Feasibility, Acceptability, and Effectiveness of Adding an Evidence-Based Parent/Caregiver Program for Bereaved Families to Usual Community-Based Services

Abstract

This paper briefly describes the development of the Resilient Parenting for Bereaved Families program (RPBF) and presents an evaluation of adding the RPBF to usual care (UC) provided by community agencies supporting families of bereaved children. The RPBF was adapted from the caregiver component of a family program that demonstrated significant benefits for parentally children and their parents in a randomized controlled trial. The current study found that the implementation of the RPBF program was feasible for implementation by community providers and was highly acceptable to caregivers. Subgroups of caregivers (n = 44) who received the RPBF in addition to UC (i.e., child groups and caregiver support groups) reported greater improvement in quality of parenting and complicated grief and reductions in children’s behavior problems as compared with caregivers (n = 30) who received UC only. Improvement in parenting mediated the RPBF program’s effect to reduce children’s behavior problems.

This paper reports on the feasibility, acceptability, and effectiveness of a program for caregivers of children bereaved from the death of a parent, the Resilient Parenting for Bereaved Families program (RPBF), as implemented by community agencies. The RPBF was based on the caregiver component of the Family Bereavement Program (FBP) (Masked 2013), the most extensively evaluated program for parentally bereaved children (Bergman et al., 2017). The FBP was a 12-session, multi-component, group-based program that included separate and joint sessions for children/adolescents (hereinafter collectively called children) and caregivers. A randomized controlled trial (RCT) found that the FBP as compared with a literature comparison condition reduced parent and child complicated grief and mental health problems, with benefits lasting up to 15 years later (Sandler et al., 2010, 2016, 2018; Sandler & Ayers, 2010). The caregiver component of the FBP was recently translated from a university-based experimental program to a community-based service for bereaved families. This paper reports on an evaluation of the adapted program.

Although the benefits of the FBP were demonstrated in an RCT in which the program was delivered at a university research center, the feasibility, acceptability and effectiveness of the program when delivered by community-based agencies have yet to be assessed. An initial test of the implementation of this program by a community agency found that delivering it with fidelity required a commitment of staff, time, agency resources and training that made it unsustainable as a continuing service (Ayers et al., 2011). This finding indicated the need to translate the FBP into a program that is feasible, acceptable, and sustainable as a community-based service. We used a two-step approach in the adaptation process.

The first step was to identify the components of the FBP to be included in the adapted program (i.e., the RPBF). We decided to focus on the caregiver component for several reasons. The effect of the FBP to strengthen parenting was the most consistent mediator that explained the program’s benefits to reduce children’s mental health problems at 11-month and 6-year follow-ups (Sandler et al., 2015; Tein et al., 2006) as well as suicidality at 6 and/or 15-year follow-up (Sandler et al., 2016). The FBP also had significant effects to reduce bereaved parents’ complicated grief, depression and alcohol abuse, and some of these effects were partially explained by improved parenting (Sandler et al., 2016). The focus on strengthening parenting is further supported by multiple studies that find that quality of parenting following the death of a parent is one of the most robust predictors of resilience of bereaved children (Alvis et al., 2022; Jiao et al., 2020).

The caregiver component of the FBP provided a supportive group environment in which specific parenting (e.g., active listening) and self-care tools (e.g., goal setting) were taught and practiced. Our research found that parents’ perceptions of group support were associated with decreases in depression and their use of the parenting tools was associated with positive change in parenting (Schoenfelder et al., 2013). Therefore, one goal of our adaptation was to preserve the group support and parenting activities that were in the parent component of the FBP. A second goal was to maximize the fit of the adapted program to existing organizations that provide services to bereaved children and their families. We conceptualized the program as a supplement to, rather than a replacement for, services that were currently offered in the community. If effective, the program would add to the effects of the usual care services (i.e., UC) provided to reduce problem outcomes for both bereaved children and their caregivers.

The second part of our approach involved community stakeholders (bereaved caregivers and UC service providers) as collaborators in the design of the adapted program to ensure that it was feasible for providers to implement and acceptable to caregivers. We involved four community-based grief support agencies representing diverse contexts in the United States in this process. Providers at each agency reviewed each module of the caregiver program to provide input as to feasibility of delivering the program. Both caregivers and service providers reviewed the program activities to provide input as to their acceptability to caregivers. Input as to fit with the agency service delivery system was assessed by site visits to each agency and interviews with agency directors and staff. The resulting program, the RPBF, consisted of 10 group meetings.

The current study has three objectives. First, we aim to test the feasibility of community agencies to implement the RPBF with fidelity and quality, and the acceptability of the RPBF to caregivers of bereaved children. The second objective is to test the impact of adding the RPBF to UC. Although meta-analyses have reported small-to-moderate effects of intervention programs for bereaved children (Bergman et al., 2017; Rosner, et al., 2010), the current evaluation is unique in studying the impact of adding a new program to UC. It is hypothesized that consistent with the effects of the FBP, the addition of RPBF to UC will significantly strengthen quality of parenting, reduce caregiver’s psychiatric distress, grief, and grief-related impairments at post-test. In addition, because self-compassion activities were an added component of RPBF we hypothesized an increase in caregiver self-compassion. Although we did not hypothesize significant direct effects to reduce children’s mental health problems because such effects were not found in the RCT of the FBP until the 11-month follow-up, we examined whether the program affected children’s mental health problems and tested the theoretical pathway on which the RPBF is based: that the program’s effects to strengthen the quality of parenting would relate to reductions in children’s mental health problems (indirect effects). These analyses seek to replicate findings from the efficacy trial of the original FBP (Tein et al., 2006).

Method

Procedures: Collaborative Development of RPBF

The collaborative adaptation process we used is fully described elsewhere (Masked, 2022) and so will be briefly reviewed here. We recruited four community agencies as collaborators. The agencies differed along the following dimensions: a) type of community (e.g., low-income inner-city, suburban), b) location (East Coast, West Coast), c) population served (diverse racial and ethnic backgrounds) and d) organizational structure (e.g., free standing non-profit agency, a program embedded within a large metropolitan Hospice organization). Within each agency, we collaborated with providers, bereaved caregivers and executive directors who were responsible for ensuring that the program fit the mission, needs, and resources of the agency.

The collaboration began with a 2-day meeting (Sandler, 2021) to review the program content and plan the adaptation process. This was followed by site visits to get to know each of the four agencies’ programs and community contexts and learn about the experiences of providers and caregivers receiving UC. For the site visits, an ethnographer spent 1–2 days at each agency, conducting interviews with the directors, clinical staff, non-clinical staff and volunteers, reviewed site materials. She also conducted participant-observation of at least one regular program event. Program events included orientations to the UC programs for children and caregivers, targeted support groups for children in a specific age group and their caregivers, site-based support groups for families in a particular neighborhood, and larger-scale “nights of support” for children of all ages and caregivers. All four agencies used the “Dougy Center Model” (Schuurman, 2003) for their child-focused support groups (separate groups by age and sometimes by type of death and who died), providing semi-structured peer support, activities, and space for grieving. The four agencies had varying structures and staffing for their caregiver-support groups. Observations across the four agencies’ six caregiver-support groups, preparatory meetings and debriefs of these groups indicated a similar orientation, with a non-clinical, non-judgmental peer support as the core component.

The core of our program adaptation process involved an iterative process in which providers and caregivers reviewed prototypes of the meetings and program developers used this feedback to redesign them. The providers and caregivers reviewed the modules in two rounds of 10 virtual focus-group meetings (using the Zoom platform). In the first round, RPBF developers sent a draft of a Microsoft PowerPoint presentation of a meeting, and providers and caregivers provided verbal feedback in separate focus groups. RPBF developers then modified the meeting to respond to each suggested change and a second round of meetings were held for providers and caregivers to provide feedback on the modified meeting. At the completion of the review, there was consensus across all collaborators that the program was a good fit for diverse caregivers and providers and that it retained the integrity of the activities in the caregiver component of the FBP (Sandler et al., 2013). A separate set of discussions were held with each agency’s director focused on the fit of the program with the agency (e.g., length of meetings, resource and training needs).

Participants

The sample consisted of 74 caregivers (M_age = 43.30, SD = 9.03; 78.4% females; 86.5% biological parents of bereaved child). Over half (64.9%) identified as White, 21.6% Black, 4.1% Asian American, 2.7% multi-races and 6.8% other races; 17.6% identified as Hispanic/Latinx. Their education levels were high school (13.5%), some college (9.5%), diploma or certificate beyond high school (10.8%), associate degree (10.8%), Bachelor’s (29.7%), Master’s (21.6%), or doctorate degree (4.1%). Their children were on average 10.58 years old (SD = 3.67; Range [3–17]); 52.7% were female. On average, the death of their parent occurred 20.5 months (SD = 16.36) prior to the study. Cause of death was homicide or suicide (17.8%), illness (61.6%), and accident (20.5%). The sample size was limited by the number of caregivers who could be recruited for the groups by the four collaborating agencies. The sample size provided adequate power of .76 to detect a moderate effect size (i.e., d = .50) of mean differences, assuming the pretest scores and covariates accounting for 36% of the variance. We also had adequate power of 0.85 and 0.95 for our supplemental analyses to detect pre-post differences of d = 0.50 within UC and RPBF, respectively.

Evaluation Design

The evaluation used a non-equivalent control group design (i. e., caregivers not randomly assigned to conditions) in which pre-post change in families who received the RPBF in addition to UC at the agencies were compared with that of families receiving UC but not the RPBF. The UC condition was given in year one. Recruitment of caregivers for both conditions was conducted by the four agencies from families whose children were participating in the usual services at the agency (i.e., child groups plus in the UC condition some caregiver support groups). Agencies were asked to select caregivers to participate in the usual care condition of the study using the same eligibility criteria as they would use in the following year when the agency implemented the RPBF. To be eligible, the person had to be in a parenting role for at least one child between ages 8 to 18 who experienced the death of a parent or caregiver a minimum of 3 months earlier. In the following year caregivers who met these eligibility criteria and whose children were receiving usual care services were invited to participate in the RPBF. Caregivers were told that the purpose of the assessments was to learn more about how bereaved families were adjusting and what kinds of services might be most helpful. They were also told that their participation was strictly voluntary and would not affect the other services they were receiving from the agency and that all responses would be kept strictly confidential. All caregivers participated in two telephone assessments (pre- and post-tests) separated by 20 weeks, which corresponds to the amount of time required to run the RPBF. Caregivers were paid $45 for each assessment. All study procedures were approved by the Institutional Review Board at Arizona State University.

RPBF and UC Conditions

Caregivers in the RPBF condition participated in 10 group meetings (75–90 minutes each) over 20 weeks on a bi-weekly schedule. Simultaneously, all children in families in the RPBF condition participated in a child support group provided by the agency. The RPBF had a dual focus on supporting caregivers’ Self-Care (i.e., meeting their own needs and dealing with their grief) and Family-Care (i.e., building a supportive, “new normal” family environment). Caregivers were taught practical tools which were framed as the Five Building Blocks of Resilient Parenting: Self-Care, Strong Family Bonds, Active Listening, Family Rules, and Helping Children Cope. The program preserved all the parenting tools from the FBP (Sandler et al., 2013) and added Self-Care tools that were based on the theory of self-compassion that involves three components: mindfulness, self-kindness, and common humanity (Germer & Neff, 2019). In each meeting, caregivers learned a new tool for Self-Care and Family-Care using interactive exercises and role plays. They were asked to use these tools at home and record how well they went. At the beginning of each meeting (after the first meeting), there is a check-in on their use of the tools, which included problem solving difficulties and celebrating successes. The teaching of Self-Care and Family-Care tools occurred in the context of a supportive group environment. The RPBF groups were coled by two providers who were trained on program implementation. Training consisted of a 3 day workshop which included role play of program activities and supervised delivery of the program.

The children in the families in the UC condition participated in the agency’s child support group and 70% of the caregivers also attended a caregiver support group. Site visits and a review of training materials found that in all four agencies, there was a cluster of practices, and in two agencies an in-depth training model, that discourages group leaders from education and advice-giving and explicitly prohibits commenting on caregivers’ parenting practices. In this way, the groups in the UC condition differed dramatically from those in the RPBF condition.

Measures

Implementation Feasibility.

Program feasibility of implementation was assessed only for the RPBF groups. Using an online reporting system, leaders reported on their completion of each program activity on a 3-point scale (2 = Complete, 1 = Partially complete, 0 = Didn’t do) and on the quality of implementation (“How did it go?”; 1 = Very well, 0 = Not very well). in each meeting

Acceptability.

Caregivers reported on their perception that the group was supportive using a 14-item scale (α = 0.80; e.g., “People in this group understand my experiences”) developed for this evaluation. Items were written based on previously open-ended responses of bereaved caregivers concerning behaviors that they found helpful in a grief support group. Caregivers’ satisfaction was assessed by three items about how helpful the program had been for themselves and their family, (α = 0.89; e.g., “Overall, how helpful has the program been for you?”). Items were rated on a 5-point Likert scale (1 = “Not at all helpful” to 5 = “Very helpful”). Caregivers’ responsiveness was assessed as frequency of use and perception of the helpfulness of each of the 17 tools taught in the program (1= “Not at all” to 5 = “A lot”; helpfulness: 1 = “Not at all helpful” to 5 = “Very helpful”). Overall ratings of frequency (α = 0.96; e.g., “How often did you use Family Fun Time?) and helpfulness (α = 0.94; e.g., “How helpful was it to use Family Fun Time?”) were computed. Responsiveness was also assessed as number of meetings attended.

Quality of Parenting.

Quality of parenting was assessed using subscales from the parent version of Children’s Report of Parental Behavior Inventory (CRPBI; A configural analysis of children’s reports of parental behavior., 1965), Acceptance (16 items, α = 0.74; e.g., “You saw child’s good points more than his/her faults”), Rejection (16 items, α = 0.78; e.g., “You almost always complained to child about what he/she did”) and Consistency of Discipline (8 items; α = 0.79; e.g., “You punished child for doing something 1 day, but you ignored it the next day”). These subscale have been found to predict child mental health problems of bereaved children (Lin et al., 2004).

Children’s Mental Health Problems.

In families with more than one child was randomly selected for parental report of mental health problems. T-scores on the Brief Problem Monitor scales (BPM; Achenbach et al., 2011) were used. BPM is a brief, reliable parent report measure of children’s internalizing (6 items, α = 0.81; e.g., “Too fearful or anxious”), externalizing (6 items, α = 0.83; e.g., “Disobedient at home”) and attention (6 items, α = 0.82; e.g., “Can’t concentrate, can’t pay attention for long”) problems in the past month. Total behavior problems were the sum of all 18 items (α = 0.90). BPM scores have been found to have good concurrent validity in relating to scores on other measures of child mental health problems (Achenbach et al., 2011).

Caregiver’s Psychiatric Distress Grief and Grief-Related Impairment.

Caregivers’ psychiatric distress was assessed using the Psychiatric Epidemiology Research Inventory (PERI, Dohrenwend et al., 1980; 25 items, α = 0.91; e.g., “How often have you felt anxious?”), which has been found to be related to other measures of psychopathology. Caregiver grief was assessed using two measures that have been found to have good validity (Neimeyer, et al., 2008): the 13-item Texas Revised Inventory of Grief--Present Scale (TRIG; Faschingbauer, 1981, α = 0.87; e.g., “I still get upset when I think about [deceased name]”), which assesses normative grief, and the 19-item Inventory of Complicated Grief (Prigerson et al., 1995, α = 0.89; e.g., “You think about [deceased name] so much that it’s hard for you to do the things you normally do”), a measure that is considered to indicate problems with the grieving process that extend over time. In addition, we assessed grief impairing functioning in work, home life, leisure activities, and social relationships using the 5-item Work and Social Adjustment Scale (Mundt et al., 2002; α = 0.87; e.g., “Because of my grief, my ability to work was decreased or impaired during the past month”), which has been found to relate to impaired functioning from a wide range of physical health conditions.

Caregivers’ Self-Compassion.

We used the 12-item Self-Compassion Scale—Short Form (Raes et al., 2011, α = 0.87 in the current sample; e.g., “I try to be understanding and be patient towards those aspects of my personality I don’t like”). The scale has been found to have the same factor structure as the original scale (Neff, 2003) and its scores are strongly correlated with the long version. Validity of the scale for bereaved caregivers has been demonstrated (Zhang et al., 2022).

Data Analysis

To test feasibility and acceptability of implementation of RPBF, descriptive statistics are presented of provider report of quality and fidelity of implementation, parent attendance, and caregiver report of program satisfaction, perceived group support and home practice of program tools. For outcome evaluation, we applied an intention-to-treat (ITT) approach to analyze all effects. The ITT analysis includes data from all participants who are in a condition regardless of level of attendance. Although this approach is conservative, it allowed us to discount attributing effects that were detected as being due to selective attrition across conditions (Sagarin et al., 2014). We compared demographic variables and pretest scores at baseline across conditions using t-tests for continuous variables and chi-square statistics for categorical variables. We conducted analysis of covariance (ANCOVA), adjusting for the differences in the demographic and controlling for the baseline scores on the same variable, to compare the posttest scores across the two conditions. A supplemental analysis was conducted to assess pre-post change using paired t-tests separately for caregivers in the RPBF and UC conditions to assess whether, similar to prior uncontrolled studies of child bereavement programs (Rosner et al., 2010), there was positive change over time in each condition.

Although the small sample size provided limited power for detecting moderators of program effects, we tested moderation for variables that had moderated effects in the evaluation of the efficacy of FBP (Sandler et al., 2003): child age and gender, and baseline score on the outcome variable. For all significant moderation effects, we conducted post-hoc tests to probe the magnitude and direction of the effects across different levels of the moderators (e.g., males and females; families with low levels of positive parenting [−1 SD] and families with high levels of positive parenting or behavior problems [+1 SD] at program entry].

To test the theory that changing parenting would lead to reductions in child mental health problems we tested whether program effects to strengthen parenting had an indirect path to mediate change in child outcomes, using structural equation modeling (SEM). The two-wave mediation model involved 1) a test of the intervention effect on posttest parenting (“a” path) as examined in the outcome analysis using ANCOVA; and 2) the effect of the parenting mediator on the child mental health problem outcome (“b” path) controlling for the direct intervention effect. We controlled for any covariates (i.e., pretest variables that were different across conditions) and pretest levels of the mediator and outcome variables on their respective posttest levels. If the effect of the program on the posttest parenting mediator was moderated by age, gender or baseline level, we included that moderator in the mediational analysis. We then examined the intervention effect on posttest parenting at the level of the moderator where the intervention effect was significant. We assessed mediation by computing the 95% or 90% confidence intervals for the mediation effect (a × b), using the bootstrapping method (MacKinnon, et al., 2002) and concluded the mediation effect to be significant if the confidence interval did not include zero. We utilized Mplus (Muthén & Muthén, 1998–2017) to conduct the ANCOVA and SEM analyses which handled missing data with the full information maximum likelihood method (Schafer & Graham, 2002).

Results

Significant pretest differences were found between the two conditions on 5 of 24 demographic and outcome measures. There were fewer male caregivers in the UC compared to RPBF condition (10.0% vs. 29.5%, p < .04) and more male children in the UC compared to the RPBF condition (63.3% vs. 26.7%, p < .02). Compared to families in the UC, those in the RPBF experienced more recent deaths (16.02 vs. 27.02 months, p <.01). Caregivers in the RPBF reported higher normative grief (TRIG) (49.60 vs. 44.70, p < .03) and grief-related impairments than those in the UC (22.95 vs. 18.00, p <.04). These variables were included as covariates in evaluating program effects. Weighted effect coding was applied for the gender variable to account for the imbalance of the sizes across condition.

Implementation Feasibility and Acceptability

Leaders reported a high level of implementation of each RPBF program activity (mean % completed = 94%; partially completed 4%; did not do 2%) and of how well each activity went (M = 0.91, SD = 0.09, on a 0 vs. 1 scale). Of caregivers in the RPBF condition, 52.3% attended seven or more meetings; 25.0% attended two or fewer meetings. As a supplemental analysis, we compared attendance at RPBF with attendance at the UC support groups. The 70% of caregivers in the UC who reporting attending a support group attended significantly fewer meetings than caregivers in the RPBF (M_uc = 3.40, SD = 2.84; M_RPBF = 5.59, SD = 3.50; t = 2.85, p = .006). Caregivers in the RPBF were in general very positive about their RPBF experience (Satisfaction: M = 4.46, SD = 0.80 on a 1–5 scale; Group support: M = 3.48, SD = 0.46 on a 1–4 scale) and program skills (Frequency of skill use: M = 4.16 SD = 0.74 on a 1–5 scale; Skill helpfulness: M = 4.23, SD = 0.85 on a 1–5 scale).

Effectiveness

The ANCOVA comparing posttest scores, while controlling for the pretest scores and covariates, indicated that RPBF had significant effects to strengthen quality of parent-child relationship and reduce parent complicated grief. There were mixed findings on child behavior problems. All these effects were moderated by child gender, child age, or the baseline scores (see Table 1) rather than main effects.

Table 1.

Effects of the Resilient Parenting for Bereaved Families Program on Child and Caregiver Mental Health Problems at Posttest.

Outcome	Adjusted Mean (RPBF)	Adjusted Mean (UC)	Main Effect (SD)	Main Effect p-value	Group × Gender p-value	Group × age p-value	Group × T1 p-value
Parenting
CRPBI -- Acceptance	2.842	2.800	0.043(0.049)	.381	.353	.111	.001
CRPBI -- Rejection	1.280	1.352	−0.072(0.052)	.165	.652	.010	.295
CRPBI -- Consistency of discipline	2.635	2.567	0.068(0.074)	.357	.685	.575	.972
Child problem behaviors
BPM attention problems	0.669	0.756	−0.086(0.078)	.271	.021	.020	.379
BPM internalizing	0.681	0.692	0.011(0.103)	.912	.215	.269	.922
BPM externalizing	0.499	0.459	0.039(0.084)	.640	.002	.852	.325
BPM total problems	0.620	0.614	0.006(0.066)	.933	.001	.201	.832
Parent mental health and grief
PERI -- Demoralization	2.227	2.117	0.110(0.115)	.342	.090	.573	.850
TRIG	3.318	3.371	0.054(0.140)	.702	.124	.158	.074
Complicated grief	2.287	2.341	0.054(.130)	.680	.016	.221	.984
Work & social adjustment issues	3.241	3.416	0.175(.402)	.663	.524	.887	.133
Caregiver self-Compassion
Self-Compassion	3.344	3.548	0.204(.134)	.128	.474	.867	.048

Note. Adjusted mean—means controlling for the pretest score and covariates. SE—Standard error. T1—Pretest score of the same variable. CRPBI—Parent version of Children’s Report of Parental Behavior Inventory. BPM—Brief Problem Monitor. PERI— Psychiatric Epidemiology Research Inventory. TRIG—Texas Revised Inventory of Grief--Present Scale.

For parental acceptance there was a significant condition × baseline interactions on acceptance ([unstandardized) B = −0.62, SE = 0.19, t = −3.22, p = .001]. The post-hoc tests indicated that for caregivers with lower scores on acceptance at pretest, those in the RPBF reported higher acceptance at posttest than did caregivers in the UC (at −1SD, B = 0.18, SE = 0.08, t = 2.26, p = .02; M_UC = 2.62, M_RPBF = 2.80; d = .54). Figure 1a illustrates the mean differences between the two conditions on acceptance for caregivers who had low (−1SD), average (M), and high scores (+1SD) of acceptance at pretest. There was also a significant condition × child age interaction on rejection (B = 0.03, SE = 0.01, t = 2.57, p = .01). The post-hoc tests indicated that caregivers in RPBF who had younger children (−1SD of age; approximately 7 years old) reported less rejection than those in the UC (at −1sd, B = −0.17, SE = 0.06, t = −2.78, p = .005; M_UC = 1.41, M_RPBF = 1.25; d = .67) at posttest (see Figure 1b).

Figure 1.

(a): Intervention effects on posttest acceptance. (b): Intervention effects on posttest rejection.

For child behavior outcomes, there were significant condition × gender interactions on attention problems (B = 0.17, SE = 0.07, t = 2.31, p = .02), externalizing problems (B = 0.23, SE = 0.08, t = 3.08, p = .002), and total problems (B = 0.18, SE = 0.06, t = 3.26, p = .001). The post-hoc tests indicated that for caregivers who had a girl as the target child, those in the RPBF reported less attention problems (B = −0.26, SE = 0.09, t = −2.93, p = .003; M_UC = 0.88, M_RPBF = 0.63; d = 0.67), externalizing problems (B = −0.19, SE = 0.10, t = −1.85, p = .06; M_UC = 0.60, M_RPBF = 0.41; d = 0.44), and total behavior problems at posttest (B = −0.17, SE = 0.07, t = −2.59, p = .01; M_cont = 0.71, M_RPBF = 0.54; d = 0.62) as compared with those in the UC. However, for caregivers who had a boy as the target child, caregivers in the UC reported that boys had lower externalizing problems (B = 0.25, SE = 0.12, t = 2.16, p = .03; M_UC = 0.40, M_RPBF = 0.64; d = 0.52) as compared with those in the RPBF. There was also a significant RPBF × age interaction on attention problems (B = 0.04, SE = 0.02, t = 2.33, p = .02) such that caregivers who had a younger child in the RPBF reported significantly lower attention problems at posttest than those in the UC condition (at −1sd, B = −0.23, SE = 0.10, t = −2.42, p = .02; M_UC = 0.84, M_RPBF = 0.61; d = 0.58).

For caregiver outcomes, a significant condition × child gender interaction on caregivers’ complicated grief (B = 0.32, SE = 0.13, t = 2.40, p = .02) indicated that for families with a girl in the study, caregivers in the RPBF reported lower complicated grief than those in the UC (B = −0.37, SE = 0.15, t = −2.43, p = .02; M_cont = 2.92, M_RPBF = 2.54; d = 0.58). A significant condition × baseline interaction on caregivers’ self-compassion (B = −.26, SE = .13, t = −1.98, p = .05) indicated that for caregivers who had higher levels of self-compassion scores at program entry those in the UC reported higher scores at posttest than caregivers in the RPBF (at +1SD, B = −0.392, SE = 0.148, t = −2.65, p = .01; M_UC= 4.20, M_RPBF = 3.81; d = 0.64).

Supplemental analyses found significant or marginally significant improvements from pretest to posttest in both the RPBF and UC conditions to reduce parent psychiatric distress (RPBF t = 3.37, p = .002, (Cohen’s) d = .53; UC t = 3.79, p < .001, d = 0.69) and normative grief (RPBF t = 3.43, p= .001, d = 0.54; UC t = 1.96, p = .059, d=0.36). There was significant improvement in RPBF but not in the UC to reduce parental rejection (t = 2.14, p = .04, d = 0.34), increase consistency of discipline (t = 1.96, p = .057, d = 0.31), decrease complicated grief (t = 3.36, p = .002, d = 0.53), and decrease grief-related impairments (t = 3.99, p < .001, d = 0.63).

Mediation Test of Parenting as a Theoretical Pathway from RPBF to Child Mental Health Problems

We examined the theoretical model in which the effects of the RPBF to increase acceptance and reduce rejection would account for reductions in child behavior problems using mediation analysis (see Figure 2 for an illustration). As described above, there were significant moderated program effects on posttest acceptance by baseline acceptance and on posttest rejection by child age. Testing the mediation effects with the bootstrap method showed that for caregivers with low pretest acceptance scores, the effects of the RPBF on acceptance significantly mediated the RPBF effects to reduce attention problems (B_ab = −0.073, 95% CI = [−0.140, −0.005]), externalizing problems (B_ab = −0.096, 95% CI = [−0.188, −0.004]), and total behavior problems (B_ab = −0.067, 95% CI = [−0.127, −0.008]). For families with younger children, the effects of RPBF on rejection significantly mediated the RPBF effects to reduce attention problems (B_ab = −0.139, 95% CI = [−0.252, −0.027]), externalizing problems (B_ab = −0.075, 95% CI = [−0.144, −0.005]), and total behavior problems (B_ab = −0.092, 95% CI = [−0.166, −0.018]).

Figure 2.

An illustration of moderated mediation model for the effect of RPBF on child externalizing problems through the intervention effect on acceptance. Note: For simplicity of presentation, the covariates are omitted in the fig.

Discussion

The findings of this study demonstrate the feasibility and acceptability of the RPBF program for delivery by community-based agencies serving bereaved families. They also showed significant moderated benefits of the program when added to UC. The RPBF strengthened quality of parenting as well as reduced child mental health problems and caregivers’ complicated grief. We discuss the contribution of these findings, practical recommendations for integrating the program as a community-based service and study limitations below.

The findings on the feasibility and acceptability of the RPBF demonstrate the successful translation of a component of a university-based program, the FBP, which has been shown to have long-term benefits for bereaved children and caregivers into a service that can be provided by community agencies. The translation of a research-based programs into community services has been recognized as an important national priority to benefit the public health (National Academies of Sciences, Engineering and Medicine, 2017). This study provides one example of how this translation can bring evidence-based services to parentally bereaved families. The key methodology in adapting the caregiver component of the FBP into a community service was the collaborative process between the program developers and community agency providers, caregivers, and executive directors. The collaborative process integrated these multiple perspectives into the design of the RPBF so it fit the needs and constraints of all stakeholders as well as preserved the integrity of the components of the FBP that accounted for the program effects on children’s mental health problems.

Evidence that the RPBF was feasible to implement was provided by group leaders’ report of high levels of quality and fidelity of delivery of the program activities. Evidence that the RPBF met agency needs is provided by the fact that each of the four agencies is continuing to offer the RPBF and has shown significant investment in training staff and volunteers as group leaders and supervisors. One limitation of these findings is that agency enthusiasm for RPBF is likely in part due to their significant investment in the program’s development. An important next step will involve working with agencies that are not co-producers of the program to facilitate a level of commitment that is needed to ensuring the program’s success.

Evidence of program acceptability to caregivers is provided by several findings. Parental attendance at the RPBF was similar to levels of attendance in other parenting programs for families who experienced major life stressors (e.g., Mauricio et al., 2018). Attendance at RPBF was also significantly higher than attendance at parent support groups in the UC condition. RPBF acceptability to caregivers was also evidenced by their reports of high levels of satisfaction with the program and use of the program tools as well as reports that the program tools were very helpful. In addition, caregivers saw the RPBF as highly supportive, demonstrating that the structured nature of the program did not diminish group support.

The RPBF demonstrated the hypothesized additive benefit above that of UC to strengthen the quality of parenting. Its effect to strengthen acceptance for those who had lower acceptance scores at program entry indicates that the RPBF was most effective for those who are in most need of help in strengthening their parenting. The effect to reduce parental rejection was significant for preadolescent children, perhaps indicating that they are more sensitive than adolescents to decreases in parental rejection over this brief 20-week period. Prior evidence of positive parenting as a protective resource for bereaved children (Alvis & Kaplow, 2022; Jiao et al., 2020; Tein et al., 2006; Zhang et al., 2021) indicates that the positive impact of the RPBF on parenting has important implications for the long-term well-being of bereaved children.

Because the RCT of FBP did not find significant effects on child behavior problems at posttest we did not hypothesize such effects in this study. However, there were five findings of significant gender or age moderated effects, four of which favored the RPBF. Relative to the girls in the UC, those in the RPBF had lower externalizing problems, total behavior problems and attention problems at post-test. However, for boys, being in the UC was associated with lower externalizing problems. For younger children being in the RPBF was associated with lower attention problems. The finding that the RPBF significantly reduced mental health problems for girls is consistent with that from the FBP, which showed reductions in mental health problems for girls but not boys at the 11-month follow-up as compared to the control condition. These effects indicate that early benefits of RPBF on child mental health is stronger for girls than boys. However, it is notable that at the 6-year and 15-year follow-ups of the FBP, significant effects on mental health problems were found across gender (Sandler et al., 2010, 2018).

The results of the mediation analyses are consistent with the underlying theory of the program that strengthened parenting would lead to reduced child behavior problems. They are also consistent with findings from the randomized trial of the FBP that program effects to strengthen parenting at posttest led to reductions in child mental health problems 11 months and 6 years later (Sandler et al., 2015; Tein et al., 2006). However, a limitation of the mediation models in the current study is that the measures of parenting were concurrent with measures of children’s mental health problems so that the direction of causality between these variables cannot be determined (Cole & Maxwell, 2003).

The finding that the RPBF led to lower complicated grief scores than the UC replicates findings that the FBP reduced bereaved caregivers’ grief at posttest (Sandler et al., 2016). That this effect was only reported by caregivers of girls may indicate a reciprocal effect whereby caregivers’ perception that their female child is adjusting more positively may reinforce their own sense that they are successfully adapting following the death. Given that the RPBF included multiple activities to enhance self-compassion, the lack of an effect to increase self-compassion is surprising. It may be that this component needs to be strengthened to achieve the benefits reported in other self-compassion training programs (Germer & Neff, 2019). The positive effect of UC vs RPBF on self-compassion for those who had higher self-compassion at program entry may be due to the greater focus of the UC services on self-compassion, especially self-kindness and common humanity, which may be particularly impactful for those who express higher initial levels of self-compassion.

A strength of this study is the assessment of the added benefits of the RPBF as compared with UC in which children in both conditions received services and 70% of the caregivers in the UC attended a support group. Caregivers in both conditions were told that the assessments were to help the agency evaluate and improve their services, so that expectancy or social desirability effects are unlikely to account for differences found between conditions. This is a much more conservative test of the effectiveness of the RPBF than a study with a less active comparison condition. The fact that caregivers in the RPBF and UC conditions each reported positive change on multiple variables indicates that the efficacy of the RPBF as compared to not receiving any services is likely underestimated.

Five limitations of this evaluation are acknowledged. The evaluation was conducted in four agencies who were active contributors to the adaptation of the FBP to create the RPBF, so that implementation in other settings is needed to assess whether similar findings would be achieved in agencies that were not involved in the creation process. A quasi-experimental design was used in which the participants were not randomly assigned to RPBF or UC so that although variables on which the groups differed at baseline were used as covariates, selection due to differences on factors that were not assessed cannot be totally discounted. Also, all measures used caregivers as the reporters. It would be important for future studies to include child report as well. A fourth limitation is that the relatively modest sample size did not provide power to detect other moderators of program effects such as ethnicity, social class or cause of death. A larger randomized trial is needed to test program effectiveness across subgroups. A fifth limitation is that effects were assessed only at post-test. Given findings of cascading effects of the FBP over development (Sandler et al., 2015), future research that includes follow-up into subsequent developmental periods would be important.

There are other fruitful research directions. Given the protective effect of parents’ self-compassion for parents’ and children’s mental health (Zhang et al., 2022), it would be useful to investigate the possible different effects of RPBF and UC service on unique aspects of self-compassion (mindfulness, self-kindness, and common humanity). Although the RPBF was successfully implemented in diverse communities in the current study, systematic research on program adaptations to meet the culturally specific needs of different communities is needed.

Conclusion

The study demonstrated the feasibility and acceptability of the RPBF and the benefit of adding it to the usual services provided by four bereavement agencies. The results provide an important step supporting dissemination of the RPBF as a community-based service for families who have experienced the death of a parent. A rigorous training program has been developed which makes it practical and realistic for providers of services for bereaved families in the community to offer the RPBF (see <bereavedparenting.org>).