Effectiveness and utilization of a parent education curriculum: a two-level evaluation of educators and parents Sheetal Malhotra , MBBS, MS Diane Santa Maria, APHN, MSN Melissa Steiner, MSA, CHES

Objectives Describe a training of educators to provide a parenting-adult curriculum to their communities. Evaluate the effectiveness and utilization of the curriculum training Identify challenges to curriculum training implementation and possible solutions.

Background The Medical Institute developed the Building Family Connections (BFC) curriculum Developed from previous work with grandparents and parents Information and skills training for parenting adults on parent-child connectedness Goal to increase parent-child sexual health communication and connectedness Ref: Markham CM, Lormand D, Gloppen KM, et al. Connectedness as a predictor of sexual and reproductive health outcomes for youth. J Adolesc Health. 2010 Mar;46(3 Suppl):S23-41. Epub 2010 Jan 22. Review. To review research examining the influence of ‘‘connectedness’’ on adolescent sexual and reproductive health (ASRH). Connectedness, or bonding, refers to the emotional attachment and commitment a child makes to social relationships in the family, peer group, school, community, or culture. A systematic review of behavioral research (1985–2007) was conducted. Inclusion criteria included examination of the association between a connectedness sub-construct and an ASRH outcome, use of multivariate analyses, sample size of 􏰂100, and publication in a peer-reviewed journal. Results were coded as protective, risk, or no association, and as longitudinal, or cross sectional. Findings from at least two longitudinal studies for a given outcome with consistent associations were considered sufficient evidence for a protective or risk association. Eight connectedness sub-constructs were reviewed: family connectedness (90 studies), parent–adolescent general communication (16 studies), parent–adolescent sexuality communication (58 studies), parental monitoring (61 studies), peer connectedness (nine studies), partner connectedness (12 studies), school connectedness (18 studies), and community connectedness (four studies). There was sufficient evidence to support a protective association with ASRH outcomes for family connectedness, general and sexuality-specific parent– adolescent communication, parental monitoring, partner connectedness, and school connectedness. Sufficient evidence of a risk association was identified for the parent over control sub-construct of parental monitoring. Connectedness can be a protective factor for ASRH outcomes, and efforts to strengthen young people’s pro-social relationships are a promising target for approaches to promote ASRH. Source: Markham,CM et al. J Adolesc Health. 2010 3

Background Parent-child communication and connectedness associated with reduction in adolescent risk behaviors including sexual activity1,2 Parents face many barriers to communicating with their children about sex lack of knowledge, communication skills, and self-efficacy3,4 Kirby, D., Lepore, G., & Ryan, J. (2005). Sexual risk and protective factors–factors affecting teen sexual behavior, pregnancy, childbearing and sexually transmitted disease: Which are important? which can you change FIX Connectedness as a Predictor of Sexual and Reproductive Health Outcomes for Youth Christine M. Markham, Ph.D.a,*, Donna Lormand, M.P.H.a, Kari M. Gloppen, M.P.H.b, Melissa F. Peskin, Ph.D.a, Belinda Flores, M.P.H.a, Barbara Low, Dr.P.H.a, and Lawrence Duane House, M.A.c de Graaf, H., Vanwesenbeeck, I., Woertman, L., Keijsers, L., Meijer, S., & Meeus, W. (2010). Parental support and knowledge and adolescents' sexual health: Testing two mediational models in a national Dutch sample. Journal of Youth and Adolescence, 39(2), 189-198. doi:10.1007/s10964-008-9387-3 Miller, K. S., Fasula, A. M., Dittus, P., Wiegand, R. E., Wyckoff, S. C., & McNair, L. (2009). Barriers and facilitators to maternal communication with preadolescents about age-relevant sexual topics. AIDS and Behavior, 13(2), 365-374. Sources: 1. Kirby, D et al Sexual risk and protective factors 2. Markham,CM et al. J Adolesc Health. 2010 3. de Graaf, H et al J Youth Adolescences 4. Miller, K et al AIDS and Behavior

Exponential Program Effects Community educators can be effective mediators to overcome parental barriers through education and skill building Each trained educator can reach numerous parenting adults producing an exponential effect on parent-child sexual health communication Training community educators across the country The train the trainer or train-the-facilitator model is popular in public health education to reach large portions of the target population by training a small cadre of trainers/facilitators. Several evaluations of community educators trainings have been conducted to assess effectiveness of such trainings by assessing changes in knowledge and skills of educators. However, there is not much information on what happens after educators leave the training with their new skills. There is not much information on the uptake and utilization of training information by the trainers/facilitators. This study aims to assess the utilization and real effectiveness of a sexual health education and communication curriculum after the educators have been trained in it. Not only does this study assess effectiveness of the training, but also aims to evaluate effectiveness at a second level – transfer of this information to the end-user. The study will address these topics by discussing two levels of evaluation: that of the training for the trainers as well as the course conducted by these trainers in their communities and how well this information is transferred to the community members. This abstract will add to the practice by determining how training evaluations can be taken further to assess the real impact of any training on the end-users who are the ultimate target of such trainings. In a way, such two level evaluations are essential to assess the real effectiveness of the train-the-trainer model. Such evaluations can also help improve the train-the trainer model to ensure maximum effectiveness for the target population.

Objectives Evaluate the effectiveness of BFC curriculum training for community educators Assess uptake and utilization in educators’ communities nationwide Evaluate effectiveness in transferring this information to parenting adults through trained community educators.

Methods: Training & Delivery 10-hour BFC curriculum 2.5-day training for community educators to learn and practice facilitation skills plan, recruit, & market program provide BFC to parents in their communities

Methods: Training & Delivery (cont.) Community courses implemented based on parent feedback scientific knowledge and effective parenting & communication strategies interactive and skill building formats

Methods: Evaluation Training evaluation usability capacity building logistics & delivery Pre/post-surveys knowledge attitudes intents behaviors

Results May 2008: BFC Curriculum Training 34 educators trained pre/post surveys training evaluation 2008 - 2009: BFC curriculum courses 23 courses by 7 educators >320 parents reached

Results: Educators 34 educators; 6 males, 27 females Age: 25 to 65 years; median = 37 years Ethnicity 26% Black 15% Hispanic 44% White 12% Asian 3% Other

Results: Educators Significant increases in participant knowledge Item Pre-survey N (%) Post Survey p Site of fertilization 18 (60) 33 (100) <0.05 Problem of dating violence 14 (44) 23 (70) Risk of pregnancy in girls with boyfriends more than 3 years older then them 23 (74) 32 (97) <0.10 Decision making maturity among teens 17 (57) 25 (78)

Results: Educators

Results: Educators Participants strongly agreed that the training was useful (97%) was enjoyable (94%) materials were useful (91%) objectives were achieved (82%) prepared them to hold the BFC course (82%)

Results: Parenting Adults 7 trained educators have held 34 courses >320 parenting adults; 32 males, 287 females Age: 18 to 80 years; median = 39 years Ethnicity 89% Hispanic 7% White 4% Black 1% Other

Results: Parenting Adults Matched Responses: 209 parenting adults; 22 males, 186 females Age: 18 to 69 years; median = 40 years Ethnicity 85% Hispanic 9% White 5% Black <1% Other

Results: Knowledge Item Pre-survey N (%) Post survey N (%) p Cause of cervical cancer 124 (66) 193 (95) <0.001 Risk of infertility with STIs 154 (78) 188 (90) <0.01 Condoms make sex “safe” 152 (73) 196 (94) Early sexual debut and risk of multiple sexual partners 137 (69) 198 (95) Most pregnant teens are abandoned by their partners 180 (87) 199 (96)

Results: Knowledge (cont.) Item Pre-survey N (%) Post Survey p Risk of pregnancy in girls who have a boyfriend more than 3 yrs older than them 100 (49) 182 (88) <0.001 Site of fertilization 50 (26) 192 (95) Dating violence problem 128 (63) 163 (79) <0.01 Link between dating violence and sexual activity 138 (72) 178 (89) Abuse as a risk factor for multiple sexual partners 97 (52) 180 (88)

Results: Attitudes Item Pre-survey N (%) Post Survey p Its okay for my child to start having sex when they are in a committed relationship such as marriage 159 (79) 197 (95) <0.001 Feel comfortable talking to children about STIs and how to prevent them 156 (79) 187 (92) <0.01

Results: Skills & Behaviors Item Pre-survey N (%) Post survey p Strategies to start a conversation with youth about sex 174 (88) 201 (97) <0.01 Frequency of communication regarding sexual health 89 (47) 121 (61) <0.001

Results: Parenting Adults

Results: Parenting Adults

Conclusions Training is effective in increasing knowledge and skills of educators Trained educators can then provide BFC curriculum to parents in their communities Utilization of BFC curriculum has shown enhanced parent-child sexual health communication

Implications for Evaluation Practice and Research Use of trained educators to reach parents is a viable and effective model Training evaluations can be taken further to assess the real impact on end-users Two level evaluations can help improve the train-the-trainer model to ensure effectiveness Further research on utilization and impact of such models needed ie., in youth This abstract will add to the practice by determining how training evaluations can be taken further to assess the real impact of any training on the end-users who are the ultimate target of such trainings. In a way, such two level evaluations are essential to assess the real effectiveness of the train-the-trainer model. Such evaluations can also help improve the train-the trainer model to ensure maximum effectiveness for the target population.

Funding for the Study This study was supported by grant # 5U58DP000409 from the Centers for Disease Control (CDC) and Prevention Division of Adolescent and School Health (DASH). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC, DASH, or the Department of Health and Human Services or the U.S. government. 31

Thank You! For more information contact Sheetal Malhotra, MBBS, MS smalhotra@medinstitute.org 512-328-6268 ext 206 32