Process evaluation of the implementation of a parenting programme for Somali-born parents living in Sweden

doi:10.21203/rs.3.rs-20706/v3

Download PDF

Research article

Process evaluation of the implementation of a parenting programme for Somali-born parents living in Sweden

https://doi.org/10.21203/rs.3.rs-20706/v3

This work is licensed under a CC BY 4.0 License

Version 3

posted

You are reading this older preprint version

Read the latest preprint version →

Background: Forced migration has been shown to have a negative impact on family dynamics, parenting and the parent-child relationship. Parental support programmes aim to strengthen family functioning and the parent-child relationship and to promote the mental health of children and parents. However, there is a lack of knowledge on how parenting support programmes can be implemented for newly arrived immigrant parents. This process evaluation, therefore, describes the implementation of a successful parenting programme for immigrant parents from Somalia and identifies key components in the implementation process.

Method: This process evaluation considered context, implementation and mechanism of impact, in accordance with the Medical Research Councils guidance. Data were collected through focus group discussions, a questionnaire, attendance lists, field and reflection notes, and observations of the sessions. The data were then analysed using content analysis and descriptive statistics.

Results: The findings showed that of the 60 parents who were invited to the parenting programme, 58 participated in the sessions. The study showed that involving key individuals in the early stage of the implementation facilitated reaching the Somali-born parents in the parenting programme. To retain the participants in the programme, parents were offered free transportation. The programme was implemented and delivered as intended. A majority of the parents were satisfied with the programme, and they reported increased knowledge about children’s rights and the support they might seek from social services.

Conclusions: This study illustrates how a parenting support programme can be implemented for Somali-born parents and provides guidance on how to engage and attract immigrant parents to participate in parenting support programmes.

International Relations

Health Economics & Outcomes Research

culturally sensitive

immigrant

implementation

parenting programmes

parental support

reach

recruitment

Increased global displacement over the last few decades has led to approximately one million refugees resettling in European countries by 2015. Most of the refugees have come from Syria, Afghanistan, Eritrea and Somalia and have been fleeing from war, conflict and persecution. This displacement is also called forced migration [1]. Sweden is one of the European countries with the highest number of asylum seekers per capita [2]. Forced migration has a strong effect on the health of the individual [3], a family’s transition to the host country (i.e. acculturation) [4, 5] and parent-child relationships [6-8]. Several studies have addressed the challenges faced by immigrant parents due to forced migration and acculturation in the new home country [9, 10]. On a family level, challenges to acculturation include the lack of an extended family, a change in roles and power conflicts between parents and children due to their different levels of acculturation [8, 11]. On a societal level, challenges to acculturation include a lack of understanding in terms of the parenting system in the new home country, fear that authorities will remove children from their families and a sense of discrimination by social services [7, 12, 13]. The immigrant parents’ fear of social services and sense of discrimination may hinder them from seeking support for their parenting [7, 12, 13, 14]. Forced migration and the acculturation process are challenges that may impact family dynamics, parenting and the parent-child relationship [9-11].

However, immigrant parents have described resettling in another country as improving their relationship with their children and have said that they modified their parenting [14]. The need for culturally tailored parenting support programmes has been stressed by immigrant parents in order for them to adapt their parenting role and skills in the new home country and to strengthen parent-child relationships [11, 14, 15]. Offering culturally tailored parenting support programmes has been highlighted in studies and reports as reducing the existing inequality in health [16, 17, 18]. Parenting programmes tailored for immigrant parents have been shown to strengthen the functioning of families and parent-child relationships and to promote the mental health of children and parents [19, 20]. Despite these benefits, studies have revealed numerous challenges when it comes to engaging, recruiting and retaining immigrant parents in parenting programmes [21, 22, 23]. Lack of cultural sensitivity in such programmes contributes to low participation and high dropout rates among immigrant parents [22, 24]. Most other types of parenting programmes also lack cultural sensitivity, and all are delivered in the language of the host country [22]. From a human rights perspective, it is crucial for a parenting programme to be delivered in the participants’ native language and by people with a similar background and culture [6, 8, 14, 15].

Implementation, the process of putting a programme into use [25], involves dimensions such as reach, fidelity and adaptation [26]. Reach is defined as the ability of a programme to engage its target audience and is crucial for the programme’s potential to impact public health [26]. Programme fidelity is generally defined as the degree to which a programme is delivered as intended [27]. Knowledge of programme fidelity is crucial if conclusions are to be drawn about the outcome of a programme. Although the importance of programme fidelity is widely accepted, less focus has been given to the need for clarity on the strategies that are used to implement a programme [28]. Adaptation is defined as modifying or tailoring the intervention to the needs and characteristics of the target group. There is often tension between fidelity and adaptation; however, adapting intervention to the target groups may be crucial to the reach and relevance of the programme [26]. If the strategies used for implementation of parenting programmes are not properly evaluated and core components of the strategies not described, no guidance for future implementation of such programmes will be available. In this study, we evaluate the strategies that were used for the implementation.

In previous studies [19, 20], we developed and evaluated the effectiveness of a culturally tailored parenting programme (the Ladnaan Programme) for Somali-born parents in Sweden. Our findings showed that the Ladnaan Programme decreased children’s behaviour problems [19] and improved parents’ mental health and sense of parental competence [20]. Somali-born parents reported that the culturally tailored parenting programme strengthened their parenting and their parent-child relationships [30]. Because of the proven benefits of the programme, it is crucial to explore how implementation strategies and reach of the target group were accomplished. This will guide future implementation of similar programmes and provide information to policymakers about the potential for the programme to be employed in other settings.

In conclusion, there is a lack of knowledge about effective strategies used to support the implementation of culturally tailored parental support programmes. Such knowledge is crucial for the implementation of beneficial parenting programmes that can reach and retain hard-to-reach groups in ordinary practice. The aim of this process evaluation was to describe the implementation of a successful parenting programme for immigrant parents from Somalia and identify key components in the implementation process.

This study addressed the following research questions:

What were the contextual barriers and facilitators for reaching and retaining the target group?
What were the contextual barriers for participation of the group leaders?
To what extent did parents in the target group participate in the intervention?
To what extent was the Ladnaan Programme delivered as intended and how did group leaders perceive the delivery?
What adaptions of the implementation strategy were made, and how was the strategy perceived?
Were group leaders satisfied with the delivery of the intervention?
Were the parents satisfied with the intervention?

Design

The study was a process evaluation that was conducted in parallel with a randomised controlled trial. The process evaluation was guided by the framework developed by the Medical Research Council Guidance by Moore et al. [26]. Three components, context, implementation and mechanism of impact, were used to describe the context for the implementation, the way in which the implementation strategy was carried out and potential mechanisms for achieving implementation (Table 1).

Setting

The study was conducted in a medium-sized municipality in Sweden with a population of 51,000. By the end of 2017, 17% of the municipal population was foreign-born [31], with Somalis making up one of the largest immigrant groups. The municipality’s social services had experienced considerable difficulty reaching out to immigrant parents and were therefore determined to find ways to engage hard-to-reach groups in parenting programmes [32]. Thus, this study was conducted together with the social services.

Intervention

The Ladnaan Programme has two components: the Connect parenting programme [33] and societal information (Figure 1). The Ladnaan programme was delivered four times to four separate groups, and each programme had 12 sessions, which were attended by 12–17 participants and were delivered by two group leaders (one female and one male).

Connect is a 10-session parenting programme derived from attachment theory [33]. Its primary aim is to promote children’s mental health and strengthen the parent-child attachment relationship [33]. The Connect programme was chosen based on findings from previous research [14] showing that Somali-born parents were expressing a need to strengthen their relationships with their children. Each Connect programme session lasted one hour, and each societal session lasted 2–3 hours. The Connect programme comprises 10 sessions that are based on nine attachment principles: 1) All behaviour has a meaning, 2) Attachment is for life, 3) Conflict is a part of attachment, 4) Autonomy includes connection, 5) Empathy – the heartbeat of attachment, 6) Balance our needs and the needs of others, 7) Growth and change are part of relationship, 8) Celebrating attachment, and 9) Two steps forward, one step back (see Figure 1). In each session, parents are introduced to one attachment skill. The session is presented through reflections, case examples, role plays and exercises in which group leaders illustrate attachment principles in-depth. After each Connect session, parents receive translated and summarised hand-outs about the session.

The societal information component comprised two of the 12 sessions of the Ladnaan Programme and was developed from a previous study on the need among Somali immigrant parents for parenting support [14]. The societal information component of the current programme contained three parts: 1) Child Welfare Services, which aimed to provide parents with an overview of Swedish Child Welfare Services; 2) Parenting Styles, which was aimed to introduce different parenting styles, such as democratic and authority parenting; and 3) the United Nation’s Convention on the Rights of the Child (CRC), which aimed to provide parents with knowledge about the international human rights of children and the promotion of children’s agency. The societal information sessions were delivered as workshops in which group leaders gave a short introduction of the theme and proceeded with discussions and questions from the parents.

All group sessions for this study were conducted in Somali except for the single session on parenting styles that was delivered by a Swedish-speaking professional from Family and Child Welfare Services and interpreted by one of the group leaders. The programme was delivered with a culturally sensitive approach by group leaders who had cultural competence relating to both Swedish and Somali society. The culturally sensitive approach was developed from the findings of a previous study [14] and involved tailoring the parenting programme to the parents’ needs, culture and context. The programme was named Ladnaan (a Somali word referring to a sense of health and wellbeing), and the term “parent empowerment” was to reflect the fact that the programme was meant to empower the parents rather than control them. In addition, Somali metaphors and proverbs were used during the sessions to make the content comprehensible and to affirm certain content.

Implementation strategies

The implementation strategies focused on the implementation of the Ladnaan Programme, the recruitment and training of the group leaders and lecturers, and the reaching and retaining of parents.

Recruitment and training of group leaders

The main task for group leaders was to deliver the Connect sessions. Initially, nine group leaders (five males and four females) with a Somali background who were employed by social services, the integration office for newly settled refugees and schools were recruited to ensure that the parenting programme would be sustainable even after the study had concluded (Table 2). Mixing the gender of group leaders in each session (one female and one male group leader) aimed to attract both mothers and fathers to the programme. The group leaders received four days of standardised Connect training provided by Connect instructors qualified to train group leaders [34].

Two of the group leaders and one lecturer from the municipal Family and Child Welfare Services department delivered the societal information sessions.

Strategy for reaching and retaining the target group

Strategies for reaching and retaining parents included the following components: 1) informal information meetings (held in small groups and at the individual level); 2) diploma for parents who participated in the parenting programme; 3) times for meetings adapted to the needs of the parents; 4) session venue in the neighbourhood where most families lived; 5) reminders; 6) babysitting services; and 7) assistance with reading and answering letters from government agencies.

Parents first received information about the parenting programme at informal meetings held in Somali associations and schools and at the Workers’ Educational Association. The meetings were arranged together with the Somali associations and key individuals (Somalis from the municipality who were well respected within the Somali community). Parents who were interested in receiving more information were phoned by the external facilitator (member of the research group), who gave them detailed information about the parenting programme.

The key individuals and the external facilitator suggested that the awarding of a diploma to parents could be a way to facilitate recruitment; therefore, parents were informed that they would be given a participation diploma if they completed the parenting programme. The sessions were held late afternoon in a neighbourhood where most of the parents lived, at a time and place chosen by the parents.

Text-message reminders were sent to parents by internal facilitators the day before each session. Childcare was offered to parents who required it so as to increase the chances of both parents attending the sessions. Parents were also offered assistance with reading and replying to letters from authorities. According to the Somali associations, many parents in the community often sought their assistance to read government letters.

Study participants

Involved in the study were group leaders, a lecturer, Connect instructors and internal facilitators who participated in the implementation process (Table 2), as well as parents who participated in the parenting programme. The participants involved in the implementation of the programme included eight females and six males. Their roles and characteristics are described in Table 2.

The parents who participated in the parenting programme (n=58) were between 30 and 70 years of age and had children aged 11 to 16 years. The majority (65%) of the parents had lived in Sweden for <5 years.

Data collection

For this process evaluation study, both qualitative and quantitative data were collected and analysed [35]. The combination of qualitative and quantitative data allowed for a focus on different aspects of the implementation of the programme. Data were collected during the delivery of the four rounds of the programme and after its completion.

Ethical approval for this study was obtained from the Swedish Regional Ethical Review Board in Uppsala, Sweden (Dnr 2014/048/1). All participants were informed about the aim of the study, that their participation was voluntary and that data would be treated in a manner that respected their confidentiality.

Qualitative methods of assessment

The qualitative data were collected through focus group discussions (FGDs), field and reflection notes and observations of the societal information sessions. A semi-structured interview guide was used in the interviews, which was tested with the first FGD. No further revisions were made on the interview guide. Six FGDs were conducted with group leaders, a lecturer, Connect instructors and internal facilitators. The FGDs with the group leaders, lecturers and internal facilitators concerned their experiences with delivering the intervention, including their contact and interaction with participants, and contextual factors that affected the implementation. The FGDs lasted from 60 to 105 minutes. Five FGDs were conducted in Somali and one in Swedish.

To capture the fidelity of the Connect programme, each session was video-recorded, and the recordings were sent to the Connect instructors. For this study, we did not analyse the video recording but held focus group interviews with the instructors who had been supervising the group leaders each week throughout the sessions. Connect instructors were asked about their experiences of delivering training and supervising the group leaders, as well as about the fidelity of the programme. The FGDs with the instructors were conducted in Swedish and lasted approximately 60 minutes.

Moreover, to capture the fidelity of the societal information sessions, two observations and reflection notes from three leaders of the societal information sessions were collected. The observation and reflection protocols contained similar information and were about overall impressions and interactions with the parents, the most common participant questions and session duration.

Field notes were taken during the implementation of the parenting programme to examine the contextual factors that facilitated or hindered the implementation.

Quantitative methods of assessment

The quantitative data included a questionnaire and an attendance list. The questionnaire measured parents’ satisfaction with the intervention. The Consumer Satisfaction Questionnaire (CSQ) was used [36]. The questionnaire was administered to participants two months after intervention completion. The CSQ was a standardised instrument which was adapted for this study, meaning that the questions focused on the current intervention. The questionnaire was also translated into Somali in accordance with the five steps of translation process [37]: 1) forward translation, 2) backward translation, 3) expert panel back-translation, 4) pre-testing and 5) final version. The CSQ comprised 22 items addressing the impact of the parenting programme on the parents’ knowledge, confidence with parenting, and parent-child interactions and relationships. Parents were asked to rate each item on a scale from 1 (e.g. satisfaction with the programme or improvement of problems or parent-child relationships) to 4 (dissatisfaction with the programme or worsened problems or parent-child relationships). The 22 items were summarised to yield a total score between 22 and 88, with low scores indicating higher satisfaction. Dose was assessed using the attendance list.

Data analysis

All FGDs were transcribed verbatim and analysed inductively with content analysis [38]. This method was chosen to understand how the phenomenon (i.e. implementation strategies) was perceived and experienced by the participants. The transcribed FGDs with the Connect instructors were analysed separately. All transcribed data were read by the first author several times to capture the participants’ overall experiences. Phrases, paragraphs and words that captured the key concepts were then highlighted and coded into initial codes. The next step involved sorting codes based on their similarities. Co-authors reviewed the coding, and when consensus was achieved, the codes were then sorted according to the components of the process evaluation guidance.

The field notes, observations and reflection notes were analysed using deductive content analysis [38]. The analysis started with a reading of the text and then placed the text according to the components of the process evaluation guidance.

The CSQ was analysed in SPSS version 24 [39]. Descriptive statistics (frequencies and percentages) were calculated to describe the data.

The results of the process evaluation were outlined in accordance with the framework developed by Moore et al. [26], considering the main components of contextual condition, implementation and mechanism of outcome.

Contextual conditions for the implementation

Contextual barriers and facilitators for reaching and retaining the target group

According to the group leaders’ interviews and the field notes, one contributing factor to the implementation was the involvement of key individuals who were well-known Somalis and respected within the community. These key individuals arranged and participated in initial informal meetings and reassured parents about the benefits of participating in the programme. Additionally, group leaders and internal facilitators stated that the mixed gender of group leaders had contributed to reaching and retaining fathers for the sessions. The group leaders and external facilitators emphasised that they were crucial in terms of the cultural competence that the programme required. One group leader stated, “It was the right person behind each post/work that we are very grateful for” (FGD 4 FR 2).

It was crucial that we began by talking about social services work with children and youth. This gave parents an understanding of the true purpose of social services and also helped relieve them of some of their worries. It also facilitated the engagement of parents with other topics in the parenting programme. I think we should always start with what is important for parents or what concerns them. (FGD 1, FR1)

The internal facilitators stressed the fact that the venue was unsuitable for more than three children and lacked toys: this may have prevented couples from bringing their children and thereby being able to participate in the programme together. They suggested a more suitable and child-friendly venue where both young and older children could play during the sessions.

Contextual barriers for participation of the group leaders

An additional contextual factor that threatened the group leaders’ ability to deliver the intervention was the lack of manager support. Some group leaders reported that they lacked support from their manager, while group leaders who worked at schools reported that they did not have enough preparation time for the sessions. The group leaders suggested that the managers should be involved in the planning phase so that they could set aside time for group leaders to prepare and deliver the sessions. The group leaders estimated a need for 8–10 hours per week for preparation and delivery.

The group leaders emphasised that programmes become sustainable when funded by the municipality or civil society. On the one hand, they believed that if the Somali associations (and not social services) had implemented the parenting programme, it might have been easier to recruit parents; on the other hand, this might have been difficult in terms of sustainability or quality assurance.

Implementation process

Reach – the extend that the target group was reached and participated in the intervention

A total of 60 parents were invited to participate in the programme. Of these, 58 parents participated and nearly one third were fathers (n=17). Only two families arrived with both fathers and mothers. Of the 58 parents, 40 attended more than eight sessions while 17 attended fewer than eight sessions. The mean attendance for all 12 sessions was 8.01 (SD=3.4) sessions. A majority of the participants (n=40, 70%) took part in the two societal information sessions, seven participants (12%) took part in only one session and eleven participants (18%) didn’t attend any of the sessions with societal information. For the Connect sessions, most of the participants (n=40, 67%) took part in all ten of the Connect programme sessions.

Fidelity – the extend that the Ladnaan Programme was delivered as intended

The interviews with the group leaders described that the training with other group leaders before and during the programme, along with the supervision, enhanced their competence and self-confidence in delivering the parenting programme.

Connect instructors reported that the group leaders were knowledgeable both during the Connect training course and during delivery of the sessions. According to the Connect instructors, group leaders delivered the programme according to the manual. The Connect instructors felt that the group leaders delivered the sessions sensibly and that they listened to the parents and sought to explain information in different ways. They also encouraged group leaders to use metaphors and proverbs as well as verses from religion, as one Connect instructor explained:

I had encouraged them to use metaphors, proverbs and religious verses because we had noticed that parents became engaged in the topic and had a lot to discuss when the group leaders used a proverb, something from the Quran or sometimes their own experiences.

Connect instructors pointed out that the supervision sessions were very important to ensure that the programme was delivered as intended. The lectures on parenting style and on the work of social services were held in one session and took longer than planned. As a result of the FGD with the group leaders and the lecturer’s reflection notes, a suggestion was made to divide the two topics (societal information and parenting styles) into two sessions and to deliver the Parenting Styles lecture in Somali.

Adaptations of the implementation strategy

The field notes showed that in addition to the components of the strategy to reach and retain parents, peer information (i.e. parents who completed the programme informing other presumptive participants about their experience) was added after the first two groups in the programme had completed their sessions. The reason for adding this strategy was because of difficulties in recruiting further parents to the programme. The two internal facilitators emphasised that peer information had contributed to reaching more parents.

According to the group leaders and facilitators, parents appreciated receiving a diploma upon successful completion of the programme, which was a strategy to retain their involvement.

Another implementation strategy aimed at retention was the sending of reminders to participants. However, it was soon realised that this strategy needed reinforcement and, subsequently, internal facilitators offered parents not living within the neighbourhood free transportation, which contributed to high attendance. One internal facilitator said:

In the beginning, when we saw that they [parents] hadn’t arrived 30 minutes before the session, we phoned them. If they told us that they had difficulties coming due to a lack of transportation, we offered them a lift. However, we later came to give all parents who lived outside the neighbourhood a lift. (FGD3, MR)

Many participants took advantage of the willingness of group leaders and facilitators to read and write their letters at most of the sessions. One group leader described his experiences of supporting participants:

It was positive supporting parents with reading or writing letters for them because parents were stressed about all the letters they received. In addition, this kind of support was helpful to engage and retain the participants in the sessions.

Mechanism of impact

Group leaders’ satisfaction on the delivery

Group leaders reported that it took two to three sessions to build trust with parents and for parents to accept the programme. According to the group leaders, at the beginning, parents were hesitant, concerned about the motives of the involvement of social services, and some of the parents denied that they needed training in their parenting. However, some group leaders stated that most of the parents and group leaders knew each other and that this facilitated the building of trust with parents. Another crucial factor that contributed to the retention of participants was the Ladnaan Programme with its societal information component because most parents were eager to receive this information.

The group leaders agreed that the fact Somali was both their mother tongue and that of the parents served to increase parental involvement, which, in turn, contributed to their completing the programme. Further, the group leaders felt that the fact that they and the parents shared the same cultural background was a contributing factor for success. As one group leader stated:

I would say that the biggest success factor was that the group leaders and the parents shared the same country, culture and language and understood each other… for instance, a Swedish group leader would present the message, and I would add examples from the culture or examples that they could identify with. (FGD3, FR)

The use of poetry, proverbs and metaphors served to make the programme culturally sensitive; this seemed to help the parents understand, recognise and realise the universality of parenting. Group leaders noted that the adaptation of role-play exercises and examples was crucial for parents to understand and view parental-child interaction from different perspectives, which led to further reflections and discussions on the part of the parents.

Parent satisfaction with the programme

Parents were asked about their satisfaction with the Ladnaan Programme, and the CSQ showed that 96% (n=55) of participants were very satisfied. Most (70%) reported increased knowledge about social services and children’s rights and increased confidence in seeking support from social services when facing difficulties with their children. All participants (n=57) stated that their relationships with their children had improved. They reported a better post-programme understanding of themselves as parents and of their children’s needs and behaviour; they also reported feeling more secure in their parenting role in Sweden. The total satisfaction, according to the CSQ (n=39), ranged from 24 to 43 (M = 26.38, SD = 4.13), which indicates that families were highly satisfied with the programme.

Overall, our results showed that the most important contextual factor that facilitated the implementation strategy of reaching and retaining the Somali-born parents was the involvement of key individuals. They built trust with the Somali community, which contributed to reaching and retaining parents in the programme. In addition to the implementation strategies prior to the delivery, additional implementation strategies were used to reach and retain participants. For instance, peer information was used to recruit more parents. To retain the participants in the programme, they were offered free transportation. The overall findings also showed that the programme was implemented and delivered as intended. A majority of the parents were satisfied with the programme, and they reported increased knowledge of children’s rights and the support they might seek from social services. They also acknowledged an improvement in the parent-child relationship.

Given previous reports of involving key individuals who are trusted and known by the target group [23], our study showed that the success of the programme was the contextual adaptability, cultural sensitivity and trusting relationship. The trusting relationship was facilitated by the involvement of key individuals within the Somali community in the early phase of the study, which enabled reaching, recruiting and retaining the Somali-born parents in the programme. Moore et al. [26] emphasises the importance of understanding and taking into consideration the contextual factors that may impact the implementation and outcome. Crucial to the engagement of parents in the programme were their understanding of its benefits to both them and their children and the face-to-face provision of information at meetings. During the recruitment of participants, several challenges regarding reach of parents occurred, and adding peer-information facilitated by the parents who had already participated in the intervention contributed to reaching more parents. The programme was delivered by two group leaders, one female and one male, and this strategy contributed to reaching and retaining more fathers. This study included more fathers when compared with other studies [39]. To attract both mothers and fathers to participate in the parenting programme, group leaders of both genders might be beneficial to deliver the programme. Parenting in Sweden jeopardized traditional gender roles for both fathers and mothers, where fathers felt a loss of authority in the family, while mothers experienced inadequacy as a mother with the societal expectations that they would also work or study outside the home. Having access to both a male and a female leader facilitated a discussion on these issues and a reconstruction of gender expectations and parenting in the new country.

Our findings indicate the benefits that came with having social services deliver the parenting programme as this led to less fear and increased confidence when it came to parents seeking support from them. Having social services deliver the intervention can contribute to quality assurance and sustainability of support services to the most vulnerable parents. A contextual factor that needs to be considered in terms of sustainability and quality assurance is involving group leaders within the municipality because this will ensure sustainability and trust-building with the community. Another contextual factor is ensuring that group leaders receive time for preparation. In this study, some group leaders prepared for the sessions in their spare time.

Retention of parents in the programme was improved as a result of the cultural awareness of the facilitators and group leaders. Our finding showed that majority of the parents attended eight sessions or more, retaining parents in the sessions might be linked to their satisfaction of the programme. According to the group leaders, the programme was designed according to the parents needs and delivered in their native language with people who shared the same cultural background as parents. Secondly, any hinders or stressful factors that might result parents not attending the sessions were eliminated by offering them child care, and offering the session time that are convenient for parents. Previous studies [22, 23, 44] report on the practical issues that may hinder parents from participating in the parenting programme, such as transportation, childcare, scheduled times and other stressful factors. Parents in our study were offered childcare services during the sessions but few used it. The study demonstrated the importance of offering childcare in a child-friendly venue with age-related activities for children. The phone reminders, assistance with reading government correspondence and transport to the sessions were reported to reduce parental stress.

Limitations of the study

The programme fidelity was assessed by interviewing instructors, who evaluated the recorded sessions. It would have been preferable to assess the recorded sessions using a checklist. However, during the delivery of the intervention, the external facilitator, researchers and instructors had weekly meetings to assure that the programme was delivered according to the manual. The contextual factors of this implementation process relate to only one municipality; however, they are in line with previous international research [22, 23, 44]. Nevertheless, this is a limitation of this study, and, therefore, studies need to be made of the delivery of this type of programme in major cities and with other groups.

This study provides knowledge about a well-described strategy for the implementation of a parenting programme and guidance on how to reach and retain immigrant parents for parenting programmes. We found that contextual factors, such as matching the group leaders and the parents (shared language), and cultural awareness, are important when it comes to building trust with immigrant parents and engaging them in parenting programmes. Another factor that is important that have wider applicability for other immigrants is designing and delivering parenting programmes in a culturally sensitive manner. In the implementation of evidence-based practice in the delivery of social services, it is important to consider both the specific group for which the intervention is intended as well as any prevailing contextual factors. The fact that social services delivered the parenting programme led to confidence among Somali-born parents when it came to their seeking support from social services. The findings may inform policies as an example of how to adapt and deliver evidence-based programmes to immigrant groups coming to high-income countries. The experiences from the process evaluation also provide knowledge on how to reach other target groups so that this can be transferred to other settings.

Ethics approval and consent to participate

This study has received ethical approval from the Regional Ethical Review Board in Uppsala, Sweden (Dnr 2014/048/1). Participants have received an information letter before participating and gave written consent (in-person interview) and verbal consent (phone interview) to participate. At any time during data collection, participants were allowed to decline from answering any questions or withdraw from the study without consequence.

Consent for publication

All participants gave written consent to publish the research findings.

Availability of data and materials

Data will not be shared as ethics approval does not permit the sharing of data because of issues of confidentiality.

Competing interests

The authors declare that they have no competing interests.

Funding

This research was funded by the Public Health Agency of Sweden (grant number: 802/2014-6.2). The funder had no role in the design of the study, the collection, analysis, and interpretation of data, or in writing the manuscript.

Authors’ contribution

All authors: F.O., U-K.S., M.K.A. and R.F. were responsible for the study design. F.O. collected the data and was responsible for the data analysis and the writing of the manuscript. FO, MT and U-K.S were responsible for the analysis. All authors took part in analysing, reviewing the manuscript and critically revised, read and approved the final manuscript.

Acknowledgements

The authors would like to thank all parents, group leaders and internal facilitators who took time out of their busy schedules to be part of this study.

CSQ Consumer Satisfaction Questionnaire

CRC Convention on the Rights of the Child

FGD Focus group discussion

Migration and migrant population statistics2019. January, Eurostat https://ec.europa.eu/eurostat/statistics-explained/index.php/Migration_and_migrant_population_statistics#Migrant_population:_22.3_million_non-EU_citizens_living_in_the_EU_on_1_January_2018
Swedish Migration Agency, 2015, Applications for Asylum Received, https://www.migrationsverket.se/English/About-the-Migration-Agency/Statistics/Asylum.html
Lindencrona F, Ekblad S, Hauff E. Mental health of recently resettled refugees from the Middle East in Sweden: the impact of pre-resettlement trauma, resettlement stress and capacity to handle stress. Soc Psychiatry and Psychiatr Epidemiol 2008;43:121-31.
Chen W, Ling L, Renzaho AM. Building a new life in Australia: an analysis of the first wave of the longitudinal study of humanitarian migrants in Australia to assess the association between social integration and self-rated health. BMJ Open 2017;7:e014313.
Warfa N, Curtis S, Watters C, Carswell K, Ingleby D, Bhui K. Migration experiences, employment status and psychological distress among Somali immigrants: a mixed-method international study. BMC Public Health 2012;12:1-12.
Betancourt TS, Abdi S, Ito BS, Lilienthal GM, Agalab N, Ellis H. We Left One War and Came to Another: Resource Loss, Acculturative Stress, and Caregiver-Child Relationships in Somali Refugee Families. Cultur Divers Ethnic Minor Psychol
Nilsson JE, Barazanji DM, Heintzelman A, Siddiqi M, Shilla Y. Somali Women's Reflections on the Adjustment of Their Children in the United States. J Multicult Couns Dev 2012;40:240-52.
Renzaho AMN, McCabe M, Sainsbury WJ. Parenting, role reversals and the preservation of cultural values among Arabic speaking migrant families in Melbourne, Australia. Int J Intercult Relat 2011;35:416-24.
Deng SA, Marlowe JM. Refugee Resettlement and Parenting in a Different Context. J Immigrant Refug Stud 2013;11:416-30.
Lewig K, Arney F, Salveron M. Challenges to parenting in a new culture: Implications for child and family welfare. Eval Program Plann 2010;33:324-32.
Renzaho AMN, Green J, Mellor D, Swinburn B. Parenting, family functioning and lifestyle in a new culture: the case of African migrants in Melbourne, Victoria, Australia. Child Fam Soc Work 2011;16:228-40.
Degni F, Pöntinen S, Mölsä M. Somali Parents' Experiences of Bringing up Children in Finland: Exploring Social-Cultural Change within Migrant Households. Forum: Soc Research Social Work Pract 2006;7:3.
Heger Boyle E, Ali A. Culture, Structure, and the Refugee Experience in Somali Immigrant Family Transformation. Int Migr 2010;48:47-79.
Osman F, Klingberg-Allvin M, Flacking R, Schön U-K. Parenthood in transition – Somali-born parents’ experiences of and needs for parenting support programmes. BMC Int Health Hum Rights 2016;16:1-11.
Bowie BH, Wojnar D, Isaak A. Somali Families’ Experiences of Parenting in the United States. West J Nurs Res 2017;39:273-89.
Belsky, J. Bell, B. Bradley, R. H., Stallard, N., Stewart-Brown, S. Socioeconomic risk, parenting during the preschool years and child health age 6 years, Eur J Public Health, 2007;17:508–513, https://doi.org/10.1093/eurpub/ckl261
Waylen, A. Stallard, N. Stewart-Brown, S. Parenting and health in mid-childhood: a longitudinal study, Eur J Public Health, 2008;18:300–305, https://doi.org/10.1093/eurpub/ckm131
Goverment Office of Sweden, R., Nationell strategi för ett utvecklat föräldrastöd - En vinst för alla (In Swedish). Stockholm:Social Department. 2013.
Osman F, Flacking R, Schön U-K, Klingberg-Allvin M. A Support Program for Somali-born Parents on Children’s Behavioral Problems. Pediatrics 2017;139:3.
Osman F, Salari R, Klingberg-Allvin M, Schön U-K, Flacking R. Effects of a culturally tailored parenting support programme in Somali-born parents’ mental health and sense of competence in parenting: a randomised controlled trial. BMJ Open 2017;7:12.
Baker CN, Arnold DH, Meagher S. Enrollment and Attendance in a Parent Training Prevention Program for Conduct Problems. Prev Sci 2011;12:126-38.
Griner D, Smith TB. Culturally adapted mental health interventions: A meta-analytic review. Psychotherapy 2006;43:531-48.
Mytton J, Ingram J, Manns S, Thomas J. Facilitators and Barriers to Engagement in Parenting Programs. Health Educ Beha. 2014;41:127-37.
Koerting J, Smith E, Knowles MM, Latter S, Elsey H, McCann DC, et al. Barriers to, and facilitators of, parenting programmes for childhood behaviour problems: a qualitative synthesis of studies of parents’ and professionals’ perceptions. Eur Child Adolesc Psych 2013;22:653-70.
Rabin, B. A., & Brownson, R. C. Terminology for Dissemination and Implementation Research. In R. C. Brownson, G. A. Colditz, & E. Proctor [Eds.], Dissemination and Implementation Research in Health. New York: Oxford University Press, 2018. p. 19-45.
Moore, G. F., Audrey, S., Barker, M., Bond, L., Bonell, C., Hardeman, W., . . . Baird, J. Process evaluation of complex interventions: Medical Research Council guidance. BMJ 2015; 350:350, h1258.
Proctor, E., Silmere, H., Raghavan, R., Hovmand, P., Aarons, G., Bunger, A., . . . Hensley, M. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health 2011;38:2: 65-76.
Slaughter, S. E., Hill, J. N., & Snelgrove-Clarke, E. What is the extent and quality of documentation and reporting of fidelity to implementation strategies: A scoping review. Implement Sci 2015;10:
Proctor, E. K., Powell, B. J., & McMillen, J. C. Implementation strategies: recommendations for specifying and reporting. Implement Sci 2013; 8:139.
Osman F, Flacking R, Klingberg Allvin M, Schön U-K. Qualitative study showed that a culturally tailored parenting programme improved the confidence and skills of Somali immigrants. Acta Paediatrica 2019;108:1482-90.
Statistics, SCB. Befolkning efter födelseland, ålder och kön. 2019. http://www.statistikdatabasen.scb.se/
Osman F. Ladnaan: evaluation of a culturally tailored parenting support program to Somali-born parents: Stockholm: Karolinska institutet; 2017.
Moretti, M. M., Obsuth, I., Craig, S. G., & Bartolo, T. An attachment-based intervention for parents of adolescents at risk: mechanisms of change. Attach Hum Dev 2015;1:119-135.
Moretti MM, Braber K, Obsuth I. Connect. An Attachment-focused treatment group for parents and caregivers–A principle based manual. Burnaby, British Columbia, Canada: Simon Fraser University. 2009.
Creswell JW: Research design: Qualitative, quantitative, and mixed methods approaches. California, USA: Sage publications; 2013.
Eyberg, S. Consumer satisfaction measures for assessing parent training programs. Innovations in clinical practice: A source book, 1993; 12: 377-382.
World Health Organization. Process of translation and adaptation of instruments. 2013.
Elo, S., & Kyngas, H. The qualitative content analysis process. J Adv Nurs 2008; 62:107-115.
Salari, R., Wells, M.B., Sarkadi, A. Child behaviour problems, parenting behaviours and parental adjustment in mothers and fathers in Sweden. J. Public Health. 2014;42: 547-553.
Osman F, Flacking R, Klingberg Allvin M, Schön U-K. Qualitative study showed that a culturally tailored parenting programme improved the confidence and skills of Somali immigrants. Acta Paediatr. 2019;108:1482-1490.
Sundell, K., Beelmann, A., Hasson, H., & von Thiele Schwarz, U. Novel Programs, International Adoptions, or Contextual Adaptations? Meta-Analytical Results From German and Swedish Intervention Research. J Clin Child Adolesc Psychol 2016; 45:784-796.
Birman, D., Beehler, S., Harris, E. M., Frazier, S., Atkins, M., Blanton, S., . . . Liautaud, J. International Family, Adult, and Child Enhancement Services (FACES): A community‐based comprehensive services model for refugee children in resettlement. Am J Orthopsychiat 2008;78:121-132.
Murray, K. E., Davidson, G. R., & Schweitzer, R. D. Review of refugee mental health interventions following resettlement: best practices and recommendations. Am J Orthopsychiat 2010;80:576-585.
Goodkind, J. R. Effectiveness of a community‐based advocacy and learning program for hmong refugees. Am J Community Psychol 2005; 36:387-408.

Table 1: Blueprint of key components in the process evaluation

Description of the components

Questions in the process evaluation

Data sources

Context

Contextual factors that affect the implementation process and mechanism of change

What were the contextual barriers and facilitators for reaching and retaining the target group?

What were the contextual barriers for participation of the group leaders?

Focus group discussions [FGDs] with group leaders and internal facilitators

Field notes

Implementation process

How delivery of the implementation is achieved

Reach: To what extent did parents in the target group participate in the intervention?

Adaptation: What adaptions of the implementation strategy were made and how was the strategy perceived?

Fidelity: To what extent was the Ladnaan Programme delivered as intended and how did group leaders perceive the delivery?

Attendance list

Field notes

FGDs with group leaders

FGDs with internal facilitators

FGDs with Connect instructors

Participant observations during societal information

Reflection notes from lecturer

FGDs with group leaders

Mechanism of impact

How participants respond to the implementation strategy

Were group leaders satisfied with the delivery of the intervention?

Were the participants/parents satisfied with the intervention?

FGDs with group leaders

Client satisfaction instrument to parents

Table 2: Characteristics of the study participants, their area of responsibility and workplace

	Area of responsibility in the intervention	Workplace	Educational background
*Group leaders [n=8]**	Delivering the Connect programme Help reading and writing letters from government agencies	Social Services: Department of Family, Children and Youth	University degree [n=1]
		Social Services: Department of Employment and Integration	Upper secondary diploma [n=1]
		Integration office	University degree [n=1] Upper secondary diploma [n=1]
		Schools: primary and secondary school	University degree [n=1] Upper secondary diploma [n=2]
		Interpreter	Upper secondary diploma [n=1]
*Lecturer [n=1]**	Delivering the societal information component	Social Services: Department of Family, Children and Youth	University degree [n=1]
Connect instructors [n=2]	Training the group leaders in the Connect programme Supervising group leaders once a week in the Connect programme	Social Services from another municipality – external quality assurance	University degree [n=2]
Internal facilitators [n=2]	Sending text messages and calling parents Babysitting Taking care of the welcoming refreshments for the participants Arranging transportation	Social services	Vocational training diploma [N=2]
External facilitator [n=1]	Overall responsibility of the implementation process Observing the societal information sessions Quality assurance of the intervention	University	University degree [n=1]

*Two of the group leaders also served as lecturers and delivered the societal information component. One group leader also had the responsibility for recruiting parents and facilitating the implementation of the intervention.

Table 3: Data collection sources, participants and data analysis

Data source	Participants/instruments	Data collection	Data analysis
FGDs with Connect instructors, group leaders and internal facilitators [n=6]	Group leaders who delivered the intervention [n=7] Internal facilitators who were responsible for the practicalities [n=2] concerning the implementation Instructors of the Connect programme [n=2]	FGDs were conducted after the four parent groups were finished	Inductive qualitative analysis
Field notes	Field notes of the external facilitator during planning, delivery and evaluation phases	Field notes were made during delivery of the programme	Deductive qualitative analysis
Participant observation	Participant observation of the external facilitator on the societal information sessions [n=2]	Observations were conducted during the delivery of the programme	Deductive qualitative analysis
Reflection	Reflection notes from the two group leaders and the lecturer	Reflections were made after the delivery of the societal information sessions	Deductive qualitative analysis
CSQ	CSQ is a standardised instrument measuring parents’ satisfaction with the programme	The questionnaire was administered two months after the programme ended	Descriptive statistical analysis
Attendance list	Attendance list collected from all the sessions [n=12] in the programme	Attendance list was noted at all sessions	Descriptive statistical analysis

Download PDF

Version 3

posted

You are reading this older preprint version

Read the latest preprint version →

Process evaluation of the implementation of a parenting programme for Somali-born parents living in Sweden

Status:

Version 3

Abstract

Figures

Background

Methods

Results

Discussion

Conclusion

Declarations

Abbreviations

References

Tables

Status:

Version 3