Scaling Population-based Parenting Interventions in Socially Disadvantaged Communities: Challenges, Opportunities, and Future Directions

A population approach needs to ensure sufficient reach, which we defined as ‘enough participating parents to reduce the prevalence rates of parenting difficulties and child problems being addressed, while increasing parental confidence and efficacy in the overall population’. Having a system that engages large numbers of eligible parents is key to prevalence reduction (Sanders et al., 2017). Strategies that destigmatize parental participation in a parenting and family program help to eliminate barriers to broad community reach (Higgins et al., 2019). Therefore, the development of a population-based implementation plan needs to commence with an understanding of who lives within the participating communities (Wight et al., 2016), and should attend to the proportion of participants in relation to the total eligible population and to the representativeness of the sample (Glasgow et al., 1999). To determine the overall proportion and representativeness required to achieve adequate reach in a study of children and families, the size of the overall community population is not sufficient. To ensure that the effort is reaching the eligible or focus population, information about the number of families and children residing in those communities is needed. In addition, the distributions of socio-economic (e.g., poverty, workforce participation, types of work, housing, social mobility), demographic (e.g., proportion of sole parents, teenage parents, cultural diversity, age of children) and neighbourhood factors (e.g., availability of support, social cohesion, collective efficacy) present in a community, provide information on who needs to be supported to ensure that families likely to benefit participate in the program and its evaluation. This information also provides insights into factors that are likely to influence the deployment of resources available to support parents, and parents’ attitudes towards help-seeking and engaging with their community (Wight et al., 2016).

Understanding who to reach is a key aspect of intervention selection but is insufficient on its own. Different communities may comprise people with differing levels of need for support (Marmot and Bell, 2012). In theory a population approach may employ an entire suite of evidence-based interventions including universal and indicated programs. In poorly resourced communities it is likely that only a few of the available interventions can be offered and accessed in the population of focus. Some families require significant and ongoing input from formal family support services, while others may benefit from a brief single session program (Prinz, 2019). Therefore, it is critical to ensure that the most suitable mix or combinations of universal and indicated interventions are available, accessible, and deliverable.

To accommodate the varying needs of families within the Triple P system, a range of group and individual programs (6–12 sessions) has been developed to address high risk and vulnerable families to complement universal programs. As demonstrated in Fig. 1, these include Enhanced Triple P for parents with relationships difficulties or mental health problems, Stepping Stones Triple P for parents of children with developmental disabilities, Fear-Less Triple P for parents of anxious children, Pathways Triple P for parents at risk of child maltreatment, Family Transitions Triple P for parents who have separated or divorced, Lifestyle Triple P for parents of overweight or obese children, Grandparent Triple P for custodial grandparents, Indigenous Triple P for Aboriginal and Torres Strait Island families and Family Life Skills Triple P for parents with high levels of adverse childhood experiences in their families of origin. In addition, several mainstream Triple P programs such as Group Triple P have been used successfully with vulnerable families involving parents in homeless shelters, parents in prisons, and refugee parents. In socially disadvantaged communities there are likely to be more families with special or additional needs who might benefit from tailored programs.

The design of the Triple P system assumes that parents can have a long-term association (beginning at birth of a first child) with the program across successive phases of development. At each phase a parent might access one or more levels of intervention of varying intensity depending on the type and severity of the child’s problem, associated family concerns, their own availability, preferences (online vs. in person), and the local accessibility of a particular variant. Parents can enter the system of support at any stage of their child’s development and are encouraged to access the level of support they need (from “light touch” or low intensity support to more intensive programs). Having online variants of programs greatly increases access for parents living in rural communities providing they can access a stable internet connection.

Understanding the wider community context in which the intervention will be deployed is just as critical as having clarity about the recipients and issues being addressed by an intervention. The context refers here to the issues facing the potential participants and their families, and to the broader social-ecological context. The community context influences the prevalence of problems or issues within the community via rules, laws and shared values that promote or inhibit the behavior of members. Context can also act as a barrier or facilitator for program promotion and participation (Sanders et al., 2017). Advisedly, early and sustained analysis is required of factors that have potential to directly and indirectly influence the outcomes being addressed by the intervention, or that may impact the access pathways for parents. This may include local, state and federal policies, laws and strategic priorities, as well as elements of the service context, and socio-economic and geographic factors. For example, the introduction of a National Disability Insurance Scheme part way through a state-wide implementation of the Stepping Stones Triple P system in Queensland, Victoria and New South Wales had a marked adverse effect on agencies being able to offer group-based parenting programs (Einfeld et al., 2018). Learnings from such analysis may influence the choice of practitioners and agencies, promotional strategies, program delivery modes and locations for delivery.

Assessing the service delivery context will assist with the identification of existing networks and alliances that are designed to enhance agency and practitioner collaboration, and are useful for reaching the parent population (McWilliam et al., 2016). Workforce planning benefits from understanding the service context and how it varies across the communities in which the program will be implemented (McWilliam et al., 2016). Relevant to this endeavour are agencies that have interest, capacity, and practitioners who could deliver an EBPS, and agencies or individuals capable of supporting engagement of specific segments of the community. It is also useful to assess the services context where agencies and individuals might undermine implementation efforts due to views and allegiances or perhaps funding arrangements in competition or contrast with the selected intervention approach (Ginter et al., 2005). Knowing about potential opposition and blockages to achieving adequate reach allows design of a strategy that respectfully engages these individuals and agencies.

Ensuring the availability of a well-trained and sustainable workforce is critical to achieving program adoption and population reach (McWilliam et al., 2016). The workforce may come from existing agencies within the intervention area, or from teams established for the purpose of the initiative, or a combination of the two. Establishing a workforce requires consideration of what skills and organizational structures already exist within a community. Is it possible to tap into an existing workforce? Are there already people trained and delivering the intervention, or willing to be trained to deliver? Are there existing organizational structures that would support implementation to all or part of the community? If there is a partial or potential workforce within the community, what training and support do they need? Where there is a potential workforce within the community, it is necessary to assess whether this will be sufficient to reach all relevant parents and carers in the community. It is also important to assess the support systems that will be required to sustain a sufficient workforce over time.

From a program management perspective, training fewer staff who deliver many programs and become very experienced in program delivery can improve staff retention and achieve greater population reach than training many practitioners who each deliver to relatively few parents.

To achieve population-level change, EBPS programs need broad appeal for a variety of parents, taking into account their varying needs and preferences (Sanders & Prinz, 2018). Engagement and retention is a particular challenge, with some programs reporting rates of 25% attrition just prior to starting a program, and an additional 26% attrition from parents who begin participating and then drop out before completion (Chacko et al., 2016).

A population approach will not succeed if too few parents participate in the intervention (Glasgow et al., 1999). There are two related challenges around this. First is the challenge of attracting, recruiting and motivating parents to sign up (Chacko et al., 2016). To successfully engage parents, they need to be aware that the program is available in their community, and that participation offers them something they find attractive or useful for their children, themselves and their families. Second, once parents are engaged, they need to be retained to complete enough of the program to learn how to apply the skills with their children on a regular basis (Chacko et al., 2016). It is not known what proportion of the eligible population of parents needs to have participated to achieve a “tipping point” where it becomes socially normative to participate and complete a parenting program. Surveys of the parenting population in Australia show only a minority of parents actually participate in an evidence-based parenting program (i.e., less than 10%; Tully et al., 1999). In an effort to improve population reach, considerable research has been conducted on parent preferences regarding how they wish to access parenting programs (Metzler et al., 2012). Increasingly, parents (including those who are socially disadvantaged) show a preference for easy-to-access online programs (Love et al., 2013). Even though there is increasing evidence that online programs produce comparable effects to in-person delivery of the same program (e.g., Bert et al., 2008; Prinz et al., 2022), they can have similar or even greater attrition problems to their in-person counterparts.

Engagement therefore requires planning, decision-making and adaptation prior to and through-out implementation (Hackworth et al., 2018). Engagement strategies that address logistical and other barriers to parental participation and that destigmatize program involvement can help to eliminate impediments to broad community reach (Hackworth et al., 2018; Higgins et al., 2019). Normalizing such participation through use of peer and professional testimonials, and delivery through universal access points (e.g., transition to school programs, early childhood education centres, workplaces) can help reduce stigma associated with seeking parenting support. Though small in number, some empirical studies that assess the efficacy of specific engagement strategies have uncovered health promotion- and prevention-focused strategies that have the potential to increase community reach (Salari & Backman, 2016). Further, it is likely that engagement strategies differentially impact various stages of the engagement process, and that each stage might need multiple tailored strategies (Gonzalez et al., 2018).

The engagement strategies used in a population-based approach should aim to enlist the workers who have existing mandates to provide support to families and engage parents directly. There are three key agents through which engagement activities may be focused:

1) Parent consumers. When parents are convinced of the value of the parenting program, they become powerful advocates for other parents to become involved (Prinz, 2019). Engagement strategies focusing on parents directly must outline the benefits of program participation for themselves, and their children (Ingoldsby, 2010; Spoth & Redmond, 2000). A blending of messages that promote positive outcomes for their children, and messages indicating the reduction in problems, are likely to be required to engage parents across the whole community (Salari & Backman, 2016).

2) Schools and early childhood education providers. Education providers have regular contact and trusted relationships with a large proportion of the parents in their community. They have long been involved in initiatives to assist parents to raise happy, healthy children, and are a key support for families who experience social, emotional and behavioral issues with their children (Giallo et al., 2008). Engaging schools in a population-based implementation of EBPS can take many forms, from promoting the program to their school community via newsletters and social media, to hosting programs and having their own personnel trained to deliver programs directly (Boyle et al, 2026).

3) Community agencies who work with parents and children. Family support organizations and community health and hospital services provide services to segments of the community experiencing the most difficulty. Engaging with these agencies to explore the role of EBPS for parents accessing their services, and to identify pathways for efficient access to these interventions, is critical to a successful population-based implementation (McWilliam et al., 2016). The approach relies on successful engagement and collaboration with the local agencies and service providers within a community. Even when there is great local need, the support of local agencies might not occur. Although much can be done to successfully engage organizational leaders, disagreements might still arise that undermine efforts to introduce a new program. These differences between program implementers and local organizations can arise due to differences in theoretical or intervention models, biases relating to preferred interventions, differences in priorities, and misunderstandings about the new intervention and its perceived relevance to the local population. It is not necessary for all local organizations to support an EBPS; however, enough organizations must be willing to participate to ensure that the intervention is accessible and is delivered in the local community (Glasgow et al., 1999).

Differences in the level of support families need can be better accommodated within a multi-level population system of parenting support. Having access to a range of program options of differing levels of intensity, means parents’ preferences and capacity to engage in an intervention are considered. Having clear referral pathways, and access to a multidisciplinary workforce trained to deliver more intensive program variants (e.g., Pathways Triple P), means that the severity and type of child behavioral and emotional problems combined with professional guidance can assist parents to access the most appropriate levels of support. The decision is multifaceted and cannot be based on arbitrary clinical cut offs or population screening. Parents themselves need to play a major role in deciding which programs they are interested in.

In our experience, many large-scale roll outs of parenting interventions take longer than anticipated (e.g., three to four years) to ensure that programs become properly embedded within the service mix provided by agencies in a community. A four-year period appears to be a reasonable timeframe to ensure a population-level intervention is being successfully deployed. This means that enough practitioners have been trained in various levels and variants of the program to build, and then meet, ongoing demand. The promotion of programs to parents without the capacity to meet the demand created should be avoided.

Developing an implementation plan that has enough flexibility to respond to changes in the social or political context (e.g., government restructures, major policy initiatives, changes in priorities), major events (e.g., bushfires, pandemics, earthquakes), and learnings regarding consumer experiences and preferences, is critical to the success of a large-scale community implementation. It is also highly likely over the course of a four-year period, that changes and adjustments will need to be made to the original implementation plan based on the evidence collected about reach and outcomes. Therefore, ongoing tracking of program delivery needs to assess factors such as the programs that parents from each local area are choosing to attend, how far parents are willing to travel, and where the most and least popular venues are (Shapiro et al., 2015). It is essential that implementation plans can be modified in response to changes in the implementation team and practitioner workforce, with sufficient flexibility to seek out, and take advantage of, new opportunities and strategies for engaging parents as needed (Hodge & Turner, 2016).

A theory of change lays out a causal framework for how change occurs and the mechanisms responsible for producing change (Rogers, 2008). A program logic provides a summary of some or all of the theory in a programmatic context via program components – inputs, activities, outputs, intermediate outcomes, and long term outcomes (Rogers, 2008). As a causal model, the program logic enables examination of the links between these components (Rogers, 2008). Prior to commencement, development of program logic should be accomplished in parallel with implementation planning, and can be used to identify the underlying assumptions and external or environmental factors that could impact the delivery and success of the intervention (Rogers, 2008). Sanders and Prinz (2018) provided an example of a program logic (see Fig. 2) for how a population-based approach to delivering an EBPS, specifically the Triple P system of interventions (Sanders, 2012), would apply within a child maltreatment context. This approach outlines the aims for sustained improvements in child outcomes, and links Triple P programmatic content, approach, and activities to short- and long-term changes in child, parent and family, wider community, and policy level outcomes. For example, the overarching goal of improving child wellbeing involves activities that assist parents/carers and communities provide interesting, age-appropriate and engaging activities in an environment that is safe, caring, healthy and nonviolent. Child maltreatment prevention efforts using evidence-based parenting support within a public health model works best when all relevant local stakeholders including government and non-government agencies and service providers supporting families share a common vision and a language for supporting all children and families. This type of partnering is likely to increase the reach of parenting programs and reduce the number of vulnerable families who cannot access parenting support appropriate to their level of need. In conjunction with the model for determining the appropriate Triple P program for delivery within a given context (Fig. 1), this program logic provides measurable outcomes for evaluation activities. Evaluation activities and outputs should be sensitive to contextual matters such as the cultural and demographic characteristics of the populations involved in the intervention and evaluation activities to ensure the evaluation does not further stigmatise already disadvantaged groups. Consideration should also be given to the outcomes that are of relevance to various stakeholders (e.g., parents, practitioners, policymakers) to ensure the evaluation meets the needs of stakeholders and has maximal impact.

Developing an evaluation plan for a population approach to EBPS is a complex and nuanced undertaking. The gold standard approach to evaluation of interventions, where the objective is to understand if the intervention causally affects the outcome as expected, emphasizes a randomised controlled trial (RCT) experimental design (Hariton & Locascio, 2018). In an RCT, participants or clusters of participants are randomly allocated to an intervention (also called an experimental condition) or control (also called a comparison condition) (Hariton & Locascio, 2018). Population-based approaches do not lend themselves easily to this type of design. It is widely acknowledged that effects estimated in tightly controlled efficacy RCTs can differ significantly from results obtained when the same intervention is deployed at scale in the general population (Arnold et al., 2010). Ethical, political, and service-sector considerations may make it impossible to withhold an effective intervention from segments of the population, meaning that true randomisation is far more difficult to achieve (Miller et al., 2020). Further, randomization processes require that participants allocated to a “control” community do not have access to the intervention (Miller et al., 2020). This can be difficult (if not impossible) to manage where there is likely to be movement of residents across the boundaries of intervention areas. If there is not a sufficient geographic “buffer” between all included communities, randomization will therefore not be possible. With the increasing use of online program variants, “leakage” across arms of a trial becomes the norm not the exception. Moving to a whole-of-population context requires an evaluation strategy that tests whether interventions work in real-world settings and conditions with usual providers and clients.

Population-based evaluation often necessitates the use of quasi-experimental designs, to approximate the randomization process by creating a set of intervention and comparison communities that are matched on a set of population and environmental characteristics (Miller et al., 2020). One such design that allows for causal inference is the matched cohort design, in which baseline data at the community-level is used to match intervention communities with potential comparison communities (Arnold et al., 2010; Stuart, 2010). These approaches involve an evaluation design in which a study population is defined prior to implementation, with a subset of that population selected to receive the intervention without randomisation processes (Arnold et al., 2010). In these designs, methods of matching community pairs that will receive and not receive the intervention, such as Propensity Score Matching (Austin, 2011), are used to overcome the inability to generate randomly-allocated intervention and comparison communities (Arnold et al., 2010). These methods allow the control of baseline community characteristics when assessing the effect of the intervention (Stuart, 2010).

A further aspect of the evaluation design to be considered is the unit of analysis. Whether outcomes will be analysed based at the individual- (e.g., parent, child, family) or the community-level, as in cluster or place-based designs, needs to be determined prior to commencement (Cleary et al., 2012). This is key, as it influences the type and level of data that will be required, the access permissions or consents that need to be obtained, and the analytic approach for evaluating the objectives of the implementation.

Determining the number, proportion, and representativeness of parents who participate in various levels of the intervention can be a difficult process.

A significant challenge to program evaluators of population-based approaches is the need for baseline and follow-up outcome data for an entire population. Capturing population-level outcomes for community-wide initiatives not only requires data on participants and non-participants but can also present contextual and environmental issues that need to be considered. As implementation of the population intervention is expensive and may take some years to implement, it will be cost-effective to plan and design a digital online data collection system at the beginning. This means that the various levels of data required can be input to a central database system by multiple stakeholders. This should be included as part of the costings, as it can save time and resources throughout the project.

The sustained implementation of an intervention that involves synergistically bringing together and coordinating multiple program elements that include different program variants, delivery modalities, multiple disciplines, service delivery systems, a mix of publicly funded and private providers, government agencies, end-users and consumers is a complex system. Modelling the real-life behavior of how dynamically changing elements within the system operate over time might reveal new insights important for future program refinement and deployment (Pfadenhauer et al., 2017; Wilkins et al. (2021). For example, there are likely to be different trajectories of parental participation in a system of evidence-based parenting support. It is not known what characterises parents (family risk profile, type of child) who are single occasion users or who become multiple-occasion users accessing further Triple P support (online or in person). Do parents accessing a higher level of support (e.g., Group Triple P) subsequently seek less intensive support (e.g. seminars) to maintain improvements or do they access more intensive support if problems continue or deteriorate.