Lessons learned in evaluating the Familias Fuertes program in three countries in Latin America
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Informe especial / Special report Pan American Journal
of Public Health
Lessons learned in evaluating the
Familias Fuertes program in three countries
in Latin America
Pamela Orpinas,1 Ashley Ambrose,2 Matilde Maddaleno,3
Lauren Vulanovic ,2 Martha Mejia,4 Betzabé Butrón,2
Gonzalo Sosa Gutierrez,5 and Ismael Soriano 2
Suggested citation Orpinas P, Ambrose A, Maddaleno M, Vulanovic L, Mejia M, Butrón B, et al. Lessons learned in
evaluating the Familias Fuertes program in three countries in Latin America. Rev Panam Salud Publica.
2014;36(6):383–90.
abstract This report describes 1) the evaluation of the Familias Fuertes primary prevention program
in three countries (Bolivia, Colombia, and Ecuador) and 2) the effect of program participation
on parenting practices. Familias Fuertes was implemented in Bolivia (10 groups, 96 parents),
Colombia (12 groups, 173 parents), and Ecuador (five groups, 42 parents) to prevent the
initiation and reduce the prevalence of health-compromising behaviors among adolescents by
strengthening family relationships and enhancing parenting skills. The program consists of
seven group sessions (for 6–12 families) designed for parents/caregivers and their 10–14-year-
old child. Parents/caregivers answered a survey before the first session and at the completion of
the program. The survey measured two important mediating constructs: “positive parenting”
and “parental hostility.” The Pan American Health Organization provided training for facili-
tators. After the program, parents/caregivers from all three countries reported significantly
higher mean scores for “positive parenting” and significantly lower mean scores for “parental
hostility” than at the pre-test. “Positive parenting” practices paired with low “parental hos-
tility” are fundamental to strengthening the relationship between parents/caregivers and the
children and reducing adolescents’ health-compromising behaviors. More research is needed to
examine the long-term impact of the program on adolescent behaviors.
Key words Parenting; adolescent; adolescent behavior; primary prevention; family; Bolivia;
Colombia; Ecuador; Latin America.
Parents/caregivers play pivotal roles tional and physical well-being and pro- at parenting have a warm and caring
in the lives of the children they raise. tect them from harm and adverse cir- relationship with the children (3); com-
They can promote the children’s emo- cumstances such as discrimination and municate family values against high-risk
poverty. Quality of family relationships behaviors (4); and maintain consistent
1
Department of Health Promotion and Behavior, is important in the parenting process. discipline, supervision, and involvement
University of Georgia, Athens, Georgia, United
States of America. Send correspondence to: Good parenting skills can protect chil- (5–8). Parenting that reflects a combina-
Pamela Orpinas, porpinas@uga.edu dren and adolescents from engaging in tion of all of these characteristics may
2 Department of Family, Gender and Life Course,
Pan American Health Organization, Washington,
behaviors that compromise their health, have the strongest positive effect on pre-
District of Columbia, United States of America. such as drug use, early sexual activ- venting risk behaviors (9, 10). Strong pa-
3 Ministry of Health, Santiago, Chile.
4 Pan American Health Organization, La Paz, Bolivia.
ity, school dropout, and peer aggression rental control may be particularly impor-
5 Ministry of Health and Social Protection, Bogotá, (1, 2). Decades of family research have tant for children living in areas where
Colombia. determined that those most successful drugs and violence abound (3, 11). Con-
Rev Panam Salud Publica 36(6), 2014 383Special report Orpinas et al. • Lessons learned in evaluating the Familias Fuertes program in three countries
versely, researchers have consistently TABLE 1. Familias Fuertes program: session objectives
shown that harsh parental discipline and
lack of parenting skills can lead youth to Session Objectives
engage in numerous problem behaviors 1 Parents/caregivers give love and set limits
(12, 13). Youth communicate goals and dreams
Whole family supports goals and dreams
Most parents/caregivers would like to
provide a good environment for the chil- 2 Parents/caregivers establish home rules
Youth learn to appreciate parents
dren to succeed, but some do not have
Whole family promotes family communication
the knowledge and skills to create a posi-
3 Parents/caregivers stimulate good behavior
tive home environment that balances
Youth deal with stress in healthy ways
affection with age-appropriate limits. Whole family appreciates family members
Programs designed to improve parent-
4 Parents/caregivers learn to set appropriate consequences
ing skills may be particularly important Youth learn to obey the rules
in low- and medium-income countries Whole family uses family reunions
where parents/caregivers have limited 5 Parents/caregivers practice listening and paying attention to feelings
resources (2). Youth deal with peer pressure
In 2007, the Pan American Health Whole family understands family values
Organization (PAHO) selected the 6 Parents/caregivers help protect youth against high-risk behaviors
Strengthening Families Program (SFP) Youth practice resisting peer pressure and choosing good friends
for parents and youth aged 10–14 years Whole family talks about peer pressure and establishing expectations
as the best model for prevention for Latin 7 Parents/caregivers focus on connecting to community resources
American families (14). PAHO adapted Youth learn ways to help others and interact with positive role models
Whole family reviews program content and graduate
the program for Latin Americans by
modifying some of its strategies and cre-
ating videos with actors who reflected a
wide range of Latino racial groups but based on the presence of behavioral or success (25); and savings of US$ 9.60 for
used a standardized Spanish language emotional problems. Second, as a family- every dollar invested (26).
(15). The adapted version, known as Fa- centered prevention program, the values The goal of this report was to describe
milias Fuertes (FF), has been implemented promoted by FF are consistent with the 1) the evaluation of FF in three countries
in 13 countries in Latin America and the strong ties of the Latino family (18). La- in Latin America—Bolivia, Colombia,
Caribbean, as well as in the United States tino parents/caregivers and adolescents and Ecuador—and 2) the effect of FF on
(16). The program is designed for youth have both emphasized the importance parenting skills of parents or caregiv-
living in any family configuration and of the whole family participating in the ers who participated in the program.
the videos portray different types of program (16). Third, FF has the poten- Parents/caregivers completed a survey
family structures. All adults who take tial to bridge the gap between theory before and after participating in the
care of youth are invited to participate (research) and practice (implementation) seven-session program (“pre-test” and
as research conducted among traditional because the program can be organized “post-test”). It was hypothesized that
family structures indicates family inter- and administered by community mem- participating parents/caregivers’ “posi-
vention programs are more successful bers without advanced degrees. Fourth, tive parenting” skills would increase and
when they include both the father and FF is relatively inexpensive to imple- “parental hostility” would decrease.
mother (17). The long-term goal of FF ment and only comprises seven short
is to prevent the initiation of high-risk sessions. All of the materials—includ- MATERIALS AND METHODS
behaviors among adolescents (e.g., use ing videos, printable facilitator manuals,
of alcohol and other drugs, early sexual and PAHO’s manual for measuring The intervention
intercourse, teen pregnancy, aggression, behavior-mediating constructs (19)—are
and school dropout) and reduce their free and can be downloaded from the FF consists of seven weekly two-hour
prevalence by strengthening relation- PAHO website.6 Fifth, FF is based on the sessions for parents/caregivers and chil-
ships among family members and pro- SFP, which has been shown to be very ef- dren in the family aged 10–14 years. The
moting self-regulation and positive con- fective. In clinical trials conducted among participants are divided into groups of
flict resolution strategies. a predominantly white student popula- 6–12 families each. During the first hour
FF has several characteristics that make tion in Iowa, completion of the SFP was of each session, parents/caregivers and
it ideal for prevention of high-risk behav- associated with long-term reductions in children work in separate groups; during
iors. First, FF is designed as a primary the initiation and past-month use of al- the second hour all family members work
prevention program for all families with cohol and cigarettes (20); slower overall together in the same group. Table 1 pro-
an adolescent aged 10–14 years. The goal growth in substance use (21); reduced vides details about the objectives of each
of the program is to prevent initiation use of methamphetamine (“meth”) and session by group (youth, parents/care-
of the “slippery slope” of trying drugs, prescription drugs (22); reduced high-risk givers, and whole family). The sessions
missing school, and becoming teen par- sexual behaviors (23); reduced aggression include videos, interactive exercises,
ents, and thus falling into a self-defeating and hostility (24); increased academic and discussions. Facilitators who have
process of cumulative disadvantage. Se- completed the FF program’s three-day
lection of adolescent participants is not 6 http://tinyurl.com/PAHO-ES-FF training workshop lead the sessions. FF
384 Rev Panam Salud Publica 36(6), 2014Orpinas et al. • Lessons learned in evaluating the Familias Fuertes program in three countries Special report
facilitators do not require clinical training behavior, and 3) increase their consis- supervision. Figure 1 depicts the pro-
or advanced degrees but do need to have tency in monitoring and supervising the gram’s conceptual model, including the
good facilitation skills, enthusiasm, and child’s whereabouts. Parents/caregivers hypothesized mediators and outcomes,
the ability to maintain program fidelity. also learn to communicate family values and details about the specific behaviors
“Effective group leaders can be drawn that do not support high-risk behaviors. the program targets among parents/
from the following: family and youth ser- Youth are encouraged to communicate caregivers, youth, and the community.
vice workers, mental health staff, teach- more effectively with their parents/care-
ers, school counselors, ministers, church givers, share their goals, and understand Study design and sample
youth staff, skilled parents/caregivers and follow home rules.
who have previously attended the pro- In addition to teaching parents/ FF was implemented in the three
gram, and staff from [Iowa’s] Coopera- caregivers how to express love and set countries as a community service, not
tive Extension Service” (14). As a primary limits within the family, FF is designed as a research study. The purpose of the
prevention program, FF is designed for to improve the children’s ability to make subsequent evaluation described here
all families, not just those with children decisions with their peers and to enhance was to document change in behavior
with behavioral or emotional problems. youth cognitions that have been shown to among participants upon their comple-
FF is guided by two principles of be effective in preventing drug use. Most tion of the program, under the auspices
effective child rearing. The first prin- children are not “pulled” into groups of PAHO and based on its ethical guide-
ciple is to express love. FF is designed with values that conflict with their own. lines, with the goal of improving parent-
to enhance parents/caregivers’ positive Rather, they will choose friends with dis- ing practices. Thus, none of the countries
relationship with the child by reinforc- positions that match their own, which are had a control group. In all countries, the
ing skills that better enable them to influenced by parenting practices (27). program was implemented in schools.
give compliments, show affection, ap- Thus, parents/caregivers have an indirect Participants completed the pre-test at
preciate the child’s goals and activities, role in influencing the child to choose the beginning of the first session and the
and be involved in the child’s world. positive friendships. As a community- post-test at the end of the seventh ses-
The second principle is to set limits. based program, FF facilitates the interac- sion. The surveys used in all three coun-
Parents/caregivers learn to 1) establish tion among the parents/caregivers who tries measured the mediating constructs
home rules, and effective consequences participate in the program, enhances so- identified in the program’s theoretical
for breaking them, 2) reinforce positive cial support, and provides community model. Between September and Decem-
FIGURE 1. Familias Fuertes program conceptual model
Activities Mediators Outcomes
PARENTS/CAREGIVERS
Improve positive parenting practices
– Enhance positive relationship with child
(compliments, affection, appreciation,
involvement)
– Communicate family values against
high-risk behaviors Reduce health-compromising
– Increase consistent parental discipline behaviors among youth:
and supervision
1) Decrease initiation and/or
Program Effects: delay onset of alcohol,
Deliver 7 sessions of YOUTH tobacco, and other drug
Familias Fuertes Program Enhance preventive cognitions use
– Increase negative attitudes toward 2) Reduce prevalence of
high-risk behaviors school dropout and
– Enhance goal-oriented decisions aggression
Improve decision-making with peers
– Increase resistance to peer pressure
– Increase appreciation of good friends
Improve family relationships
– Enhance positive relationship with
parents (compliments, affection,
appreciation, involvement)
– Understand and accept family values
against high-risk behaviors
– Follow parental rules
Community Effects:
Provide opportunities for COMMUNITY
interpersonal communication Increase sense of empowerment
in a safe and relaxed – Increase communication and social
environment support with other parents/neighbors
Rev Panam Salud Publica 36(6), 2014 385Special report Orpinas et al. • Lessons learned in evaluating the Familias Fuertes program in three countries
ber 2012, PAHO trained local facilita- Quito. The mean age of parents/caregivers Positive parenting. The “positive par-
tors in La Paz (Bolivia) (n = 35), Bogotá was 40.4 (SD = 6.9, range 27–52). Over half enting” construct refers to parental be-
(Colombia) (n = 31), and Quito (Ecua- of the participants were women (54%). haviors that show love, appreciation,
dor) (n = 21). All FF sessions were imple- Approximately 30% of the families had and interest in the child’s ideas and ac-
mented after the training. Participants finished high school, and another 30% had tivities. In Bolivia, “positive parenting”
included the parents/caregivers, mostly some college education. Three siblings was measured by six items (alpha = 0.79);
mothers, and one child per family. The participated but did not complete the pre- in Colombia, it was measured by only
children’s age ranged between 10 and 14 test or the post-test. three of those items (alpha = 0.71). In
years. In all countries, the sample of par- Ecuador, it was measured with two dif-
ticipating children was evenly divided Measures ferent scales: one determining the level
by gender (girls: 48%; boys: 52%). of “parental appreciation” (seven items,
All surveys measured the two main alpha = 0.80) from the Positive Parenting
Bolivia. In Bolivia, 10 FF groups were constructs that the program is designed Style Scale (28) and the other determin-
conducted with a total of 119 families. to influence: “positive parenting” and ing the level of “parental warmth” (five
The large majority of these families had “parental hostility.” However, because items, alpha = 0.82) based on the Behav-
an indigenous ethnic background (Ay- this was not a research study, there ioral Affect Rating Scale (19, 29).
mara). Participants lived in low-income were some differences in the instru-
areas in suburbs of the city of La Paz, ments selected in each country. In Bo- Parental hostility. The “parental hostil-
with high levels of insecurity and high livia and Colombia, parents/caregivers ity” construct refers to parental behav-
exposure to social risks. The mean age of completed a short survey, whereas in iors that can indicate anger, such as
parents/caregivers was 37.3 (standard Ecuador parents/caregivers completed losing control, shouting, or hitting. In
deviation (SD) = 8.7, range 18–68). The a longer survey. For Ecuador, four Bolivia, “parental hostility” was mea-
majority of participants were women additional constructs were reported: sured by five items (alpha = 0.72); in
(86%). Three older siblings and a few “parental involvement,” “consistent Colombia, it was measured with three
grandparents also participated. discipline,” “parental monitoring,” and of those items (alpha = 0.71). In Ecua-
“parental communication against high- dor, “parental hostility” was measured
Colombia. In Colombia, 12 FF groups risk behaviors.” All scale scores were using the hostility subscale (seven items,
were conducted with 182 families. The computed as the average of all the alpha = 0.85) from the Behavioral Affect
program was implemented in four cit- items, with higher scores representing Rating Scale (19, 29).
ies: Barranquilla, Cúcuta, Manizales, stronger support for the construct. Re-
and Palmira. The mean age of parents/ sponse categories are listed in Table 2. Parental involvement. “Parental in-
caregivers was 40.6 (SD = 8.1, range 27– Completion of the survey was volun- volvement” in the child’s life was mea-
71) and the majority were women (75%). tary and did not affect whether or not sured with 10 items (alpha = 0.79) based
families could participate in the pro- on scales used in previous studies (19)
Ecuador. In Ecuador, five FF groups were gram. Participants were informed that but modified to incorporate behaviors
implemented with 82 families. The pro- they could skip questions or refuse to reinforced by the FF program, such as
gram was conducted in three schools in answer. support for the child’s goals and dreams.
TABLE 2. Comparison of parent/caregiver responses before and after the implementation of the Familias Fuertes
program, Bolivia, Colombia, and Ecuador, 2012–2013
Pre-test Post-test
Behavior-mediating constructa mean (SDb) mean (SD) tc df d P
Bolivia
Positive parentinge 3.10 (0.63) 3.30 (0.57) –3.610 90 0.001
Parental hostilitye 2.04 (0.54) 1.88 (0.51) 3.031 92 0.003
Colombia
Positive parentinge 3.38 (0.65) 3.54 (0.52) –3.069 172 0.002
Parental hostilitye 2.07 (0.63) 1.90 (0.68) 2.803 172 0.006
Ecuador
Parental appreciationf 3.80 (0.53) 4.15 (0.51) –5.230 41 < 0.0001
Parental warmthf 4.18 (0.63) 4.51 (0.44) –4.386 41 < 0.0001
Parental hostilityf 2.78 (0.67) 2.50 (0.53) 3.593 40 0.001
Parental involvementf 4.12 (0.47) 4.33 (0.42) –3.439 41 0.001
Consistent disciplinef 3.23 (0.82) 3.69 (0.69) –3.838 41 < 0.0001
Parental monitoringf 4.15 (0.69) 4.42 (0.55) –4.140 41 < 0.0001
Parental communication against high-risk behaviorsg 2.04 (0.98) 2.38 (0.76) –2.596 41 0.013
a All scales were computed as the average of all items, with higher values indicating a stronger support for the construct.
b SD: standard deviation.
c t: Student’s t-test result for paired samples.
d df = degrees of freedom.
e Response categories ranged between “never” (1) and “always” (4).
f Response categories ranged between “never” (1) and “always” (5).
g Response categories ranged between 0 times (0) and 3 or more times (3).
386 Rev Panam Salud Publica 36(6), 2014Orpinas et al. • Lessons learned in evaluating the Familias Fuertes program in three countries Special report
Consistent discipline. “Consistent dis- FIGURE 2. Proportion of sample that reported Among those with lower room for im-
cipline” (consistency in applying conse- an increase in “positive parenting,” by “room provement, on average across countries,
quences for the child’s behaviors) was for improvement” (“high” versus “low”) 21% increased their “positive parenting”
measured using three items (alpha = 0.84). at baseline, after completing the Familias at post-test and 25% decreased their “pa-
Fuertes program, Bolivia, Colombia, and rental hostility.”
Ecuador, 2012–2013
Parental monitoring. “Parental monitor-
ing” (parents/caregivers’ solicitation of
90
High room for improvement DISCUSSION
information from the child about his/her Low room for improvement
whereabouts and friendships) was mea- 80 The design and content of the FF pro-
Percent of sample increasing mean
sured with 11 items (alpha = 0.92) (30). 70 gram is consistent with the evidence-
based SFP, which was proven effective
Parental communication against high- 60 through rigorous randomized control tri-
score at post-test
risk behaviors. “Parental communica- 50 als, and is therefore expected to achieve
tion against high-risk behaviors” was similar results. The strict facilitator
measured with eight items (alpha = 0.93) 40 training guidelines and standardized
adapted from the “Parent-Child Com- 30 materials guarantee the consistency of
munication About Smoking” measure FF with the SFP. Although several stud-
20
to include alcohol, drugs, gangs, fights ies of the SFP have been conducted, the
at school, school dropout, and sexual 10 literature on FF is nascent: one study in
behaviors (19). Honduras (31), an evaluation of the pro-
0
Bolivia Colombia Ecuador gram in Chile (32), and a pilot evaluation
RESULTS Positive parenting
with Latino families living in the United
States (16). Given the importance of par-
Of the 383 participants, 311 sets of enting programs, the World Health Or-
results for the pre-test and the post-test ganization (WHO) has called for more
were matched (Bolivia: n = 96, 81%; Co- FIGURE 3. Proportion of sample that reported evaluation of these types of programs
lombia: n = 173, 95%; Ecuador: n = 42, an decrease in parental hostility, by “room for (1). The current FF evaluation is useful
improvement” (“high” versus “low”) at base- for increasing understanding of the ef-
51%). In Ecuador, 82 families started the
line, after completing the Familias Fuertes
first session, but only 51 completed all ficacy of FF in Latin America, but more
program, Bolivia, Colombia, and Ecuador,
sessions. Of these, 42 completed both a 2012–2013 research is needed.
pre-test and a post-test. Parents/caregivers changed in two
Table 2 provides details on the mean High room for improvement dimensions that both theory and re-
scores of parents/caregivers before and 90 Low room for improvement search highlight as key to positive child
after the implementation of the FF pro- 80 development (9, 12). First, they reported
Percent of sample decreasing mean
gram. The Student’s t-test was used to an increase in their “positive parenting”
assess whether changes in scores for 70 skills in the form of showing more love,
paired samples were statistically dif- 60 appreciation, and interest. Second, they
score at post-test
ferent. After the program, parents/ reported less hostility toward the chil-
50
caregivers from all three countries re- dren in the form of less shouting and in-
ported statistically significant higher 40 sulting. The literature shows that nurtur-
“positive parenting” and lower “pa- ing and responsive parenting provides
30
rental hostility.” In Ecuador, parents/ a shell of protection and reduces ado-
caregivers reported statistically signifi- 20 lescent risk behaviors (33). The change
cant higher “parental involvement,” 10 in the participating parents/caregivers’
“consistent discipline,” “parental moni- perceptions of these important dimen-
toring,” and “parental communication 0 sions is promising, but the results do
about health-compromising behaviors.” Bolivia Colombia Ecuador not indicate if the changes will be sus-
Parents/caregivers with very high Parental hostility tained over time. Theoretically, these
“positive parenting” and those with very changes should lead to reductions in the
low “parental hostility” at pre-test had initiation and frequency of adolescents’
very little possibility of improving their reported an increase in “positive parent- health-compromising behaviors. More
scores. Thus, to examine the proportion ing” and Figure 3 shows the proportion research is needed to examine the long-
of parents/caregivers that improved that reported a decrease in “parental term impact of this intervention.
their scores at post-test, the sample was hostility,” by room for improvement in The improvement of parenting skills
divided into the approximately one- their scores. The more room for improve- through participation in the program
third of the group with “low room for ment, the larger the proportion that im- can be attributed to several factors. First,
improvement” and those with higher proved their scores. Among those with the evaluated program materials were
room for improvement (i.e., lower initial “high room for improvement,” on aver- consistent with the original program
scores in “positive parenting” and higher age across countries, 75% increased their materials with the exception of some
scores in “parental hostility”). Figure 2 “positive parenting” at post-test and cultural adaptations for Latino fami-
shows the proportion of the sample that 68% decreased their “parental hostility.” lies. In addition to being translated into
Rev Panam Salud Publica 36(6), 2014 387Special report Orpinas et al. • Lessons learned in evaluating the Familias Fuertes program in three countries Spanish and modified to fit the reality conducted several weeks after the last Personal Communication, 19 February of some countries in Latin America, the session. However, this best-case scenario 2014). Although it is expected that the program was revised by PAHO experts is not possible in most countries where adapted FF program will achieve similar in gender and health to eliminate pos- the main focus is to provide a service, results as the SFP, a rigorous impact sible gender biases. PAHO has built a not conduct a rigorous research study. evaluation of FF in Latin America is legacy around FF in the Americas, offer- The training of facilitators should in- integral to the continual improvement ing technical cooperation to countries in clude skills for data collection. As ac- and growth of the program. A clustered all aspects of program implementation. cess to phones and computers increase, randomized control trial measuring the Second, using videos and practical ac- online data collection and audio-assisted impact of the FF program on alcohol and tivities, the program provides a model interviewing could help reduce literacy drug use, school dropout, and aggres- of the skills that parents/caregivers need limitations and social desirability (34). sion, using a control group as compari- to learn, followed by practical exercises In spite of these implementation prob- son, would allow for the examination to enhance learning. Third, the program lems, results consistently showed posi- of changes in drug use and other risk addresses the fundamental parenting tive changes. In addition, the comments behaviors relative to the trajectories in skills: showing love, reducing harsh par- from parents/caregivers in this evalua- the “normal” population. Many of the enting, setting age-appropriate limits, tion showed high levels of satisfaction outcomes, such as adolescent alcohol having consequences for the behavior, with the program and positive changes. use, will increase over time. Previous communicating without negativity, and Characteristics of the sample may also research has shown that the growth of supervising the child’s whereabouts. affect the results. Factors such as qual- increase was lower in the intervention The low response rate in Ecuador was ity of the relationship between parents/ group than the control group but ado- due to lack of support from the principal caregivers or levels of stress may be lescents in both groups increased their of one of the schools, who limited access influencing the results and should be alcohol use (21). A longitudinal study to the building during the weekends. taken into account. Another limitation with a control group will help ensure the Meetings could not be held for a couple was the low participation of fathers or sustainability of the program as fund- of weeks, after which parents/caregivers male caregivers. The predominance of ing and commitment to the program stopped attending. This problem high- female caregivers is not uncommon in by country governments increases with lights the need for strong administra- family programs. Part of the problem is strong evidence. tive support for successful program that in families where parents are single, implementation. Another problem that divorced, or separated, the mother usu- Conclusions reduced participation in low-income ally has custody of the children and is communities was lack of transportation the only parent to attend school events Familias Fuertes is a primary pre- and the cost of public transportation to (32, 35). More research is needed on vention program designed to prevent the schools. Providing funds for trans- recruitment strategies to increase partici- health-compromising behaviors among portation, or implementing the program pation of male caregivers. Volunteer bias adolescents by strengthening family in the community instead of the schools, should also be considered as a potential relationships and enhancing parent- may alleviate this problem. confounding factor in the analysis of ing skills. In this evaluation, parents/ The process of evaluating FF revealed the data. Invitations to participate in the caregivers from Bolivia, Colombia, a number of challenges and areas for im- program were distributed to all parents/ and Ecuador who participated in FF provement. Because this evaluation was legal guardians at each school, and it is increased their “positive parenting” not a research study, in which rigorous possible that families with greater moti- practices and reduced hostile behav- attention to measurement is paramount, vation and resources chose to participate iors. Expressing caring feelings, setting facilitators from different countries did in the program. Therefore, characteris- clear and age-appropriate limits, and not use the same scales. However, in tics of participating families should also being involved in the life of children all three countries where the program be measured carefully to account for are fundamental to strengthening fam- was evaluated, scales that measured the these factors. ily relationships. A strong and positive expected changes in mediating the fam- The scores did not follow a normal parent/caregiver–child relationship has ily variables were used. Facilitators sug- distribution. Many parents/caregivers been consistently linked to adolescents gested that the scales should be short- had high scores for “positive parenting” exhibiting fewer health-compromising ened and alternative ways of measuring and low scores for “parental hostility,” behaviors. More research is needed to should be incorporated to accommodate an expected outcome given that the pro- determine the best strategies to measure parents/caregivers with low literacy lev- gram is designed for the general popula- impact, the possible adaptations to local els. In this evaluation, use of just three tion, not for families with children with cultures, and the long-term impact of the items provided as good an estimate of behavioral problems. In spite of this ceil- program on adolescent behaviors. the construct as the longer scales. Future ing effect, scores did reflect change in the To ensure the sustainability of the evaluators should consider using short expected direction. program in the Americas region, PAHO scales and common instruments to fa- The short-term evaluation and the lack has streamlined the distribution and cilitate the comparisons across countries. of control group were also limitations. availability of FF materials (including To reduce social desirability, the persons The evaluation of FF in Chile showed manuals and videos), which are avail- who facilitate the intervention should changes in adolescent outcomes only able online at no cost. An adaptation of not be the same as those who assess after the third year (T. Zubarew, Pon- FF for Latinos living in the United States the families and the post-test should be tificia Universidad Católica de Chile, is available from the lead author (PO). 388 Rev Panam Salud Publica 36(6), 2014
Orpinas et al. • Lessons learned in evaluating the Familias Fuertes program in three countries Special report
With program materials and evalua- dean Community Anti-Illicit Drug Pro- program; the families who participated
tion instruments defined and available, gram (PRADICAN), and the Pan Ameri- in it; and the European Union and the
PAHO has established strong commu- can Health Organization (PAHO) for Royal Norwegian Embassy, for their
nication networks with governments their leadership and technical support financial contributions.
and communities to share knowledge, in the implementation and evaluation
including evaluation results and sugges- of the Familias Fuertes (FF) program. The
Funding. The European Union and
tions for program implementation and authors also thank the implementing
the Royal Norwegian Embassy helped
adaptation. partners, the trainers, and the facilitators
fund this evaluation.
of FF in Bolivia, Colombia, and Ecuador,
Acknowledgments. The authors thank for their dedicated commitment to the
the Andean Community (CAN), the An- implementation and evaluation of the Conflicts of interest. None.
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resumen Este informe describe 1) la evaluación del programa de prevención primaria Familias
Fuertes en tres países (Bolivia, Colombia y Ecuador) y 2) el efecto de la participación
en el programa sobre las prácticas de crianza. El programa Familias Fuertes se llevó a
Lecciones aprendidas al cabo en Bolivia (10 grupos, 96 padres), Colombia (12 grupos, 173 padres) y Ecuador
evaluar el programa (5 grupos, 42 padres) para prevenir el inicio y reducir la prevalencia de comporta-
Familias Fuertes en mientos que constituyen un riesgo para la salud de los adolescentes, mediante el
fortalecimiento de las relaciones familiares y la mejora de las habilidades de crianza.
tres países de América Latina El programa consta de siete sesiones de grupo (para 6 a 12 familias) dirigidas a padres
o cuidadores y sus hijos de 10 a 14 años de edad. Los padres o cuidadores respondie-
ron a una encuesta antes de la primera sesión y al término del programa. La encuesta
midió dos conceptos importantes: la “crianza positiva” y la “hostilidad parental”. La
Organización Panamericana de la Salud capacitó a los facilitadores. Después del pro-
grama, los padres o cuidadores de los tres países presentaron puntuaciones m edias
significativamente mayores en “crianza positiva” y significativamente menores en
“hostilidad parental” que en la encuesta previa. La prácticas de “crianza positiva”
asociadas con una baja “hostilidad parental” son fundamentales para fortalecer la
relación entre los padres o cuidadores y los niños, y reducen los comportamientos
que constituyen un riesgo para la salud de los adolescentes. Es necesaria una investi-
gación más amplia para analizar la repercusión a largo plazo del programa sobre los
comportamientos de los adolescentes.
Palabras clave Responsabilidad parental; adolescente; conducta del adolescente; prevención primaria;
familia; Bolivia; Colombia; Ecuador; América Latina.
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