MATERNAL PERCEPTIONS OF PARENTING FOLLOWING AN EVIDENCE-BASED PARENTING PROGRAM: A QUALITATIVE STUDY OF LEGACY FOR CHILDREN^™

Abstract

This article presents the findings of a qualitative study of maternal perceptions of parenting following participation in Legacy for Children^™ (Legacy), an evidence-based parenting program for low-income mothers of young children and infants. To further examine previous findings and better understand participant experiences, we analyzed semistructured focus-group discussions with predominantly Hispanic and Black, non-Hispanic Legacy mothers at two sites (n = 166) using thematic analysis and grounded theory techniques. The qualitative study presented here investigated how mothers view their parenting following participation in Legacy, allowing participants to describe their experience with the program in their own words, thus capturing an “insider” perspective. Mothers at both sites communicated knowledge and use of positive parenting practices targeted by the goals of Legacy; some site-specific differences emerged related to these parenting practices. These findings align with the interpretation of quantitative results from the randomized controlled trials and further demonstrate the significance of the Legacy program in promoting positive parenting for mothers living in poverty. This study emphasizes the importance of understanding real-world context regarding program efficacy and the benefit of using qualitative research to understand participant experiences.

Current estimates indicate that in the United States, approximately 21% of children ages 0 through 17 live in poverty, as do almost 24% of children ages 5 years and under (Federal Interagency Forum on Child and Family Statistics, 2016). These estimates rise when considering race and ethnicity; Hispanic and Black, non-Hispanic populations face an additional burden related to childhood disadvantage (Federal Interagency Forum on Child and Family Statistics, 2016). Over the past 30 years, research on poverty during childhood has revealed significant effects on child health and developmental outcomes (Brooks-Gunn & Duncan, 1997; Korenman, Miller, & Sjaastad, 1995; Parker, Greer, & Zuckerman, 1988). Many negative outcomes are associated with poverty during childhood, including increased risk of chronic disease and stress as well as behavior and emotional problems, difficulties in concentration and memory, and delays in language development (American Psychological Association, 2013; Bitsko et al., 2016; Duncan, Ziol-Guest, & Kalil, 2010; Luby et al., 2013; Pascoe, Wood, Duffee, & Kuo, 2016). Studies also have demonstrated that children living in poverty during early childhood experience negative effects into adulthood (Cheng, Johnson, & Goodman, 2016; Duncan et al., 2010).

To address these concerns, the Centers for Disease Control and Prevention (CDC) developed Legacy for Children^™ (Legacy), an evidence-based prevention model designed to foster positive parenting among low-income mothers to promote child developmental outcomes (Kaminski et al., 2013; Perou et al., 2012). From 2001 to 2010, the CDC implemented the group-based model among low-income families in Miami and Los Angeles, and conducted a pair of randomized controlled trials (RCTs) to assess Legacy (Perou et al., 2012). Results from this study have indicated that children of mothers participating in Legacy, when compared to controls, experienced lower rates of behavioral and socioemotional concerns at the Miami site and a lower rate of hyperactive behavior at the Los Angeles site (for more detailed results, see Kaminski et al., 2013). These initial findings point to the positive effect of Legacy on child developmental outcomes and the potential for widespread public health impact.

To better document the impact of the intervention and to understand how and for whom it was effective, the CDC collected a range of sociodemographic and family data as potential control variables or mediators for child outcomes. The key constructs of interest included family background, parental self-efficacy, parental responsibility, parental investment, devotion of time and energy, parenting behavior, and quality of the mother–child relationship (Perou et al., 2012). However, quantitative data can capture only some aspects of the intervention. As a complement to this work, we decided to explore qualitative data on parent experiences within Legacy. Qualitative research can further our understanding of how to adapt parenting interventions to address parental beliefs and needs (Holtrop, Parra-Cardona, & Forgatch, 2014), and supplement and strengthen quantitative findings (O’Cathain, Thomas, Drabble, Rudolph, & Hewison, 2013). As part of the larger RCTs, the CDC contracted with RTI International to collect an array of process evaluation data (Wallace, Fraser, Dempsey, Borntrager, & Lasater, 2009), including focus groups with mothers participating in Legacy in Miami and Los Angeles. The current study examined data from those focus-group discussions, which allowed participants to describe their experience with Legacy in their own words.

IMPACT OF POVERTY ON PARENTING

Poverty exhibits direct and indirect effects on families’ social, emotional, and physical health and well-being, disproportionately affecting the capacity to address basic needs and access healthcare and education as well as overall morbidity and mortality (Evans & Kim, 2013; Johnson, Riis, & Noble, 2016). The burden of income inequality, coupled with the chronic stress associated with resource-poor environments (Cheng et al., 2016), leads to increased challenges related to parenting for families living in poverty as compared to their higher income counterparts (Brooks-Gunn & Duncan, 1997; Jocson & McLoyd, 2015; Pascoe et al., 2016). Just as low-income populations are denied access to buffering supports, parents living in poverty may lack access to those resources which specifically support positive parenting, such as the ability to spend time with their children, procurement of childcare and transportation, and access to parenting information and social support (Johnson, Riis, & Noble, 2016; Kaiser & Delaney, 1996). Parents living in poverty are more likely to face higher rates of psychological distress, substance abuse, and intimate partner violence (Murali & Oyebode, 2004). The literature has indicated that parental stress resulting from economic hardships also can decrease the quality of parenting (e.g., Conger, Conger, & Martin, 2010; Ellingsen, Baker, Blacher, & Crnic, 2014). For instance, chaotic neighborhood conditions are associated with harsh and inconsistent discipline and lower warmth (Conger et al., 2010; Jocson & McLoyd, 2015), and overall poverty with lower rates of cognitive stimulation and parental supervision (Murali & Oyebode, 2004). These outcomes, in turn, place children at risk for socioemotional and cognitive difficulties throughout development and into adulthood (Duncan et al., 2010; Luby et al., 2013; Pascoe et al., 2016), as outlined previously.

IMPACT OF PREVENTION AND INTERVENTION

Despite the harmful effects of poverty on families, research has demonstrated that promoting positive parenting can reinforce the resilience of low-income parents. The literature has highlighted the importance of promoting learning and caregiver–child interactions for families overall and those living in poverty (Kaminski, Valle, Filene, & Boyle, 2008; Thompson, 2016), and has indicated that a focus on early caregiving is especially significant (Luby et al., 2013). Although the literature has not indicated a single parenting behavior that is most important, a number of strategies have been associated with positive child outcomes. For example, a meta-analysis by Kaminski et al. (2008) has supported the efficacy of parenting programs in preventing and improving child behavior problems. Specific findings have indicated that the inclusion of positive parent–child interactions, emotional communication skills, and parent use of timeout and consistency in the curriculum were strongly associated with larger program effects. A more recent review of the literature by Mesman, van IJzendoorn, and Bakermans-Kranenburg (2012) has indicated significantly lower levels of parental sensitivity among ethnic minority parents stemming from increased social and economic burdens and the importance of both reducing family stress and strengthening parental sensitivity. Seminal studies by Baumrind (1966, 1967) have noted the importance of parental control, nurturance, and maturity demand, all concepts which she illustrated were associated with improved child development and continue to serve as a framework for parenting research today. The literature also has emphasized the importance of developmental stimulation during early childhood, which has been associated with later child outcomes such as improved language development and school readiness (Baker & Iruka, 2013; Walker, Chang, Powell, & Grantham-McGregor, 2005). As these studies have revealed, parenting behaviors such as reciprocity and sensitivity, parental control, developmental stimulation, commitment to parenting, nurturance, and maturity demand are associated with positive parenting and improved child outcomes.

THE LEGACY APPROACH

The Legacy philosophy prioritizes three tenets: Child outcomes depend upon the quality of the relationship between mother and child, successful parenting comes in many different forms, and—regardless of their environment—mothers hold the power to positively influence their child’s development. The five overall goals of Legacy are to (a) promote maternal responsibility, maternal investment, and maternal devotion of time and energy; (b) promote responsive, sensitive mother–child relationships; (c) support mothers as guides to their children’s behavioral and emotional regulation; (d) promote each mother’s facilitation of their children’s verbal and cognitive development; and (e) promote mothers’ sense of community. These goals apply to parents of all socioeconomic backgrounds; however, mothers affected by poverty may lack the opportunity to safely discuss and explore parenting issues in a supportive environment, observe positive role models who demonstrate sensitive and responsive parenting behavior, or experience positive support from others. The group sessions afford mothers these opportunities, with the support and guidance of the group leader. The Legacy logic model (Figure 1; Perou et al., 2012) describes these goals, the conceptual pathways through which they affect the positive parenting practices of interest in this study, and the ultimate intended child development outcomes.

Figure 1.

Logic model for the Legacy for Children^™ parenting intervention.

Note. This figure has been adapted from the original article “Legacy for Children^™: A pair of randomized controlled trials of a public health model to improve developmental outcomes among children in poverty” by Perou et al., 2012, BMC Public Health, 12, 691. https://doi.org/10.1186/1471-2458-12-691; http://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-12-691). The original article is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The Miami and Los Angeles sites each developed and implemented their own curricula based on the Legacy model and the needs of their respective communities. While they share the same foundation and many similarities, the resulting interventions also showed some differences as a result of each site’s community, demographic, and cultural characteristics. Both sites tested and developmentally sequenced curricula adhere to the five program goals and core model components; were based on the same evidence from successful existing intervention studies; and repeatedly covered themes which the literature has identified as key constructs in early childhood development, such as discipline, attachment, developmental milestones, parenting stress management, establishment of goals and dreams for their children, and early literacy. These curriculum themes evolve as children develop; for instance, sessions focused on discipline move from mothers discussing how daily routines and rituals guide their children’s behaviors to mothers encouraging their children’s cooperation through praise and modeling, and eventually to mothers supporting positive behaviors and addressing inappropriate behaviors using consistent feedback such as praise and timeout. Sites differed in how they sequenced and used discussion and activities to introduce and reinforce concepts presented in the curricula. Sites also differed in the length and timing of the intervention. The Los Angeles curriculum is offered prenatally through child age of 3 years, and the Miami curriculum is offered from birth through child age of 5 years.

For both sites, Legacy groups cluster tightly around the age range of children to follow the developmentally sequenced curricula and create a shared experience among mothers. Trained facilitators deliver regular group meetings of mothers; components include mother-only time and mother–child time with a targeted “Legacy child.” Mother-only time focuses on discussion of topics to promote sensitive caregiving and understanding of developmental stages, and building social connections between the mothers. During mother–child time, group leaders support and model positive parent–child interactions and allow mothers to practice skills learned during mother-only content. In Miami, each group session included a mother-only and a mother–child component; in Los Angeles, group sessions alternated between mother-only and mother–child sessions. Group leaders present information in a nondidactic manner and respond to and reflect on each individual mother’s growth and needs. Both curricula also include community-building events and one-on-one time between mothers and the group leader to reinforce curriculum content. Perou et al. (2012) provided additional information on the Legacy model and curriculum delivery.

In addition to site differences in curricula, there also were some differences in the sample they served. Although both sites used the same basic eligibility criteria (e.g., poverty, English-speaking maternal primary caregivers; see Perou et al., 2012), demographic comparisons conducted during the original RCTs had indicated that mothers in Los Angeles were significantly older, more educated, and more likely to speak a language other than English in the home, as compared to mothers in Miami. In addition, mothers in Los Angeles were more likely to be married, Hispanic, and employed (Kaminski et al., 2013). Therefore, site differences in outcomes cannot be separated from both the differences in implementation/curriculum and sample characteristics. This study will examine mothers’ responses separately by site and provide additional context regarding some of these differences. This study will support interpretation of participant experiences through examination of mothers’ own words.

CURRENT STUDY

The current study examines how mothers participating in Legacy describe parenting following involvement in the program, particularly across implementation sites in Miami and Los Angeles. Specifically, we wanted to explore how mothers in Miami and Los Angeles describe knowledge and use of positive parenting practices, and compare the nature and content of discussions in both sites. Our intent at the outset was not to combine the distinct populations in Miami and Los Angeles but to better understand how different samples could benefit from the program. We focused our study around positive parenting practices frequently cited as effective within the literature and targeted by Legacy. Using these practices as a framework, we analyzed data from Legacy focus-group discussions to examine how mothers describe their commitment to parenting, nurturance of and sensitivity and responsivity to their child, parental control, maturity demands, and practices that encourage developmental stimulation (for a description of these practices as defined for this study, see Table 1).

TABLE 1.

Legacy for Children^™ Positive Parenting Practices Examined

Parenting Practices	Definition
Commitment to Parenting	Dedication to the responsibility of parenting and involvement as a parent
Maturity Demand	Expectation for one’s child to achieve his or her best according to their developmental stage and flexibility offered to the child to make his or her own decisions as appropriate
Nurturance/Sensitivity/Responsivity	Instrumental acts that ensure a safe and emotionally supportive environment; maternal awareness of their child’s needs and responding appropriately to these needs
Parental Control	Provision of structure to guide child behavior, follow-through with disciplinary guidelines, and encouragement of child achievement of parental standards
Developmental Stimulation	Practices that directly support or enhance child development (e.g., providing books and learning materials, offering opportunities and experiences for learning)

Note. Authors selected and defined listed parenting practices based on the current child development literature and the Legacy model.

METHOD

The current study is a secondary analysis of focus-group data collected alongside the original RCTs. For the original study, the CDC contracted with RTI International to collect and broadly analyze focus-group discussion data (RTI Project No. 0206030.011); this initial exploration is summarized next and is described in more detail elsewhere (Fraser, 2009). The institutional review boards (IRBs) of the CDC; RTI; the University of California, Los Angeles; and the University of Miami reviewed and approved the focus-group protocol and discussion guides.

From 2005 to 2008, RTI researchers conducted a total of 21 focus groups with Legacy participants (n = 166), with 13 groups in Miami (n = 110) and 8 groups in Los Angeles (n = 56). Researchers created discussion groups based on levels of attendance and engagement in the program,¹ as well as recentness of program completion (for the frequency of participants by wave and site, see Table 2). RTI utilized purposive sampling, which allows researchers to recruit information-rich individuals (Hennink, Hutter, & Bailey, 2011). Participants provided informed consent, and each received transportation and $50 in recognition for their time and contribution. A trained moderator utilized a semistructured, pilot-tested guide to lead hour-long discussions. The guide focused on mothers’ reasons for participating in Legacy, aspects of the intervention that contributed to mothers’ sense of community, mothers’ motivation to attend group sessions (including facilitators of and barriers to attendance), and mothers’ perceptions of learned knowledge about parenting and child development. The guide also included follow-up probes to more fully capture participants’ perspectives. A second staff member compiled detailed notes and audio-recorded the discussions. Staff de-identified and transcribed the discussions verbatim. RTI International produced a final report with results of broad analyses as well as the participant characteristics described next (Fraser, 2009).

TABLE 2.

Number of Legacy Participants Sampled and Included in Each Focus Group, by Category and Site

Focus Group by Wave	Sampling Pool n	Participants n (%)
LOS ANGELES
Wave I, 12/2005
Engaged Regular Attenders	20	5 (25)
Unengaged Regular Attenders	14	6 (43)
Sporadic Attenders	26	5 (19)
Wave II, 12/2006
Engaged Regular Attenders	10	8 (80)
Graduates	10	7 (70)
Nonattenders	10	7 (70)
Wave III, 12/2007
Older Graduates	19	9 (47)
Newer Graduates	17	9 (53)
TOTALa	126	56
MIAMI
Wave I, 7/2006
Engaged Regular Attenders	10	7 (70)
Unengaged Regular Attenders	10	6 (60)
Sporadic Attenders	12	6 (50)
Wave II, 1/2007
Engaged Regular Attenders	10	4 (40)
Unengaged Regular Attenders	10	9 (90)
Sporadic Attenders	12	6 (50)
Wave III, 10/2007
Repeat Participants	24	12 (50)
New Participants, Groups A and B	29	22 (76)
Wave IV, 10/2008
Older Graduates, Groups A and B	20	21 (95)a
Newer Graduates, Groups A and B	21	17 (81)b
TOTALc	158	110

Note. Adapted from Legacy for Children^™: Focus Group Summary Report, p. 18, by Fraser et al., 2009, Research Triangle Park, NC: RTI International.

^aOlder graduates, Group A comprised 12 participants, 1 of whom was a newer graduate. Older graduates, Group B comprised 9 participants, 1 of whom was a newer graduate.

^bNewer graduates, Group A comprised 9 participants. Newer graduates, Group B comprised 8 participants.

^cIncluded repeat participants.

Participants

As with the overall sample, there were site differences in demographic characteristics for focus group participants. In Miami, the majority of mothers participating in the focus groups identified as Black/non-Hispanic (75%). Of the remaining mothers, 17% identified as Haitian, 7% identified as Hispanic, and 1% identified with another racial/ethnic group. In Los Angeles, the majority of mothers identified as Hispanic (49%) or Black/non-Hispanic (35%). Five percent of respondents identified as White/non-Hispanic, and another 5% identified as Asian. Roughly 7% identified with another racial/ethnic group. RTI International examined participant sociodemographic characteristics to determine the representativeness of the focus-group sample to the overall population of Legacy participants and determined that the racial/ethnic composition of focus groups mirrored that of Legacy participants overall (Fraser, 2009).

Employment status also differed by implementation site. In Miami, roughly 61% of focus-group mothers were unemployed, 13% were employed part-time, and 26% were employed full-time. In Los Angeles, roughly 34% of focus-group mothers were unemployed, 18% were employed part-time, and 47% were employed full-time. RTI examined differences across focus-group participants to determine whether employment status influenced participants’ level of engagement with the program. No clear patterns emerged related to the relationship between employment status and attendance level (Fraser, 2009).

Although participation in Legacy required that participants were comfortable speaking and reading English, many mothers enrolled in the program were bilingual. The majority of participants reported speaking English at least most of the time in the home; however, 45% of focus-group mothers reported speaking a language other than English at least some of the time in the home. No clear patterns emerged across groups related to language preference and engagement level (Fraser, 2009).

Qualitative Secondary Analysis

Procedures

RTI International conducted preliminary qualitative analyses by coding and identifying themes within the data to better understand facilitators of and barriers to engagement, factors that contributed to successful sessions, and mothers’ perceptions of how Legacy affected their parenting (Fraser, 2009). In the current study, we used qualitative methods to conduct a secondary data analysis of focus-group discussions to identify the effects of Legacy on parenting. To examine the data from the focus groups, we utilized grounded theory techniques (Hennink et al., 2011), which follow a cyclical process involving multiple revisions and recoding and focus on participants’ own words through the use of verbatim transcripts.

At the outset of the study, the first author was blinded to the intervention site and participant attendance level of each focus group. While relatively uncommon in qualitative research, this technique allowed the researcher to analyze the data without prior knowledge of site differences, and thus limit observer bias during the current study (Berk et al., 2011; Sarris et al., 2012). The methods utilized for this study consisted of four main phases: (a) code and codebook development, (b) application of codes, (c) second coding process, and (d) thematic data analysis. The Emory University IRB determined the secondary data analysis exempt from review.

Code and codebook development

A coding framework was created based on the Legacy model, the child development literature, and review of the focus-group data. The first author then developed a coding tree to illustrate the hierarchy of codes and subcodes used. From the coding tree, the first author created a codebook that listed each code, its definition, and an example from the focus-group data. Both the coding tree and codebook were refined in collaboration with coauthors, and are available upon request from the first author.

Application of codes

The first author coded transcripts using MAXQDA 10 qualitative software (Belous, 1995–2011). Transcripts were first coded according to the broad areas covered in the discussion guides. The researcher then coded the section of transcripts related to the effects of Legacy on parenting based on relevance to the research questions. Finally, transcripts were coded in their entirety to capture text related to changes in parenting not appearing in the effects of Legacy on parenting section. Following the second and third rounds of coding, the researcher used the constant comparative method (Boeije, 2002; Glaser, 1965) to confirm similarity and adequacy of codes.

Codebook refinement

To inform the coding process, an outside researcher, trained using a protocol developed for this study, coded 2 of the 21 focus-group transcripts. The second coding process was not intended to calculate intercoder reliability but instead to serve as a tool for developing and refining the codebook used in this study. Final revisions to the codebook were made once the two researchers reached a consensus on discrepancies.

Thematic data analysis

To see how themes were discussed across sites, the researcher created different document groups and sets within MAXQDA and analyzed them using the constant comparative method (Boeije, 2002; Glaser, 1965). Patterns and themes were analyzed and compared across participants and study location. The first author compared the relevant text associated with each code of interest, detailed the basic concept within each, and grouped these concepts into major themes. The analysis described here focuses on mothers’ knowledge and use of positive parenting practices, and examines differences across sites related to these practices.

RESULTS

The current study focuses on positive parenting practices (commitment to parenting, nurturance/sensitivity/responsivity, parental control, maturity demand, and developmental stimulation) as they connect to the Legacy goals regarding the relationship between the mother and child (see Figure 1) (for a summary of the themes related to each positive parenting practice as described in this section, see Table 3).

TABLE 3.

Emergent Themes Related to Positive Parenting Practices, Across Legacy Implementing Site

Parenting Practices	Themes
	MIAMI	LOS ANGELES
Commitment to Parenting	Involvement, focus on child, parental role engagement, lifestyle changesa	Involvement, focus on child, parental role engagement
Nurturance/Sensitivity/Responsivity	Supportive actions, patience, concern for well-being, expressions of affection and approval,b providing for child,a talking/communicating, awareness of child’s emotions, awareness of own responses	Supportive actions, patience, concern for well-being, expressions of affection,c talking/communicating, understanding of child’s individual emotions,b awareness/explanation of own responsesb
Parental Control	Noncorporal discipline (satisfaction), corporal techniques (reducing use, challenges,a continued usea)	Noncorporal discipline (satisfaction), corporal techniques (reducing use)
Maturity Demand	Expectations for behavior, flexibility, granting control, recognition of limits	Expectations for behavior, flexibility, granting control, recognition of limits, allowance of creative expressiona
Developmental Stimulation	Reading,d other activities (writing/ABCs, arts/crafts, “grown-up tasks”)d	Reading, other activities (singing/instruments, pictures and colors)

Note. Differences in themes between sites are marked using the key below; footnotes describe comparisons between sites.

^aTheme exclusive to site.

^bExpanded content of theme discussed compared to other site (i.e., wider breadth of discussion).

^cMore detailed discussion of theme compared to other site (i.e., greater depth of discussion).

^dMore time spent discussing theme compared to other site.

Promote the Mother’s Responsibility for, Investment in, and Devotion of Time and Energy to Her Child

We examined commitment to parenting to address the first goal of Legacy. For the purposes of this study, commitment to parenting is defined as dedication to the responsibility of being a parent and involvement in the role of parenting.

Commitment to parenting

Mothers in Miami discussed their commitment to parenting in terms of being involved with and focusing on their children as well as being engaged in the role of parents. Involvement included paying attention to and making time for their children. One mother explained her involvement with her children, stating,

I spend all my time with them . . . . If I’m not working, you know, I’m home with them . . . . It shouldn’t always be about TV. You should be spending time, you know. Teaching them how to read, you know. Spending all of the quality time because kids need it, kids need it a lot. (Miami mother [M], Wave 2)

Many mothers emphasized prioritizing their children—as one mother in Miami explained, “[I]t’s all about your kids. Your kids are first” (M, Wave 4). While mothers described wanting to improve as parents and taking steps to develop in that role, some mothers in Miami also discussed having to make significant life changes of their own prior to addressing concerns related to parenting. One mother described parenting this way:

It’s a job, it’s a force of habit you have to put upon yourself because you’re not used to it . . . like for me, I’m twenty-four, I had my child when I was twenty, I was still in the partying stage. (M, wave 2)

Legacy helped guide mothers through these changes and supported mothers’ growth in their commitment to parenting. As one mother explained,

I think if it wasn’t for Legacy I don’t know where my kids would probably be at. You know I probably would have been out partying and all kinds of crap. Not paying no attention to my kids . . . that’s stupid for me. I pay more attention now. I got to. (M, Wave 4)

Mothers in Los Angeles described their commitment to parenting in much the same way as most Miami mothers—being involved with and focusing on their children and remaining engaged in their role as parents. One mother described her commitment to parenting with an example: “I changed my schedule to fit Legacy in. My job wanted me to work on my Legacy meeting day and I explained to them I had to attend my Legacy meetings and they let me change my schedule” (Los Angles mother [L], Wave 1). As in Miami, mothers in Los Angeles described wanting to improve as parents, citing “to be a better parent” as one reason for attending the program (L, Wave 1). Mothers here spoke of growing more understanding and confident as a result of their participation in Legacy. As one mother explained, “I’m more secure that I’m preparing a future for [my children]. I know that I know how to do it, if I keep up with the work, because I know it’s no easy, but I feel I can do it” (L, Wave 1). In contrast with these similarities, however, mothers in Los Angeles did not discuss any significant life changes like those of Miami mothers, beyond those related to improving as parents.

Promote Responsive, Sensitive Mother–Child Relationships

To address the second goal of Legacy, we reviewed nurturance and sensitivity/responsivity as discussed by mothers in Miami and Los Angeles. For this study, nurturance and sensitivity/responsivity are defined as instrumental acts that ensure a safe and emotionally supportive environment as well as maternal awareness of their child’s needs and responding appropriately to these needs.

Nurturance and sensitivity/responsivity

The most prevalent themes for mothers in Miami were related to actions that create a supportive environment for the parent–child relationship, patience, and communicating in response to their children’s developmental needs. Supportive actions included knowing how to interact with their child, considering their feelings, including them in activities, and bonding with them. As one mother explained,

Before Legacy, [I] didn’t ask my kids how their day was. Now I take the time, ask them how their day was, take them to the library on the weekend too. By coming [to Legacy], I learned how to just modify the things that I do. (M, Wave 3)

Discussion among mothers in Miami revealed how these supportive actions contribute to child development and the mother–child relationship. Mothers’ references to the theme of patience were less in depth compared to discussions around supportive actions; however, these mentions typically indicated an increase in their patience levels. Discussion among mothers in Miami also included statements that illustrated concern for their children’s well-being, expressed approval of and affection for their children, and reflected wanting to provide for their children.

Themes around responsiveness in Miami mothers’ discussions included the importance of talking to and communicating with their children, increased understanding of their children, and comprehension of how their own responses affect their children. One mother explained what she learned about being more responsive to her children: “[y]ou have to be able to have yourself open and [your children] have to be able to come and talk to you about any and everything . . . You’re asking questions, you’re paying more attention” (M, Wave 2). As this example illustrates, mothers’ discussions indicated awareness of the importance of listening to their children and providing opportunities for interactions. Along with this awareness, mothers in Miami described recognizing their child as a person. One mother put it this way: “[T]hey have feelings. They feel just like we feel. Now I understand that more” (M, Wave 1). Mothers in Miami especially communicated how staying calm and physically getting down to their child’s level while communicating (vs. yelling in particular) had an effect on their children’s behavior. For example, one mother stated:

Sometimes I get frustrated. Like “go sit down, I don’t want to hear that,” or put them in front of the TV or something like that. But you learn to communicate with them more. Talk to them and find out what going on with them. “What happened in school today, what you did.” Because I had a big problem . . . my son he’s real shy, he won’t open up. But now the more I talk to him, it’s like he’s coming around more. He talks and everything. (M, Wave 4)

Another mother echoed this statement, seeing improvements in her children’s behaviors by adapting the way she communicates: “I think once you get to their level and you become a child, too, they—they start to listen to you and start to respond more to you. And that’s what Legacy teaches me” (M, Wave 2). These statements suggest that mothers in Miami became more attuned to their child’s needs and adept at altering their responses through their participation in Legacy.

In Los Angeles, mothers also described supportive actions for the parent–child relationship (e.g., engaging in quality time, playing with their child, and learning how best to interact with their child), learning patience, and the importance of effective communication. Just as in Miami, mothers in Los Angeles described the importance of individual time with their children. One mother explained that Legacy was

a time that my [child] and I spent together apart from everybody else and it, with my other kids, I never had that time . . . [a]nd now that it’s over . . . we have that special bond right there . . . because of the time that we would spend together so she would always want us to come and let’s lay down and read or you know . . . roll the ball, get bubbles, blow bubbles. (L, Wave 2)

Mothers again expressed concern for their child’s well-being, frequently through statements about feeling protective. Mothers in Los Angeles also communicated expressions of affection; here, however, mothers’ responses indicated more specific references to emotions such as loving, caring, and comforting versus the more general statements in Miami. For instance, while one Miami mother stated that she was “more affectionate” (M, Wave 3), a mother in Los Angeles stated, “I learned how to be more caring, loveable, patient, respectful” (L, Wave 1). As this representative example illustrates, Los Angeles mothers’ discourse related to the concepts of nurturance and sensitivity/responsivity generally contained greater detail, as compared to that of Miami mothers.

Discussion among mothers in Los Angeles also included themes related to verbally responding to their children. As one mother described, she learned “how to communicate more with my son, how to talk more” (L, Wave 1). Like Miami mothers, mothers in Los Angeles expressed an understanding of their child’s needs; here, however, they also spoke of recognizing their child as an individual person with unique needs. One Los Angeles mother described her daughter:

[S]he has her special needs. She’s not like the other boy or the other girl. She’s her own person. I respect that. It’s the way she is . . . . So I respect the person that is the child . . . . I understand why she does the things that she does. (L, Wave 3)

Finally, in addition to understanding how their own responses influence their child’s behavior, mothers’ responses in Los Angeles indicated that they took more time to explain their own behaviors to their child. One mother described a conversation with her son:

I talk with him, like when he’s hungry in the car, “Mommy, I’m hungry, I want something.” “I know you’re hungry. You have to wait, we’re going to buy something, but now you have to wait. No kicking no screaming. Mommy is going to drive,” and he’s like “okay, I’ll wait.” . . . My sister-in-law is always like, “Why do you talk to him like that” and I’m like . . . “He’s a kid, he understands. You have to talk to them.” (L, Wave 3)

This example illustrates how, in addition to trying to understand their children’s perspectives (as with mothers in Miami), mothers in Los Angeles attempted to help the child understand their own responses as parents. This quality is indicative of a more reciprocal parent–child relationship, where mothers can adapt their behaviors based on those of their children. Mothers here also reported seeing improvements in their child’s behavior (e.g., listening more and understanding expectations)—as with one mother who stated her child communicated more with her now as a result of her responsiveness: “He feels good because . . . he can talk, he can tell me, what he wants and what he doesn’t like” (L, Wave 2).

Support Mothers as Guides in Their Children’s Behaviors and Emotions

We examined parental control and maturity demand to address the third goal of Legacy. For this study, parental control is defined as maternal provision of structure to guide child behavior, follow-through with disciplinary guidelines, and encouragement of child achievement of parental standards. Maturity demand is defined as maternal expectation for their child to achieve their best according to their developmental stage as well as flexibility offered to the child to make their own decisions where appropriate.

Parental control

Mothers in Miami discussed a variety of topics related to discipline, including how to gain control of themselves and their child. A strong theme among these mothers was not spanking or trying not to spank their children, as Legacy tries to show parents the value and effectiveness of noncorporal parenting techniques. Mothers communicated knowledge of alternatives to corporal punishment, such as taking away toys or privileges and using timeout. Some of these mothers expressed that although it took time and effort, these techniques work for them. This was in contrast to spanking, which they felt either confused their child or did not discourage undesired behaviors. For example, one mother described how she has changed in terms of discipline:

I used to get a ruler and pop him in his hands. Now I take what he likes and I take it away. I do my daughter the same way . . . . It’s better than popping them. I feel like whooping don’t do nothing because they keep on doing the same things. Once you pop them or beat them . . . they do the same old thing over. They do it and it gets worse. (M, Wave 1)

Despite Legacy’s emphasis on noncorporal techniques, a few mothers in Miami communicated different perspectives. Some expressed dissatisfaction with techniques like timeout, and others described wanting to spank, or the difficulty of trying not to spank. One mother explained, “[My daughter] is really hard because I want to spank her . . . . [I]t’s a transition. It’s hard for me” (M, Wave 1). This example reveals the effort and process involved in using noncorporal techniques and in examining one’s own parenting and considering alternative parenting behaviors.

Mothers in Los Angeles described parental control in much the same way as did the first Miami group described earlier. These mothers also described using noncorporal techniques such as timeout and taking away toys for discipline. One mother described how Legacy changed the way she used discipline, stating during “Legacy I got ideas how to discipline . . . . [Y]ou had to use a firm toned voice and before I would be like screaming. I have learned a lot” (L, Wave 3). Mothers in Los Angeles expressed satisfaction with noncorporal methods overall, stating that they have learned other options. One mother explained, “We don’t have to let the kid get away with everything . . . . You can punish, like take away a favorite toy or giving him a time out or all of the things that not hitting the kid” (L, Wave 2). Mothers here emphasized not screaming or spanking their children, in alignment with Legacy’s goals, verbalizing that they do not want to teach their children to hit by doing it themselves.

Maturity demand

In Miami, mothers discussed expectations for their child’s behavior, such as giving others respect. Mothers also talked about granting their children an appropriate level of control; for instance, providing two options to choose from and refraining from correcting or telling their child what to do. One mother commented,

When I do her homework with her I never say that’s wrong. I always say that was a great try, let’s try another answer. I don’t ever make her feel like she, oh that she did something wrong, just it wasn’t the right answer. Let’s try something different. (M, Wave 4)

In addition, mothers expressed recognition of their child’s limits based on age, as well as flexibility in how much to expect from their child. Another mother in Miami explained change related to this type of expectation:

[Y]ou know like you was yelling at kids like “sit down.” You know how you be like that? I learned not to do that so much, just sometimes give them their own little space . . . [l]et them do whatever they want to do and then rest for a while and then just come out there. (M, Wave 4)

As in this example, mothers in Miami recognized their children’s limits and responded appropriately.

In Los Angeles, mothers also conveyed recognition of their child’s limits based on their age and developmental stage, and flexibility in terms of their expectations. However, in contrast to Miami participants, mothers in Los Angeles engaged in additional discussion around granting their children more freedom to express themselves, such as by showing their emotions or through creative outlets. For instance, one mother stated, “I’m the mother, but she has to be able to express her feelings. Exactly. That’s one thing I learned from Legacy, she has to be able to express herself” (L, Wave 2). Another mother commented,

I don’t care if they put their Halloween costumes on and play . . . . My family would come over and be like, you know, [child]’s running around looking like a bumble bee, you know, and it’s not Halloween, it’s Christmas . . . . I’m like, well it’s okay, because she’s just being imaginative . . . . I’m just letting her express herself . . . . [W]hy not let them play with them, you know, and express themselves? (L, Wave 2)

Mothers in Los Angeles communicated not only establishing appropriate expectations and acknowledging their child’s limits (like mothers in Miami) but—as this example illustrates—also encouraging their children to express themselves fully.

Promote Each Mother’s Ability to Influence Her Children’s Verbal and Brain Development

We addressed the fourth goal of Legacy by investigating discussions of developmental stimulation. Here, developmental stimulation is defined as practices that directly support or enhance child cognitive and verbal development (e.g., providing books and learning materials, opportunities and experiences for learning, and reading to or playing with child).

Developmental stimulation

In Miami, mothers emphasized the importance of practices that help with their children’s development. The emergent theme within these was reading, which mothers reported their child enjoyed and from which they saw positive results. Mothers also described other activities meant to support their children developmentally, which included practicing written and oral language skills (e.g., ABCs, rhyming), participating in arts and crafts activities, and letting their child play at “grown-up tasks” (e.g., cooking, putting on makeup, and cleaning). A mother describes one such task:

I’ll buy all the stuff they eat with their pizza and let them create their own stuff. They are actually very good. They end up making less of a mess than I do. I be in such a hurry to get everything done and organized. They have their own table, they have their little chairs and they sit down. (M, Wave 4)

In Los Angeles, there was less discussion overall of practices to support development. However, mothers in Los Angeles again stressed the importance of reading to their children as well as seeing the positive results in terms of their child’s literacy and language development. One mother described her experience this way:

I read twenty minutes every day at night no matter how tired, no matter how much homework I have . . . . I used to think I would be too tired, that it’s a waste of time, but with my daughter, I learned that it’s reading to a child really works. You know, she uses words that I don’t know a two-year-old knows . . . . I emphasize when you’re reading to a child that has to be the one thing that will change them. (L, Wave 2)

Other activities described by mothers in Los Angeles included singing and playing instruments, and focusing on pictures and colors while reading. One mother explains, “I talk to my son, or I read him books, show him the pictures, colors so he can start learning” (L, Wave 1). Mothers in Los Angeles, like those in Miami, expressed how these practices contributed to their child’s development and the importance of engaging in them regularly.

DISCUSSION

Overall, Legacy mothers participating in focus-group discussions demonstrated understanding and use of positive parenting practices targeted by the Legacy goals. Mothers’ discussions clearly indicated their commitment to parenting—mothers described focusing on their child and the importance of staying engaged in their roles as parents. Mothers at both sites reported prioritizing their children and trying to become better parents. In addition, mothers’ statements also reflected nurturing cognitions and behaviors. Mothers reported wanting to be involved in their child’s life, learning to have more patience, and having concern for their child’s well-being. Mothers’ descriptions also reflected high levels of sensitivity and responsivity; they described talking and communicating more with their children versus before Legacy, improving in their understanding of their children, and realizing how their own responses affect their children. Mothers particularly highlighted the importance of physically getting down to their child’s level while communicating and reported seeing consequential improvements and growth in their children. Furthermore, mothers described improvements in their levels of parental control. Mothers explained that they felt more control of themselves and their children, described behavior change related to trying not to spank, and demonstrated increased knowledge of other disciplinary techniques. In addition, mothers expressed developmentally appropriate levels of maturity demand. They reported clear expectations for their children, but also flexibility regarding these expectations, granting their child a level of control tailored to their children’s ages, needs, and limits. Finally, mothers’ discourse revealed knowledge and use of practices to increase developmental stimulation (reading mostly, but other activities as well). Mothers’ statements indicated an understanding of how these practices help child development and why they are important.

These results align with the literature on supporting positive parenting. Positive parenting can promote the long-term health and well-being of children (Morris et al., 2017; Sandler, Ingram, Wolchik, Tein, & Winslow, 2015). For example, parental sensitivity in early childhood, as demonstrated in this study, can result in long-term positive child outcomes such as enhanced social skills and academic achievement (Raby, Roisman, Fraley, & Simpson, 2015). Likewise, parental involvement can lead to improvements in social skills and reductions in problem behaviors (El Nokali, Bachman, & Votruba-Drzal, 2010). Appropriate levels of parental control and demands can protect against behavior problems and externalizing disorders well into adolescence, as reviewed by Hoskins (2014). Finally, practices that stimulate children’s development, like reading together as discussed by mothers in this study, have demonstrated positive effects in vocabulary and comprehension as well as later language and cognition (Raikes et al., 2006).

These results also align with the prior findings on child outcomes from the Legacy RCTs, and offer preliminary support for the effects of the intervention activities on Legacy goals as described in the Legacy logic model (Figure 1). Taken alongside quantitative findings, this knowledge can inform future dissemination and scaling up of Legacy by helping to understand what Legacy mothers at each site value regarding their growth as parents, and what Legacy concepts and strategies they apply at home. Already, examination of the focus-group data has shaped the creation of intervention training and enrollment materials, and helped to develop implementation supports and technical assistance for current and future implementers of the Legacy program (Robinson, Perou, & Leeb, 2014). As a Spanish language adaptation of Legacy is being developed, a similar complementary qualitative approach is being used to ensure the cultural congruence and effectiveness of the Legacy program in a community-based implementation.

Finally, these findings contribute to methodological advancements in the evaluation of parenting programs overall. Recent research has emphasized the value of combining qualitative methods with quantitative ones—often within RCTs—to evaluate interventions (Catallo, Jack, Ciliska, & Macmillan, 2013; Furlong & McGilloway, 2012; O’Cathain et al., 2014; O’Cathain et al., 2013). Although some research has examined changes in parenting, many qualitative studies of parenting programs have focused more on areas such as participant satisfaction, and facilitators and barriers to engagement (Koerting et al., 2013; Rahmqvist, Wells, & Sarkadi, 2014), and have looked less at specific parenting practices. Finally, while prior studies have focused less on secondary analyses of qualitative data, there is evidence that this method can serve as an effective tool when aligned with the aims of the original study (Corti & Bishop, 2005; Heaton, 2000).

A notable finding of this study consists of the differences between sites related to characteristics and strategies of parenting described. In Miami, mothers described the necessity of making life changes prior to increasing commitment to parenting, such as reducing their amount of partying. These themes did not emerge in Los Angeles, suggesting that Los Angeles mothers may be focusing on different aspects of the parenting role. Mothers in Miami also made more varied statements about the practices discussed, including different and often contrasting views related to commitment and parental control. For example, some mothers in Miami discussed the challenges in using noncorporal techniques while mothers in Los Angeles did not. Despite these differences, discussion among mothers at both sites indicates that Legacy successfully encourages mothers to be reflective in their consideration of alternatives to spanking and changes in their parenting role. In Los Angeles, mothers also provided greater detail and more specific examples of their parenting cognitions and behaviors, as compared to mothers in Miami. In addition, mothers in Los Angeles described not only being sensitive to their children but also taking the time to explain behaviors and consequences to their children. In this respect, the discourse of mothers in Los Angeles demonstrated an increased capacity to discuss and interpret how their relationship with their child functions.

These site differences may not be as surprising considering the demographic differences across the sites. Although both Legacy sites recruited participants based on poverty criteria, the sites varied significantly on demographic variables such as maternal education, maternal IQ, employment status, marital status, and racial/ethnic composition, with the Los Angeles sample overall having more social and economic resources. These demographic factors have all been previously associated with parenting (Ellingsen et al., 2014; Fox, Platz, & Bentley, 1995; Lucas-Thompson, Goldberg, & Prause, 2010; Quintana et al., 2006). Previous research also has demonstrated a relationship between adult cognitive skills, such as working memory, and poverty-related chronic stressors (Evans & Schamberg, 2009). Alternatively, mothers in Los Angeles in general simply may have been better able to articulate changes in their parenting, as compared to mothers in Miami.

Differences across sites, taken in conjunction with the overarching positive parenting results among mothers in Miami and Los Angeles, have important implications for program developers and implementers. As evident in this study, mothers in different contexts and with different backgrounds may present varying needs and outcomes related to parenting—for example, in receiving and processing information about discipline. Legacy aims to meet mothers wherever they are in their development as parents, and recognizes the importance of fostering mothers’ sense of self-efficacy. This study indicates that even alongside curriculum and individual-level differences, Legacy promotes knowledge and use of positive parenting practices. Legacy implementers should continue to follow the Legacy approach of reflecting on and responding to each mother’s individual needs. In terms of larger program dissemination, these findings suggest the importance of creating a safe, nonjudgmental group environment where mothers can cognitively reflect on current and past parenting practices and try out new ones. This highlights the importance of training and staffing supports. Nonjudgmental and nondidactic implementation over the long-term necessitates special skills and experience; in-depth and consistent selection and training of group leaders may significantly affect mothers’ participation and engagement in the program, and the overall effect of Legacy on their parenting. In addition, this work, similar to other quantitative and qualitative research with low-resourced families (Landy, Jack, Wahoush, Sheehan, & MacMillan, 2012; National Center for Parent, Family and Community Engagement, 2015), supports the Legacy tenet that parents can make positive changes that support their children’s development even when they are experiencing the stressors, disadvantage, and chaos of a poverty environment. While additional research would clarify the generalizability of Legacy to other populations, these findings are supportive of dissemination of the program on a broader scale.

Strengths and Limitations

The iterative and inductive research process used in this study allowed for changes to and further development of the research questions based on data provided by participants. In addition, the methods included a second coding process to strengthen codebook development. Finally, the qualitative findings of this study serve to enhance the knowledge gained from the RCTs, as they emphasize participants’ own words and experiences.

Many of the limitations are related to the challenges of qualitative and secondary data analysis. Due to the nature of qualitative research, the findings reported here are not intended to generalize to a larger population. In this case, one should interpret the findings with additional caution, as those that participated in the focus groups may not accurately represent the larger group of Legacy participants. Even so, these results align well with the child outcomes demonstrated in the RCTs (Kaminski et al., 2013), and preliminary analyses revealed focus-group participants were demographically similar to Legacy participants overall. This secondary data analysis was completed after the design, data-collection, and transcription processes in the original study. Thus, analyses were limited by the data collected, and the researchers could not fully apply all grounded theory techniques. For example, the CDC did not conduct focus-group discussions among control mothers (i.e., mothers not participating in Legacy), which limited analyses and possible explanations of intervention group effects. We also had intended to assess mothers’ descriptions of parenting across levels of program engagement. Despite recruiting groups by strata of attendance, inconsistencies between some mothers’ Legacy attendance patterns and participation in the corresponding focus-group discussions limited our ability to draw conclusions about levels of engagement. Future work could explore how attendance patterns correspond to mothers’ descriptions of their parenting. Finally, as stated previously, each site implemented a different version of the Legacy model, and mothers in Miami and Los Angeles differed on a number of demographic and cultural factors. This study therefore cannot speculate on the cause of those differences; instead, it adds rich context to the existing research base on Legacy.

Future Directions

For parenting interventions overall, this study emphasizes the importance of understanding real-world context regarding program efficacy, and the benefit of using qualitative research to understand participant experiences. Future studies of parenting programs may wish to incorporate qualitative elements or mixed methodologies to help interpret findings and improve program outcomes. Forthcoming studies also may consider implementing and evaluating the use of qualitative analyses to obtain new knowledge, and further understand the utility of this methodology.

An important next step in the evaluation of Legacy will be to examine quantitative data on parent and family outcomes, especially within the context of the qualitative findings. These explorations may explain how these factors act as potential control variables or mediators for child outcomes. Additional analyses using Legacy focus-group data could examine mothers’ comparisons of their own childhoods to their current parenting, and specifically review mother-reported changes in child behavior, especially as compared to the findings of the Legacy RCTs. Forthcoming studies also may wish to explore mothers’ experiences receiving feedback and providing advice to family and friends outside of the Legacy program, and investigate mothers’ descriptions of parenting during subsequent implementations of the Legacy program. By conducting additional qualitative research across implementation sites, researchers also may be able to generate larger theories regarding participant differences. Theories thus grounded in the data would serve to inform adaptation of Legacy to best fit participant needs and dissemination of the program to wider audiences, thereby maximizing the effects of Legacy on child development and its overall public health impact.