Criando Niños Con Cariño: Primary Care-Based Group Parenting Program Adaptation and Pilot

Abstract

Objective:

This study culturally adapted and piloted a primary care-based group parenting program (Child Adult Relationship Enhancement in Primary Care, PriCARE) for Spanish-speaking, Hispanic parents of 2-6-year-old children.

Method:

The process was informed by the cultural adaptation literature, expert consultation, and focus group data from 18 previous PriCARE, eligible Cariño, and initial Cariño test participants. As adaptations were made, an implementation framework was applied to systematically record all changes. Lastly, parents of children, 2-6 years old, participated in the Cariño pilot study (n = 32). Enrollment and attendance data were used to examine feasibility and the Therapy Attitude Inventory (TAI) was administered post intervention to measure acceptability.

Results:

Most adaptations were minor changes to make the adapted program, Criando Niños con Cariño, more appropriate, applicable, or acceptable. Some changes required reframing Cariño concepts (e.g., child-led play) or incorporating new concepts (e.g., respeto, armonía, educación) to better align Cariño goals with parents’ values. Among the 121 dyads invited to participate in the Cariño pilot study, 52 (43%) enrolled. Among the 52 enrolled, 32 (62%) attended at least 4 of the 6 sessions and reported high satisfaction on the TAI (mean 47/50, range 33-50).

Conclusions:

Cariño is the result of a rigorous adaption process and incorporates multiple changes to ensure the translation reflects the intended meaning and to reframe the program goals and concepts in a culturally congruent manner. Pilot data suggest Cariño is feasible and acceptable to parents.

Parenting programs delivered in group settings have been created to help parents develop parenting skills that improve parent-child relationships and child behavior.¹ Ample research provides evidence of the effectiveness of parenting programs in reducing challenging behavior and improving educational and mental health outcomes in children.^1,2 Parenting programs are especially important given that early behavioral problems impact at least 1 in 5 children under age 5 in the US and are associated with impairments in multiple domains (e.g., family, academic, and social functioning) which often continue into adulthood.³

Yet, in spite of the positive effects of parenting programs, their full potential has not been realized because of their limited reach. One important barrier to dissemination has been cultural adaptation. Although some programs have been developed or adapted for Hispanic, non-White, or non-English speaking populations, the majority of existing programs have been developed for and tested in non-Hispanic (NH), White, English-speaking populations. They have not been designed to enroll and engage racial/ethnic minority participants.⁴ Because diverse population groups are more likely to participate in programs that resonate with their cultural norms, values, and experiences, adapting parenting programs for racial/ethnic minorities may improve program engagement and attendance among these underserved groups.⁵ Attending to culture in parenting interventions specifically may be particularly salient as cultural differences in rules, beliefs, preferences, communication, and standards of acceptable behavior have implications for parenting practices.⁶ To that end, several parenting programs have been culturally adapted.^7,8 These include adaptations of programs serving Spanish-speaking populations within the US such as Fortalezas Familiares/Family Strengths, an adaptation of Keeping Family Strong,⁹ Criando a Nuestros Niños hacia el Éxito (CANNE)/Raising our Children to Success, an adaptation of Parenting Our Children to Excellence,¹⁰ and Criando con Amor, Promoviendo Armonía y Superación (CAPAS)/Raising with Love, Promoting Harmony, and Overcoming, an adaptation of Parent Management Training, the Oregon Model.¹¹

Cultural adaptation is the process of applying modifications intended to increase the fit of interventions to their target populations while protecting scientific integrity.¹² There are several conceptual frameworks to guide the cultural adaptation of interventions.¹³ Generally, these models recommend including stakeholders in the process, using formative research methods, rigorously documenting changes, and evaluating the adapted intervention.¹⁴

In addition to applying conceptual frameworks and rigorous methodology to cultural adaptation, it is critical to subsequently report what has been adapted, how, and why.⁸ In the absence of such publicly available, systematic documentation, adaptations cannot be replicated, cannot be evaluated, and thus are poorly understood.^8,14

In this article, we describe the process of adapting a group parenting program, Child Adult Relationship Enhancement in Primary Care (PriCARE), for Spanish-speaking, Hispanic families and present the results of a feasibility and acceptability pilot study of the adapted program, Criando Niños Con Cariño/Raising Children with Care. PriCARE is a 6-sesssion evidence-based intervention for parents of 2-to-6-year-old children which has demonstrated improvements in child behavior, harsh and permissive parenting, and parent stress.^15–17 This manualized skill-based program is delivered in the primary care setting by two trainers who are LCSWs. They work with groups of 4-8 parents during 6 weekly 90-minute sessions. The curriculum aligns with adult learning theory and relies extensively on brainstorm activities, role play, and live coaching. Free childcare, dinner, a toy to use during home practice, and transportation reimbursement are provided to facilitate participation. Sessions 1-4 teach parenting skills focused on giving attention to children’s positive, pro-social behaviors, while ignoring minor misbehaviors (strategic ignoring). Mastery of the 3 P skills (Praise, Paraphrase, and Point-out-Behavior) helps parents learn how to promote positive behaviors in their children. Sessions 5-6 teach techniques for giving children effective commands to set age-appropriate limits. The importance of play in supporting a child’s development and establishing a strong foundation for the relationship between the child and parent is emphasized. Although children do not attend the sessions, parents are encouraged to practice the skills at home during brief (3-5 minutes) 1-on-1 play sessions with their child daily. Text-based communications are used to reinforce of key messages/skills between sessions and provide encouragement.

The target population for the Cariño adaptation of PriCARE is Spanish-speaking, Hispanic families because (1) this is a significant and growing population in the US; (2) Hispanic children are at heighted risk for the specific adverse outcomes targeted by parenting interventions; and (3) notable disparities exist in mental health services access and utilization by Hispanic children.

Twenty-five percent of children in the US are Hispanic, a percentage that has grown from 9% in 1980 and is expected to continue growing in the coming years.¹⁸ Hispanic children are at disproportionate risk of experiencing poverty and of exposure to environmental stress and trauma during early childhood, thus increasing their risk for future psychosocial problems.¹⁹ For example, compared to NH White youth in the US, Hispanic youth are at higher risk for mental health problems, substance use, low educational attainment, and delinquency.²⁰ These are the very outcomes that parenting interventions have been shown to improve.²¹

Yet, despite comprising a significant portion of the population and facing elevated risk for adverse psychosocial outcomes, Hispanic children are underrepresented with regard to mental health treatment in the US. They receive half as many counseling sessions as NH White children, have lower mental health service use after controlling for socioeconomic status, and even when accessed, may receive lower quality health services.²² For all these reasons, it is important to extend parenting interventions to this underserved population in a way this is culturally appropriate, accessible, and replicable.

METHOD

Study Setting

This program adaptation was conducted in a pediatric clinic associated with an academic institution in a suburban southeastern town in the US. In this state, 54% of foreign-born Hispanics are Mexican; 26% are Central American (Guatemala, El Salvador, Honduras), 6% are Caribbean (Dominican Republic, Cuba) and the remainder are from countries in South America.²³ The clinic cared for about 12,000 patients in 2020, including 1,385 unique children ages 2 to 6 years. Of all patients, 72% are insured by Medicaid, 32% are Hispanic, 34% are NH Black, and 27% are NH White. The University Committee for the Protection of Human Subjects and Institutional Review Board approved this study. Participants were compensated $20 for each study visit.

Participants

Participants in the Adaptation Process.

Between November 2018 and February 2019, we relied on experts (N=4) and focus group participants (N=18) to inform the adaptation process. Four experts were consulted: a NH White pediatrician with 10 years of experience in the development, implementation, and evaluation of parenting interventions; a bilingual Hispanic faculty member with over 20 years of experience conducting community-based research to promote the well-being of Hispanic people; and two bilingual Hispanic licensed clinical social workers (LCSWs) with years of experience treating Hispanic families. Three of the experts were also parents. Focus group participants were selected from three distinct groups: (1) Previous PriCARE Participants were English-speaking, Hispanic parents, with children ages 2-6 who participated in the original program (PriCARE) at the clinic in the previous year; (2) Eligible Cariño Participants were Spanish-speaking, Hispanic parents with children ages 2-6 years old who were patients at the clinic and eligible for participation in Cariño; (3) Initial Cariño Test Participants were Spanish-speaking, Hispanic parents with children ages 2-6 years old recruited from the clinic to take part in an initial test of Cariño. This initial test was used to finalize adaptations before the Cariño pilot study.

Cariño Pilot Study Participants.

Following completion of the adaptation process, we recruited participants from the clinic into the Cariño acceptability and feasibility pilot between October 2019 and February 2021. Individuals were eligible to participate if they self-identified as Hispanic, spoke primarily Spanish, and had children ages 2-6 years who were patients at the clinic. Concern for a behavior problem or problematic parenting were not required for participation. We excluded children: (1) whose parents were younger than 18 years or did not have legal custody of the child; (2) whose global developmental performance was less than 2 years (because the PriCARE/Cariño techniques target a developmental level of at least 2 years); or (3) who were receiving medical treatment for a psychiatric condition other than ADHD. Exclusion criteria were determined based on a brief recruitment interview and review of the medical record.

Procedures

Adaptation Process.

To begin the adaptation process, we convened a panel of experts to review PriCARE and suggest a priori modifications. In their review, the panel applied a modification of Bernal et al.’s (1995) framework for culturally-responsive interventions. Drawing on research of ecological validity and cultural sensitivity in treatment and interventions,^24,25 the framework provides a hierarchy for cultural adaptation.⁷ At the bottom of the hierarchy are the most visible adaptations of programs – language, setting, and staff. In the middle are modifications to the methods of delivery and content to incorporate specific histories and circumstances of the population being served. At the top are adaptations requiring more fundamental shifts in goals and concepts to ensure the cultural consonance of interventions. These adaptations require a shift from an etic (outside the culture) to an emic (within the culture) perspective, as well as a shift from a cultural deficit model towards an integrative model of cultural strengths and developmental competencies.²⁶

After our expert panel identified a priori changes, we translated all PriCARE materials into Spanish. Initial forward and back translations were completed by native Spanish-speakers from a professional language institute. Then a group of both native Spanish- and native English-speakers (two bilingual LCSWs and two bilingual research assistants) reviewed all materials independently followed by a group conference to identify inadequate expressions/concepts of the translation and resolve discrepancies between the translated and original PriCARE materials.

Next, we recruited each of the three sets of participants described above to participate in the adaptation process. First, we recruited Previous PriCARE Participants by telephone, invited them to participate in a focus group, and made initial adaptations based on this focus group. Second, we identified Eligible Cariño Participants using electronic medical records, recruited them in-person at the time of their well-child visit, and invited them to participate in a focus group. A second set of adaptations was implemented after these 3 focus groups. Third, we identified Initial Cariño Test Participants using electronic medical records, recruited them in-person at the time of their well-child visit, and invited them to attend 6 weekly Cariño sessions and 3 focus groups after sessions 2, 4, and 6 as part of the initial test. A final set of adaptations to the Cariño curriculum were applied after these last 3 focus groups.

Focus group participants completed a brief survey to collect demographic information. The focus groups lasted about 90 minutes and touched on each aspect of the hierarchy of cultural adaptations with questions related to the linguistic, setting, and staff appropriateness of parenting programs; the mode of delivery and degree to which culturally-specific elements are represented in parenting programs; the cultural congruence of parenting program ideas and skills; and the ease with which these practices can be incorporated into the family environment.

Cariño Pilot Study Procedures.

After completing the adaptation process and recruiting Cariño Pilot Study Participants, we conducted interviews with them pre-intervention and 8 to 12 weeks later (post-intervention). A native Spanish-speaking research assistant conducted the interviews using an interviewer-administered survey. At the pre-intervention interview, parents answered demographic questions, questions on parents’ acculturative stress, anxiety, depression, and parenting behaviors, and questions on child behaviors. At the post-intervention interview, a program satisfaction measure was completed. Because of the necessity to maintain physical distancing during the COVID-19 pandemic, we began delivering Cariño virtually in June 2020.

Measures

Demographic Questions.

For all participants, demographic questions included sex, age, Hispanic/Latino background (Caribbean: Puerto Rico, Domincan Republic; Central American: Honduras, El Salvador, Guatemala; Mexican; Other/South American), years in US, highest level of education (grades 1-8, high school, trade school, college), annual household income (< $20,000; $20,000-$39,999; $40,000-$79,999; unknown), English and Spanish spoken and reading proficiency (very well/well vs. not well/not at all), preferred language (English or Spanish), any household receipt of cash (Temporary Assistance for Needy Families/Work First), food (Supplemental Nutrition Assistance Program), or medical assistance (Medicaid) in the past year, degree (0=low to 5=high) of family economic hardship in the past year (indicated by sum of responses to five questions on housing evictions and ability to pay for phone services, utilities, rent/mortgage, food), and degree (a lot, a moderate amount, not too much) of deportation worry.

Participants in the Cariño Pilot Study completed the demographic questions and five additional sets of questions pre-intervention and a satisfaction measure post-intervention. Cronbach alphas are provided for these 6 instruments for this pilot study sample.

Acculturative Stress Index (ASI) measures racial/ethnic discrimination, intergenerational conflict, and language conflict (α = .70).²⁷ Summed across 9 items (range: 9-45), higher scores indicate more stress.

Generalized anxiety disorder (GAD)-7 measures anxiety severity with good reliability and validity including among Spanish speaking populations (α = .94).²⁸ Summed across 7 items (range: 0-21), scores of 10 or greater indicate moderate to severe anxiety.

Patient Health Questionnaire (PHQ)-9 measures depression severity with excellent reliability and high discriminant validity including among Spanish speaking populations (α = .91).²⁹ Summed across 9 items (range: 0-27), scores of 10 or greater indicate moderate to severe depression.

Eyberg Child Behavior Inventory (ECBI) contains the Intensity Scale (α = .93) which measures the frequency of child disruptive behavior from (1) never to (7) always; and the dichotomous (yes-no) Problems Scale (α = .93) which measures the number of child behaviors the parent finds problematic. The ECBI is well validated and has been standardized for Hispanic children with Spanish-speaking parents.³⁰ Summed across 36 items (range: 36-252), scores greater than 130 on the Intensity Scale are clinically significant. The sum of “yeses” across 36 items (range 0-36) yield Problem Scale scores, which are clinically significant if greater than 14.

Parenting Scale (PS) is a well-validated 30-item scale designed to assess dysfunctional parenting discipline strategies including Laxness (permissive inconsistent discipline, providing positive consequences for misbehavior), Over-reactivity (harsh, emotional, authoritarian discipline characterized by irritability and use of verbal or physical force), and Verbosity (inappropriately placed, long verbal explanations).³¹ Scores are calculated as an average across items (range: 1-7) for a Total Score (α = .81) and three subscales: Laxness (α = .84), Over-reactivity (α = .79), and Verbosity (α = .68). Higher scores reflect more problematic parenting.

Therapeutic Attitude Inventory (TAI) is a satisfaction measure of parent training and parent-child treatments (α = .90). Scores are summed across 10 times (range:10-50) with higher scores indicating greater satisfaction. Psychometric evaluation of the TAI demonstrated excellent internal consistency and test-retest reliability and showed strong correlation between satisfaction and symptom improvement during treatment.³²

Analysis

Analysis of Focus Groups.

All focus groups were conducted in-person and audio recorded. Then, recordings were transcribed and translated. Transcripts were reviewed for accuracy and uploaded into MAXQDA 2020 (VERBI Software, 2019) for coding and analysis. The research team met after each focus group to familiarize themselves with each group’s transcript, generate initial codes, and recursively examine, discuss, and review coded themes.³³ Codes were developed collectively by the team, and focus groups were then coded individually. As the data were analyzed, new codes were added to the coding scheme for statements that did not fit the existing codes and previously coded transcripts were re-analyzed and updated. We compared codes, concepts, and categories from different respondents to examine their universality and to identify cases where they did not fit. Themes presented below represent concepts that were present across multiple respondents. We used four analysts to code the data, with at least two coding each transcript, and resolved discrepancies in coding by consensus in research team meetings.

During each step of the adaptation process (a priori expert changes, translation, focus groups, initial test) all changes were tracked and coded using the system developed by Stirman et al. (2013).³⁴ We recorded and characterized each adaptation with a change code (what was modified) and a cultural code (nature of the modification based on the cultural adaption hierarchy). The following change codes were used: (1) tailoring: minor changes that make the intervention more appropriate, applicable, or acceptable; (2) adding: additional material inserted consistent with fundamentals of the intervention; (3) lengthening: a longer amount of time is spent to complete the concept; (4) substituting: an activity is replaced with something different in substance; (5) repeating: a concept is repeated more than once; (6) format: changes made to the format of intervention delivery; and (7) personnel: intervention is being delivery by personnel with different characteristics.

Analysis of Cariño Pilot Study.

We used descriptive statistics to characterize the sample, feasibility, and acceptability. To evaluate whether those who completed the pilot differed significantly from those who did not, we examined differences in pre-intervention characteristics/measures between these two groups. In addition, we evaluated whether there were differences in session attendance (feasibility) and intervention satisfaction (acceptability) between those who completed the intervention in-person or virtually.

RESULTS

Participant Characteristics

Adaptation Process Participants.

Overall, the adaptation process included 18 parents who participated in 7 focus groups (3-6 participants/group): 1 focus group included Previous PriCARE Participants (N=3); 3 focus groups included Eligible Cariño Participants (N=9); and 3 focus groups included Initial Cariño Test Participants (N=6) who attended the preliminary adaptation of Cariño and participated in a focus group after every other Cariño session. Of the 18 focus group participants, 17 completed the brief demographic survey (Table 1). There were 4 men and 13 women ranging from 26 to 53 years. The majority (64%) were of Mexican background and had been in the US for an average of 17 years.

Table 1.

Demographic characteristics and baseline measures of parent participants

Characteristic	Focus group (n=17) N (%)	Pilot: Followed-up (n=32) N (%)	Pilot: Lost to follow-up (n=20) N (%)
Female	13 (76%)	32 (100%)	18 (90%)
Age in years (mean, range)	35, 26-53	34, 21-66	35, 22-50
Background
Caribbean	3 (18%)	5 (15%)	--
Central American	3 (18%)	2 (9%)	3 (15%)
Mexican	11 (64%)	21 (66%)	16 (80%)
Other/South American	--	4 (13%)	1 (5%)
Years in US (mean, range)	17, 5-32	15, 4-30	15, 3-24
Education
Grades 1-8	5 (30%)	4 (12%)	7 (35%)
High School	6 (35%)	14 (44%)	9 (45%)
Trade School	4 (23%)	8 (25%)	2 (10%)
College	2 (12%)	6 (19%)	2 (10%)
Annual household income
<$20,000	6 (35%)	10 (31%)	5 (25%)
$20,000-$39,999	5 (29%)	11 (34%)	7 (35%)
$40,000-$79,999	4 (23%)	7 (22%)	3 (15%)
Unknown	2 (12%)	4 (13%)	5 (25%)
English spoken proficiency
Very well/Well	6 (35%)	17 (53.5%)	7 (35%)
Not well/Not at all	11 (65%)	15 (46.5%)	13 (65%)
English reading proficiency
Very well/Well	8 (65%)	15 (47%)	5 (25%)
Not well/Not at all	6 (35%)	17 (53%)	15 (75%)
Spanish spoken proficiency
Very well	15 (88%)	22 (69%)	11 (55%)
Well	2 (12%)	10 (31%)	9 (45%)
Spanish reading proficiency
Very well	14 (82%)	22 (69%)	10 (50%)
Well	3 (18%)	10 (31%)	10 (50%)
Preferred language
Spanish	13 (76%)	28 (88%)	19 (95%)
English	2 (12%)	3 (9%)	1 (5%)
Don’t know	2 (12%)	1 (3%)	--
Medicaid, TANF,1 or SNAP2	16 (94%)	29 (91%)	15 (75%)
Economic Stress (mean, range)	0.5, 0-4	0.6, 0-3	0.2, 0-2
Deportation Worry
Not too much	1 (6%)	6 (16%)	6 (30%)
A moderate amount	8 (47%)	10 (31%)	6 (30%)
A lot	8 (47%)	17 (53%)	8 (40%)
ASI3 (mean, range)	--	16 (9-28)	15 (9-29)
Moderate-Severe Anxiety	--	5 (16%)	11 (55%)*
Moderate-Severe Depression	--	2 (6%)	9 (45%)*
ECBI4 (mean, range)
Intensity Scale	--	92, 43-157	100, 45-187
Problem Scale	--	9, 0-31	10, 0-27
PS5 (mean, range)
Total	--	2.6, 1.3-4.4	3.1, 1.8-3.7*
Laxness	--	2.4, 1.0-5.9	2.8, 1.5-4.8
Over-reactivity	--	2.2, 1.2-3.6	2.4, 1.0-4.0
Verbosity	--	3.4, 1.1-6.1	4.3, 2.0-5.4*

¹Temporary Assistance for Needy Families;

²Supplemental Nutrition Assistance Program;

³Acculturative Stress Index;

⁴Eyberg Child Behavior Inventory;

⁵Parenting Scale;

^*p<0.02 in comparing Pilot to Lost to Follow-up

Cariño Pilot Study Participants.

Among the 121 parents invited, 52 (43%) consented to participate and completed the pre-intervention interview. Among the 52 participants enrolled, 44 (85%) attended at least 1 program session, 38 (73%) attended at least 2 sessions, and 32 (62%) attended 4 or more sessions and completed the post-intervention acceptability measure. The final pilot sample included 32 parents who attended at least 4 Cariño sessions. All 32 pilot participants were female ranging in age from 21 to 66 years (Table 1). The majority of parents were of Mexican background (66%) and on average had been living in the US for 15 years. Half of the children were female. Child age in years was 2 in 28%, 3 in 12%, 4 in 25%, 6 in 16%, and 6 in 19%.

Cariño Pilot Study Participants Lost to Follow-up.

The demographic characteristics of Cariño Pilot Study participants lost to follow-up (N=20) did not differ significantly from those who remained in the pilot study (Table 1). In comparison to those who completed the pilot, those lost to follow-up did not differ significantly in acculturative stress (ASI) or perceptions of their children’s behavior (ECBI). However, those lost to follow-up were more likely to endorse moderate to severe depression symptoms (45% vs. 6%, p<0.001) and moderate to severe anxiety symptoms (55% vs. 15%, p=0.020) and had higher scores on the baseline total PS (3.1 vs. 2.6, p=0.017) and Verbosity subscale (4.3 vs. 3.4, p=0.006).

Focus Group Results: What did we learn?

Following the cultural adaptation hierarchy, we classified focus group themes into three tiers (Table 2): (1) Language, Setting, and Staff, (2) Delivery Methods and Culture, and (3) Concepts and Goals. We did not observe any differences in comments made by male or female members of focus groups.

Table 2.

Themes and illustrative quotes by tier and category

Tier	Theme	Illustrative Quotes
1
Language	Language translation generally good but exact translation did not always convey intended meaning	“There are times when they send information from their school and it’s very confusing… But I have read what you sent to us and I think it’s perfect.”
		“I wanted to tell you when you were pretending to play, that you used the word, ‘this is stupid.’ I have heard that children use this word, but they have explained to me that white people use this word and it’s like saying something is silly. But for Hispanics, if your child says this then you are going to tell them, ‘Don’t use this word.’ Because stupid is a very strong word for a child to use even if they are playing. I feel you shouldn’t ignore the fact that they are using this word. You should tell them, ‘Listen this word is not appropriate.’”
Setting	Childcare and no cost facilitate participation	“People often say they won’t go because they don’t have anyone to take care of their children, but if they find out there is someone to take care of them, they’ll go.”
	Leaving home is risky and stressful	“I took a ride here because, honestly, I’m afraid of the police. And they make me nervous.”
Staff	Staff created safe environment	“I think the trainers were really good at asking questions and just interacting and making sure that you understood, and it was a safe environment to ask questions.”
2
Delivery Methods	Interactive nature of classes (role plays, brainstorms) helped participants stay engaged	“If I just read it, I will not retain the knowledge. Whenever you do demonstrations and ask questions that keeps me interested and it’s not something boring like hearing someone talk.”
		“I thought the examples were very useful, like the game you were pretending to play. It helped me a lot to see what we are not supposed to do and what we are supposed to do.”
	Small class size conducive to participation and building trust	“The fact that they keep participants involved from the beginning by introductions and telling a little bit about themselves, that kind of makes you feel a little bit more comfortable, too, asking questions, talking with your neighbor.”
Culture/ Experience	Address stress faced by families with regard to anti-immigration	“My children are afraid. I’ve talked to them about immigration, and my eldest daughter says she can’t imagine being in this country taking care of her brothers, and my son gets very nervous. I think that it affects them psychologically.”
		“We’re living in a moment where children are being attacked by racism.”
	Reluctance to ask for help with parenting due to fear of rejection	“That’s why a lot of people don’t like to ask for help, they don’t like to talk. They fear rejection, more than anything… and sometimes, if you’re rejected once, you don’t want to go back. You’re afraid of trying again.”
	Difficulty implementing daily, 1-on-1 activity as concept of routines was not embraced	“Yes, because I see that American people here are very organized. They get up at 7:00 am and they do this and that… And they ask me, what are you going to do at 7:00 am and I am like, I don’t know. Maybe I will be cooking or maybe I will be with my children.”
	Difference in laws and culture regarding corporal punishment	“It’s good to know because we are a different culture. Where we come from it is normal to hit a child with a shoe, but as we know the child will have a mark and here that is something very serious.”
		“So, the way we were raised is different than the way they were raised here. Sometimes some things that are supposedly bad or that parents shouldn’t do, like, if they misbehave, I don’t know, spank them. Here they tell me, if you spank me, I’m going to call the police.”
3
Concepts/ Frameworks	Desire for explicit instruction on how to share Cariño skills with co-caregivers and extended family	“My husband just returned a month ago and I would love for him to come and attend these classes because many times I am learning, but I see that my husband keeps on doing the same things that I learned that we are not supposed to do and I don’t know how to explain things to him.”
	Desire for clarity on how to operationalize home practice and how to apply new skills	“In the last session I was asking what type of games I could play with my son. So, maybe you could give recommendations about what games we could play according to our children’s age.”
		“I believe that direct and specific orders is something easy to do. The thing is that we didn’t know exactly how to put them into practice. Like, giving an order without saying, can you? We would always say that before the order and therefore that’s no longer an order.”
	Novelty and discomfort overcome by willingness to try new skills	“I don’t know about your case but in many cases, we were not raised with praises. So, for some of us it’s difficult to praise our children. For example, in my case I can’t find the words to tell my son. Like for example, I say, well done. But I don’t tell them specifically what they did well. So, that part was complicated. So, when they gave us these tools like you can say this and that then it’s helpful.”
	Ability to change parenting practices without diminishing cultural roots	“It’s not because I don’t like my country. It’s not because I don’t like my roots but the things that I have learned here have helped me to have a different outlook on life. So, I think that I will keep the different things that this country has taught me.”
Goals	Value of personal family connections and creating opportunity to spend quality time with children	“Just like she says, it’s been very good. It has helped me a lot with the kids because I spend more time with them. We play a lot more.”
		“In my case it has helped me become more patient with my daughter and to spend more quality time with her. I spend time just with her. It’s just the two of us. I don’t usually play with her, but we have spent special time together. She calls it mommy time. And it has been very helpful.”
	Importance of co-parenting and need to address shared goal-setting and decision-making	“Give an approach or take the time to see the side of the partner, the other person that you’re doing co-parenting with. Open or give space to talk about that because we’re not doing this on our own and we have the very strong input of the other parent… I’ve seen it with the ladies in my group that they were like yeah, but my husband doesn’t do that. He has this other parenting style. The other parent might agree with you about the techniques that you’re going to use, but there’s so many other things that can affect how those techniques are perceived by the child. It would be good if you could do at least a little bit more of asking, talking about how we struggle in parenting styles with our partner.”

Language, Setting, and Staff.

Parents felt the language translation was appropriate. However, there were several examples in which the exact translation did not convey the intended meaning. Critical aspects of the setting included the availability of childcare and the provision of the program at no cost. Many participants expressed that venturing out of their home setting for any service, including a parenting group, creates risk and stress in the current anti-immigrant environment. Consequently, participants reported that the ability of the staff to create a safe environment for learning was essential.

Delivery Methods and Culture.

Most methods employed in the original PriCARE program were endorsed by participants. Parents particularly praised the interactive and participatory nature of class exercises, role plays, and brainstorm activities. Themes emerged pertaining to cultural experiences, including recognition that Hispanic parents in our study experience stress related to fear of deportation, racism, and discrimination that requires attention in the parent-child relationship. Participants expressed that such experiences cause many Hispanic parents to avoid asking for help or clarification for fear of rejection. Participants also referenced difficulty implementing “routines” and a desire to maintain flexibility in their schedules which sometimes created a barrier to completing 3-5 minutes of daily 1-on-1 play practice at home.

Concepts and Goals.

Giving commands without asking a question (e.g., Bring me the toy vs. Can you bring me the toy?) and distinguishing between necessary and unnecessary commands were concepts that required additional clarification. Participants were open to learning positive parenting skills and were appreciative of the way in which new skills and concepts were presented; even when different from how parents were raised, the program’s parenting methods still retained cultural and family values. The most important goals that emerged were the desire to strengthen family relationships, to find positive parenting approaches that incorporate cultural experiences, and to introduce new skills while accommodating multiple caregiver perspectives.

Cultural Adaptations: What did we change?

Changes to PriCARE were made, recorded, and coded based on expert feedback and focus group analysis (Table 3). Many adaptations were minor changes to make the program more appropriate, applicable, or acceptable (tailoring). A few changes required substitutions. For instance, one delivery method that caused participant discomfort was an exercise requiring parents to give commands to the trainers and thus the activity was changed. Instead, parents gave commands to a puppet that the trainer was manipulating.

Table 3.

Summary of cultural adaptations informed by focus group data and expert analysis with change and cultural codes¹

Description of change and rationale	Change codes2	Cultural codes
Tier 1
Created meaningful name, Cariño: Criando Niños con Cariño (Care: Raising Children with Care)	Tailoring	Language
Multiple substantial changes in the back-translation process where the exact translation did not convey intended meaning (i.e. changed strategic ignoring to ignoring on purpose, inside voice to quiet voice, parking lot to “question-keeper”)	Tailoring	Language
Included several culturally relevant metaphors (take the reins; don’t fall in the trap; you have to know when to shoot on goal; attention is like gold to a child; add fuel to the fire; losing their head)	Tailoring	Language
Reduced literacy throughout the curriculum: eliminated reading from group practice by having trainers read and families repeat back, eliminated writing from home practice activates, reduced/simplified language on parent handouts and added images	Tailoring	Language
Facilitated sessions with 2 Spanish-speaking, culturally competent trainers	Personnel	Staff
Tier 2
Substituted puppet for a trainer to animate during an activity to practice giving effective commands because parents felt uncomfortable giving trainers commands in role play due to trainers’ teacher/authority position	Substituting	Methods
Conducted mid-week makeup calls for parents who missed class/included additional review during in-person sessions due to attendance challenges	Repeating	Methods
Invited families to arrive 10 to 15 minutes early to chat with other parents to reflect values of personalismo	Format	Culture
Substituted names/activities with culturally relevant examples (e.g. soccer in place of baseball, Maria in place of Sally)	Substituting	Culture
Addressed corporal punishment and child abuse laws due to potential differences in national laws and cultural perceptions	Adding	Culture
Tier 3
Changed “trainers” to “promoters,” conveying their role as promoters of behavior change	Tailoring	Concepts
Changed “training” to “group program” to emphasize group dynamic and colectivismo	Tailoring	Concepts
Provided additional justification for 1-on-1play as it conflicts with cultural emphasis of Hispanic families doing things together as a group (colectivismo) (“These 3-5 minutes will be very special for your children, with the ultimate goal of cultivating a connection and also helping the child to behave themselves better.”)	Lengthening	Concepts
Changed “Letting the child lead playtime” to “Letting the child guide playtime” because deference given with age in Hispanic culture could result in friction with the idea that a child is leading/directing	Tailoring	Concepts
Acknowledged letting children lead/guide could be seen as disrespectful (respeto) and provided additional explanation (“Letting the child lead while you play together doesn’t mean you’re letting them direct every activity in the home.”)	Lengthening	Concepts
Emphasized that although praising a child for something that they are expected to do may not resonate culturally with Hispanic parents, this is a crucial skill that can improve parent-child relationships and child behavior	Lengthening	Concepts
Changed “When compliance is not required” to “When there’s more than one adequate response” to be consistent with concept of respeto, which would expect children to always obey	Tailoring	Concepts
Incorporated concept of familismo into group practice by praising sharing with family members and helping family members	Tailoring	Concepts
Provided extra rationale to address resistance to allowing bad behaviors to go unaddressed (“Provoking a response from a parent is one way a child demonstrates power in a situation, but if the parent pays attention to the child only when the parent decides to, this communicates to the child that the parent has the authority in the situation.”)	Adding	Concepts
Aligned Cariño goals with parent goals by incorporating the ideas of respeto, armonía, and educación in the program (“We start by establishing an even stronger and more caring relationship between you and your children, which will help cultivate respect, raise well-behaved children, and promote harmony in the family.”)	Adding	Goals
Reframed a core program goal as improving communication and strengthening relationships between parents and their children (rather than one parent and one child)	Tailoring	Goals
Invited other caregivers to the program and provided suggestions for how to discuss/share new skills with family members unable to attend	Adding	Goals

¹A detailed record of exact language, location, and justification of all changes is available from authors upon request.

²Change codes from Stirman (2013).

Some of the changes required more time dedicated to reframing a program concept (lengthening). For example, additional time was used to acknowledge that letting children lead/guide could be considered disrespectful and parents were reassured that letting a child lead during play does not mean the child will direct every activity in the home. Another concept that required additional attention was praising children for good behavior. It was recognized that although praising a child for something that they are expected to do (e.g., saying “thank you” or cleaning up toys) may not seem necessary, this is a crucial skill to improve child behavior. Other changes included additions such as explicitly aligning program goals with parent goals by incorporating the ideas of respect, harmony, and manners into the program introduction.

Cariño Pilot Study: Was it feasible and acceptable?

Of the 32 parents who completed at least 4 sessions, 15 (47%) participated in all 6 sessions, 12 (37%) participated in 5 sessions; and 5 (16%) participated in 4 sessions (Table 4). All parents who missed sessions participated in a make-up phone call with a trainer before the following session; 11 parents attended Cariño in-person and 21 parents attended Cariño virtually. There were no differences in attendance or satisfaction between the in-person and virtual participants. Furthermore, participants were generally satisfied with their participation in Cariño (Table 4). Among the 32 parents who completed the TAI following participation in Cariño, the mean score was 47 (out of a maximum of 50) with a range of 33 to 50.

Table 4.

Pilot outcomes (n=32)

	All (n=32)		In-Person (n=11)		Virtual (n=21)
	N	Percent	N	Percent	N	Percent
Attendance
4 sessions	5	16%	3	27%	2	10%
5 sessions	12	37%	5	45%	7	33%
6 sessions	15	47%	3	27%	12	57%
	Mean	Range	Mean	Range	Mean	Range
Therapy Attitude Inventory	47	33-50	48	38-50	47	33-50

DISCUSSION

In this cultural adaptation of the group parenting intervention PriCARE, we sought to make changes in a rigorous and reproduceable manner to increase intervention accessibility and appropriateness among Spanish-speaking, Hispanic families; to record the process in a systematic way; and to pilot the feasibility and acceptability of the adapted program in the target population. For the adaptation, we consulted the literature, engaged a panel of experts, conducted focus groups with previous and eligible participants, and continually sought participant and trainer feedback during an initial test of Cariño. Iterative changes to the new Cariño program were made and recorded throughout the process. We made a substantial number of changes by translating, revising, and fine-tuning the language; incorporating experiential elements; adjusting delivery methods as needed; clarifying concepts that may be unfamiliar; and reframing program goals to align with parent-described goals.

We found that with cultural adaptations, the Cariño intervention was feasible and acceptable for Spanish-speaking, Hispanic parents. In our pilot, 43% of the 121 invited parent-child dyads enrolled. Ultimately, 85% of the 52 parent-child dyads who enrolled attended at least 1 session and 62% attended 4 or more sessions. These enrollment and attendance rates are excellent and support the feasibility of Cariño. In previous research on parenting programs, only 4-18% of families expressing interest in parenting programs actually attended at least 1 session; of these, 40-60% dropped out even when financial incentives, childcare, refreshments, and transportation were provided.³⁵ Enrollment rates were lowest and dropout rates were highest among low-income families, racial and ethnic minorities, and non-English speaking families.⁴ Thus, our enrollment and attendance rates are particularly high for a low-income, non-English speaking population during a pandemic.

Among parent-child dyads enrolled in the Cariño pilot, high TAI scores suggested strong support for its acceptability. High rates of satisfaction were similarly reported by participants in Fortalezas Familiares,⁹ CANNE,¹⁰ and CAPAS,¹¹ three other group-based parenting programs culturally adapted for a Hispanic audience. Compared to Cariño, these interventions are slightly longer (8-12 sessions) and use different recruitment methods (e.g., school or community, vs. primary care), eligibility criteria (e.g., maternal depression or child behavioral problem vs. primary prevention), and delivery methods (community health worker vs. LCSW). Our study shared many of the methods employed by these previously published adaptations and similar changes in language, culture, and staff were made. The high satisfaction and attendance data reported in these adaptions and ours support the value of rigorous cultural adaptation.

In particular, we found cultural adaptation was essential for feasibility and acceptability and required an interactive process and attention to multiple aspects of intervention design. A priori adaptations involving language, setting, and staff could be made based on the literature and expert consultations. However, more mid-level adaptations to methods of delivery and content as well as high-level changes to goals and concepts required focus group feedback from our initial Cariño test participants and discussions with trainers on how best to adapt the curriculum.

Additionally, discussion with Hispanic parents participating in focus groups and pre- and post- interviews with participants in the Cariño pilot highlighted the importance of considering the broader social context when implementing parenting interventions for Hispanic parents. Over 90% of Cariño pilot participants were low-income and received some type of public assistance (e.g., Medicaid, TANF, or SNAP). Often their days were not structured by routines which occurred at specific times. Instead, their days were structured by sequences of events and the need for constant flexibility and adjustments due to unexpected events. In addition, 84% were worried about the deportation of themselves or family members. This made them cautious about leaving their homes to attend Cariño, especially in the evenings when they could not easily walk or obtain public transportation. Moreover, the COVID-19 pandemic began midway through the pilot study. Consequently, the intervention needed to be accessible at no additional cost to participants for transportation or childcare; the intervention needed to address the lack of routine in parents lives and their need for flexibility; and the intervention needed to be located in a safe environment to which the participants could easily walk or take public transportation. When the COVID-19 pandemic began and the intervention needed to transition to a virtual setting, additional steps needed to be taken to deliver materials to participants’ homes, ensure participants had access to the internet via a mobile phone or laptop, and instruct participants on how to connect to sessions via zoom.

This study has limitations, including limited generalizability due to its focus on the Hispanic population living in a single Southeastern US state. Given the specific nature of cultural adaptations, variations in geography and demographics may substantially affect the cultural reception or appropriateness of a given adaptation. Consequently, Cariño should be implemented and evaluated in other geographies in the future. In addition, we included only a small number of participants, and therefore may not have included all perspectives related to the target population. In particular, 20 participants (38%) were lost to follow-up in the Cariño pilot. Compared to those who completed the pilot, those lost to follow-up reported higher rates of moderate to severe anxiety and depression symptoms, two well-known barriers to participation in parenting interventions, ³⁶ and higher rates of dysfunctional parenting. This is unfortunate because these parents may be most likely to benefit from Cariño, which, similar to other positive parenting interventions, focuses on replacing maladaptive and dysfunctional parenting practices with evidence based positive behavioral management strategies. Future studies should seek to understand and improve the acceptability of Cariño to parents with depression, anxiety, and/or dysfunctional parenting. Finally, 78% of focus group participants and all pilot participants were women and therefore the adaptation may not reflect the experience of fathers. Women may be over-represented because mothers more often bring children to well-child visits where dyads were recruited; future studies should be more purposeful in recruiting fathers.

CONCLUSIONS

Existing parenting interventions can be successfully culturally adapted while applying a system to track, describe, and characterize the adaptations. This manuscript summarizes the process of adapting PriCARE based on a cultural adaptation framework, expert consultation, parent stakeholders, and an initial test implementation. The adapted program, Criando Niños con Cariño, incorporated multiple changes to ensure the translation reflected the intended meaning, to substitute cultural metaphors and culturally relevant examples, and to reframe the program goals and concepts in a culturally congruent manner. By systematically documenting what we changed, how we changed it, and why, we ensured that our adaptations are reproducible and paved the way for more rigorous evaluation. Pilot data demonstrate that Cariño is feasible and acceptable. The next step is to conduct a randomized controlled trial to evaluate the efficacy of Cariño for use with Spanish-speaking Hispanic populations in the US.