Strong families: a new family skills training programme for challenged and humanitarian settings: a single-arm intervention tested in Afghanistan

Abstract

Background: Children living in challenged humanitarian settings (including those in rural/underserved areas, the displaced, refugees, in conflict/post conflict situations) are at greater risk of mental health difficulties or behavioural problems, with caregivers acting as their main protective factors. While many family skills programmes exist, very few were developed for, or piloted in, low resource settings (settings with limited infrastructure, typical of humanitarian settings). We therefore designed a brief and light programme; the Strong Families (SF) programme, consisting of 5 h contact time over 3 weeks. We conducted a pilot study with the aim to test the feasibility of implementation, and a preliminary look at the effectiveness of SF, in improving child behaviour and family functioning in families living in Afghanistan. Methods: We recruited female caregivers and children aged 8-12 years through schools and drug treatment centres in Afghanistan and enrolled them in the SF programme. Demographic data, emotional and behavioural difficulties of children and parental skills and family adjustment measures were collected from caregivers before, 2 and 6 weeks after the intervention. Outcome was assessed through the SDQ (Strengths and Difficulties Questionnaire), assessing children's behavioural, emotional, and social issues, and PAFAS (Parenting and Family Adjustment Scales), measuring parenting practices and family functioning. Results: We enrolled 72 families in the programme with a 93.1% retention rate (n = 67) for data collection 6 weeks post intervention. Mean age of caregivers was 36.1 years, they had 3.8 children on average and 91.7% of them had experienced war/armed conflict in their past. The average total difficulty score of the SDQ (ranging from 0 to 40, with scores above 16 being indicative of high problems) of the 72 children reduced significantly, from 17.8 at pretest to 12.9 at post-test and 10.6 at second follow-up, with no difference in gender and most noticeably amongst those with the highest scores at baseline. Likewise, PAFAS scores decreased significantly after the programme, again with caregivers with the highest scores at baseline improving most.

Impact of a Brief Family Skills Training Programme (“Strong Families”) on Parenting Skills, Child Psychosocial Functioning, and Resilience in Iran: A Multisite Controlled Trial

“…Based on the experiences, made with the PAFAS scores in Afghanistan, before and after the Strong Families programme delivery [ 38 ], and to show similar effects over time, a sample size of 59 was considered the minimum number of participants to be enrolled, keeping the power at 90% and the 2-sided confidence interval at 95% [ 55 ]. To compare the effect sizes in each group, a sample size of 59 families in the intervention group and 59 in the waitlist/control group seemed appropriate (See Appendix A , Table A1 ).…”

“…The standardized FDQ had been previously used in other country contexts, such as Afghanistan [ 38 ], Uzbekistan, Zanzibar, Serbia [ 39 ], the Philippines, and the Dominican Republic, and only minor changes in some of the questions were made to reflect the Iranian context. Our aim to collect demographic questions was to perform stratified analyses, as indicated in the aims of our study.…”

“…Participants with scores above the upper third at baseline represent those with higher levels of difficulties, and, for better readability, we call them the “most-at-risk families” throughout the text. Through the PAFAS, we intended to measure the potential changes in caregivers, related to the short-term impact, such as “Improved caregiver confidence in family management skills”, “Improved caregiving in parenting skills”, and “Increased capacity to cope with stress”, as outlined in the logical framework [ 38 ] ( Figure 1 ).…”

“…The Strong Families programme was first piloted in Afghanistan [ 38 ] and has since been implemented with families in seven additional countries, in four different continents. Research findings, so far, from single-arm implementation studies in Afghanistan [ 38 ] and Serbia [ 39 ], have indicated that the Strong Families programme was feasible in low-resource and challenged settings and can be delivered by trained lay facilitators.…”

“…The main aim of the current study was to expand the experience with the Strong Families programme, which had, so far, tested on its feasibility and effectiveness with one-arm research modality [ 38 , 39 ], through a two-arm intervention/control trial, that would further assess its impact on the different domains of its logical framework ( Figure 1 ). The dimensions of impact to be evaluated were, namely, child mental health, parenting, family adjustment skills, and child resilience.…”