Experiences of Native Participants in the Promoting First Relationships^® Intervention: Focus Group Findings

Abstract

Objectives

We tested Promoting First Relationships^® (PFR), an evidence-based preventive intervention program for caregivers promoting attachment and social and emotional development of infants and toddlers, in a randomized controlled trial in a Native community. Quantitative results yielded evidence of efficacy; but in this report, our objective was to assess the participants’ real-life experiences, challenges, and suggested enhancements to further adapt the program.

Methods

At the end of the study we conducted three focus groups (N = 17)—two groups for participants who completed the 10-week intervention and one group for those who did not. Focus groups were structured to generate discussion about (1) elements or activities of PFR they enjoyed and others that were challenging, (2) suggested solutions to participant challenges, (3) experiences with video recordings and handouts, and (4) aspects of the program that could be changed to make it more culturally-relevant.

Results

Qualitative analysis of the focus group transcripts revealed five themes: (1) appreciation for PFR providers and program, (2) personal growth, (3) improved caregiver-child relationships, (4) participant challenges, and (5) participant suggestions to improve the program.

Conclusions

These qualitative results complement our quantitative assessment of the positive impact of the PFR program. Additionally, they provide importance guidance for future implementation of PFR in this, and other Native communities, as well as insight into broader issues to consider when adapting intervention programs for Native families.

Introduction

Extensive evaluation of evidence-based intervention programs modified for specific populations, such as Indigenous (Native) people residing in reservation communities, is critical to the long-term success and sustainable implementation of programs (Hiratsuka et al., 2018). One such program, Promoting First Relationships^® (PFR; Kelly et al., 2008), was modified and tested in a randomized controlled trial (RCT) in a Lakota Tribal community in the United States. Vol.:(0123456789)PFR is an evidence-based, 10-week strengths-based home visiting program based on attachment theory. It focuses on the quality of the relationship between the caregiver and the child and supports the caregiver’s capacity to meet the child’s underlying social and emotional needs and to strengthen their relationship. Our Native PFR providers used educational handouts and video-recorded observations to help caregivers reflect on their child’s unique social and emotional needs, their nonverbal communication, and the experience of interaction. During visits, PFR providers asked participants to interact with their children under different conditions (i.e., teaching, playing, or separation and reunion); providers set up a camcorder to record the interaction for approximately 10 min. Alternative options such as audio-only recordings, or replacing video recordings with live feedback were offered upon request. At the next visit, caregivers and PFR providers viewed the videos and jointly reflected on their observations of the interaction; providers offered positive and instructive feedback to the caregiver and used reflective questions to help the caregiver gain insight into the child’s or caregiver’s underlying social or emotional needs, behavior, or communications. In RCTs with this community and with other populations, PFR has improved caregiver sensitive and responsive care and caregiver knowledge about children’s social-emotional needs (Booth-LaForce et al., 2020, in press-a; Oxford et al., 2016a, 2016b, 2021; Spieker et al., 2012). It also improves child emotion regulation (Hastings et al., 2019), social attention and competence (Jones et al., 2017; Spieker et al., 2012), and normalizes stimulated cortisol (Nelson & Spieker, 2013), while decreasing the child’s affective communication errors (Oxford et al., 2016a, 2016b) and externalizing behaviors (Oxford et al., 2021; Pasalich et al., 2019).

We culturally adapted PFR for Native populations in our previous work with two non-Lakota Tribal communities (Oxford et al., 2020) using a community-based participatory approach. Examples of modifications included providing more time for visits, provision of alternative meeting locations if the family chose not to do home visits, developing a new handout on supporting children through transitions or separations, and changing one activity to focus on positive caregiving experiences. The culturally adapted PFR for Native communities was recently tested with a Lakota Tribal community as an RCT called Thiwáhe Patítaŋ (Supporting Families). The outcome of this RCT serves as one objective source of evidence about the success of the program (Booth-LaForce et al., in press-a). However, of equal importance are the real-life experiences of the participants in the program, typically garnered through qualitative research methods. Using a content analysis framework, we report here the results from focus groups with participants who completed the culturally-adapted PFR intervention and those who enrolled but did not complete the intervention. Our authorship team includes a Native researcher from the Lakota Tribal community, a Native analyst from another community, and university-based non-Native investigators.

The purpose of the present study was to gain insight into our participant’s experiences, challenges, and suggested enhancements to further adapt the program, because the Tribal community where the RCT was conducted was not represented in the initial cultural adaptations. This approach of learning from participants after their participation is unique, as few post-participation focus groups were identified in the existing literature.

Method

Sample

Focus group participants were recruited from the Thiwáhe Patítaŋ (Supporting Families) RCT of PFR, which enrolled 81 participants in the intervention arm and 81 in a control condition. The selection of focus group participants is depicted in Fig. 1. The study team reviewed the list of participants randomized to the PFR group then sorted participants by those who completed the intervention (n = 41) and those who did not (n = 40). Participants who received the PFR intervention from the local Native focus group moderator (n = 11) were ineligible due to the possibility of bias. The focus group moderator was not involved in data collection during research visits. All eligible participants were invited by telephone to join the appropriate focus group. Of the eligible 32 completers, 11 participated in the focus groups and 21 were lost to follow up, refused, or were unavailable. Of 38 eligible non-completers, 6 participated, and 32 were lost to follow up, refused, or were unavailable. Of the 17 participants, 16 were female and 1 was male, 12 were parents and 5 were grandparents, and the present ages of children in the caregiver-child dyad ranged from 1 to 4 years old (Table 1). Participants in the completer groups finished all 10 intervention sessions of PFR, 2 participants in the non-completer group never began the intervention, and 2 began but dropped out after completing 1–3 sessions and 2 dropped out after completing 4–7 sessions. Among non-completers, the range of PFR sessions completed was 0–7, with a mean of 2.17, and median of 1. Because recruitment for the RCT study occurred on a rolling basis, time from completion of PFR for completers or last contact for non-completers to the day the focus group was held ranged from 2 to 20 months for both groups. As in many reservation-based communities, the local study staff were acquainted with, or related to some of the research participants. However, none of these were close relationships. All participants signed a written informed consent form and were given $50 to compensate them for their transportation costs and time. The study protocol, consent form, and moderator script were approved by the University of Washington and Great Plains Area Indian Health Service Institutional Review Boards and by the relevant Tribal Council, which is unidentified for confidentiality.

Fig. 1.

Diagram for focus group participant selection

Table 1.

Demographics of focus group participants

	Completers (n = 11)	Non-Completers (n = 6)
Gender
Female	11 (100%)	5 (83%)
Male	0 (0%)	1 (17%)
Relationship to child
Parent	9 (82%)	3 (50%)
Grandparent	2 (18%)	3 (50%)
Race or ethnicity
American Indian	10 (91%)	6 (100%)
White	1 (9%)	0 (0%)
Age of child	1–4 years	1–4 years
PFR Visits Completed
0	0 (0%)	2 (33%)
1–3	0 (0%)	2 (33%)
4–6	0 (0%)	2 (33%)
7–10	11 (100%)	0 (0%)

Interview Structure

Moderator scripts were developed to explain the purpose of the research, introduce the moderator and her interests in this research topic and introduce participants to each other, as well as structuring the focus group discussions regarding participants’ perspectives on family needs, and the delivery of the PFR intervention within the Tribal community (scripts are available as Supplementary Material). Funding and time constraints did not allow for pilot testing of the script. Focus groups took place in a conference room at a research office centrally-located on the reservation, with only the moderator and participants present. Focus group members were asked to reflect on (1) elements or activities of PFR they enjoyed and others that were challenging, (2) suggested solutions to challenges they identified, (3) their experience with video recordings and handouts, and (4) changes to the program that would make it more culturally relevant. Participants in the completer groups were also asked to reflect upon parts of PFR they were still using, and skills gained during PFR. Participants in the non-completer group were asked to reflect upon whether the intervention and study were adequately explained when they signed up, what they had hoped to gain from participating, and why they dropped out. Relevant materials, such as PFR thoughts for the week, handouts, and videos were available for all participants to reference.

Focus groups were moderated by the lead author, a local Native Research Coordinator with graduate-level course-work in general public health and qualitative interviewing methods, as well as prior experience conducting focus groups. She also served as a PFR provider and was therefore knowledgeable about the study protocol and all PFR elements and activities. Data saturation was reached for the completer focus groups, but was not attainable due to a small sample for non-completers. Focus groups lasted 45–75 min. Field notes were not made during the focus groups. Focus groups were video- and audio recorded with permission from participants and then transcribed verbatim for data analysis. Transcriptions were not returned to participants for comment, but results of the focus groups were shared with participants and no feedback was received.

Data Analysis

We used Dedoose Version 8.3.47 (2021) to code the data, which was then categorized through an open coding process. One independent qualitative analyst identified the most relevant codes and themes from the data for completer and non-completer focus groups combined (Strauss & Corbin, 1990), then created a codebook. Together, the analyst and three of the authors analyzed excerpts from the codes and themes, constructed subthemes, and chose representative quotes. All themes contained examples from both completers and non-completers, but due to relevance and the amount of time spent on specific topics, quotes for each theme tend to represent completers or non-completers, but rarely both. Each author made recommendations for subthemes independently. Any subtheme that was recommended by multiple authors and had quotes from multiple participants was discussed and considered for inclusion. Subthemes with only one recommendation, or those that lacked representation from multiple participants were not included. A coding tree was not used.

Results

The authors have followed the COREQ criteria for reporting qualitative research. Five main themes about the program content and experience were identified from the focus groups; main themes were then broken into sub-themes. The first theme, appreciation for PFR providers and program, included accolades for the staff, materials, and general positive feelings. The second theme, personal growth, had four sub-themes, namely, personal or emotional growth, insight regarding their child’s behavior, and better communication. The third theme, caregiver-child relationships, included an improved relationship and a deeper connection to the child. The fourth theme concerned participant challenges with sub-themes of desire for more video instructions and discomfort with being video recorded, barriers to completing the intervention, and lack of time to interact with their child. The fifth theme comprised participants’ suggestions about program improvements such as inclusion of other caregivers in PFR and hopes for the program to continue. Quotes exemplifying each subtheme are provided in the following text (C1-C11 are from completers and NC1-NC6 are from non-completers).

Theme 1: Appreciation for PFR Providers and Program

The PFR program was generally strongly endorsed. Participants appreciated the staff, the structure and flexibility of the program, and PFR materials (such as the handouts).

Appreciation for PFR Intervention Staff and Structure

• “I liked it that she [provider] came to our house, and she [provider] was comfortable. Honestly, after the first visit, it was easy for me because I didn’t feel judged, so that made it 100% easier to be open to more of like, ok they’re not judging me. That first visit did it for me. It kind of washed away my insecurity.” -C1

• “I felt it was valuable because I learned a lot. I have kids, and I don’t really have someone to help me, like this is what you do. So, I learned a lot from [provider], and from this program.” -C10

Handouts

• “I liked all the handouts. I really liked it because it was like a huge refresher course and I kept all the paperwork and gave it to my daughter and told her to read them.” -C3

• “The handouts helped me know what my daughter’s needs and wants are. Now she grabs my hand and takes me where she wants.” -C8

Theme 2: Personal Growth as a Caregiver

As shown in the following quotes, caregivers referenced multiple ways in which they grew as a result of the program, including personal or emotional growth, insights regarding their child’s behavior, deeper connection to their child, and better communication.

Personal or Emotional Growth as a Parent

• “It [PFR] taught me coping skills too because I get frustrated very easily and overwhelmed very easily. So my personality would either shut down or just get mad. It kind of helped me not to do that. …. It definitely helped me with coping skills.” -C1

• “I see it when I get frustrated with him. I have to look back and think, ok this is the wrong way. I need to calm down. He’s just a little boy. Let him do things, and let him help.” -C2

• “It [the social and emotional needs handout] helped me understand my child more. I learn from him just as much as he learns from me.” -C5

Insight into Their Child’s Behavior

• “It kind of helped me understand; maybe there’s a reason why my daughter is spitting. Maybe I’m not giving her as much attention as I probably should be. Before she’d go to school, I wouldn’t really ask her what she did in school, but now I do.” -C1

• “I give them more choices because I just feel like [if I say] you’re going to do this, I don’t think I would like that.” -C4

• “This [PFR] helped me just to better understand my daughter’s behavior and to work with her more. Like meeting her social cues. Like if she’s upset, try to work with her while she’s upset and not making her more upset because it’s not going to work.” -C10

Improved Communication

• “Like I said, it helped me understand my daughters more, communicate with them more. I was able to kind of put myself in their shoes and see it from their point of view. Now I can talk to my daughter.” -C1

• “Before [participating], I kind of didn’t really talk to them that much because I felt like they don’t understand anyway… [Now] I talk to them, I’m sure it helps…I keep reminding myself that kids understand.” -C10

Theme 3: Improved Caregiver–Child Relationship

In another theme, caregivers indicated that their relationship with their child improved as a result of the program and that they felt a deeper connection as shown in the following quotes.

Improved Relationship and Deeper Connection to Child

• “Mine [favorite resource] was ‘Staying Connected During Difficult Moments.’ I get frustrated. It doesn’t do anything if you’re arguing with your toddler, so this really helped with staying calm. Just pause. It’s best to just keep them calm, ask them what’s going on and try to find out why they’re acting out.” -C3

• “As an adult, it’s easier to get caught up on ourselves, that we forget that we need to be paying attention to them [children] more, and this [PFR] helps with that.” -C10

Theme 4: Participant Challenges

Challenges for participants included discomfort being videorecorded, unclear video instructions, and barriers to completion. Some challenges differed between completers and non-completers. In both PFR completer and non-completer focus groups, participants expressed a desire for more instructions related to the video recordings. Non-completers reported being too busy to interact with their child or to participate in the program, to questioning the purpose or personal benefit of the program, to feeling uneasy about conditions of their home.

Camera Discomfort

• “I don’t like people taking pictures of me or taking any kind of pictures. When I was younger, I was always covering my face. But I knew these were important. It was a little hard for me to get used to.” -C2

• “I’m really shy of taking pictures.” -C6

Video Instructions

• “I think more direction on what to do rather than just interacting with your child. I mean like what do you want from us- you give us a room full of toys well, what do we do?“ -NC2

• “I raised all my kids. I know how to play with my kids. I know how to play with my grandkids. I just didn’t know what I was supposed to do [during video].” -NC4

Reasons for Not Completing

• “You just sit there to interact with your child for an hour. That’s not the way I do it at home. I’ll set something down. When he gets busy, I’ll get up and try to do something else because there’s always a ton of other things to do in the house.” -NC1

• “I couldn’t really find time to come over there” -NC3

• “At the time, I was living with his (child’s) dad’s family, and it was really crowded there, so like the home visits weren’t really working.” -NC6

Theme 5: Participant Suggestions

Some participants expressed that it would be helpful for the other members (e.g., other caregivers, extended family) of the household to participate in PFR to gain a mutual appreciation for the child’s social and emotional needs and generate new parenting ideas. Several hoped the intervention would be offered in the Tribal community so others could benefit. Representative quotes are shown in the following text.

Include Others

• “Bring a family together so that everyone has the same information to help each other because there’s times that dad takes care of the kids because mom can’t do it all.” -C2

• “The emotional part – it’s not just the moms or the dads that are involved in the child’s life. It’s everybody.” -C5

• “I think it would work with more adults, like my grandma that helps me, so she would know how to cope with my child.” -C7

Hopes for Continuation

• “It’s awesome. I just wish all of you young mothers could get it. Even the grandmothers I think would appreciate it too.” -C2

• “Stuff like this is really needed. A long time ago, there was a program here called Phasor, then it went to Healthy Start. Then there’s nothing here right now so this is a good resource.” -C3

Discussion

In this qualitative study of participants who had received the PFR intervention in a Native community, we gained considerable knowledge about their real-life experiences, reactions, and challenges, as well as their suggestions for culturally-based suggestions to improve PFR. In other PFR studies, participants’ ratings (Oxford et al., 2018) affirmed their positive PFR experiences. Our study extended previous simpler evaluations of PFR to a more nuanced and in-depth examination of this intervention. Moreover, use of a previous version of PFR adapted for Native communities called for a critical assessment by participants from the Lakota Tribal community through focus group discussions.

Participants identified several specific characteristics of PFR providers that improved their overall experience, such as being knowledgeable, flexible, relatable, and easy to talk to. Participants also enjoyed the handouts, especially “Staying Connected During Difficult Moments,” “Balancing Parenting: Guidance through Limits and Choices,” and, “Meeting the Social and Emotional Needs of Infants and Toddlers.” Staying Connected During Difficult Moments focuses on helping the caregiver regulate their emotions first so that they can “stay connected” emotionally with the child when the child is having big feelings. Balancing Parenting depicts the struggle many parents have when parenting a young child; it opens for discussion what happens when too many choices are given without limits or when too many limits are given without choices, with the emphasis on finding a balance between both ends of the continuum. Meeting the Social and Emotional Needs of Infants and Toddlers is a key handout with concepts that are referenced at every PFR home visit. This handout helps caregivers identify social and emotional needs of their child (to feel safe and secure, to have a sense of belonging, to be acknowledged, to have help managing upset feelings and so on) and ways caregivers can meet those needs. Enhancing use of these handouts in relevant Tribal programs may benefit communities with similar demographics and needs.

Consistent with PFR philosophy and training, participants felt providers offered non-judgmental support. As a strengths-based intervention, PFR providers are trained to identify caregiver strengths during the video-recorded caregiver-child interaction segments, then provide instructive feedback about the interaction, which is observable and specific to what the caregiver did (Booth-LaForce et al., in press-b). We speculate that positive instructive feedback augmented the caregivers’ confidence.

We also observed that participants experienced personal growth. This is consistent with PFR’s goals of enhancing caregivers’ insight into their child and their relationship with their child, and is accomplished by increasing caregivers’ reflective capacity. Reflective questions are scattered throughout the hour-long PFR sessions, but are concentrated during the video observation/viewing session. While providers and caregivers watch the video, providers may pause the video observation and ask caregivers what they think their child is feeling or needing. Through this process, participants gained insight into what precipitated feelings of being overwhelmed and frustrated during parenting and also discovered ways to cope and manage difficult emotions. We believe reflective questions promoted caregivers’ understanding of their child, insight into the child-caregiver relationship, personal growth, and greater communication and confidence.

Not surprisingly, participants reported PFR improved caregiver-child relationships and that they felt more connected with their child. PFR is based on attachment theory and this theme is woven throughout the sessions; the model’s aim is to promote a deeper parent–child bond within the relationship, hence the name Promoting First Relationships. During video feedback, providers can point out moments when the child is seeking comfort or protection, signaling key attachment needs of young children. When caregivers respond to those needs, the greater attunement translates into improved relationships and deeper connection between caregiver and child. These constructs reflect the core purpose of the PFR program. Again, video feedback is an essential feature of these outcomes offering the opportunity to reflect on the caregiver’s observation of their child.

In contrast to these areas of positive feedback, some participants expressed discomfort with being video-recorded, which is important to note because recording and watching the filmed interactions is an integral component of PFR. Future studies might consider alternatives to video-recording the dyad, such as filming only the child and keeping the caregiver out of the frame, recording audio rather than video, or skipping video all together and providing live feedback during dyadic interactions, all of which would maintain the integrity of the intervention. One participant suggested recording the entire visit, lessening the pressure when the camera begins recording. To address the request for more video instructions, the caregiver could be shown a demonstration video of a caregiver-child interaction and of a PFR provider giving positive and instructive feedback to the caregiver. Another option would be to solicit questions prior to beginning and during the video recording session. Concerns about time constraints and uncertainty regarding PFR’s purpose and benefit could be addressed by more fully explaining the benefits of PFR and offering office-based visits may be helpful for caregivers concerned about home conditions.

Participants’ suggestions to include other family members and recommendations to continue offering PFR for the betterment of the entire Tribal community do not explicitly reference cultural beliefs, but authors believe they reflect local inherent Lakota lifeways and family traditions. The Lakota language has multiple terms to describe family and community relationships. Concepts of family include: immediate family such as parents, children, and siblings (Thiwáhe); extended family, such as grandparents, aunties, uncles and generations of cousins (Thiyóšpaye); people unrelated by blood or marriage but treated like a relative and who may be adopted into a family with a ceremony (Huŋká); a sense of interconnectedness that comes with the belief that all are related (mitákuye oyásiŋ); and the practice of helping care for others in the community (Oyáte). Focus group participants who expressed a desire to include others from their immediate family or even members of their extended family were voicing values consistent with Lakota family traditions. While the biological parents or grandparents typically are responsible for day-to-day child care, in Lakota communities many other adults and older siblings or cousins in the household contribute to the social and emotional welfare of young children. Similarly aligned with Lakota values, the hope for continuation of the program supports the Lakota practice of mitákuye oyásiŋ. While each Tribal Nation is unique, these Lakota beliefs and family traditions may translate into similar concepts in other Tribal Nations.

We acknowledge this qualitative study had several notable limitations. First, our sample size was small and therefore may not have been representative of the cohort enrolled in the RCT. Furthermore, some potential participants were deemed ineligible due to conceivable bias since their PFR provider also served as the focus group moderator. Second, many non-completers did not participate in the focus groups for the same reason they dropped out of the RCT, i.e. lost to follow-up, too busy, or uninterested, which may have created a sample bias. Third, the focus groups were held 2–20 months after conclusion of the intervention, and this variable and extended time could influence participants’ recall and observations. Finally, although an independent analyst was used to identify themes, the other researchers may have had biases about the PFR intervention that influenced their objectivity in determining focus group subthemes.

Nonetheless, this qualitative study conducted with members of a Lakota community that received the PFR intervention underscored the value of PFR specifically for this Lakota Tribal community, and in general. At the time of publication, the authors were not aware of any Tribal communities implementing the PFR intervention, however, as of spring 2022, the PFR intervention was approved by the Home Visiting Evidence of Effectiveness (HomVEE) review and is eligible for Maternal Infant and Early Childhood Home Visiting (MIECHV) funding (Promoting First Relationships, 2022). Three percent of all MIECHV funds are set-aside for Indian Tribes, consortia of Tribes, Tribal organizations, and urban Indian organizations (U.S. Department of Health & Human Services, 2021). The results of this study should be considered in future implementations of PFR in Tribal communities.

Participants encouraged a more inclusive format for future implementation of PFR that incorporates the multigenerational Lakota family structure. Collectively, participants’ observations will facilitate further modification of PFR to better fit community needs and to test in future studies. The information gained from these focus groups is critical to our ongoing efforts to culturally tailor and implement the PFR intervention program for Native (and other) communities more broadly. This study also highlights the importance of gathering qualitative data to evaluate study participants’ real-life experiences with intervention programs, in order to modify and improve them and thereby increase their impact.

Significance.

Preventive intervention programs for caregivers and young children have been studied extensively in the general population, but relatively few studies have focused on Native families living on reservations. We have demonstrated the efficacy of the Promoting First Relationships^® (PFR) intervention program in two Native communities. However, this qualitative study increases our understanding about the positive impact of the program, the challenges participants faced, and their suggested enhancements to further adapt the program to align with cultural values. Together, these results provide a roadmap for future implementation of PFR and other intervention programs in Native communities.

Data Availability

N/A due to Tribal regulations.