Gac Sanit. 2019;33(1):10–16 Original article Effectiveness of a parent-training program in Spain: reducing the Southern European evaluation gap Noelia Vázqueza,b,∗ , M. Cruz Molinaa , Pilar Ramosa , Lucía Artazcoza,c,d,e a Public Health Agency of Barcelona, Barcelona, Spain b Department of Research Methods and Diagnosis in Education, University of Barcelona, Barcelona, Spain c Institute of Biomedical Research Sant Pau, Barcelona, Spain d CIBER of Epidemiology and Public Health (CIBERESP), Spain e Department of Experimental and Health Sciences, University of Pompeu Fabra, Barcelona, Spain a r t i c l e i n f o a b s t r a c t Article history: Objective: We implemented and evaluated the Parenting Skills Program for families in Spain 1) to examine Received 27 March 2017 differences in parenting skills, social support, children’s behaviours and parental stress pre, immediately Accepted 19 June 2017 post and six months post intervention and 2) to identify mechanisms by which the intervention is related Available online 9 August 2017 to changes in the four outcomes examined. Methods: Quasi-experimental study design with pre (T0), post (T1), a follow-up (T2) and no control group, Keywords: complemented by a qualitative study was used. The outcome variables were social support, parenting Parent-training skills, parental stress and children’s behaviours. 216 parents completed pre and post questionnaire and Program evaluation Social support 130 parents the follow-up questionnaire. 39 professionals and 34 parents participated in 17 interviews Parenting skills and 5 discussion groups. Parental stress Results: Compared with T0, all four outcomes improved significantly at T1. 76% of the participants Child behaviour improved parenting skills and 61% social support. 56% reduced children’s negative behaviours and 66% parental stress. All outcomes maintained this significant improvement at T2. Parents and professionals describe different changes in parents’ parenting skills, stress and social support after participation in the PSP, and in their children’s behaviours. Some subcategories emerged after analysing parents’ and professionals’ discourses. Conclusions: This study describes positive parenting effects on participants of a parent-training program in Spain, which is a country where implementation and evaluation of these kind of interventions is an incipient issue. © 2017 SESPAS. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Efectividad de un programa de educación parental en España: reducir la brecha en cuanto a evaluación en el sur de Europa r e s u m e n Palabras clave: Objetivo: Se introdujo y evaluó el Programa de Habilidades Parentales para familias a fin de: 1) exami- Educación parental nar las diferencias en cuanto a habilidades parentales, apoyo social, comportamientos infantiles y estrés Evaluación de programas parental preintervención, inmediatamente después y 6 meses después de la intervención, y 2) identi- Apoyo social ficar los mecanismos que explican los cambios generados por la intervención para las cuatro variables Habilidades parentales examinadas. Estrés parental Comportamiento infantil Método: Estudio cuasiexperimental con pre (T0), post (T1) y seguimiento (T2), sin grupo control, com- plementado con un estudio cualitativo. Variables: apoyo social, habilidades parentales, estrés parental y comportamientos infantiles. Completaron el cuestionario pre y post 216 padres/madres, y 130 el de seguimiento. Treinta y nueve profesionales y 34 padres/madres participaron en 17 entrevistas y cinco grupos de discusión. Resultados: Comparado con T0, las cuatro variables mejoraron significativamente en T1. El 76% de los participantes mejoraron las habilidades parentales y el 61% el apoyo social. El 56% redujo los compor- tamientos infantiles negativos y el 66% el estrés parental. Las variables mantuvieron significativa la mejora en T2. Padres/madres y profesionales describieron cambios en las cuatro variables tras participar en el Programa de Habilidades Parentales. Surgieron subcategorías tras el análisis discursivo. Conclusiones: Este estudio describe efectos positivos en la parentalidad de los participantes en un pro- grama de educación parental español, siendo este un país donde la introducción y la evaluación de este tipo de programas son incipientes. © 2017 SESPAS. Publicado por Elsevier España, S.L.U. Este es un artı́culo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/). ∗ Corresponding author. E-mail address: nvazquez@aspb.cat (N. Vázquez). https://doi.org/10.1016/j.gaceta.2017.06.005 0213-9111/© 2017 SESPAS. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc- nd/4.0/). N. Vázquez et al. / Gac Sanit. 2019;33(1):10–16 11 Introduction their children age. The main contents of the program are devel- opment stages understanding; attention, respect, recognition and Positive parenting is defined as ‘parental behaviour based on the warmth needs; self-esteem and assertiveness; active listening and best interest of the child that is nurturing, empowering, non-violent empathy; effective communication; problem-solving; negotiation and provides recognition and guidance which involves setting of and agreements; everyday family organization and boundaries boundaries to enable the full development of the child’.1 There and norms for children’s behaviour regulation. The PSP was piloted is evidence of a relationship between positive parenting and chil- between 2011 and 2013.11 dren’s development in different socioeconomic contexts.2 Coercive parental behaviours have been related to children experiencing dif- Research design ficulties in self-regulation and aggressiveness, while warmth and effective parental communication have been associated with pos- This is a quasi-experimental study with measures before, imme- itive child development.3 Moreover, parenting effects go beyond diately after the-intervention and after a follow-up of six months childhood, having consequences in adolescence and adulthood. (T0, T1 and T2, respectively), with no control group. It combines Insecure emotional attachment, lack of stimulation and failure to quantitative and qualitative methods. The quantitative study aimed regulate problem behaviours during childhood are associated with to identify the magnitude of changes from the baseline situation, children’s negative development leading to mental problems in immediately and six months later in the four outcomes examined. teenagers,4 as well as academic underachievement, engagement in The objectives of the qualitative study were descriptive and explan- risky, aggressive or criminal conduct during adolescence (violence, atory. Specifically, the aim was to identify mechanisms related drug use, unsafe sexual relations).5 to changes in the four outcomes examined, increasing breadth of Parent-training programs aim to improve children and adoles- understanding of quantitative outcomes. cents positive development by giving parents or primary caregivers knowledge about child development, and teaching them skills and self-efficacy for effective parenting (e.g., praise or appro- Sample and data collection priate discipline).6 They have shown positive effects on several health indicators such as reduction of risky health behaviours, Professionals involved in the intervention: 1) worked in social, reduction of unintended pregnancy, improvements on emotional health or educational services or in socio-educational associations child/adolescent regulation, stress and depression reductions or related to family’s issues; 2) received training on PSP; and 3) self-esteem increments.7,8 implemented the interventions in Catalonia, primarily in Barcelona. These interventions have been extensively used and evaluated Parents selected to participate: 1) had children 2 to 12 years old; 2) primarily in Anglo-Saxon countries and in some Central Euro- spoke Catalan or Spanish; 3) had not participated in other parent- pean countries. However, parenting programs are an incipient training program; and 4) were recruited by education, health or issue in Southern European countries9 where, although implemen- social services or socio-educational associations. Professionals used tation of such programs has increased in recent years, in most different types of recruitment strategies (poster, personal inter- cases they lack standard implementation and any evaluation of the views, phone calls. . .). intervention.10 In order to overcome these limitations Southern European Quantitative sub-study countries, and specifically in Spain, a group-based parent- training intervention [Parenting Skills Program for families (PSP)] A questionnaire with five sections was used in order to col- was developed, implemented and preliminary evaluated in lect data from parents about: 1) parental stress, 2) social support, Barcelona.11,12 The objectives of this study were: 1) to compare 3) parenting skills, 4) children’s negative behaviours, and 5) parenting skills, social support, children’s behaviours and parental sociodemographic profile. The four initial sections were based on stress before the parent-training intervention, immediately after it, previously validated scales in similar populations. The first section and again after six-months, and 2) to identify the mechanisms by included the Spanish version of the Parental Stress Scale16 con- which the intervention is related to changes in the four outcomes sisting of 12 items distributed in two subscales (baby’s rewards examined. [␣ = 0.77] and stressors [␣ = 0.76]) scored on a five point Lik- ert scale (degrees of agreement/disagreement) (points scored Methods between 1-5). Section two included the Duke-UNC Functional Social Support Questionnaire17 consisting of eight items grouped Description of the intervention into two subscales (confident [␣ = 0,92] and emotional [␣ = 0,81] social support) scored with a five point Likert temporal scale In the context of the community health strategy “Health in (points scored between 1-5). Section three used a scale that the Neighbourhoods”13 in Barcelona (Spain), parenting problems included 19 items distributed into six dimensions of parental were identified as a community problem. After confirming that no skills, scored using a four point Likert temporal scale (points parent-training interventions based on a theoretical framework scored between 0-3), which has previously been translated into had been previously used in the city, the Parenting Skills Program Spanish and validated.18 Its subscales were: 1) children’s under- for families (PSP) was designed and implemented. PSP is based on standing, 2) emotional self-regulation, 3) parenting self-esteem, the “Program Guide to Development of Emotional, Educational, and 4) empathetic and assertive communication, 5) agreements, and Parental Competencies”,14 which includes components associated 6) behavioural regulation (Cronbach alpha ranged between 0,69 with more effective parent training programs and, in addition, for subscale 6 and 0,89 for subscale 4). The fourth section used incorporates scientific recommendations.15 The program consists the five-item problems behaviours subscale of the Strength and of 11 weekly sessions of 90 minutes in which, following written Difficulties Questionnaire (␣ = 0,83)19 where items are scored on guidelines, 10-14 parents with children 2-17 years old participate. a three point Likert scale (points scored between 0-2). The fifth Children only participate in two sessions. The program suggests section collected sociodemographic data about sex, age, coun- some different strategies depending on the children’s age, but the try of birth, marital status, educational level and employment core components are the same. Parents are grouped according to status. 12 N. Vázquez et al. / Gac Sanit. 2019;33(1):10–16 Twenty-two groups were carried out between 2013 and 2015, Qualitative sub-study 257 parents started the intervention and 216 completed the ques- tionnaire both at baseline and immediately after the intervention The qualitative information was audio recorded and then tran- (84% retention rate), and 130 of these completed it six months after scribed. After that, a content analysis performed by an external the intervention (51% retention rate). researcher using a system of categories previously created by one researcher and checked by the other two, based on the quantita- Qualitative sub-study tive sub-study and on theoretical considerations. The categories were: 1) general effects, 2) positive factors, 3) barriers, 4) parent- The qualitative study included 39 professionals and 34 parents, ing skills effects, 5) children’s behaviour effects, 6) parental stress who participated in seventeen semi-structured interviews and five effects, 7) social support effects, 8) outcome variables relationships, discussion groups. These instruments were used to collect infor- 9) personal determinants of change, and 10) contextual determi- mation to describe the main effects of the PSP and the processes nants of change. These categories were the same for each of the explaining these effects. They were conducted immediately after informants’ transcriptions. The first step of the analysis was textual, finishing the PSP sessions by an external researcher in an isolated, selecting quotes from transcripts of the interviews and discussion comfortable setting. Depending on the number of people, we used groups. The second step was conceptual in order to identify emer- focus group scripts (for parents) and group or individual inter- gent subcategories and the interrelations between them. These view scripts (for professionals). Sessions duration were variable, were defined when the data had reached saturation. For the quali- depending on the number of participants (0.5-1.5 hours). Scripts tative analysis, the Atlas.ti 6.2 program was used. Some quotes were were prepared based on a literature review of the subject in which selected and organized according to the emergent subcategories in key elements to be examined were identified and were related to order to show the main effects of the PSP as well as the processes quantitative instruments. The questions sought to provide oppor- that could explain them. tunities for participants to present their own experiences (parents) or parents’ experiences (professionals) in processes of participa- Ethical considerations tion in PSP. Scripts had seven questions piloted before starting the evaluation study. They were similar for professionals and parents, Ethical considerations were taken into account in the study. but worded differently. They focus on: a) the main effects of PSP; Participants received a document where the research process was b) the mechanisms of changes associated to the four outcomes explained and granted their authorization by signing an informed analysed; and c) the individual or social variables related to those consent. Two datasets were created, one with personal informa- effects. tion and a code assigned to each participant, and another without We analysed information from 12 secondary documents with personal information and with the code and the different variables. facilitators notes about the program effects. The parents who par- Participants were informed about the study during the implemen- ticipate in the qualitative study were a subsample of those included tation of the qualitative study. The research procedure adhered to in the quantitative sub-study. Some of them deny their participa- the Barcelona Public Health Agency and University of Barcelona tion in the qualitative sub-study because they did not have time to protocols of ethical considerations for good research practices of attend the focus groups or interviews or because they did not want the ethical committee of each institution. It followed all legal to share their experiences verbally with an external researcher. requirements. Data collection ended when data saturation was reached. Variables and data analysis Results Quantitative and qualitative data were collected and analysed Description of the sample separately and they were triangulated at the discussion phase. Data came from 22 groups of 10-14 parents with a child 2-12 Quantitative sub-study years old. Most parents were married or cohabiting, almost one third were 36-40 years old; 40% were immigrants, mostly from Sociodemographic variables were sex (woman vs. man), age Latin-American countries; one quarter had primary studies or less (<30 years old, 30-35 years old, 36-40 years old or > 40 years old), and 31% were unemployed. The main reasons for not finalizing the origin (born in Spain vs born in other country), marital status intervention were work-related factors (e.g. change in work sched- (married or cohabiting vs non-cohabiting), educational level (no ule or finding a job), family reasons (having a new child or caring studies or primary studies, secondary studies or university stud- for a dependant relative) and change of house. Difficulties to con- ies finished) and employment status (unemployed, homemakers, tact participants after six months (because they changed mobile employed or others). Four outcomes were examined: parent- phone number, they didn’t answer to phone call or they move to ing skills, parental stress, social support and children’s negative another city) were the main reason for losses to follow-up and behaviours. For parenting skill variables, results were examined for most of them where men and people with secondary educational each dimension separately. Regarding the scales, pre-, immediate- level. Statistically significant differences between participants in post and 6-month post-intervention item scores for each variable the pre-intervention and in the immediate post-intervention were were summed and medians calculated. The bivariate association observed for educational level with people with secondary studies between sociodemographic and outcome variables were tested being more likely to drop out. When participants who started the with the chi square test. Differences between T0, T1 and T2 were intervention were compared with those followed up at six months, analysed. The percentage of parents that showed any improve- the same pattern for educational level was found and addition- ment between baseline and immediately after the intervention, and ally the proportion of men at the follow-up significantly decreased between baseline and six months after the intervention were cal- (Table 1). Most participants had one child (between 34%) or two culated for the four outcomes. Since the Kolgomorov-Smirnov test children (between 43%), most of whom were aged between 3 and 5 confirmed a non-normal distribution of data, medians were com- years; 50% were girls. Professionals (n = 39) were 95% women and pared through the non-parametric Friedman test, carried out with 51% were community nurses. All of them implemented PSP and had SPSS.20. previous experience as facilitators of family groups. N. Vázquez et al. / Gac Sanit. 2019;33(1):10–16 13 Table 1 in these situations should be to avoid returning to prior patterns General description of the parents participating in the different phases of the of behaviour.20 This study is considered a success in this respect intervention. because improvements remained significant at the follow-up six T0 T1 T2 months later. N % N % N % Our study is consistent with others reporting that parent- training programs have positive short-term quantitative effects,21 Total 257 100 216 100 130 100 however there are fewer mixed and follow-up studies evalu- Sex ating effects in parental psychosocial health22 or on children’s Woman 224 87.2 191 88.4 121 93.0 behaviours.7 In addition, many of these evaluation studies only Man 33 12.8 25 11.6 9 6.9b explore one outcome, but few simultaneously explore more than Age (years) one.8 In Spain this gap is more evident because the vast major- <30 50 19.6 42 19.6 23 18.0 30-35 64 25.1 55 25.7 35 27.3 ity focus only on parenting skills23 and there is a lack of programs 36-40 81 31.8 65 30.4 36 28.1 showing effects on children and on parental stress. This study con- >40 60 23.5 52 24.3 34 26.6 tributes to fill this gap with similar evidence as that reported by Country of birth studies in other countries. Spain 152 59.4 131 60.9 76 58.5 The reduction observed in children’s negative behaviours, such Other 104 40.6 84 39.1 54 41.5 as aggressiveness or defiance, but also the increase in chil- Latin America 51 49.0 40 47.6 22 40.7 dren’s positive behaviours, was consistent with studies from other Africa 22 21.2 20 23.8 16 29.6 Europe 16 15.4 14 16.7 11 20.4 countries (immediately and six months after the intervention).24 Others 15 14.4 10 11.9 5 9.3 Children’s improvement in their ability to express feelings and communicate with their environment, understand parents Marital status Cohabiting or married 196 76.9 165 77.1 106 81.5 demands or improve some habits (sleeping, hygiene or others)25 Neither cohabiting nor married 59 23.1 49 22.9 24 18.5 have been previously reported. Previous studies also show that changes in children should be understood as a consequence of Educational level University 92 37.9 79 38.7 60 48.4 changes in parenting.26 Secondary 90 37.0 68 33.4a 33 26.6c Studies carried out in other countries have reported stress Primary or lower 61 25.1 57 27.9 31 25.0 reduction immediately after intervention22 and six months later.24 Employment status Some of the mechanisms consistent with our study were that Unemployed 80 31.4 65 30.4 35 26.9 parents learned to understand children’s behaviours and what is Workers 105 41.2 89 41.6 56 43.1 expected of them according to their needs.27 In addition, they incor- Homemakers 50 19.6 45 21.0 28 21.5 porated strategies to manage their anxiety and learned how to keep Others 20 7.8 15 7.0 11 8.5 calm.28 Furthermore, they perceived that other parents felt similar T0: baseline; T1: immediately after the intervention; T2: 6 months after the inter- concerns of self-demand,29 and that also helped them to reduce vention. a stress. p <0.05. b p <0.01. Finally, findings about the effects of parent-training programs c p <0.001. in social support are contradictory. Although some metanalyses30 concluded that social support effects were not significant, they also suggested that quantitative instruments were not designed to col- Quantitative sub-study lect data about specific social support associated via qualitative Table 2 presents medians of the evolution of the 216 partic- studies with effects of parent-training programs (for example, peer ipants who completed the intervention. Compared with T0, all support). However, other studies are consistent with our findings.31 outcomes significantly improved at T1. Specifically, 76% of the Qualitative findings provided answers to these divergences and participants improved their parenting skills, 56% reduced chil- shown that parents felt isolated in parenting.28 Yet, after partic- dren’s negative behaviours, 66% decreased parental stress and 61% ipating in a parent-training program this situation changed and reported increased social support. parents identified the program content and the facilitator strate- Table 3 presents the results of the follow-up six months after gies as a source of social support for improving their parenting the intervention. All the outcomes significantly improved and the skills.32 In other studies parent peer support was identified as a magnitude of the percentages of improvement was similar to that main social support, not only during program implementation, but seen at T1 for most outcomes. also afterwards.31 Qualitative sub-study Limitations Parents and professionals described different types of changes This study has several limitations. The response rate immedi- in parents’ parenting skills, stress and social support and in the ately after the intervention (84%) was higher than in some previous children’s behaviours after the participation in the PSP. Table 4 studies7 and similar to other studies that have been highlighted shows emergent subcategories resulting from parents and profes- as successful because of their high participation.33 However, the sionals’ discourses. These allow us to identify the main changes for higher dropout rate at the six-month follow-up was a limitation. each outcome. Different quotes are included to illustrate each main Almost half of the sample was lost to follow-up after six months, effect of participation in the PSP. again similar to other studies.34 The causes of this dropout were the difficulties to contact or meet with families 6 months later Discussion of the intervention (telephone number or living place changes, or they did not answer phone calls). In the future, specific recruitment As far as we know, this is the first study in Spain where a parent- strategies should be implemented in order to reduce the dropout training program shows a positive impact in four outcomes both in this phase of data collection (i.e. incentives or reminder con- immediately after the intervention and six months later, and the tent session). This was an important limitation and the follow-up qualitative mechanisms that specified that changes. The challenge results should be viewed with caution, because the trend observed 14 N. Vázquez et al. / Gac Sanit. 2019;33(1):10–16 Table 2 Comparison of scores before and immediately after the intervention. T0 Participants that improved from T0 to T1 Dependent variables N Md (IR) T1 %b Md (IR) Total parenting skills (57 points) 216 35 (30-40) 40 (36-47)a 76 DI - Children’s understanding (3 points) 216 2 (1-2) 2 (2-2) 38 DII - Emotional self-regulation (6 points) 216 3 (2-4) 4 (3-4)a 47 DIII - Parenting self-esteem (15 points) 216 10 (8-12) 12 (10-13)a 64 DIV - Empathetic and assertive communication (12 points) 216 9 (6.8-10) 11 (9-11)a 61 DV - Agreements (15 points) 216 8 (7-10) 10 (9-12)a 66 DVI - Behavioural regulation (6 points) 216 3 (1-4) 4 (3-5)a 56 Children’s negative behaviours (10 points) 202 3 (2-4.3) 2 (0-3) 56 Parental stress (60 points) 216 29 (23-35.3) 23 (20-27)a 66 Social support (40 points) 216 30 (20-36) 36 (28,8-39)a 61 IR: interquartile range; Md: median; N: participants. a Friedman test p<0.001. b Participants that improved in the post-test compared with pre-test [(N that improved/ total N) x 100]. Table 3 Comparison of scores before, immediately after the intervention and six months later. Participants that improved from T0 to T2 Dependent variable N T0 T1 T2 % Md (IR) Md (IR) Md (IR) Total parenting skills (57 points) 130 37 (30.8-40) 43 (38.8-49) 40 (36-44)b 71.5 DI - Children’s understanding (3 points) 130 2 (1-2) 2 (2-3) 2 (2-2)b 36.2 DII - Emotional self-regulation (6 points) 130 3 (2-4) 4 (3-4) 4 (3-4)a 43.8 DIII - Parenting self-esteem (15 points) 130 10 (8-12) 12 (11-14) 12 (10-13)b 67.8 DIV - Empathetic and assertive communication (12 points) 130 9 (7-10.3) 11 (9-11) 10.5 (9-11)b 59.2 DV - Agreements (15 points) 130 9 (6-11) 10 (9-13) 10 (9-11)b 56.2 DVI - Behaviour regulation (6 points) 130 3 (1-4) 4 (3-5) 3 (2-4)b 53.1 Children’s negative behaviours (10 points) 118 3 (1.8-4) 1.5 (0-3) 2 (0-2.3)b 57.6 Parental stress (60 points) 129 27 (23-37) 23 (17.5-27) 24 (21-28)b 58.1 Social support (40 points) 128 32 (20-36.8) 37 (31-39) 36 (28-38)b 60.9 IR: interquartile range; Md: median; N: participants. Friedman test:. a p < 0.01. b p < 0.001 participants that improved in the post-test compared with pre-test [(N that improved/total N) ×100]. in post-intervention results is less robust because of the sample reduction. Another limitation was that a randomized control trial design with a control group was not used. Therefore, the quantitative out- What is known about the topic? comes identified should be viewed with caution and considered The evaluation of parent-training programs is an incipient as an association and not a direct effect caused by the interven- issue in Southern European countries. Moreover, most previ- tion. Although randomized control trial is the most recommended ous studies have only assessed results immediately after the design for effectiveness evaluation, some authors35 consider that end of the intervention, whereas this study also includes the the evaluations with no control group should be accepted when results after six months of follow-up. an intervention is well developed, meets generally accepted stan- dards, and qualitative methods show the involved mechanisms. What does this study add to the literature? Therefore, our qualitative findings helped to reduce this limitation, and contributed to confirm effects caused by PSP. This parent-training program is effective for improving par- enting skills, children behaviours, parental stress and social Conclusions support immediately and six-months after participation. Quan- titative and qualitative findings are described. The quantitative and qualitative findings show that parents PSP participants not only improved in aspects directly related to the intervention (parenting skills) but also in others related to the for- mation of positive parenting and family wellbeing (social support, parental stress, and children’s behaviour). In addition, these pos- itive effects with respect to the four indicators were maintained after six months without returning to pre-intervention values. Transparency declaration Therefore, PSP seems to be an effective intervention to promote positive parenting and family wellbeing. The corresponding author on behalf of the other authors guar- antee the accuracy, transparency and honesty of the data and Editor in charge information contained in the study, that no relevant information has been omitted and that all discrepancies between authors have Carlos Álvarez-Dardet. been adequately resolved and described. N. Vázquez et al. / Gac Sanit. 2019;33(1):10–16 15 Table 4 Qualitative findings summary. Category Emergent subcategory Quotes Parenting skills changes Doubts and fear resolution “When you educate a child sometimes some things happen and you don’t know why they happen, and with this all became coherent” (Parent) Need more time to show or to put into action some “Sometimes, I don’t have time to put into action some things that I have changes learnt” (Parent) Parenting self-confidence “Sometimes you have doubts like Am I doing it well? And now, I feel more confident and I say to me ‘you are doing it well!’” (Parent) Parent understanding of the child “Each children learn different according to their age” (Parent) Self and children esteem “To love me a little bit more” (Parent) “That children learnt to accept that they were wrong and also that they have virtues” (Parent) Own relax moments “It has given security, but also they are now no longer hard on themselves. . . They want to do it all so well, perfect. . . and it generates them stress. Sessions have been useful for them because now they say ‘Well, today is not my day and maybe I will not be a perfect parent and it doesn’t matter’. Forgiving and reduce distress” (Professional) Listening and communication skills “Express my feelings and that my daughter express their feeling to me” (Parent) Agreements, norms and conflict solving “Not shout in little conflicts and to put in my children’s position” (Parent) Specific strategies “Now parents use colour stickers to manage children behaviours” (Professional) Children’s behaviours Children’s understanding of some responses “Children are more sympathetic, they listen more” (Parents) changes Specific behaviours improved (huff. . .) “Teachers say that children are more calm, and answer badly less often” (Professional) Feelings communication “She (my daughter) is more communicative, and try to express her feelings” (Parent) Family routines (set the table, pick up toys. . .) “Now she is responsible of brushing her teeth” (Parent) Need more time to identify some changes in “In some cases children’s changes has been evident, and in others we think children that it will occur” (Professional) Parental stress changes Understanding of causes and strategies to reduce “Now I am calmer and I feel better. . .Before the program I hopped mad parental stress quickly. These sessions helped me to manage my feelings” (Parent) Understanding of causes and strategies that “There were things that she could not decide because her mother got increase parental stress between child-mother relation. Now she told us that she try to search strategies to reduce the anxiety that this generates” (Professional) Social support changes Isolation perception before program participation “Parenting is difficult and especially in big cities you feel isolated and with this sessions I feel better” (Parent) Perception of facilitator and program contents as a “Program contents are a support resource. . .and also facilitators help us” support resource (Parent) Context as a parenting support resource “You feel that the society, your community, is interested in this issue. . . Know that in your school is offered that. . . or from public institutions. . . so you feel supported” (Parent) Parent peer support “To share experiences with parents in similar situations and to know different points of view help you to have more reasons to cope situations and to feel more sure taking a decision” (Parent) Variables relation Parent’s changes as causes of children’s changes “One of the mothers was this kind of mothers that dress up, wash. . .and do everything instead of her daughter. Now she feels more capable to let her doing some things alone. She sees that her daughter goes better” (Professional) Understanding of the consequences of proceeding “I feel less nervous. Now I regret less about things that in the past I did it with and without stress without thinking because I was angry and with anxiety” (Parent) Description of consequences of social support “They created a net to exchange ideas, counsels, examples or things that received (availability of other parents to solve they feel. . . To explain their progresses. A kind of blog” (Professional) doubts or babysitting, more knowledge and “I was useful to be aware that on the health care services we do not have consultation of community services. . .) only paediatrics, we also attend adults. They saw that we also take care of parents and not only of children” (Professional) Authorship contributions Government of Catalonia (FI DGR 2013). None of the authors of this paper has a competing interest, financial or otherwise, in any of the All authors designed the study. N. Vázquez and L. Artazcoz ana- programs or interventions included in this review. lyzed data quantitative data and N. Vázquez, analyzed qualitative data and M.C. Molina and P. Ramos supported her. All authors con- Conflicts of interests tributed reviewing the literature, editing all versions of the paper and providing relevant contributions. All authors approved the final None. version. References Funding 1. Recommendation Rec(2006)19 of the Committee of Ministers to member States on policy to support positive parenting. (Adopted by the Committee of Ministers on 13 December 2012 at the 983th meeting of the Ministers’ This study has been developed as part of a PhD project Deputies). Available at: http://www.coe.int/t/dc/files/ministerial conferences/ financed and the PhD student was contract with a grant from the 2009 family affairs/Positive Parenting en.pdf 16 N. Vázquez et al. / Gac Sanit. 2019;33(1):10–16 2. Morrison J, Pikhart H, Ruiz M, et al. Systematic review of parenting interventions 20. Pritchett AM, Foreyt JP, Mann DL. 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