Introduction

Parenting programs have been recognized as effective interventions for preventing a variety of difficulties in children such as alcohol and drug use (Petrie et al. 2007), emotional difficulties (Cartwright-Hatton et al. 2011) and physical difficulties such as obesity (West et al. 2010). Recent studies show that they are effective not only at the individual/community level, but also have the potential to impact at the population level as public health interventions in, for example, prevention of child maltreatment (Prinz et al. 2009). There are a variety of programs and approaches, but recent efforts have been made to recognize those programs with a strong body of empirical research that can therefore be considered as evidence-based (CDC 2010; UNODC 2009a).

There is now an international movement towards the dissemination of existing evidence-based parenting programs into low-resource settings such as low and middle-income countries (LMIC). The World Health Organization (2013) recently recognized that in order to prevent violence in LMIC, existing evidence-based parenting programs should be disseminated and implemented. However, two recent systematic reviews suggest that there is few evidence regarding the effectiveness and “fit” of programs in these settings (Knerr et al. 2013; Mejia et al. 2012). Few randomized controlled trials of parenting programs were found in LMIC and those found had weak methodological designs.

It has been suggested that the process of dissemination of evidence-based family interventions should be guided and informed by all the actors involved (UNODC 2009b). In the case of parenting programs, practitioners can provide valuable insight into the reality of implementing and disseminating programs in a culturally sensitive manner. For example, practitioners’ lack of participation in training and subsequent implementation has been found as a significant obstacle to effective dissemination (Sanders and Turner 2005). It has been argued that research efforts to “scale up” are more likely to be successful when all actors adopt a strong consumer focus (Sanders and Kirby 2011). This implies a collaborative approach to program development and adaptation, which involves forming a partnership with stakeholders from the beginning. Few studies have examined the views of practitioners in context prior to dissemination, yet this group often acts as “gatekeepers” and so they are crucial to the success of implementation.

In 2009 the government of Panama, a LMIC in Central America, funded a research project for the dissemination of an evidence-based parenting program, the Triple P Positive Parenting Program (Sanders 2008, 2012) into low-resource communities. Triple P is a multi-level program aiming to (1) enhance the knowledge, skills, confidence, self-sufficiency and resourcefulness of parents, (2) promote nurturing, safe, engaging, non-violent and low conflictive environments for children, and (3) promote children’s social, emotional, language, intellectual, and behavioral competencies through positive parenting practices (Sanders and Prinz 2005). Level 1 encompasses universal preventive interventions for all parents, such as media campaigns. Level 2 involves “light touch” interventions not involving active skills training and targeting specific subgroups of parents believed to be at greater risk than others of developing a difficulty. Level 3 is designed for parents of children with mild to moderate difficulties who require active skills training. Level 4 is an intensive, 8-to-10 session parent training program for children with severe behavioral problems. Finally, Level 5 is an enhanced intervention for families where parental difficulties are complicated by other sources of distress such as depression or divorce. Triple P was chosen for this project as it is evidence-based (Nowak and Heinrichs 2008), has been disseminated widely to other countries (Leung et al. 2006; Matsumoto et al. 2010), and can be offered in different formats (Markie-Dadds and Sanders 2006; Sanders et al. 2009; Turner and Sanders 2006).

In the present study, practitioners from a range of disciplines based in community schools in Panama were surveyed. They were provided with written information about Triple P and were presented with sample program materials as stimulus to access their views. The first aim was to determine whether practitioners would encourage a parent to participate in Triple P and whether they themselves would participate in training. The second aim was to examine whether practitioners considered the Triple P program culturally relevant and useful as a whole and to determine their views of specific features of the program such as the principles of positive parenting used in the program, the self-regulatory theoretical framework of the program, the strategies for developing a positive relationship, strategies for encouraging desirable behavior, and the strategies for managing misbehavior. The third aim was to examine practitioners’ perceptions of the utility, interest, familiarity, cultural acceptability and complexity level of sample Triple P written material (a tip sheet). A fourth aim was to examine practitioners’ preferences in terms of delivery format. Finally, the fifth aim was to determine whether the practitioners’ age, gender, educational level, profession, years of experience, hours of parent consultation per week, training level and confidence in working with families predicted acceptability and usefulness scores. These socio-demographic variables were chosen as other surveys suggest that they have an impact on cultural relevance scores (Morawska et al. 2012). Moreover, having a profile of practitioners’ characteristics associated with higher engagement with the program might be helpful for dissemination and implementation purposes.

Method

Participants

Eighty school-based practitioners completed a survey regarding their views of Triple P. Schools are the most common setting for identifying child behavioral and emotional difficulties in Panama, and therefore the sample represented the group of practitioners most likely to be targeted for participation in training of a parenting program. They are also most likely to facilitate or act as gatekeepers to parents’ participation in a program. The recruited sample size was based on recommendations by Altman (1991) of at least 10 participants per predictor for multiple regression analysis. There were 8 predictors in this study.

Participants were recruited from four community schools in two of the major districts in Panama City, San Miguelito and Panama. Children in these schools were between 4 and 12 years old. Schools were all located in low-resource neighborhoods. Participants were volunteers, and were therefore selected by convenience. With the consent of the head teacher, 20 practitioners at each school were approached at their office and invited to participate in the study. Inclusion criteria were (1) working in a school in Panama and (2) having weekly contact with parents. Out of the 80 practitioners who were approached in total amongst the four schools, all (100 %) agreed to take part in the study and met inclusion criteria. Consistent with Triple P’s emphasis on use of a multidisciplinary work force to delivering parenting programs, practitioners comprised teachers, psychologists, social workers or learning disability specialists appointed as staff at these schools.

As Table 1 shows, 69 (86.3 %) of practitioners were women and 11 (13.8 %) were men. Just seven (8.8 %) were between 18 and 29 years old, 17 (21.3 %) were between 30 and 39, 25 (31.3 %) were between 40 and 49, 27 (33.8 %) were between 50 and 59, and none were 60 or more. Regarding educational level, four (5 %) had only finished high school, 65 (81.3 %) completed undergraduate studies, and 11 (13.8 %) had postgraduate degrees. The majority of the sample were teachers (71.3 %), followed by psychologists (12.5 %), social workers (8.8 %) and learning disabilities specialists (7.5 %). The sample was very experienced, with the average being 16.79 years of experience (SD = 9.11, range = 34). The average amount of hours per week spent in parent consultation was 9.71 (SD = 11.83, range = 44).

Table 1 Socio-demographic characteristics of the sample
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Procedure

The present study is part of a larger project involving a series of studies in Panama. Studies included surveys to examine views of parents and practitioners, translation and validation of instruments, a randomized controlled trial to determine efficacy and a qualitative study to re-examine cultural relevance after the program was delivered (see Fig. 1 for a diagram of the process). The first two studies were designed to collect data on the need and “fit” of the intervention in this setting. A survey to explore these aspects from practitioners’ perspective is described in the present paper. Results from the other stages of the process of implementation are described elsewhere (e.g. Mejia et al. 2014).

Fig. 1
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Steps of the project

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With the consent of head teachers, practitioners for the present study were approached at their office, during working hours, face-to-face by the research team and were asked whether they would like to participate in a study to examine their views on a parenting program developed in Australia. If they agreed to participate, a survey was handed to them. After 3 days, a member of the research team collected the completed surveys.

The study was reviewed and approved by the University of Manchester Ethics Committee. Written consent was collected from all participants at the beginning of the study.

Measure

A set of questions developed by Morawska et al. (2012) was translated into Spanish and adapted for the present study. This instrument was chosen as it is one of the few existing instruments to measure practitioners’ perceptions of Triple P. The instrument had three sections. The first section involved general socio-demographic questions such as gender, age, educational level, role in the community, years of experience working with children and families, and average number of hours per week spent in consultation. In section two, participants were asked to read an information sheet about Triple P. The information sheet explained the self-regulatory approach, the principles of positive parenting, the strategies for developing a positive relationship, the strategies for encouraging desirable behavior, and the strategies for managing misbehavior. Fourteen questions were presented in which participants had to rate from 1 to 5 the acceptability and usefulness of several aspects of Triple P. They were also asked to rate the acceptability of nine delivery formats (e.g. seminars, groups, home visits, online interventions and TV program). In the third section, participants were presented with a sample of Triple P material. This was a tip sheet entitled Fighting and Aggression, which offers practical advice to parents on how to deal with their children’s difficult behavior. For example, it has information on why children fight, how to teach children to play in a cooperative way, and how to solve a fight. This tip sheet was selected as it incorporates a wide range of both preventative and remedial strategies advocated in Triple P for dealing with the problem. In addition, fighting and aggression are common sources of referral in school-age children with conduct problems. Participants were asked to rate the tip sheet from 1 to 5 on aspects such as utility (e.g. To what extent do you think is the self-regulation approach in Triple P useful to Panamanian parents?), interest (e.g. How interesting do you think parents will find the tip sheet?), familiarity (e.g. How familiar do you think parents will find the information presented in the tip sheet?), acceptability (e.g. How culturally acceptable do you find the information presented in the tip sheet?) and level of complexity for most parents’ educational level (e.g. Do you think the complexity level of the information presented in the tip sheet is suitable for the educational level of most parents?).

Data Analyses

All analyses were conducted in SPSS v16. Descriptive statistics were used (1) to answer whether practitioners would encourage a parent to participate in Triple P, (2) to determine perceived acceptability and usefulness of Triple P, (3) to determine practitioners’ perceptions of Triple P material, and (4) to determine preferred delivery formats. ANOVA tests were carried out in order to examine significant differences in acceptability and usefulness scores across different professions and age groups. Finally, a series of multiple regression analyses were carried out in order to determine whether socio-demographic variables predicted acceptability and usefulness scores.

Results

Practitioners were asked if they would encourage a family to participate in a program like Triple P; 78 (97.4 %) said definitely yes. When asked if they thought a parent might participate in a program like Triple P, 49 (61.2 %) said definitely yes, 28 (35 %) said maybe and 3 (3.7 %) said definitely no. When asked whether they would be interested in being trained or having staff trained to deliver a program like Triple P, 62 (77.6 %) said definitely yes. Finally, 80 practitioners (100 %) said there was a need to implement a parenting program in their organization or community.

Practitioners rated the various aspects of Triple P, and overall felt that all the aspects were highly acceptable to Panamanian parents. The minimum possible score was 1 and the maximum was 5. Practitioners rated the Triple P program as a whole as highly acceptable (M = 4.39, SD = 0.82), as well as the self-regulatory approach (M = 4.27, SD = 0.81) and the principles of positive parenting (M = 4.14, SD = 0.90).

Some sets of strategies were considered more acceptable than others. Specifically, strategies for developing a positive relationship were rated higher (M = 4.30, SD = 0.85) than strategies for encouraging desirable behavior (M = 4.16, SD = 0.93), and both of them were rated higher than strategies for managing misbehavior (M = 4.00, SD = 0.99).

In terms of usefulness, Triple P as a whole was rated as highly useful by practitioners (M = 4.55, SD = 0.74) as well as the self-regulatory approach (M = 4.65, 0.66), the principles (M = 4.69, SD = 0.65) and the strategies (M = 4.58, SD = 0.63). ANOVA tests were carried out in order to examine significant differences in acceptability and usefulness scores across different professions and age groups. A significant difference was found amongst age groups and these results are presented in Table 2. Older participants (40–60 years old) rated the strategies for developing a positive relationship as more acceptable and useful. The strategies for managing misbehavior were rated more positively by the youngest age group (18–29) and the oldest age group (50–59). No significant differences were found amongst different professions.

Table 2 Means and standard deviations for ratings (1–5) of strategies by age group
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Practitioners were also asked to rate a Triple P tip sheet. The material was highly rated. The minimum possible score was 1 and the maximum was 5. In terms of utility, the mean was 4.58 (SD = 0.65), while in terms of interest it was 4.46 (SD = 0.67). Practitioners also found the material as familiar enough, with a mean of 4.25 (SD = 0.88). They expressed a high intention to use the material in the future (M = 4.16, SD = 0.88) and considered it as culturally acceptable (M = 4.42, SD = 0.86). However, when asked whether the complexity level of the material was adequate for the educational level of Panamanian parents, scores were lower (M = 3.97, SD = 0.96).

Finally, practitioners were asked how they thought parents would like to receive parenting information. Table 3 shows the percentage of participants that rated the format as “interesting” (4) or “very interesting” (5).

Table 3 Number and percentage of participants rating the formats as “interesting” or “very interesting”
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A series of multiple regression analyses were carried out in order to check which of a series of variables predicted acceptability and usefulness scores. Dependent variables entered were (1) program acceptability, (2) acceptability of the self-regulatory model, (3) usefulness of program, and (4) usefulness of the self-regulatory model. Independent variables entered in the model were (1) age, (2) gender, (3) educational level, (4) profession, (5) years of experience, (6) hours of consultation per week, (7) training level, and 8) confidence in working with families. Results are presented in Table 4.

Table 4 Multiple regression models predicting acceptability and perceived usefulness
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Greater hours of consultation per week and being a female were found as significant predictors of Triple P acceptability, R2 = 0.15, F(66) = 5.61, p < 0.01. However, it is important to mention that only 11 males were part of the sample and therefore, these results should be carefully interpreted. Greater age was a significant predictor of acceptability of the self-regulatory model, R2 = 0.08, F(66) = 6.05, p < 0.05. Finally, being a female was found as a predictor of Triple P usefulness, R2 = 0.10, F(66) = 7.65, p < 0.01. No predictors were found for usefulness of the self-regulatory model.

Discussion

The present study is one of few existing reports examining the views and opinions that school-based practitioners from a low-resource context have of an evidence-based parenting program developed elsewhere. Practitioners considered the program as acceptable and useful in this setting. Moreover, they also rated the self-regulatory model, which is core to the Triple P program, as acceptable and useful. Principles and strategies were considered to be consistent with common parental values of Panamanian parents, and Triple P material was seen as interesting, familiar and acceptable. It is important to note the very high percentage who said they would encourage a family to use Triple P, and furthermore, that all practitioners considered that a program should be implemented in their community. These are promising results, as they suggest that an effort towards implementing a parenting program in these communities and other similar low resource settings with similar characteristics is likely to be welcomed. Practitioners are gatekeepers of interventions, and if they are engaged there is a greater chance that the intervention will reach parents. However, it is important to recognize that this study was carried out with school-based practitioners in this specific culture, and views and perceptions about the acceptability of the program might be different in other settings. The study does offer a model or methodology which acknowledge the views of different stakeholders and which can be replicated when disseminating evidence-based interventions into different cultures.

A recent study carried out in Australia also examined practitioners’ views on Triple P and its acceptability for culturally diverse population (Morawska et al. 2012). Results were in line with the present study and the program was also rated as acceptable and useful. Moreover, traditional formats such as individual sessions with a therapist were highly rated by practitioners while self-directed formats such as online interventions were amongst the least preferred ones. In the Australian study, previous training in parenting intervention, profession and years of experience in working with parents were found to be correlated to practitioners’ ratings. In the present study, being a female and greater hours of consultation per week were associated with greater acceptability. It is important to keep in mind that few males participated in the study, and therefore, these regression models should be treated with caution. Even though results from both studies are similar, they were carried out with very different samples. The Australian study surveyed mainly healthcare practitioners who self-referred into the study after open advertisement. The present study surveyed school-based practitioners who were actively invited to participate in the study. These differences in sample type and recruitment procedures are examples of the characteristics of each context, which should be noted for future implementation.

It is also valuable to compare practitioners’ views with those of parents. A previous acceptability survey carried out with Panamanian parents showed that the Triple P program was highly acceptable (Mejia et al. 2014). Moreover, parents expressed high intention to participate in such a program. Preferences in terms of delivery formats were similar to those expressed by practitioners. As with practitioners, the most highly rated format was a resource center with materials on loan. However, parents expressed less interest in traditional formats such as individual sessions with a therapist, while this was one of the most highly rated by practitioners. Online interventions were amongst the least preferred formats for both practitioners and parents. This was not the case in an acceptability survey carried out in the United States (Metzler et al. 2011). In this survey, parents reported the strongest preference for self-directed formats such as online interventions. Online interventions represent low-cost, easy to disseminate strategies (Muñoz et al. 2006, 2010). It is possible that they are least preferred by practitioners and parents from Panama due to low computer literacy, which could suggest an opportunity to combine computer skills training with parenting information. In a previous survey with Panamanian parents, 59.2 % reported having no computer literacy, and very few parents accessed the study online (Mejia et al. 2014).

Finally, it is important to reflect on how these findings can guide implementation and scaling up of the intervention in this context. In Panama, primary school education is universal with 99 % children aged 4–12 years old attending primary school (UNICEF 2010). Therefore, most behavioral difficulties express themselves and are identified in schools, being these the main support centers for children and families. Even though school-based practitioners include psychologists, social workers and learning disabilities specialists, in this study, the sample was mainly composed of teachers. Amongst school-based practitioners in Panama, teachers are the ones with most daily contact with parents and the main gatekeepers to any type of support. They are familiarized with children and parents’ needs and what is likely to be helpful to them, being a common practice to spend after-school hours in parental consultations (usually about academic and behavioral concerns). This might be different in other LMIC. We therefore consider the views provided in this study as extremely relevant for guiding the implementation and reach of an intervention like Triple P specifically in Panama. Moreover, teachers might also be considered as potential facilitators of the intervention and some ongoing Triple P trials in other countries are evaluating the efficacy of this modality. This is a potential for universal reach of children between 4 and 12 years old and their parents in Panama. Practicalities such as time of the day to offer the intervention, adding further responsibilities to teachers’ workload, and provision of childcare during the intervention need to be further explored.

The present study has several limitations that should be noted. First, only one sample of material from Triple P was assessed. Therefore, results cannot be generalized to other materials or the entire program. Second, it was not possible to collect qualitative data on practitioners’ views. Qualitative information on what aspects of the program practitioners think it would be worth adapting would have been particularly valuable at this stage. Thirdly, practitioners were selected by convenience. As with any study using volunteers, it is possible that those who were more enthusiastic, and therefore more likely to rate the program positively, were included in the sample. Fourthly, most practitioners in this sample were teachers (71.3 %) with a high educational level (95.1 % with undergraduate studies). Teachers in Panama are only required to have a high-school diploma, and therefore, the high educational level in this sample is noteworthy. Future studies should evaluate acceptability of the intervention with a more diverse sample of professionals with a variety of educational levels in order to ensure scalability of the intervention in this context. A final limitation is that practitioners received a description of Triple P that was out of the context of a training session. Future studies should examine the views of practitioners who have attended a Triple P training session, and hence are more familiar with the program.

Implications

The present study suggests that Triple P is relevant and culturally acceptable to Panamanian school-based practitioners. A previous study points to the relevance and cultural acceptability of the intervention with Panamanian parents (Mejia et al. 2014). The next step was a randomized controlled trial to determine the efficacy of the program in this context, followed by further checking of consumer acceptability with practitioners and parents involved in the actual delivery of the intervention. These results have the potential to guide the dissemination of parenting programs into low-resource settings with similar characteristics and the study provides a methodology that can be replicated with other evidence-based interventions. Future efforts in this field should be directed towards using these empirical findings to promote and guide the implementation of parenting programs in LMIC, preferably at the population level thus increasing reach, followed by effectiveness evaluations of the services implemented rather than solely relying on efficacy trials.