A big step for EPEC success?

Recently we reported on early steps taken to test the acceptability, feasibility, and effectiveness of a peer-led parenting support intervention. While the results were promising, the study design was not particularly rigorous. Will a tougher test of the program, produce more compelling results?

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Developed by a team of south London clinicians, Empowering Parents, Empowering Communities (EPEC) is an innovative peer-led parenting support intervention specifically designed to reach hard-to-reach parents. The program aims to improve parenting and child behavior among families living in underserved areas by training local parents as “peer facilitators.” The challenge for EPEC is that the families it targets do not tend to turn to mainstream services for support.

“This may be due in part to logistical barriers, such as competing demands and difficulties with transportation, which are especially salient for highly stressed and isolated families…,” says the team of EPEC developers. “Negative parental expectancies about treatment, including concerns about the cultural acceptability of conventional parenting interventions, may also hinder initial and subsequent engagement.”

It should be of little surprise, then, that around 40% of the parents who agreed to participate in a pilot study of EPEC dropped out before the program ended. But, this did not stop the determined EPEC team. They learned from the pilot study and put the program through a more methodology rigorous test.

Will a tougher test of the program, however, actually produce more compelling results?

Upping the Test of EPEC Effectiveness

Both the pilot and the more rigorous study took place in the Southwark area of London — one of the most deprived local authorities in England. Both studies recruited parents who were seeking help with problem behaviors of their children. Both studies used the key feature of the EPEC program, trained peer facilitators who were themselves parents from the local community.

The studies differ in a particularly important characteristic. The newly released study used a randomized control design (RCT), whereas the pilot compared the “before and after” outcomes for just one group.

Randomized control trials are considered the most rigorous method to test that a cause and effect relationship exists between a program and an outcome. Participants in an RCT trial are allocated at random to either receive the program or not. Since the participants have the same chance to be allocated to either group, the two groups are considered to be statistically equivalent. This means that since everything else is equal, any differences you find between the groups after one of them receives a particular program can be attributed to that program.

Rising to the Challenge

The results of the pilot indicated that the model could work, but only for the few families who remained in the study. In the pilot, 78 parents were enrolled to receive EPEC. Five of them dropped out before the groups began and 25 more dropped out before it ended — that is a total dropout rate of 40%.

The overall satisfaction of the 48 parents who did stay was “very high.” Parents stated that they were more confident and had better relationships with their children. They also reported significant improvements in child behavior and a small number reported a reduction in their parenting stress.

But without a control group, the program developers cannot be sure that the improvements were related to the program. For example, it could be that the parents who remained in the study were more motivated to find ways to change their child’s behavior.

The results of the RCT indicate, however, that the program itself did play a role in the positive improvements among participating families.

Compared to the parents in the control group, parents in the EPEC group reported significantly fewer child behavior problems and significantly greater improvements in their competency as parents. Parental stress significantly decreased in the EPEC group, but the decrease was not very different from stress reported by the control group parents.

All in all, these findings suggest that a peer-led parenting intervention can reduce behavior problems in children and improve parenting in families characterized by a high degree of socioeconomic disadvantage.

Moreover, only 8% of the families assigned to receive EPEC dropped out before the program ended. The low rate of dropout suggests that a peer-led approach used in the RCT may be an effective way to get support to otherwise hard-to-reach families.

Reference: Day, C., Michelson, D., Thomson, S., Penney, C. and Draper, L. (2012) Evaluation of a peer led parenting intervention for disruptive behaviour problems in children: community based randomized controlled trial. BMJ, 344: e1107. doi: 10.1136/bmj.e1107