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Abstract

Purpose – The purpose of this paper is to provide insights into the potential of technology transfer in prevention interventions. It argues that contextual factors are more identifiable and more malleable than the cliché of “culture” as a barrier to implementation might suggest. The key question is how various contextual factors impact on programme implementation and effectiveness in the different cultures of a multifaceted continent such as Europe, and how successful programmes adapt to various contexts. Design/methodology/approach – Using a questionnaire survey, input was collected from people involved in the adaptation and implementation of the Strengthening Families Programme (SFP) in several European countries. Findings – The publications and experiences of the SFP implementers and evaluators in most of the European countries where it was introduced suggest that the programme is both feasible and effective (where outcomes are available). To achieve this, however, the implementers spent a considerable amount of time and effort to prepare, pre-test and consult with their target populations in order to adjust SFP to culture and context. This paper suggests restricting the use of “culture” to a set of norms and values, and to distinguish this from “context” which describes social and political organisation. Even though both condition each other, it is helpful to address culture and context separately when adapting prevention programmes. Research limitations/implications – Outcome data were not available for all implementations of SFP and some very recent ones in Austria, France and Italy could not be included in the questionnaire survey. Practical implications – An examination of social capital might help implementers to anticipate resistance from the target population that seems to emanate from history, culture and context. The level of trust of others and institutions and the willingness to co-operate with them can heavily influence the readiness of drug prevention service planners, commissioners and providers, as well as the target population, to adopt interventions and other behaviours. Programmes seem to have key principles that make them effective and that should not be modified in an adaptation: a particular example is the programme protocol. Other aspects, such as wording, pictures and the content of examples used to illustrate some issues do have to be modified and are essential for an intervention to be well-accepted and understood. In some programmes, the effective principles – so-called “kernels” – are identifiable although, overall, prevention research still strives to identify them. Social implications – Implementing complex programmes that require the cooperation of many stakeholders might increase social capital in the communities involved. Originality/value – The paper examines the common belief among many European prevention professionals that programmes from abroad, particularly from North America, cannot be implemented in Europe.
Is the Strengthening Families Programme
feasible in Europe?
Gregor Burkhart
Dr Gregor Burkhart is Principal
Scientific Analyst at European
Monitoring Centre for Drugs
and Drug Addiction,
Interventions, Policies and Best
Practice Unit, Lisbon, Portugal.
Abstract
Purpose The purpose of this paper is to provide insights into the potential of technology transfer in
prevention interventions. It argues that contextual factors are more identifiable and more malleable than the
cliché of cultureas a barrier to implementation might suggest. The key question is how various contextual
factors impact on programme implementation and effectiveness in the different cultures of a multifaceted
continent such as Europe, and how successful programmes adapt to various contexts.
Design/methodology/approach Using a questionnaire survey, input was collected from people
involved in the adaptation and implementation of the Strengthening Families Programme (SFP) in several
European countries.
Findings The publications and experiences of the SFP implementers and evaluators in most of the
European countries where it was introduced suggest that the programme is both feasible and effective
(where outcomes are available). To achieve this, however, the implementers spent a considerable amount of
time and effort to prepare, pre-test and consult with their target populations in order to adjust SFP to culture
and context. This paper suggests restricting the use of cultureto a set of norms and values, and to
distinguish this from contextwhich describes social and political organisation. Even though both condition
each other, it is helpful to address culture and context separately when adapting prevention programmes.
Research limitations/implications Outcome data were not available for all implementations of SFP and
some very recent ones in Austria, France and Italy could not be included in the questionnaire survey.
Practical implications An examination of social capital might help implementers to anticipate resistance
from the target population that seems to emanate from history, culture and context. The level of trust of others
and institutions and the willingness to co-operate with them can heavily influence the readiness of drug
prevention service planners, commissioners and providers, as well as the target population, to adopt
interventions and other behaviours. Programmesseem to have key principles that make them effective and that
should not be modified in an adaptation: a particular example is the programme protocol. Other aspects, such
as wording, pictures and the content of examples used to illustrate some issues do have to be modified and are
essential for an intervention to be well-accepted and understood. In some programmes, the effective principles
so-called kernels”–are identifiable although, overall, prevention research still strives to identify them.
Social implications Implementing complex programmes that require the cooperation of many
stakeholders might increase social capital in the communities involved.
Originality/value The paper examines the common belief among many European prevention professionals
that programmes from abroad, particularly from North America, cannot be implemented in Europe.
Keywords Family-based prevention, Programmes
Paper type Technical paper
Introduction
Some commentators[1] argue that programmes developed in one cultural context, such
asNorthAmerica(CanadaandtheUSA),areunlikelytoworkinEuropebecausemostof
the evidence for their effectiveness is from North America. Many reviews question
whether this evidence is applicable to Europe (e.g. Cuijpers, 2003; Faggiano et al., 2008;
McGrath et al., 2006).
Received 12 February 2014
Revised 28 June 2014
Accepted 7 May 2015
DOI 10.1108/JCS-02-2014-0009 VOL. 10 NO. 2 2015, pp. 133-150, © Emerald Group Publishing Limited, ISSN 1746-6660
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PA GE 1 3 3
The Strengthening Families Programme (SFP), originally a selective family-based intervention first
developed by Karol Kumpfer and associates in 1983 in Utah in the USA, was revised in 1992 into
a shorter (and more universal) version (the Iowa SFP) by Virginia Molgaard. Versions of the SFP
are currently being implemented in Germany, Ireland, Greece, Spain, the Netherlands, Poland,
Portugal, Slovenia, Sweden and the UK.
This paper aims to provide insights into the potential of know-how transfer in prevention
interventions. It argues that contextual factors are more identifiable and more malleable than the
cliché of cultureas a barrier to implementation might suggest. The key question is how various
contextual factors impact on programme implementation and effectiveness in the different
cultures of a multifaceted continent such as Europe, and how successful programmes adapt to
various contexts. Furthermore, the experiences gained during the adaptation and implementation
of SFP in Europe may help other practitioners to prepare for the main challenges when
implementing allochthonous[2] programmes, especially those concerning:
the cultural characteristics of the target groups, such as differing beliefs and values, but also
levels of education;
the determinants of context, such as organisational differences in health, social and
education systems and the degree of community organisation and civic involvement; and
aspects relevant for the implementation process, such as parenting cultures, professional
cultures, and the training level and educational background of the professionals involved in
the implementation.
Using a questionnaire survey in the summer of 2011, information was collected from people
involved in the adaptation and implementation of SFP in eight European countries. Respondents
were in Germany: Julian Stappenbeck, Universitätsklinikum Hamburg-Eppendorf; in Greece:
Dina Kyritsi, 1st Department of Pediatrics, Agia Sofia Hospital for Children, Athens; in Ireland:
Robert ODriscoll, Arbour House, St. Finbarrs Hospital, Cork; in Spain: Carmen Orte, Universitat
Illes Balears, Palma de Mallorca; in the Netherlands: Martijn Bool, MOVISIE, Knowledge centre for
social development, Utrecht; in Poland: Katarzyna Okulicz-Kozaryn, Institute of Psychiatry and
Neurology, Warsaw; in Portugal: Catia Magalhaes, IREFREA, Coimbra; in Sweden: Eva
Skärstrand, STAD, Stockholm Centre for Psychiatric Research and Education; and in UK: Debby
Allen, School of Health and Social Care, Oxford Brookes University.
The items of the questionnaire were all related to implementation aspects (delivery, training,
problems encountered and ways to solve them, protocol changes, adaptations and lessons
learnt), and less to aspects of evaluation, since this papers main focus is on the various
implementation and adaptation aspects of SFP, and less on whether it is effective in all sites.
The implementation of the more sophisticated drug prevention interventions is more likely to be
set out in a manual (i.e. manualised) to assure accuracy of implementation. Such programmes are
also more likely to have been pre-tested in order to confirm the validity of their theory base and to
have been evaluated (at best with several replications) to avoid unintentional (iatrogenic) effects
and to prove positive outcomes. Such interventions could be considered high-tech prevention
as their development and implementation requires specific know-how, research, repeated
refinement procedures, quality control, proof of effectiveness, replication studies and some
certainty that they do not harm. In medicine, most people would naturally expect such a level of
technology assessment, especially from medications, before they are allowed to be distributed
to the population.
Broadly speaking, high-tech programmes are a more common approach to prevention in
North America, and there is much research and other investment in order to improve them and to
assure their effectiveness in replication trials. There is also important market competition between
specific programmes and their developers, as they are offered to service planners, commissioners
and providers for a price. This might be due to structural differences: whereas in the EU, services
such as healthcare and education are generally of high quality and available for all, this is not the
case in the USA, so the need for complementary programmes is higher there. In Europe, such
programmes are rare, especially outside classrooms. Rather, prevention strategies consist of
varying (by country) combinations of local policies for vulnerable populations; isolated or combined
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activities for school-age youth to raise their awareness, self-competence, social skills, risk-perception
and/or autonomy; events for parents; and youth work and counselling interventions for those with
existing risky substance use patterns. Such approaches allow for innovation and adaptation to local
needs and perceptions, but are sometimes based on little more than commonsense and often
lack evidence of both effectiveness and harmlessness. While Europe has a range of innovative
and pragmatic selective prevention interventions for vulnerable groups, many of them are not
rigorously evaluated.
At a first glance, there appear to be self-evident, practical advantages of favouring manualised
programmes over isolated interventions and a freestyle arrangement of prevention activities.
Established programmes are more likely to have been evaluated and to have proven their
effectiveness in at least one context: they only need to be culturally adapted instead of being
reinvented from scratch and usually come with resources, manuals and methodologies for
training and easier implementation. However, in Europe the problems with using these high-tech
programmes from abroad are often threefold: aversion to the standardisation inherent in
manualised interventions; doubts about the validity of programme effects in another context
(Fernandez-Hermida et al., 2012); and the belief that cultural differences between North America
and Europe would make North American programmes unacceptable to European target
populations. These issues are interrelated, because North American programmes tend to have
manualised protocols and because culture and structural context are often related.
When interventions (especially those that are classroom based) are manualised, they have a
defined number and sequence of sessions with precisely described content for each session,
and are accompanied by manuals for the teachers (or whoever implements the sessions) and
workbooks for the pupils. This implies a standardisation of prevention, which is well-accepted in,
for example, Spain and in some German regions, but is opposed in many other countries (such as
Denmark, Austria and Finland) or in particular schools. In France, manualised programmes are
not used at all.
One of the main criteria for describing programmes as evidence basedis the replication of their
findings in other contexts. It cannot naturally be assumed that findings from academic efficacy
trials achieved under controlled conditions can be repeated when applied in real life(Holder,
2010). This raises the question of the level of evidence of efficacy a prevention programme needs
in order to be recommended for further dissemination. Even if unacceptable from a purist
viewpoint, it might neither be feasible nor wise to ask policymakers to wait for more and more
replications (Valentine et al., 2011) when they are seeking to fund and advance the use
of evidence-based prevention programmes rather than those without any scientific evidence of
effectiveness (Aos et al., 2011).
Andreasson (2010) notes that in both Sweden and Norway extensive efforts have been
undertaken to implement evidence-based programmes, mostly originating in the USA, without
any demonstrable effects, and some academics have recently questioned whether programme
outcomes can be effectively replicated in different contexts and especially in different cultures.
The term external validity(Fernandez-Hermida et al., 2012) has been coined for assessing the
generalisability, applicability and predictability (GAP) of intervention outcomes because
prevention interventions are complex social processes which in themselves influence and are
influenced by the social context. Context, however, is constantly changing, and Hansen (2011)
argues that it might be difficult to find any intervention that can be consistently demonstrated to
work in both randomised control trials and in studies of further implementations of the
programme. Concretely, under contextwe could subsume factors such as the density of inter-
organisational ties within communities, the centrality of the agencies that will lead the intervention,
the extent of context-level adaptation of the intervention and the level of local resources
contributed by participating agencies (Hawe et al., 2004). It is to be expected that the
acceptance, success and sustainability of prevention interventions depend on conditions of
social and political organisation. Even if culture and cultural history play a role here, distinctions
should be made between context and culture.
In the ethnographic sense, culture encompasses all aspects of our behaviour that have evolved
as social conventions and are transmitted through learning from generation to generation
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(Deutscher 2011, p. 9). Culture therefore also comprises historically developed values concerning
social behaviour, civic engagement and trust in cooperating with others. Much of the diversity of
social cultures in Europe is conditioned by history. For instance, the level of social capital (trust in
fellow citizens and respect for community values) appears to be higher in societies with historical
traditions of self-governing communes and city-states than in societies anciently ruled by
monarchies with large feudal landholdings (Putnam et al., 1994). Recent studies corroborate this
argument in the case of Italy today, where at least half of the gap in social capital between the
north and south of the country has been attributed to the absence of free city-states in the south
in the fifteenth century (Guiso et al., 2008) and the ensuing divergent social developments.
The religious divide of Europe has strongly enhanced these cultural differences because the rise
of Protestantism from the sixteenth century onwards yielded decisive importance to the idea of
self-governance (Delumeau, 1967). The political self-organisation of communities accordingly
became (and is now) more important in countries with predominantly Protestant traditions,
such as the Netherlands, Nordic countries and North America. Today, community-based
and environmental prevention are clearly defined and accepted concepts in societies with
self-government traditions and are core principles of many North American programmes.
In many European societies, however, community-based prevention has either no meaning or
no translation, or is understood as the activities of municipal agencies and administrations, not
necessarily implying civic engagement.
While such values have been formed by historical processes, they have become cultural values
and there is a lack of awareness of how political or religious contexts have shaped them. These
are not trivial when the adoption and adaptation of North American prevention programmes such
as SFP especially those with a strong community and/or normative component in Europe are
considered. Therefore, culture (a set of norms and values) and context (social and political
organisation) condition each other, but need to be addressed differently when adapting the
programmes. During the transfer of SFP into another country, social organisation (context),
values (culture) and the programmeslevel of complexity (in their manualised curricula) created
different challenges and lessons.
The SFP
The SFP (SFP 3-5, SFP 6-11, SFP 12-16) by Karol Kumpfer (1998) is a prevention programme for
parents and children aged 3-5, 6-11 and 12-16 in high-risk families. The original SFP (Utah
version) consists of parenting skills training, childrens life skills training and family life skills
training, taught together in 14 two-hour group sessions preceded by a meal that includes informal
family practice timeand group leader coaching. The SFP was first designed in 14 sessions to
assure sufficient dosageto promote behaviour change in high-risk (most substance-affected)
families. The shorter and quite different seven-session SFP 10-14 Iowa version by Molgaard et al.
(2000a), with some input by Kumpfer for application with all populations, has achieved significant
results with a lower dosage.
Originally, the SFP was designed as a selective intervention for 6-12-year-old high-risk children of
substance-using parents and evolved later into several versions, including those for universal use
and with other age groups. It has also shown positive results with high-risk children whose
parents do not have drug or alcohol problems(Kumpfer et al., 2012). In the USA, the SFP has
undergone several adaptations to make it more appealing to African-American, Asian and Pacific
Islander, Hispanic and American-Indian families.
The SFP sessions include the critical core components of effective evidence-based parenting
programmes: sessions with parents and children together, learning positive interactions,
communication and effective discipline. An essential feature of the programme is that it involves
not just parents nor children alone, but the whole family in three parallel courses for parents,
children and the family.
The parent skills training sessions review appropriate developmental expectations; teach parents
to interact positively with children, such as showing enthusiasm and attention for good behaviour
and letting the child take the lead in play activities, and increasing attention and praise for childrens
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positive behaviours; positive family communication, including active listening and reducing criticism
and sarcasm; family meetings to improve order and organisation; and effective and consistent
discipline including consequences such as time-outs.
The childrens skills training content includes sessions on communication skills to improve their
relationships with parents, peers and teachers; hopes and dreams; resilience skills; problem-solving;
peer resistance; identification of feelings; anger management; and coping skills.
The family life skills training sessions allow the parents and children time to practice what they
learn in their separate sessions, using experiential exercises. This is also a time for the training
group leaders to coach and encourage family members to improve parent-child interactions.
The major elements are the childs game, similar to therapeutic child play, where the parent
allows the child to determine the play or recreational activity; family meetings and effective
communication exercises; and the parent game on effective discipline. Home practice
assignments improve the new behaviours at home. Recent versions of the SFP include DVDs,
which the families can watch at home, reinforcing the contents of the sessions. Outcomes
include increased family strengths and resilience and reduced risk factors for problem
behaviours in high-risk children, including behavioural, emotional, academic and social problems,
as well as reductions in substance use, conduct disorders, aggression, violence and juvenile
delinquency.
Based on their research, the programme developers indicate the following conditions for
successful replication of the SFP:
implementation of all three components: parent skills training, childrens skills training and
family life skills training, conducted in 14 two-hour sessions;
implementation by experienced or effective group leaders who are also genuine, warm and
empathetic;
incentives for participation and programme completion, such as rewards for homework
and programme completions, meals and the provision of childcare and transportation when
needed; and
booster sessions lasting around three hours every six months, with a family outing afterwards.
Further details on the activities of the programme and on the elements needed to successfully
implement it can be found on the SFP web site[3].
Findings and outcomes from previous trials
In systematic reviews (Foxcroft et al., 2002; Petrie et al., 2007), both versions of the SFP (Utah
and Iowa) are considered effective including over the long term in preventing substance use
and other problem behaviours. The most recent Cochrane review of family-based interventions
cites the SFP as one of the few universal family-based prevention programmes that is effective for
the prevention of problematic alcohol use in young people (Foxcroft and Tsertsvadze, 2011).
These effects appear to be related to the programmes emphasis on active parental involvement
and on developing skills in social competence, self-regulation and parenting, which the SFP
shares with other effective parenting programmes. Such family approaches are claimed to have
an average effect two to nine time greater than child-only prevention approaches (Tobler and
Kumpfer, 2000) and are claimed to be more effective than life skills programmes in schools (Miller
and Hendrie, 2008). An overview and description of these programmes can be found in the
UNODC (2009) handbook on parenting programmes. Among these, however, the SFP is one of
the few to have been replicated with positive results by independent researchers among different
cultural groups and different ages of children (Kumpfer and Alvarado 2003a; Spoth et al., 2008a;
Spoth et al., 2008). A recent systematic review of selective prevention programmes for children
from substance-affected families (Broening et al., 2012) identified the SFP as effective for this, its
original target group. While evidence-based prevention programmes such as SFP have good
effect in preventing problem behaviours in controlled studies, developers were interested in
addressing the problem of implementing them on a large scale and into different cultural
environments.
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Implementation in Europe
The following information is mostly drawn from responses to the questionnaire survey of those
who implemented the SFP in Europe. Recent pilot studies in France, Austria and Slovenia and a
small pilot study with 35 families in Turin, Italy (Ortega et al., 2012) began too late for inclusion in
the survey.
Four of the European implementations in Germany (Stolle et al., 2010), Greece, Sweden
(Skärstrand et al., 2008) and the UK (Allen et al., 2007) used and adapted the shorter SFP
10-14 Iowa version by Molgaard et al. (2000) and Spoth et al. (1999), with seven sessions per
week and booster sessions. The remainder, in Ireland (Kumpfer et al., 2012a), Spain (Orte et al.,
2008a, b), the Netherlands (Bool, 2006) and Poland (Okulicz-Kozaryn and Foxcroft, 2012) used
the 14-session Utah version by (Kumpfer and Alvarado, 2003), mostly with three facilitators for
each of the training groups (for parents, children and families). All but one adaptation involved
changes from the US version in the stories or charts used in the programme, but not to the
structure. Only in Sweden the structure was changed, as discussed as follows.
From an economic perspective, all European implementations target low-income families, like the
original SFP version. The Polish, Swedish and UK implementations address universal target
audiences, while the German, Irish, Greek, Spanish and Portuguese ones are aimed at vulnerable
families, often in economically disadvantaged neighbourhoods. Those in Spain and the Netherlands
also target addicted parents, as intended by the original versionof the programme. The pilot studies
in France, Austria and Slovenian seem to have yielded promising outcomes for high-risk families
with the 14-session SFP (K. Kumpfe, personal communication).
The SFP programmes in Europe are carried out in mainly urban areas, unlike the rural-urban mix
of the original. The Irish and Dutch implementation of the SFP involved rural sites and also
targeted children who already had diagnosed behavioural and emotional problems. This has
implications for the family structure, and the Polish and UK versions involved more single parent
or stepfamilies than the original version. In Greece, most families managed to take good care of
their childrens physical health (which in Greece constitutes a central aspect of the parental
role), but were poorly informed about issues related to psychological well-being, adaptation to
school and learning difficulties, and in many cases fathers did not attend the programme
sessions.
Many of the Spanish programmes take place in coastal areas or tourist resorts, which might
influence the lifestyle, employment and nightlife behaviour of families. The Spanish experiences
include consideration of a different level of development of the social protection system from the
USA and that family networks of care and solidarity remain relevant, partially due to the symbolical
importance of the family as an institution. Similarly, the typical Greek family is likely to have closer
bonds than the average US family and Greek children are usually dependent on their parents
(emotionally and financially) for longer than those in the USA. In Spain and Greece, Mediterranean-
style patterns of social organisation prevail and therefore public squares and street life are important
to strengthen and maintain neighbourhood links, unlike the suburban lifestyle in the USA.
As detailed in Table I, the number of families included in European implementations of the SFP
ranges from 22 in the Netherlands to approximately 10,000 in the UK (since 2006).
Table I Characteristics of the European implementations of the SFP, drawn from questionnaire responses
Germany Greece Spain Ireland
The
Netherlands Portugal Poland Sweden UK
Version Iowa Iowa Utah Utah Utah Utah Utah Iowa Iowa
No of sessions 7 7+414 14 14 14 14 11+17
Type of intervention Selective Selective Selective Selective/
Indicated
Selective Selective Selective/
universal
Universal Universal/
Selective
Coverage (families) 150 56 243 250 22 40 500 707 10,000
Training for professional (days) 3 4 3 2 2 2 3 3 3
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The SFP is implemented predominantly by psychologists in Greece, by teachers in Sweden and
the UK, and by social education workers in Germany. In the remaining countries, a combination of
academic professionals from social, health and addiction services is used. They received two to
four days training, sometimes from the programmes developers themselves. In Ireland, Spain
and the UK, a local- or regional-certified training and supervision system was developed, which
appears to have assured an even higher level of fidelity and quality assurance than the original.
The Irish implementation model is unique, with a coalition consisting of juvenile probation
services, local drugs task forces, schools, family services and the Garda (police) all contributing
staff and recruiting families to the programme (Kumpfer et al., 2012).
Adaptations made
The most important environmental difference between Europe and the USA is that in Europe the
legal drinking age is 18 years or lower, whereas the original version of the SFP is based on
the legal drinking age in the USA, which is 21. In addition, the US references to youth drink-driving
are not relevant to many countries in Europe, where under under-18s cannot get a driving license
or can only drive with parental supervision between the ages of 16 and 18. Regarding tobacco
smoking, in Greece, for example, it is culturally considered (almost) acceptable and for the typical
Greek parent, smoking is not the same category as alcohol and drug use: reference to all
three together seemed awkward there. Further, it is unlikely that a significant number of Greek
10-14-year olds drink alcohol regularly, as the US programme assumes of its young people in this
age group. Greek teenagers are, however, allowed by the state to enter clubs and bars without
the strict ID control enforced by US law and are allowed to buy alcohol at supermarkets.
The Greek materials had to include grandparents, as many parents there are at work for most
of the day and their children spend a major part of their family life with their grandparents. It would
therefore not be very useful if, for example, the parents establish house rules that the grandparent
refused to monitor.
The Greek implementation had to accept that many fathers did not attend the sessions and that
meals could not be supplied due to lack of funding: only snacks and chocolates or sponsored
tickets for sports events were given as rewards at the end of sessions. Lack of funding also meant
that in Greece and Poland, childcare that allowed parents to attend sessions could not be
offered. In Spain, religious beliefs and practices are less relevant than in the USA, but according to
the evaluation reports, the dedication to the SFP of Spanish parents is higher than those in the
USA, with many more Spanish fathers participating in the programme. Because of such cultural
differences, almost all the implementers in Europe had to modify the materials with the input of
focus groups, the participants and/or an external advisory group. For the UK adaptation, for
example, the researchers (Allen et al., 2007) asked a group of prevention workers, parents and
young people with prior experience of the original US version to review and comment on the
materials. In the light of their proposals for adaptations, the materials were revised and then
discussed in focus groups in representative areas. Adaptations in Germany (Stolle et al., 2010),
Ireland (Kumpfer et al., 2012) and Spain (Orte et al., 2008a, b) proceeded using similar methods.
Since some sites (in Germany, Spain and the UK) had more ethnically diverse target groups than
the original, at least one of the featured families in the DVDs used there was from a minority ethnic
population, while in Greece, the minority ethnic families from the original were substituted with
Filipinos to represent immigrants. The German, Greek, Spanish, Swedish and UK programmes
reshot the DVDs to feature people from the same cultural and language backgrounds as the
target groups, using a much simpler language than the original versions, because many parents
could not follow subtitled DVDs or the language level. Several scenes (e.g. shoplifting and
cannabis use) had much milder parental reaction in the original US DVDs than is perceived as
natural by Greek parents, which made the US DVD families too good to be truein the Greek
participantseyes. Greeks parents perceive their adolescents as far more defiant than those
presented in the US material and wanted to learn how to handle more conflictive situations.
All references to non-relevant cultural contexts were replaced with their nearest culturally
appropriate equivalent. As nobody in Europe can have a driving licence before the age of 18, the
US mothers fear that her teenage son might drive drunk was replaced in Greece by the fear that
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the boy might get into a drunken older friends car or enter a strangers car because alcohol is
impeding his judgement. The Germans used a less moralising approach than the USA when they
reshot the videos, not condemning rule-breaking as much and depicting urban settings, housing
styles and clothing to reflect contemporary German society (neither too neat nor too neglected).
In Ireland, Spain, Sweden and the UK, the language had to be modified in terms of names and the
terminology was simplified[4] and softened concerning disciplinary matters. Certain activities,
games and incentives for the children had to be changed in some cases, to avoid the need for
reading and writing. The concept of punishment was not well-accepted in Spain and Poland and
the term creed[5] at the end of the sessions had to be renamed mottoin the UK, while it was
accepted elsewhere. Only Italian parents (Ortega et al., 2012) found it too religiousto read out a
creed to the others at the end of the sessions. The SFP implementers in Germany, Ireland,
Greece, Portugal and Sweden found that the programme was received well both by affluent and
less privileged families and that families from differing social levels better achieve parenting
competences by learning from each other and about different social realities.
Recruiting the families and especially adolescents was often perceived as quite difficult.
The US versions of SFP 10-14 targeted families whose children were eligible for food stamps
at high school in order to reach those with low socioeconomic status. The German version
recruited families from urban neighbourhoods that are defined as economically deprived
(i.e. having a significant higher percentage of adults with a jobseekers allowance compared
with the rest of the area). The Greek recruitment (through public schools only) led to a selection
bias, as lower-income families who could not pay for professional help were more willing to
participate. Therefore, one third of the participants in Greece were from minority ethnic
populations and more than half of the children had learning difficulties such as dyslexia and
attention deficit hyperactivity disorder (ADHD).
In Spain and Poland, a top-down approach to utilise representatives from local government
or from respected agencies made it easier to recruit families, whereas in Ireland and
Wales (in the UK) a bottom-up agency and associations-led approach worked better.
These cross-agency/cross-departmental collaborations were crucial for the Irish programme to
address delinquency and crime, educational disadvantage, poverty, homelessness and substance
use in the participating families. The inter-agency collaboration model dispersed the burden of
resource allocation and harnessed the expertise of a number of practitioners and agencies
including community drug services and drug and alcohol treatment agencies, criminal justice
agencies, and healthcare, education, homeless and social services. Many families with limited
resources or disruptive children in Spain and Poland needed the additional support provided by
psychological and social services.
It seems that low-threshold incentives (such as transportation, food, childcare and communal
meals) significantly increase attendance. The unforeseen benefit of implementing the SFP in
Ireland was that it strengthened relations between statutory, community and voluntary service
providers and allowed the programme to offer activities such as youth work, homework clubs and
arts and crafts workshops. Maybe due to this, the Irish SFP implementation had even more
significant results than the original SFP versions (Kumpfer et al., 2012).
Most of the survey respondents found that, for Europeans, the SFP is a relatively complex
programme which requires many resources and much organisational effort (to organise qualified
and experienced staff to work in the evenings, for instance). In order to implement the programme
with fidelity, substantial funding is needed, which is difficult to raise in the healthcare sector across
all European countries. However, a shortage of funding and of infrastructures led to protocol
changes only in Germany (a reduced time span between the booster sessions), Greece
(shortened activities, extra individual counselling and children who were younger than the original
target group attending sessions because there was no childcare provision), and particularly
in Sweden. The Swedish version has 12 sessions: the four original booster sessions were
integrated with the seven regular sessions, together with an additional on. In addition, whereas in
the original programme, children and parents attend separate sessions for the first hour followed
by a joint family session in the second hour, this was not feasible in Sweden for practical and
financial reasons. Therefore, the children had their sessions during the daytime in their regular
school classroom, taught by their teacher, while the parentssessions were held in the evening.
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More importantly, instead of having one family session after each children and parental session,
the overall number of family sessions was significantly reduced to only two. Box 1 details the
implications of these changes.
Lessons learned
In terms of social organisation, the involvement in the SFP of parentsassociations, sports clubs,
day care centres and the criminal justice system is essential. Above all, the involvement of all
agencies working in the field (youth, health, social work, police, etc.) boosts the impact, although
this might be limited to countries with high social capital: it has been less reported from Greece
and Portugal than from elsewhere in Europe.
A first impression is that the materials and the organisational efforts required are intimidating for the
agencies that apply such a programme, and a lot of preparation and creativity for the adaptations
and pilot tests are needed (reported from Germany, Greece and Poland). The investment in people
and in their training and involvement is as essential as the work to adapt the materials (reported from
the Netherlands and Portugal). The SFP utilises a large pool of materials and posters which need to
be processed quickly in the sessions. In practice, this might prove impossible in cases where
participantseducational levels are relatively low. Sometimes, aesthetic quality might need to be
sacrificed to maximise comprehension: colours, typeface and complexity of language need to
be addressed accordingly, and more pictures used to help get the messages across.
The adaptation of the SFP to the cultural values, priorities and characteristics of the target
population and its context is seen as essential by the European implementers. It seems to be part
of the philosophy of the programme that major efforts at cultural adaptation must be planned for
in the implementation design. Its developer defends the principle of cultural humility (a willingness
to accurately assess ones limitations, the ability to acknowledge gaps in ones knowledge and
an openness to new ideas, information and advice (Rivera et al., 2010)) and that implementers
from the local culture must adapt programmes to local conditions in order to maintain their
effectiveness (Kumpfer et al., 2008a; UNODC, 2009). Above all, this refers to the programmes
graphical elements, stories, songs and the removal of culturally inappropriate materials. At most
locations, therefore, the cultural adaptations were pivotal, while changes in the structure
(sessions, homework and programme length) were not necessary.
Mixing families with high and low vulnerability together created a good group dynamic because
many learned from each other about the different realities of parenting conditions. When younger
and older children were put together in the same session, however, it was reported from Ireland,
Greece and Poland to be more difficult to accomplish the session targets.
Box 1: The Swedish implementation of the SFPs
The Swedish implementation caused some debate (Andreasson, 2010) and certainly at
conferences seems to be a popular example of a North American programme that does not work in Europe.
The Swedish SFP managed to recruit many families to the programme but no effects were found on
substance use among the adolescents and on the risk and protective factors. This was despite using
experienced teachers and leaders, trained by certified SFP 10-14 trainers.
The hypothesis that the programme adaptation failed to appeal to Swedish familiesattitudes seems
unlikely, given that it was effective in other European cultures that probably differ even more than
Sweden from the original programmes environment. The alternative explanation is the drastic reduction
in the number of joint family sessions. According to the programme developer, Karol Kumpfer (personal
communication), the major magicof the SFP is having the whole family involved for a meal and practice
sessions after the parallel sessions. Therefore, not running those family groups an essential core
component is a major violation of fidelity to the SFP model and several commentators consider that the
Swedish evaluation has tested something that is far from the SFP (Foxcroft and Kimber, personal
communication). The survey respondent on the evaluation of the Spanish SFP, for instance, reported
that the combined effect of the three components of the application (work with children, with parents
and with families) is crucial for positive outcomes.
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For most survey respondents, it was essential for success to have run pilot SFP groups in
which the main difficulties of implementation were identified and local needs assessed; to have
tested the programme elements with the target group; and to continuously and gradually
improve the intervention with process feedback from the implementers, the families and the
SFP developer.
The Greek implementers realised that they needed a uniform policy about how to handle very
personal or sensitive issues that might be disclosed by participants opening-upduring the
sessions. For example, during a family session in which all the parents were certain that their
children were too young to know the meaning of drugsand some advised the facilitators to
refrain from talking about drugs because the kids are innocent, a ten-year-old disclosed to the
group that he had been offered hashish twice by an older student at school. The boy was
unaware of the significance and implications of what he was saying. A uniform policy was also
needed for the families after they complete the SFP. As there are almost no community
psychology services in Greece, the implementers offer each family a counselling session in private
where the facilitator offers basic guidance. The SFP in Greece therefore had a similar role to that
of an emergency team: basic assistance in crisis situations.
Many survey respondents reported that they learned that implementing North American
programmes in another context was not as difficult as they had envisaged because the issues
that families are concerned about are similar worldwide: for example, parents worry that their
children are drinking alcohol, using drugs, are in a gang, being violent, etc. They therefore
suggested avoiding cultural assumptions about the content of the programme and that
premature assumptions that a given element will not work because it is the sort of thing that only
Americans doshould not be made. For instance, in the first implementation of SFP 6-11 in
Sweden, the local implementer said Swedes would never participate in role play, but after giving it
a try as the programme developer suggested the Swedish families in fact enjoyed the role play
sessions. The Greek programmes advisors had said that reading out the creed at the end of the
session would be too Americanand awkward, but in practice it increased the group identity and
parents appreciated hearing it from their children and members of other families.
Evaluation experiences
All European implementations involved both process and impact evaluations. Most implementation
sites applying the 14-session version used a common pan-European evaluation design which is
similar to the one used in the USA and employs the same instruments.
The survey respondents report that in most cases the sample sizes for the evaluation were much
smaller than those in the USA, were sometimes unrepresentative and randomisation of the
families to SFP or to controls was often not possible. Outcomes are currently available from
the implementations in Ireland, Spain, the Netherlands, Portugal, Sweden and the UK. The Portuguese
and UK results are similar to the original US findings, the effects reported by the Dutch are slightly
smaller, whereas the Irish (Kumpfer et al., 2012) and Spanish results are better than those reported
by the SFP sites in the USA. In Sweden, no effect on adolescent alcohol, tobacco and drug
use was found for a strongly revised SFP 10-14. However, an earlier Swedish pilot study with the
14-session SFP 6-11 by Kimber and associates did report promising results, although a full
programme was not implemented because the authorities found it too demanding in terms of the
number of personnel needed (Kimber, personal communication).
The main problems during the evaluation were the difficulties in randomising families and the
attrition rates during up to four waves of evaluation questionnaires. In order to address this
challenge, evaluators recommend allowing for time to explain and to develop strong links with the
participating families and institutions, such as obtaining written agreements from the school
principals to conduct the survey several times.
Some researchers added or adapted the evaluation tools in consultation with the SFP developers.
The Greek survey respondent underlined that qualitative tools such as interviews should be
incorporated into evaluations, because quantitative measurement alone tends to underestimate the
effectiveness of the intervention in the participantslives.
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Some survey respondents reflected upon the factors that could explain the different evaluation
outcomes. Researchers from the Irish, Spanish and Portuguese sites noted that effects are
almost always larger if the families are more at risk, as they have more room for improvement: the
participants in these countries were selected and referred to the SFP by other services. This
allowed their families already stressed by adolescent problematic behaviour greater room for
improvement and strongly motivated them to participate in the skills training offered by the SFP.
When asked how their family was functioning after completing the SFP, improvements were
therefore more easily identified. Conversely, the Swedish researchers attribute the absence of any
difference between the intervention and the control group to a ceiling effect, where it is difficult
to show the effects of this type of programme in less vulnerable environments because, unlike the
USA, Sweden has a well-developed social welfare system with only small disparities in social
class and other socio-demographic indicators.
Transferability from North America to Europe: summary
Almost unanimously, European implementers consider that the SFP can feasibly be successfully
adopted in Europe with populations that are socially and culturally different from those in the USA.
These differences do not compromise effectiveness provided there are the means for careful
adaptation of the programme and an adequate workforce. If key structures of the programme
curriculum are kept (such as the family sessions of parents and children together), most of the
material can quite easily be adapted to the target group. The involvement of local consultants
from the target population is essential for this. However, the length of the SFP, its costs and the
poor recruitment of families have hindered large-scale implementation in the Netherlands where
some experts also questioned the programmes theoretical foundation.
Despite the considerable efforts and logistics needed to implement the SFP, most European
sites uphold positive views on the advantages of using such an allochthonous programme for
family-based prevention for the following reasons:
Quality: the SFP allows implementers to draw on the scientific advances of a different country
against a background of a large body of scientific work already carried out on its
effectiveness. The use of an evidence-based programme with proven results which was
tested in multiple randomised control and field trials with different populations and with
different researchers facilitated the process of grant applications to fund the implementation
of the SFP (reported from Germany and Portugal).
Innovation: most programmes produced in the same culture draw on a similar pool of
resources and they share the same mentality, the same airand the same dead-ends.
An allochthonous programme can bring a very refreshing innovation with a different perspective
to these dead-ends. This external perspective offers new ideas, aspects and proposals that an
insider or local expert may have not considered (reported from Greece and Spain).
No duplicated efforts: use of an allochthonous programme removes the need for local service
providers to investigate, develop and research culturally specific programmes, as it can be
adapted to meet local needs and cultural norms (reported from Ireland and Poland).
The SFP might be easier to disseminate across different societies than other North American
programmes since in most (western) cultures, families are concerned about similar aspects of
adolescent behaviour. In many cases, the components of the SFP were implemented better than
expected and common culture-based assumptions such as European families would not
respond well to some of the Americanprogramme elements appeared to be fallacies.
Conclusions from the respondentsexperiences and nuggets for practice
This paper has intentionally restricted and compartmentalised the idea of culture, dividing it into
context (political and social organisation) and into a narrow meaning of culture as values and
beliefs. Both influence each other, as both are conditioned by each regions history. Certainly,
many of the reported obstacles, such as lack of funding and teacher motivation, can also be
seen as cultural issues in their broader meaning, which includes not only political and social
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organisation but also material conditions, such as how spaces are used, infrastructure, buildings,
laws and the populations available leisure time. However, it is this very tendency to subsume
almost everything into culturethat has led professionals to see it as an amorphous, metaphysical
and insurmountable obstacle to dissemination. If some of the main components of culture are
disentangled while recognising that they condition each other cultural and contextual factors
that are malleable (or at least foreseeable) can be identified.
The experiences of the adapted programmes described here might help to demystify the cliché of
the programme from another culture. When local experts and key informants successfully
adapt allochthonous programmes to their culture and adjust them to context conditions, they
usually seem to work and can be transferred, at least between western cultures. Instead of
dismissing the applicability of a programme just because it originates from another culture and
context, Europeans might want to consider the following issues that are relevant for practice:
1. The key aspect for transferring a programme into other cultures is its robustness i.e. the
amount of adaptive changes the programmes core idea can bear without losing its
effectiveness. When the core principles of an effective programme are identified and
applied, it can be effective in many situations, provided that adaptations to context and
culture make it acceptable to those in the new environment.
2. Often, a programmes effective core principles have more to do with its structure than its
contents. For example, the discussion about the SFP suggests that contents can and
must be culturally adapted, while the protocol itself (such as family sessions, incentives)
should be kept. Such single identifiable and effective behavioural components that make
programmes such as the SFP effective evidence-based kernels seem to be responsible
for interventions working in different contexts (Embry, 2011).
3. Culture can be broken down into concrete factors to which adaptations of programmes
are possible:
Interventions need to be adapted to culture (in its narrow sense) by adjusting wording,
images and examples to different norms and values with the help of the target group
and others from the relevant culture.
Adaptation to context requires knowledge of organisational and sometimes
political infrastructures and involving them in the planning process.
Social capital should be considered for assessing resources and resistances to an
intervention and for adapting the implementation strategy accordingly. This helps to
decide how much local authorities should be involved, how much direct involvement of
parents can be expected and whether inter-agency cooperation can be a surrogate for
bottom-up community involvement.
Focus groups, nominal groups and other methods from qualitative research are
essential, commonly used tools to adapt programmes and they involve the target
populations from the outset. It seems that most of the innovative solutions for the
adaptation and overcoming resistances in the implementation came from the local
collaborators on the frontline.
4. People are more likely to support and be involved in community- or family-based prevention
interventions if they have a high level of trust and commitment towards strangers or
organisations. This and other dimensions of social capital could be assessed by
comprehensive, culturally and developmentally appropriate instruments such as the Social
Capital Assessment Tool by the World Bank[6]. However, prevention professionals who
implement programmes in communities rarely take this role of social capital into account in
assessments of needs, challenges or outcomes.
5. An often-reported problem in adapting North American programmes to Europe is that
the original protocols make more intensive use of social control mechanisms, such as
competitions, setting rules, reinforcing rules and introducing norms. The underlying differences
in social history (strength of self-government, social capital and Protestant traditions) and
possibly social capital explain resistances to a considerable extent and need to be taken into
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consideration. This is especially the case when such programmes are implemented in those
European cultures where social control and community values are less influential and accepted
than in northern Europe.
6. Societies with low social inequalities, high social capital, effective education systems and
cohesive communities seem to be more ready to adopt more complex and demanding
prevention interventions or systems. That said, their resulting low overall vulnerability for
social problems, including substance use, might be one of the reasons why allochthonous
programmes often have no (or fewer) effects in Nordic countries. Some respondents to this
survey said that it makes more sense to implement an intervention where the conditions are
worse and therefore the potential for improvement is larger.
7. Therefore, an influential obstacle to implementing allochthonous programmes is that many
Europeans are neither used to nor equipped for the complexity of high-tech programmes
that have been developed in North America. These have been tested and often replicated
with sophisticated trials and require the use of elaborate manuals, training systems,
technical support, supervision, the cooperation of community stakeholders, etc. Some
European countries might not have developed the relevant resources and prevention
infrastructure (Andreasson, 2010).
8. Context factors that seem to most frequently and strongly determine the successful
implementation of the SFP were communitiesself-organisation, cohesion and readiness to
commitment. Some of the European adaptors found innovative solutions to overcome the
lack of community traditions. The inter-agency model from the Irish SFP implementation might
be the most useful alternative in countries with low social capital or where communityrefers
only to local institutions, not to citizensvoluntary involvement.
9. Training systems reduce the perception among the teachers and local opinion leaders
that effective allochthonous programmes are utterly demanding and too complex.
The experiences with the SFP in Ireland suggest that having a local (or national) training
system is crucial for the acceptance of an intervention, both by the staff involved and the
target population. Since this increases feelings of ownership (or even authorship),
motivation and identification with the programme in the new sites, the implementation costs
can be minimised because individuals and services volunteer to co-operate for no (or little)
payment.
10. Family-based North American programmes seem to be easier to transfer to Europe
than others. Across western cultures at least, the meaning, value and concept of family
are shared (Cheung et al., 2011) much more than those of community.Thevarious
dimensions of parenting and their role in childrens substance use behaviour have been
well-studied across cultures (Becoña et al., 2012; Velleman and Templeton, 2005). In all
professional circles, the family is a recognised determinant of adolescent behaviour and
substance use. Much dissemination research, including in the mental health field (Bernal,
2006), has already provided insight on how to adapt family-based interventions to
different cultural family backgrounds. This might explain why the
SFP has been more popular than other programmes in Europe, has needed relatively
small adaptations and has encountered few structural obstacles. This is despite
the stark contrasts reported between European countries and North America in
their commitment to family and child welfare that also affect the transferability of
programmes (Ferrer-Wreder et al., 2004).
11. Professional cultures sometimes explain some obstacles to implementation. In France, few
international prevention programmes have been implemented. During training for the
implementation of the SFP in France, Karol Kumpfer reported (personal communication,
2012) that trainees seemed to be predominantly familiar with psychodynamics but were
reluctant to accept cognitive-behavioural interventions and rejected the concept of
disruptive disorders entirely. They commented that they would oppose any intervention
approach coming from the Anglosphere(hence not only from North America). On the
other hand, the Greek SFP implementers reported an eagerness to trust foreign
programmes, at least from North America and the UK.
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12. Among all the implementation obstacles, culture in terms of different values, language use
and traditions seems to be the easiest to overcome. Organisational and structural context
seem to be a bigger challenge and, above all, the concrete details of the recruitment of
participants and training of staff.
13. Many decision makers seem to expect that adopting North American programmes involves
high costs and discussions with the programme authors about licences. However, none of
the survey respondents reported such obstacles.
14. Despite all the efforts and challenges in adjusting North American programmes to the
cultural and structural conditions of the European implementation sites, the implementers
found it preferable to adapt allochthonous programmes with a strong evidence base and
well-developed materials. They considered this a more efficient strategy than developing a
completely new intervention.
Implications for policy and practice
Despite all the efforts and challenges in adjusting North American programmes to the cultural
and structural conditions of the European implementation sites, the implementers found it
preferable to adapt allochthonous programmes with a strong evidence base and well-
developed materials. They considered this a more efficient strategy than developing a
completely new intervention.
Among all the implementation obstacles, culture in terms of different values, language use and
traditions seems to be the easiest to overcome. Organisational and structural context seem to be
a bigger challenge and, above all, the concrete details of the recruitment of participants and training
of staff.
Family-based North American programmes seem to be easier to transfer to Europe than others.
Across western cultures at least, the meaning, value and concept of familyare shared (Cheung
et al., 2011) much more than those of community.
Training systems reduce the perception among the teachers and local opinion leaders that effective
allochthonous programmes are utterly demanding and too complex.
Context factors that seem to most frequently and strongly determine the successful implementation
of the SFP were communitiesself-organisation, cohesion and readiness to commitment.
Some of the European adaptors found innovative solutions to overcome the lack of community
traditions.
Societies with low social inequalities, high social capital, effective education systems and cohesive
communities seem to be more ready to adopt more complex and demanding prevention
interventions or systems.
An often-reported problem in adapting North American programmes to Europe is that the original
protocols make more intensive use of social control mechanisms, such as competitions, setting
rules, reinforcing rules and introducing norms.
The key aspect for transferring a programme into other cultures is its robustness i.e. the amount of
adaptive changes the programmes core idea can bear without losing its effectiveness. When the
core principles of an effective programme are identified and applied, it can be effective in many
situations, provided that adaptations to context and culture make it acceptable to those in the new
environment.
Acknowledgements
The author thanks for the crucial contributions to this paper by answering the questionnaire survey to
the SFP implementers in Germany: Julian Stappenbeck (j.stappenbeck@uke.de), Universitätsklinikum
Hamburg-Eppendorf; Greece: Dina Kyritsi (dkyritsi2000@yahoo.gr), 1st Department of Pediatrics,
Agia Sofia Hospital for Children, Athens; Ireland: Robert ODriscoll (Robert.ODriscoll@hse.ie),
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Arbour House, St. Finbarrs Hospital, Cork; Spain: Carmen Orte (carmen.orte@uib.es and
ortesocias@gmail.com), Universitat Illes Balears, Palma de Mallorca; The Netherlands: Martijn Bool
(M.Bool@movisie.nl), MOVISIE, Knowledge centre for social development, Utrecht; Poland:
Katarzyna Okulicz-Kozaryn (kokulicz@ipin.edu.pl), Institute of Psychiatry and Neurology, Warsaw;
Portugal: Catia Magalhaes (catiamagalhaes82@yahoo.com.br), IREFREA, Coimbra; Sweden:
Eva Skärstrand (eva.skarstrand@sll.se), STAD, Stockholm Centre for Psychiatric Research and
Education; and UK: Debby Allen (dallen@brookes.ac.uk), School of Health and Social Care,
Oxford Brookes University.
Notes
1. See, for instance, http://findings.org.uk/
2. originating from somewhere else, i.e. the opposite of autochthonous.
3. www.strengtheningfamiliesprogram.org
4. In the UK, the Easyread format was used, which gives the essential information on a topic without a lot of
background information and can be especially helpful for people who are not fluent in English (http://odi.
dwp.gov.uk/inclusive-communications/alternative-formats/easy-read-and-makaton.php).
5. For example, the creed for parents is We are strong and caring parents who show love and set limits.
We are helping our kids become responsible young adultsand for 10-14-year olds is We are strong
young people with a great future. We are making good decisions, so we reach our goals(www.
extension.iastate.edu/sfp/files/SF2PYF1ALL.pdf ).
6. http://siteresources.worldbank.org/INTSOCIALCAPITAL/Resources/Social-Capital-Assessment-Tool
SOCAT-/annex1.pdf
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Further reading
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skills training program,International Journal of Drug Policy, Vol. 13 No. 1, pp. 21-6.
Gorman, D.M. (2010), Understanding prevention research as a form of pseudoscience,Addiction, Vol. 105
No. 4, pp. 582-3.
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a critique of the strengthening families program plus life skills training evaluation,Drug and Alcohol Review,
Vol. 26 No. 6, pp. 585-93.
Kumpfer, K.L. and Johnson, J.L. (2007), Strengthening family interventions for the prevention of substance
abuse in children of addicted parents,Adicciones, Vol. 19 No. 1, pp. 13-25.
About the author
Dr Gregor Burkhart is since 1996 responsible for prevention responses at the EMCDDA.
He developed databases on best practice examples (EDDRA), on evaluation tools (EIB) the
Prevention and Evaluation Resource Kit (PERK) and the recently published Prevention Profiles on
the EMCDDA web sites. His main activities are to develop common European indicators on the
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implementation of prevention policies in member states and to promote a better and clear
understanding of universal, selective, indicated as well as environmental prevention in Europe.
Gregor worked on methodologies for monitoring prevention responses in Europe, how to
improve and how to evaluate them. He is a Co-Funder of the European Society for Prevention
Research and holds a Doctoral Degree in Medicine (Medical Anthropology) on the influence of
culture on the classification and perception of body and diseases in the Candomblé cults of
Bahia, Brazil as well as a MPH Degree from the University of Düsseldorf. Dr Gregor Burkhart can
be contacted at: Gregor.burkhart@emcdda.europa.eu
For instructions on how to order reprints of this article, please visit our website:
www.emeraldgrouppublishing.com/licensing/reprints.htm
Or contact us for further details: permissions@emeraldinsight.com
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... While the external observers followed the four group sessions of the SFP in loco to judge its cultural adequacy, the remaining participants were divided into mixed nominal groups, taken through the program and then indicated items in need of enhancement for its cultural appropriateness. The methodological choice of the inclusion of different actors followed the recommendations in the literature specializing in cultural adaptation, which recommends a perspective both collaborative and participative (Ferrer-Wreder et al., 2012;Kumpfer et al., 2008;Burkhart, 2015). ...
... As such, the cultural adaptation of SFP in Brazil must account for the adults' illiteracy and the functional illiteracy of younger children. As discussed by Burkhart (2015), the cultural adaptation of international evidence-based programs must go beyond language appropriateness, values, beliefs, and meanings to include adaptation to the social, economic, and political context of the target country. Thus, it seems fundamental that the management teams account for the educational and social-economic context in which the participating Brazilian families live or risk not achieving the final goals of the SFP. ...
... It is known that institutional support and local infrastructure comprise variables that affect the sustainability of health programs (Schell et al., 2013) and, in SFP's implementation, the said infrastructure is a condition for SFP's implementation. On the other hand, such elements may make the offering of SFP more expensive and complex, which may compete with its adoption, large-scale implementation, and sustainability, as already verified in European countries (Burkhart, 2015). The present author, when analyzing the European experiences when implementing Strengthening Families 10-14, argues that, in different countries, the infrastructure and services of the locale that received the program had an impact on its sustainability. ...
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This study sought to evaluate the cultural adequacy of materials and procedures of the Strengthening Families Program (SFP 10-14-UK) and to identify requirements for its cultural adaptation to Brazilian families. The descriptive study had 33 informants, including external observers, managers, multipliers, facilitators, adolescents, and parents. The data were collected at a pilot application in the Federal District. Direct observation was applied to four intervention groups, with seven meetings of 150 min for families, parents/guardians and adolescents, and mixed nominal groups at the end of the interventions. The results, analyzed through content analysis and descriptive statistics, provided evidence that SFP was perceived as sufficiently appealing, culturally relevant, and partially clear. Recommendations for cultural adaptation of linguistic aspects of the materials and procedures were made, considering the cultural and educational differences of the participant families. Focus on implementation quality, including infrastructure, families’ mobilization and continuous planning, was recommended. Replication studies in other Brazilian regions and analyses of contextual and political dimensions are suggested.
... However, on the other, the facilitators noted the low ease of intervention implementation versus contextual restrictions, such as offering snacks and gifts and its incompatibility with the deficient reading and writing skills of the target audience. Similarly, contextual barriers influenced the feasibility of SFP 10-14 in Europe as well, as indicated by Burkhart (2015). ...
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The objective of this study was to examine the feasibility (limited effectiveness, acceptability and practicality) of the Strengthening Families Program, a universal preventive intervention, for Brazilian families. A pre-experimental study was carried out, with pre-test, post-test, 6- and 10-12-month follow-ups. 74 adolescents and their parents participated. Scales on academic, parenting, and health outcomes were applied to adolescents at the four assessment times. Direct observation of implementation fidelity and families engagement in the intervention and telephone interviews with facilitators were used to investigate acceptability and practicality. The results show significant increase in parental supervision and learning self-efficacy. High levels of fidelity and parent/guardian engagement as well as moderate levels of adolescent engagement were found. The facilitators found the intervention had acceptable goals, but procedures excessively structured and unsuitable for families with low educational level. Practical implications are discussed.
... Failures in replicating the effects of SFP 10-14 have been discussed in recent years (Burkhart, 2015;Gorman, 2017;Kumpfer et al., 2020). Kumpfer et al. (2020) presented a set of possible explanations for the failure to replicate SFP 10-14 to new contexts, including errors in choosing the program in view of the families' level of risk; offering a lower 'dosage' than the original program; selection of poorly motivated facilitators; insufficient training; integrity and adherence impaired in the offer of the program; lack of cultural sensitivity in adapting the program; and flaws in the assessment, including design, assessment tools and statistical analysis. ...
Article
Full-text available
Background Substance abuse and violence are among the primary health concerns regarding Brazilian adolescents. This study sought to explore the short-term effects of the Strengthening Families Program (SFP 10-14), a preventive program for families with adolescents, adapted to Brazil. Methods A pre-experimental design was used, with a pretest and 10-12-month follow-up evaluation. A qualitative study was carried out using in-depth interviews held one to three months after the intervention to examine the use of skills learned. The sample included 126 adolescents (pre-test and follow-up comparison) and 23 adolescents (interviews) between 10 and 14 years of age from low-income families residing in northeastern Brazil. Results The comparison between pretest and follow-up showed an increase in learning self-efficacy and school absence without parental permission. Null effects were found on the consumption of alcohol in the last month; episodes of binge drinking in the last month; antisocial behavior; parenting practices regarding emotional support factors, intrusiveness, and behavior supervision; future time perspective; doing homework; grade repetition; school grades; school dropout; and satisfaction with one's relationship with school. The majority of the interviewed adolescents reported applying the learned skills during family interaction and with friends. Conclusion Mixed results were found on short-term effects of the Strengthening Families Program for Brazilian adolescents. Future studies should examine the contexts and mechanisms linked to such results.
... The suggestions for adaptations to strengthen the support systems and intervention offer evidence for the need to increase political support, which addresses the influence of the political environment to fund and promote the adherence of public services to the interventions, as well as to improve the organizational capacity-which are relevant to the sustainability of interventions in public health (Shelton et al. 2018). A similar need was also encountered in the implementation of the SFP (10-14) in Europe, whose viability was linked to social, political, educational, organizational, and community resources and restrictions that go beyond cultural peculiarities (Burkhart 2015). The reduction of health inequities by means of integrated public policies is yet again an essential aspect of issues surrounding investment and the development of human potential (UNESCO 2016). ...
Article
Full-text available
Local adaptations can promote user engagement and sustainability in the preventive program. The objective of this study is to evaluate local adaptations of the Strengthening Families Program (SFP) (10-14) for Brazilian families. Data were collected from semi-structured interviews of 42 facilitators who implemented the program. The directed content analysis was the analysis method used. The findings revealed that most facilitators did not make any additions (83.3%), while 50% reported discarding activities, largely due to the lack of time (31.6%). Adaptations were made by 73.2% of the interviewees, which most commonly (32%) addressed examples and linguistic features. Suggestions were made by 58.94% of the interviewees and focused on improving the support systems and delivery of the intervention, as well as the intervention itself to customize it to the socioeconomic and educational conditions of the target group. It was concluded that adaptations to the SFP (10-14) materials and procedures, and improvements in political support and organizational capacity are needed for its implementation.
... Diese sollten freilich nicht zulasten der qualitätsgesicherten Umsetzung wesentlicher Programmelemente gehen und im Idealfall eine Abstimmung mit den Entwicklern der Originalprogramme vorsehen (vgl. Kumpfer, Scheier, Brown, 2018;Arnaud, 2015;Murta et al., 2018;Burkhart, 2015;Stolle et al., 2010). ...
Article
Current State of Family-Based Prevention and Therapy of Substance-Use Disorders in Children and Adolescents: A Review Adolescence is a vulnerable period for substance use disorders (SUD) as indicated by epidemiological studies. Research demonstrates the family's role for the etiology of SUD and provides a rationale for interventions based on family-associated risk and resilience factors. In this article, we summarize published results for family-based interventions from 2008-2018. Taken together, prevention programs can be effective when they focus on the promotion of broader developmental competencies and familial resources, rather than narrowly addressing substance use. Moreover, programs could benefit from targeting youth and parents as done in the "Strengthening Families Program 10-14"; most existing programs however target parents and do not include the adolescents. Family-based treatment programs with an evidence base are Multisystemic Therapy, Functional Family Therapy, Multidimensional Family Therapy and Brief Strategic Family Therapy. Overall, the effects of family-based interventions are small-to-middle sized but vary significantly across populations. Across the field of family-based interventions, there is a need for more knowledge on effective components and differential effects. The results could be improved by translational research such as on the emerging concept of mindfulness. Moreover, there is a need for implementation research and the effectiveness of service delivery programs on the community level in Germany.
... This includes the equivalence of manual and video material, programme delivery in parallel parent and child sessions with following joint family activities and meals, programme delivery to groups of 10-12 families and booster sessions. We believe all necessary steps for cultural adaptation, 33 were taken. 25 Still, our results did not match previous US evidence. ...
Article
Full-text available
Background : The purpose of this study is to evaluate the effects of a German adaptation of the Strengthening Families Programme 10-14 (SFP 10-14; Familien Stärken). Methods : A multi-centre randomised controlled trial comparing the German SFP version consisting of seven sessions and four booster-sessions with a minimal intervention on parenting as control condition. Outcomes comprise measures of adolescent substance use (initiation) and behaviour problems and are assessed at baseline, after programme delivery and at 6- and 18-month follow-ups. Primary outcomes were lifetime tobacco, alcohol and cannabis use at 18 months. Data of n = 292 families were analysed using baseline adjusted logistic regressions and mixed models. Results : We observed reduced rates of lifetime tobacco use in analyses with follow-up respondents, but not in data using the complete intention to treat sample with multiple imputation estimates for missing data. Parents reported fewer adolescent behaviour problems in analyses with the total sample and multiple imputed data, but not in data with follow-up respondents only. There were no other significant effects of SFP 10-14. Conclusion Overall the medium size effects found in previous US trials could not be replicated in a German context.
Article
Full-text available
This study analyzed contextual barriers and facilitators in the implementation of Strengthening Families Program (SFP 10-14), Brazilian version, a family-based preventive program focused on the prevention of risk behaviors for adolescent health. SFP 10-14 was implemented between 2016 and 2017 for socioeconomically vulnerable families in four Northeast Brazilian states as a tool of the National Drug Policy. A retrospective qualitative study was carried out in which 26 implementation agents participated. Data from 16 individual interviews and two group interviews were analyzed through content analysis. The most recurrent barriers were the group facilitators' working conditions, weak municipal administration, precarious infrastructure, inadequate group facilitator training methodologies, low adherence of managers and professionals, and funding scarcity. The conditions highlighted as favorable to the implementation were proper intersectoral coordination, engagement of involved actors, awareness of public agency administrators, municipal management efficacy, and efficient family recruitment strategies. Favorable political contexts, engagement of implementation agents, and intersectoral implementation strategies were identified as central to the success of the implementation of SFP 10-14, especially in the adoption of the intervention, community mobilization, and intervention delivery stages. Further studies should combine contexts, mechanisms, and results for a broad understanding of the effectiveness of this intervention in the public sector.
Article
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There has been an increasing interest in the development of evidence-based parent interventions aimed at reducing the early risk factors for the development of anxiety disorders, namely behavioral inhibition (BI) during the preschool years. However, these interventions are not yet available in European countries with a high prevalence of anxiety disorders, such as Portugal. This study aimed to explore the perceptions of Portuguese psychologists toward the acceptability of the parent component of the Turtle Program, as a first step before its dissemination in Portugal. Eighteen psychologists were distributed into three focus groups. Each focus group was moderated by a trained psychologist, using a semi-structured interview guide. The deductive thematic analysis revealed that Portuguese psychologists perceived the objectives and the intervention contents as highly acceptable, with the exception of time-out. Portuguese psychologists suggested that it would be useful to give more time (lengthen, add more sessions and/or follow-up sessions) to families for the intervention and to introduce only minor changes in session procedures and materials. Portuguese psychologists anticipated that the preliminary preparation for coaching sessions, the greater focus on personal experiences, the flexibility in homework activities, and the introduction of interactive activities and materials can be useful, when implementing the intervention with Portuguese families. These findings are in line with previous studies conducted with LatinX and Southern European practitioners, who typically agree with the acceptability of evidence-based parent intervention principles and only report the need to introduce minor changes related to the manner in which the intervention is presented to families.
Technical Report
Full-text available
Policymakers and other stakeholders can use cost-benefit analysis as an informative tool for decisionmaking for substance abuse prevention. This report reveals the importance of supporting effective prevention programs as part of a comprehensive substance abuse prevention strategy. The following patterns of use, their attendant costs, and the potential cost savings are analyzed: - Extent of substance abuse among youth - Costs of substance abuse to the Nation and to States - Cost savings that could be gained if effective prevention policies, programs, and services were implemented nationwide - Programs and policies that are most cost beneficial
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Full-text available
This paper is the result of our interest in preventing adaptation problems (delinquency, academic failure and absenteeism at school, drug use, etc.) in young children and adolescents at risk, as well as the need to develop effective programmes adapted to the population in the Balearic Islands (Spain). Purpose: The objective of this paper was to describe the characteristics and outcomes obtained in the Family Competence Programme (FCP), which is an adaptation of the Strengthening Families Programme (SFP) for the population of the Balearic Islands (Spain). Programme description: Like the SFP, the FCP is a multi-component programme that aims to reduce the influence of risk factors associated with alcohol and drug use while increasing children’s resilience by reinforcing the main protective factors. The programme combines training in parenting skills, work with the entire family and children’s social skills during 14 weekly sessions. The sessions were led by group leaders with long-standing experience in handling groups and working with populations undergoing treatment and who were also trained specifically to apply the programme. Sample: Two applications of the programme were implemented. The final sample was made up of 58 adult men and women (28 in experimental groups and 30 in control groups) who attended treatment or their partners; their average age was 39. A total of 35 children who were 10.6 years of age on average took part in the programme (19 in experimental groups and 16 in control groups). There were 31 families in all (15 in experimental groups and 16 in control groups). All the participants in the experimental groups live in Mallorca (Spain), while the control groups lived in other cities in Spain. Design and methods: We used a quasi-experimental design with an unmatched control group and pre- and post-treatment measures. The subjects were not randomly assigned to the experimental (EG) and control (CG) groups. The first application took place between 28 January 2005 and 13 May 2005. The second application began on 7 October 2005 and concluded on 27 January 2006. We used participant self-reports together with information supplied by the children’s teachers. The instruments included those employed in the SFP and others that had been validated for the Spanish population. The ANOVA, t-test and Cohen’s d were used to analyse the data obtained. In addition, we recorded the programme attendance. Results: Percentages for programme attendance were very high and remained high during all 14 sessions. Family relationships, parental education skills, children’s behavior and their social skills all improved. Conclusions: Our study indicates that the FCP and its capacity to achieve its objectives are effective, although further research with a larger sample is needed.
Book
From a European Perspective This book charts territory that is profoundly important, and yet rarely fully understood. The authors have attempted a task that has relevance to the widest possible range of professionals working with children and adolescents. In describing and assessing the fields prevention and promotion they have performed an immense service to researchers in this field, but also to practitioners across the spectrum, from mental health nurses and doctors to teachers and psychologists, from social work professionals to psychiatrists and youth counselors. There are two other key elements that should be emphasized from the outset. The first is that the approach in this book is truly multi-disciplinary, with the authors making a genuine attempt to draw upon knowledge and practice derived from all the relevant disciplines. The second element which makes this book so important is that the authors have worked across countries, to ensure that work in the field of intervention from both North America and from Europe should be included. This is as welcome as it is refreshing. There appear to be so many barriers to true collaboration between the two continents, and so many examples of either North American to what is going on "across the or European social scientists appearing blind border" that the approach taken here should be wholeheartedly commended. This book is essentially a review, but a rather special review.
Article
Fragestellung: Wie evidenzbasiert sind familienbasierte Programme zur selektiven Suchtpravention? Lasst sich ein vorbildhaftes Programm identifizieren? Methodik: Uberblick uber entsprechende Ansatze und Programm-Merkmale als Ergebnis einer systematischen Literaturrecherche in verschiedenen Datenbanken. Ergebnisse: Das Strengthening Families Program 10–14 aus Iowa/USA (SFP 10–14) ist das wohl zurzeit best evaluierte familienbasierte universelle Praventionsprogramm; so liesen sich nachhaltige Effekte auch im 6-Jahres-Follow-up nachweisen. Schlussfolgerungen: Die kultursensitive Adaptation und Evaluation von SFP 10–14 fur die Bundesrepublik kann die Pravention von Suchtstorungen wirkungsvoll erganzen. Eine Adaptation fur den deutschen Sprachraum hat verschiedene kultursensitive Aspekte zu berucksichtigen sowie den Umstand, dass SFP 10–14 aufwandig durchzufuhren ist.
Article
Changes requiring greater accountability among federal agencies in the United States, along with specific criticisms of prevention activities funded by agencies such as the Department of Education, have led to an increased emphasis on what are called “science-based” or “research-based” interventions in recent years. Federal agencies such as the Department of Education and National Institute on Drug Abuse (NIDA) have produced documents describing such interventions and advocating their widespread use and dissemination. The most widely advocated of these prevention interventions is the Life Skills Training (LST) program, the effectiveness of which, its supporters argue, has been demonstrated using rigorous research methods. The research study that has attracted most attention is the randomized trial conducted with white middle-class adolescents in New York State, as this purports to demonstrate that the LST program can reduce alcohol and illicit drug use 6 years after initial implementation. In contrast to the advocates for the LST program, I argue that this longitudinal trial does not meet the rigorous methodological standards claimed on its behalf. Indeed, it violates one of the fundamental principles of a randomized trial by restricting key analyses to selective sub-samples of the experimental group. I estimate that about 7.5% of those who initially received the LST intervention in the trial were included in the most recent set of analyses reported. This falls considerably short of the proportion of intervention group participants required at follow-up in a methodologically sound controlled trial. Thus, contrary to what its advocates claim, the study tells us little about the long-tern effectiveness of the LST program in reducing alcohol and illicit drug use among adolescents.