Asian/Pacific Islander and Other), marital status (single/never married, married/domestic partnership, widowed, divorced/separated), income ($30,000 annually, $30,000-$49,999 annually, $50,000-$74,999 annually and above $75,000 annually), education (high school or less, come college/college graduate and graduate/doctoral) and having a child in the home (yes, no), were covariates in this study.

Analyses

First bivariate statistics were calculated to describe the demographic characteristics of the sample. Demographics were stratified based on whether children lived in the household. Second, two ordinary least squares linear mixed regression models explored: (1) the relationship between parents’ beliefs about seeking help for parenting, demographic covariates, and support for no-cost in-home parenting support and (2) the relationship between parents’ beliefs about seeking help for parenting, demographic covariates, and support for state government tax credits for positive parenting classes. Each model was adjusted for the alternative dependent variable and accounted for clustering at the county level. Analyses were conducted using STATA statistical software (StataCorp. 2015).

Results

Participant demographics are shown in Table 1. Study participants (n = 1,143) were primarily female (84.6%) and non-Hispanic white (65.5%), in a married/domestic partnership (58.6%) and an annual income over $50,000 (35.6% $50,000-$74,000; 42.6% more than $75,000). Participants varied in age (20.4% age 18–29; 32.5% 30–49; 25.1% 50–64; 21.9% over 65) and over half (57.5%) knew where to go in their community to get parenting knowledge and skills.

Table 1 Sample Demographic Characteristics, Stratified by Presence of Children in the Home Among a Sample of Adults in South Carolina, 2019
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Support for first-time parents having the option of no cost, In-Home parenting support

All three beliefs about seeking help for parenting were associated with support for no cost, in-home parenting support for all first-time parents after adjusting for demographic characteristics and beliefs about seeking help for parenting (Table 2). For every one-point increase in a person’s rating for “I know where to go in my community to get parenting knowledge and skills” the mean average score for support for “no-cost, in-home parenting support” increased by 0.10 of a point (B = 0.10, SE = 0.05, p = .047). A one-point increase in agreement that “the government and other organizations should help parents who don’t have support from family and friends,” was associated with a 0.55 increase in mean average score for support of “no-cost in-home parenting support (B = 0.55, SE = 0.03, p < .001). For every one-point increase in a person’s support for “Parents need support from family and friends when parenting gets hard” the mean average score for support for “no-cost, in-home parenting support” increased by 0.34 points (B = 0.34, SE = 0.07, p < .001).

Table 2 Adjusted associations between believes about seeking help for parenting and support for parenting interventions, 2019
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Support for state government credit positive parenting classes

The belief that “Parents need support from family and friends when parenting gets hard,” was associated with support for state government credit positive parenting classes after adjusting for demographic characteristics and beliefs about seeking help for parenting. For every one-point increase in agreement that “Parents need support from family and friends when parenting gets hard,” the mean average score for support for state government credit positive parenting classes increased by 0.58 points (B = 0.58, SE = 0.08), p < .001).

Discussion

Our study results indicate that beliefs around parenting may be predictive of support for parenting interventions and parenting programs. In our sample of adults in South Carolina, we found that individuals who believe they know where to get parenting knowledge and skills in their community, who believe the government and other organizations should help parents who lack support from family and friends and/or who believe parents need support from family and friends when parenting gets hard were more likely to support no cost, in-home parenting support for all first-time parents. We also found that individuals who believe parents need support from family and friends when parenting gets hard were more likely to support state government credit for positive parenting programs.

This exploratory study has important practical considerations for child and family serving systems and professionals. First, it reinforces the importance of investing in awareness efforts of existing parenting programs to help reduce barriers to accessing such programs, which may turn may also help normalize help seeking behaviors around parenting. Awareness of parenting programs however, may not be enough to reduce the stigma associated with asking for help, as many studies document difficulty in recruiting and retaining parents for government associated parenting programs (Mytton et al., 2014; Prguda & Burke, 2020). Consequently, messaging that normalizes the role of the government in supporting first time parents by providing examples of diverse families that have accessed and successfully completed in-home parenting services should be considered. One way to do this is to highlight the stories of different types of families involved the federal government’s maternal infant and early childhood home visiting program (MIECHV), which includes several different in-home parenting models, and has yielded many positive outcomes for children and families (Kim, 2019). Additionally, by expanding home visiting services to all first-time parents at no cost, the stigma and generalizations associated with the types of families (e.g. “high risk”) that access in-home parenting services may also shift.

Second, the results emphasize the importance of using trusted messengers like family and friends to increase uptake of parenting programs. Previous studies suggest that parental hesitation around help seeking often comes from norms around masculinity (Rominov et al., 2018), fear of judgement (Hill et al., 2020), and the distrust associated with child welfare (Keller & McDade, 2000). Parents are more likely to go to social supports like family or friends, as well as anonymous supports like parenting hotlines (Keller & McDade, 2000). Thus, child and family well-being advocates should consider engaging in broader community engagement to normalize the use of parenting programs, which can also increase support for state funding of these programs.

Limitations

Although this study is the first to examine help-seeking parenting beliefs and their associations with policy, several study constraints limit the scope of our findings. The response rate of 11.5% is low, females were over-represented in the sample. Increased input, including other genders may lead to a more comprehensive understanding norms, specifically, of how parental help seeking beliefs predict support for parenting interventions and parenting programs. Additionally, this study included adults in a single southeastern US state (South Carolina) may not necessarily represent the perspectives of adults living in other communities. Finally, the data used in this study captured actual norms, although research suggests that there can often been a gap between actual and perceived norms in the direction of health risk behavior which can influence our outcomes (Klika et al., 2019). Future research could examine perceived norms about parenting to further understand how parenting practices can be influenced. Despite these limitations, study findings underscore the need for future work examining constructs related to beliefs about seeking help for parenting and parenting support interventions in more depth; particularly ones aimed and better understanding what beliefs are associated with support for in-home parenting programs.

Conclusions

Parenting programs should consider increasing knowledge of where to get parenting knowledge and skills, activating beliefs that the government and other organizations should help parents who lack social support and promoting the norm that parents need support from family and friends when parenting is difficult. These norms may in turn increase local and state government investment in parenting interventions, ultimately strengthening families and promoting optimal health.