Families play a vital role in preventing risk factors and enhancing protective factors for substance use (Ashby-Wills and Yaeger 2003; Barrett and Turner 2006). Research indicates that positive parenting is a strong protective factor (Prevatt 2003; Salekin and Lochman 2008), while domestic violence (Litrownik et al. 2003) and family-expressed emotion (Peris and Baker 2000; Watts 2007) have been identified as risk factors. Based on the existing body of research, family skill training programs have been developed (Abbey, Pilgrim, Hendrickson, and Buresh 2000; Kumpfer and Alvarado 2003; Petrie et al. 2007). Systematic reviews of studies to prevent drug and alcohol use among youth suggest that family skill training programs hold great promise (Foxcroft, Ireland, Lowe, and Breen 2002; Gates, McCambridge, Smith, and Foxcroft 2006). However, it has been suggested that these programs need to be evaluated on a larger scale and in different settings.

Two recent systematic reviews indicate a significant gap in research on the efficacy of family skill training programs in developing countries (Knerr, Gardner, and Cluver 2013; Mejia, Calam, & Sanders 2012); only one study with a rigorous methodology was identified (Cooper et al. 2009). In 2010–2011, as a strategy for preventing substance use in Panama, the United Nations Office on Drugs and Crime (UNODC) implemented the Strengthening Families Program 10–14 (SFP 10–14; Molgaard, Kumpfer, and Fleming 1997). Several trials have established the efficacy of this program for preventing substance use in the USA (Spoth et al. 2006; Spoth, Randall, Shin, and Redmond 2005; Spoth, Redmond, Shin, and Azevedo 2004), but no studies have recognized its appropriateness and efficacy in developing countries.

According to Panama’s national statistics, the current prevalence of substance use from ages 12 to 19 is: 57.3 % for alcohol, 36.9 % for cigarettes, 7.1 % for tranquilizers, 6.6 % for solvents, 6.8 % for marijuana, and 2.3 % for cocaine (CONADEC 2008). The mean age for first experimentation is 12 years for marijuana and 13 years for stimulants and tranquilizers (CONADEC 2008; Delva, Bobashev, Gonzalez, Cedeno, and Anthony 2000; Dormitzer et al. 2004). Families and children living in low-resource communities are surrounded by societal sources of stress, such as urban violence and limited access to health services; both of which are associated with a higher likelihood of substance use and other behavioral difficulties (Leventhal and Dupere 2011; Viner et al. 2012). Poverty and urban crime might affect children through parental stress and neurobiological, cognitive, and socio-emotional processes (Ewart and Suchday 2002; O’Connell, Boat, and Warner 2009). Recognition of these pathways allows the development of frameworks for guiding preventive programs (Yoshikawa, Aber, and Beardslee 2012).

It has been suggested that evaluation research should not rely solely on experimental studies; moreover, other types of research designs, such as qualitative approaches, can yield valuable information regarding target populations, as they allow the exploration of participants’ unique perspective (Holloway and Todres 2003; Lewin, Glenton, and Oxman 2009; Plano-Clark et al. 2013; Stewart-Brown et al. 2011). This is particularly desirable in medical and healthcare research (Britten 1995; Brown and Lloyd 2001; Cohen and Crabtree 2008; Mays and Pope 2000). The implementation of the SFP 10–14 in Panama by UNODC presented an exceptional opportunity to explore participants’ views of an evidence-based family skill training program in a developing country. This provided a means through which to understand parents as consumers and acknowledge their views during the design, dissemination, and implementation of such services (Boote, Telford, and Cooper 2002). The main aim of the present research is to explore parents’ perceptions and beliefs about changes after taking part in the program using an inductive, participant-driven analytic strategy.

Methods

Design

The present study employs a qualitative design, and data were collected using semi-structured interviews.

Participants

One hundred and twenty parents took part in the SFP 10–14 in Panama between January 2010 and September 2011, from which participants were recruited for this study between September and December 2012. Therefore, the study was conducted between 12 (lowest range) and 35 months (highest range) after participation in the program.

Parents were included in the sample if they (1) took part in the program between January 2010 and September 2011 and (2) were the child’s primary caregiver. The UNODC recovered contact data for 65 of the 120 participating parents, of whom 47 were contactable by telephone. The study was explained briefly over the telephone, and parents were told that participation would entail an interview that would be audio-recorded. Thirty-three parents attended for the interview, and 30 agreed to take part. Three parents declined to participate after attending for the interview and reading the information sheet. Specifically, they did not consent to being audio-recorded, even though this aspect of the process had been explained beforehand over the telephone. It is possible that they changed their mind in between the phone call and the actual point of consent (i.e., the interview appointment). The six communities from which parents were recruited were all situated in the province of Panama. Table 1 presents the socio-demographic characteristics of the sample.

Table 1 Socio-demographic characteristics of the sample
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Measures

The interview schedule designed for this study comprised 16 questions focused on the following three topics: (1) overall parenting experience, (2) changes made after the program, and (3) current experience. The topic of overall parenting experience featured two questions: (1) “How did you end up coming into the program?” and (2) “How was your relationship with your son/daughter before taking part in the program?” The topic of changes after the program included three questions: (1) “How do you think that the program helped you?” (2) “To what extent has the program met your expectations?” and (3) “What are you putting into practice with your family?” Finally, the topic of current experience featured just one question and follow-up: (1) “Can you bring to mind some time when you became angry or frustrated with your child recently? Is this different from before you took part in the program, and how?” The interview schedule was semi-structured. In other words, the questions served merely as a guide to the topics being covered and prompts were used frequently, depending on participants’ responses, for example, “tell me more about this” or “can you give me an example?” In this way, participants were invited to talk freely and as much or as little as they wished, while input from the interviewer was kept to the minimum. The interview schedule was developed by the interviewer and first author (A.M.) based on the literature on changes after participation in evidence-based interventions. After it was developed, it was reviewed by the following: (1) three experts in the field of family skill training programs and (2) a qualitative expert. The interview schedule was piloted beforehand with three parents not related in any way to the project.

Procedure

Initial telephone contact with all parents was made by A.M. (first author). If they expressed an interest in participating, an interview was arranged. All interviews were carried out in Spanish and were audio-recorded and conducted by A.M., who is a native Panamanian Spanish speaker. The meetings took place individually at the community school in which the program had been delivered. Written consent was obtained prior to the interview, once participants had read an information sheet detailing the study and had the opportunity to ask any questions. The interviews lasted approximately 40 min, and once completed, the participants completed a brief socio-demographic questionnaire.

Analysis

Thematic analysis is defined as a method for identifying, analyzing, and reporting patterns within data (Braun and Clark 2006). For the purposes of this study, it was used as an essentialist method; our aim was to report the experiences, meanings, and the reality of the participants (Potter & Wetherell, 1987). The analysis was conducted by A.M. and supervised by the second author (F.U.), who is an expert in qualitative methods. First, the interview audio recordings were transcribed and translated simultaneously into English by A.M. Translation was performed with the aim of conveying meanings and maintaining local expressions.

Parents’ narratives were analyzed to uncover perceptions and beliefs about changes following participation in the program. The analysis can be divided in two stages. During the first stage, data were coded at a manifest level and inductively; that is, it was analyzed descriptively instead of exploring interpretations and explanations for the discourse. The themes evolved directly and naturally from the data set, rather than being theoretically defined; in other words, analysis acknowledged participants’ perspectives rather than a preconceived theoretical framework. Half of the interviews (N = 15) were reviewed and coded using Nvivo v9. A first thematic map was developed, reviewed, and altered based on feedback and discussion in the team. The remaining half of the interviews were then analyzed. After reviewing the interview data, the thematic map was adapted and revised. Data analysis continued in an iterative manner until the following: (1) a comprehensive thematic structure was achieved, and (2) all authors agreed with the thematic structure. Negative case analysis was conducted, and contradictions between participants were identified, coded, and analyzed.

During the second stage, the themes and codes that emerged from the first stage were compared with the content of the program, according to its manual. The program’s manual was not used during the first stage of analysis and was used only in this second stage to contextualize the results. Therefore, this stage should not be considered part of the formal thematic analysis. The comparison between results and the program’s content according to its manual is presented only in the discussion section of the paper.

Results

The following themes emerged from the data: (1) changes in the child, (2) changes in the parent, (3) changes in the couple, and (4) changes in the interaction between the parent and the child. As the interviews were carried out in Spanish, responses from participants are translations and not direct quotes. However, in translation, language was used that conveyed meanings and maintained local colloquialisms. The thematic map is presented in Fig. 1.

Fig. 1
figure 1

Thematic map

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Theme 1: Changes in the Child

Parents were able to identify several changes in their child after the program. The following changes were coded from the data: (1) communication, (2) social development, (3) obedience, and (4) responsibility.

Communication

Parents mentioned frequently that, after the program, their children began to talk with them more openly. This seemed to be due to an increase in trust.

Whatever happens to him, he tells me. When he has problems with his friends, or if something happens in the school, he tells me. (participant #29)

He is more open and he talks to us more, compared with how he was before. (participant #19)

Communication changed not only in terms of expressiveness, but also in terms of listening skills. Parents often mentioned that, after the program, their children were better at listening and following instructions.

They listen more. If they are watching TV and I say “turn that off, I want to explain something to you,” they come over and listen. (participant #9)

Moreover, some parents commented that these improvements in communication were also evident in their children’s relationship with people outside the family, such as their peers.

She has a lot of friends and I think she is now able to communicate with them better. She is also really good at giving advice. (participant #7)

Social Development

Several parents reported that, before the program, their children were withdrawn and experienced difficulty sharing with others. As noted by the following participant, the group format of the program seemed to help develop children’s social skills.

Before, she didn’t like to be in groups…she was always withdrawn. Her teacher would tell me that she didn’t want to play with anyone. I noticed that she began to change once we started coming here…. Now, she is able to join in with groups. (participant #28)

I felt he needed to share with other teens and talk about how he felt…because he didn’t socialize much. Now, he does. (participant #18)

Conversely, other parents thought their children were overly sociable before the program and that, following the sessions, they became better at selecting friends.

Before, he had too many friends, not all of whom were suitable. Now, he selects his friendships very well and analyzes what he is going to do first. (participant #26)

Also related to social development was the ability to deal with peer pressure. Some parents reported that their children became more assertive and better at handling conflict following the program. This was related to the previous code about the enhancement of communication skills.

They need to know how to say “no” politely, without hurting people or starting an argument. Before, he would say “no” but would still act aggressively. The program taught him how to say “no” firmly without creating conflict with others. (participant #26)

Obedience

Parents mentioned that, after the program, their children were better at following rules. They commented frequently that they began to respect boundaries and understand their authority as parents.

If she wants to go to the mall, she asks me for permission. Now, she returns within the specified time, whereas, before, she didn’t. (participant #25)

He doesn’t break the limits anymore; he is really obedient in that respect. If I tell him that’s enough, then that’s enough. (participant #31)

Nonetheless, some negative responses were given. For example, the participant below accepted that her children’s behavioral responses were changeable over time and that he would not always respond and obey immediately. This particular family was going through a recent bereavement of one caregiver, which might explain the child’s inconsistent behavior.

Today, if we give him an instruction, sometimes he will do it, other times he won’t. We never know how he is going to react. (participant #16)

Responsibility

Parents often mentioned that, after the program, their children were more responsible, for example, in relation to their studies and household chores.

He became more interested in his studies […] Previously, he didn’t want to study, but after the program, I saw he was becoming more responsible. (participant #26)

After the program, they began to wash their clothes. Their attitude had changed. (participant #5)

This sense of responsibility is associated with greater independence. For example, parents reported that their child would do things “by himself” rather than requiring their constant support.

He takes the broom by himself, without me having to ask. He is taking responsibility. (participant #1)

Again, however, negative comments were made. For instance, the parent below commented that, after the program, their children were still not exhibiting signs of responsibility and independence. It is important to note that participant #29 is the aunt of the child; she commented on the difficulties that she was experiencing in agreeing with the mother on how to better parent the child. This lack of agreement between caregivers might explain why the program was not perceived as effective in this case.

On the contrary, he has not become more responsible. I have to remind him to do all of his homework. As soon as he gets home from school, I ask him “do you have homework?” Otherwise, he would not do his homework. (participant #29)

Theme 2: Changes in the Parent

Parents reported several changes in themselves following their participation in the program. The following codes emerged from the data: (1) communication, (2) emotional regulation, (3) limits and rules, (4) praise, and (5) spending time with the child.

Communication

Most parents reported using more appropriate methods to communicate with their children, such as changing their voice tone and talking instead of spanking.

I learned to modulate my voice. (participant #12)

Now, I talk to them and allow them to express their feelings. I don’t go ahead and spank them immediately; instead, I try to figure out what is happening. (participant #7)

They also mentioned learning new, alternative methods for communicating with their children.

When I am mad at them, I listen to them and write them letters. (participant #12)

For some parents, these changes in communication were described alongside a greater acknowledgement of the child’s feelings.

I try not to hurt their feelings. When I am giving them advice, I use good words and always consider their feelings. (participant #11)

You have to be careful about what you say and try not to offend them. (participant #5)

Emotional Regulation

Changes in communication were related closely with more healthy approaches to emotional regulation. Most parents said that they use calming strategies during stressful situations or before making parenting decisions.

Okay, I realized that, before, I rushed to make decisions. Now, I try to listen to them and take a moment to be calmer. (participant #9)

Before, I would be harsher. Now, I am able to communicate and express myself. (participant #5)

In the example given by the following participant, better ways of regulating emotions are associated with a decrease in physical punishment. Parents often said that, after the program, they were able to calm down without exploding emotionally.

I am very impulsive and I don’t listen to reason. If I had to spank, I would. But not anymore. Now, I know that I can approach situations more calmly. (participant #25)

However, participants gave mixed views regarding physical punishment. Some parents reported that the program reinforced the use of physical punishment, while others said that they have since learned to communicate instead of spank. In the two extracts below, both mothers are part of the same community and the same group, thereby suggesting that parents might have understood the information provided in very different ways. Overall, participant #2 noted fewer positive experiences than participant #7. Participant #2 reported severe problems with her partner, including violence. Conversely, participant #7 described her very positive experience with the program and had taken away a new and healthy way of relating to her family and her neighbors.

They taught us to correct the children and, if necessary, spank them because nothing will happen to them. (participant #2)

However, they also taught us to not spank them immediately but instead try to figure out what is happening. (participant #7)

Some of the strategies that they used as an alternative to spanking included taking time for themselves, breathing, and counting in order to avoid administering physical punishment or scolding.

I learned to count and to breathe in order to express myself without hurting her. (participant #13)

When I was angry, I would say, “Give me five minutes.” Then, I would go away and check my diary. (participant #12)

Furthermore, they reported being able to communicate their emotions with confidence and in a more appropriate way. For example, this participant commented on experiencing a feeling of fear when communicating with her children and partner.

It helped me to know I can express myself without being afraid when I have something to say. Previously, I would speak up, but with fear. (participant #12)

Once again, some negative responses were given. Several parents recognized that they remained unable to regulate their emotions in a healthy way. However, the participant below described being in a high-conflict family environment, clashing with both with her husband and her eldest son. This stressful environment might have been associated with her difficulty in emotional regulation.

I haven’t been able to stop the yelling…. Sometimes, I just can’t calm down. (participant #14)

Limits and Rules

Some parents acknowledged that the program helped them to clarify their roles within the relationship. For example, they noted the necessity of recognizing their children in the relationship and providing them with opportunities to participate in decision making.

I learned that the kid has his place, while the mum and the dad have their own place. Together, they can overcome problems and make decisions. (participant #3)

Nevertheless, negative cases were also found. Some parents recognized that they did not allow their children to contribute to decision making and described a more authoritarian style of parenting, such as the example of the mother below. In this case, her daughter was experiencing serious behavioral difficulties, such as absconding from home/school and having multiple sexual partners.

I always make her feel that things are done my way, not hers, at home. I am the only one with authority in the house. (participant #25)

Parents also commented that, after the program, they began to use schedules to establish structure and limits in the relationship with their children.

I began to place posters listing the rules in her bedroom. Now, she knows what is expected of her. (participant #13)

The schedules have helped. She knows that she can have the TV on until 9 p.m. But, at 7 or 8 p.m., she wants to go to bed. (participant #21)

Use of Praise

It appears that, following the program, parents realized the importance of rewarding their children for good behavior.

I put into practice praising him when he gets a good grade and rewarding him with a small gift when he does something good. (participant #1)

Compensating or rewarding them for abiding by the rules and accomplishing their goals also worked for us. (participant #16)

However, some parents, such as the mother below, described using the strategy in an unstructured way, instead of offering praise for specific behaviors in a timely manner. This mother described buying her boy a computer for a general change in his behavior (i.e., being obedient), rather than for a specific change (e.g., washing the dishes on request).

Not long ago, I bought him a computer. I told him that if he behaved well and was obedient, I would buy him a gift. (participant #2)

Spending Time with the Child

Parents reported that, during the program, they had the opportunity to spend time with their children through games and activities. It seemed that, once the program was over, these activities were internalized and became routine.

The program helped us to become closer. We share more together. During the program, we shared through games and all that, and now we do the same at home. (participant #27)

They also described how their partners began to spend more time with their child as a result of the program.

My husband has always been present, but now he spends even more time with us and displays more affection. He comes home earlier and shares more with the children. (participant #31)

While some parents stated their children enjoyed spending time with them, others recognized that because they were growing up and approaching adolescence, their children preferred to spend time with their peers. They acknowledged this as a positive sign of independence.

Some people say that when kids enter adolescence, they want to be alone. Well, mine are not like that. They want to be closer to me. (participant #27)

I try to put myself in his position and talk to him. I would say, “let’s go to the movies together,” but it is not the same. Because I am older and I think differently from him, he prefers to be around kids his own age and talk about other things. (participant #23)

Theme 3: Changes in the Couple

When parents discussed the changes that they perceived following the program, some reported changes in the relationship with their partner. These were coded as follows: (1) communication, (2) co-parenting, and (3) spending time together.

Communication

As it was the case when describing changes in the child and in the parent, participants reported an improvement in communication with their partner. In the first example, below, the participant recognized an increase in confidence when relating to her partner. In the second example, the participant summarized an overall sense of closeness and better communication with her partner. In the third example, the participant commented on how, after the program, her partner became more involved in the relationship by giving her feedback regarding her parenting practices.

Before, I didn’t communicate; I would stay quiet. But now, I have changed and I communicate more. (participant #28)

We are closer now. Before, we didn’t talk. That was a big lesson. (participant #31)

For example, when I do something wrong, such as treating our daughter harshly, he tells me, “look, you are doing this wrong, don’t treat the girl like that.” (participant #21)

However, other parents described the programs as helping reinforce existing methods of communication. The comments made by participant #8 are interesting because, throughout the interview, she maintained that the program was not an active agent of change and that it only reinforced skills already being used by her children, herself, and her partner. She did not describe any major difficulty before the program and was described by other participants as the leader of the group. She might be considered “healthy” among the group, in comparison with other families who had higher levels of risk.

Basically, it just reinforced what we have been doing for years in terms of communication. (participant #8)

Co-Parenting

After the program, parents seemed to be able to work together as a team and share parenting responsibilities. Decisions were made by both parents, regardless of whether they were still together as a couple.

Before, I would say something and my husband would say something else. He used to step on my authority. But now, we make decisions together. (participant #21)

Some parents stated that, before the program, each partner would assume a role in the relationship with their child, one being good and the other bad. Following the program, the roles were interchanged in different scenarios.

We had to change because we were hurting the kids and ourselves. They see me as the evil mum who punishes them, while he is the hero dad. It shouldn’t be like that, so now, sometimes I am the good one and vice versa. (participant #26)

In the case of the participant quoted below, she commented on sharing responsibilities with her ex-partner even though they were going through a divorce. Therefore, the program also seemed to be effective in enhancing co-parenting among separated parents.

We are working together. When I implement a rule at home, I talk to him. We agree things jointly. (participant #12)

Spending Time Together

Several participants commented on the difficulties of their partner balancing work and family life. However, it appears that the program was helpful in this respect as partners began to invest more time in their families.

We spend more time together as a couple and the kids like it when we go out together as a family. (participant #27)

Others mentioned that their partner had become more supportive following the program, which is also associated with spending more time together.

He helps me with everything. I call him on the phone and he goes to the kids’ appointments. He is a really wonderful man. (participant #28)

Not all parents reported changes in the relationship with their partner. Seven participants out of 30 were not in a relationship. Moreover, participants who mentioned changes came from two particular communities, thereby suggesting that facilitators in the other four communities might not have focused on developing skills in the couple. Finally, all of the participants who reported changes in this regard attended the program with their partner.

Theme 4: Changes in the Interaction Between the Parent and the Child

A final theme that emerged from the data concerned changes in the interaction between parents and their children. Instead of commenting on these changes as particular to themselves or their children, parents referred to changes in the relationship and in the mutual space between them. These were coded in the following: (1) working as a team, (2) acknowledging each other, and (3) respecting each other’s feelings.

Working as a Team

It seems that, after the program, responsibilities were shared among all members of the family. Moreover, a sense of being part of a team and being responsible for the success of that team developed among family members.

We learned the concept of team working. Each of us is responsible for something and does it. And when we don’t do it, we remind them, “Remember that if someone in the team fails, the team doesn’t work.” (participant #16)

Now, everything is shared between us: the housework and the responsibilities. (participant #7)

Acknowledging Each Other

After the program, some parents recognized sharing decision making with their children and having a mutual involvement in the relationship, for example, by caring about each other’s well-being.

I asked her yesterday, “How is our family doing?” and she said, “We are fine, but you want to move to a different city and I don’t want to, because it’s too far away.” So I said, “What if we discuss this a little bit more?” Now, we are always asking each other how we are doing. (participant #13)

We have learned to respect each other’s opinions. (participant #9)

Some parents mentioned applying this to practical exercises, in which they exchanged roles with their children for a day.

Today, we are going to step into each other’s shoes. You will do my activities and I will do yours. Then, you are going to tell me how it feels to be a mom and I will tell you how it feels to be a daughter. (participant #7)

Respect for Each Other’s Feelings

Some parents reported that, after the program, they and their children were able to recognize each other’s feelings and respect their differences.

We learned to respect each other; the parents should respect their kids and the kids should respect their parents. We understand that we are all allowed to feel differently. (participant #1)

We have learned to respect opinions and each other’s space. (participant #12)

Our communication is bidirectional. We talk and understand each other’s feelings. (participant #13)

This sense of mutual understanding was described as reciprocal and associated with a sense of empathy and the ability to acknowledge different perspectives.

Discussion

There is a lack of research regarding the cultural fit and efficacy of family skill training programs in developing countries (Knerr et al. 2013; Mejia, Calam, & Sanders 2012). The present study targeted this gap by exploring Panamanian parents’ perceptions of changes after participation in the SFP 10–14. Previous quantitative studies have demonstrated that the SFP 10–14 is efficacious in preventing substance use (e.g., Spoth et al. 2004, 2006). However, in-depth exploration of participant perceptions and these pointers to mechanisms behind change has not previously been documented. This study provides a picture of parents’ needs and the appropriateness of the program to satisfy them and offers some knowledge of the new skills that parents acquire from the program and the subsequent changes that occur within their families.

Four themes emerged from the data: (1) changes in the child, (2) changes in the parent, (3) changes in the couple, and (4) changes in the interaction between the parent and the child. It is important to recognize that even though none of the parents mentioned that the program was efficacious in preventing substance use, all of the changes described can be considered assets to prevent the future engagement of their children in substance use. In this sense and according to our analysis, the program addressed relevant risk factors.

Communication was a common change across several relationships in the lives of participants, and it has previously been recognized as a protective factor for involvement in substance use (Ackard, Neumark-Sztainer, Story, and Perry 2006; Kafka and London 1991). Parents recognized that, after the program, children became more adept at following rules. A sense of independence and identifying their own responsibilities were also described, for example, in regard to household chores and their studies. All these aspects have been recognized as protective factors against involvement in substance use, especially among Hispanic youths (Calzada et al. 2010; Pantin, Schwartz, Sullivan, Douglas, and Szapocznik 2003). A change in their ability to relate to others outside the family, such as their peers, was also mentioned and has also been identified as a protective factor for substance use later in life in relation to the behavior patterns of peers (Catalano and Hawkins 1996; Fleming, White, and Catalano 2010).

Most of the parents’ narratives referred to changes in their own parenting practices. They seemed to notice changes in the way that they regulated their emotions. Reducing the use of shouting and bad words, being able to calm down before making decisions, and acknowledging their child’s feelings were some of the changes described. Parental emotional regulation has been associated with children’s own emotional regulation skills (Dunsmore, Booker, and Ollendick 2012; Morris, Silk, Steinberg, Myers, and Robinson 2007); therefore, it is particularly important to target this facet in any family skill training program.

Another aspect to mention was the mixed views revealed with regard to physical punishment. While some parents said that the program suggested using alternative disciplinary methods, others reported that it reinforced the use of physical punishment. It is important to clarify this aspect during delivery and to assess facilitator training for consistency, as physical punishment is associated with negative outcomes, such as difficulties with executive functioning, anxiety disorders, substance use, and behavioral problems (Elliman and Lynch 2000; McMillan et al. 1999; Talwar, Carlson, and Lee 2011).

While we did not use the program’s manual as a framework to analyze the data, this qualitative study offers an opportunity to reflect on the extent to which parents adopted the strategies targeted by the program’s curriculum. According to the program’s manual, the following topics are covered in the parents’ sessions: (1) using love and limits, (2) making house rules, (3) encouraging good behavior, (4) using consequences, (5) building bridges, (6) protecting against substance use, and (7) using community resources. Based on our analysis, most parents described internalizing the majority of these topics. In particular, making house rules and using limits were described frequently as changes made following the program. However, not many parents mentioned learning-specific strategies for encouraging good behavior, such as praise, and there were inconsistencies in the use of consequences (i.e., some parents mentioned that the program reinforced the use of physical punishment). It is important that these aspects are reinforced during the training of facilitators, to ensure that they are transmitted adequately to parents.

In the case of youth sessions, the following topics are covered in the manual: (1) having goals and dreams, (2) appreciating parents, (3) dealing with stress, (4) following rules, (5) handling peer pressure I, (6) handling peer pressure II, and (7) reaching out to others. Aspects, such as handling peer pressure and following rules, were mentioned explicitly by parents as a change in their children after the program. Conversely, some other aspects, such as having goals or dealing with stress, were not mentioned by parents as specific changes and might require further reinforcement during delivery in order to fit the aims of the program’s manual. Nevertheless, these aspects might not be relevant or easily visible to parents; children’s views and accounts might differ completely from those of their parents.

The present study has several limitations. First, it is possible that those parents who had more positive experiences during the program were more likely to be reached and to agree to take part in the study. However, we have provided as much contextual information as possible to clarify any potential biases in the sample. Moreover, the final sample was diverse in terms of socio-demographic variables and its size (N = 30) followed the guidelines for qualitative studies (Crouch and McKenzie 2006; Marshall 1996). A second limitation is the variability in the time elapsed between the delivery of the program and the interviews. While some participants were interviewed 12 months after taking part in the program, others were not interviewed until 35 months had passed. This long period can potentially impact, negatively or positively, the participants’ perceptions of the program. However, this limitation was difficult to avoid, given the nature of the opportunity to evaluate. Hopefully, future systematic trials will complement these qualitative results with data yielded from experimental studies. The present qualitative methodology does not aim to replace experimental studies, but rather to offer a different, more in-depth view of perceptions and beliefs about changes from the user’s perspective. Moreover, it offers a potential methodology for exploring changes when it is not possible to perform experimental studies because the program has already been delivered. Randomized controlled trials should also be conducted, and it is important to perform explorations of efficacy before large-scale implementation occurs. Finally, it would be valuable to include children in the assessment of changes, as they might offer further important information regarding the program.