Impact Evaluation of Nadie es Perfecto, a Program to Improve Parenting Skills in Chile

Nobody's Perfect (NEP) has a long history, beginning with the work of community nurses in Canada in the 80s , they systematized the main concerns of parents of children under 6 years and develop a teaching a curriculum designed to cover all these needs. In 1987, and from the lessons learned by the first facilitators, the program reached across the country becoming today in the training program more widespread in the Canadian parenting skills.

In 2009, Nobody's Perfect began to be implemented in primary health care in Chile. Canada supported the training of facilitators and coaches first program in order to start their dissemination in 2010. To this end, Chile undertook the task of translating and adapting materials for parents, program facilitators and coaches. At the end of 2010, Chile had already begun implementing the program on a small scale first reaching a critical mass of 1320 under the original model trained facilitators. By the end of 2010 had been implemented 656 workshops. In August 2012, they have completed a total of 3,137 workshops in 768 health centers spread over 299 municipalities, with a total of 20,361 primary caregivers participants, resulting in a successful expansion and acceptance of the program to local communities.

Program Objectives
Nobody's Perfect is a training program to improve parenting skills to maintain and promote the health of their young children. It is based on a model of adult learning that focuses on the student and based on family strengths. The program uses the experiences of parents, and previous knowledge and individual capacities to shape group discussion and problem-solving activities, increasing and enhancing those that can be positive for the child and family.
Some basic assumptions of the program are:
-Nobody is born knowing how to be a dad or mom and all need information and support. Being part of a support group can help parents, mothers recognize their strengths and understand their needs.
-The help parents and caregivers (s) to meet their needs is an important help them meet the needs of their children step.
-The cultural background and life experiences of parents are valued and respected.
-Participants have a say in deciding what they will learn and the workshop is based on what they want and need to learn.
-The workshop allows them to increase self-confidence and self-esteem by providing opportunities to try new skills and behaviors
-The role of the facilitator is to remain neutral and help the group to find common ground where beliefs and values ​​of all participants are respected.
-Nobody is Perfect Basic consists of 6-8 group sessions free of cost.

Curriculum design and Intervention

Among the topics that parents and primary caregivers can choose are: Behavior, Safety and Prevention, Self-care of the Fathers, Mothers, Caregivers, The Mental Development and Physical Development. Of these issues a lot of specific topics among which derives feature: (i) the positive interactions between children and adults, (ii) the use of nonviolent discipline strategies, (iii) the importance of accident prevention, (iv) child nutrition, (v) the emotional relationship with the child, (vi) the basic health problems, (vii) self-care strategies for parents, and (viii) the creation of a stimulating environment and learning in childhood. Each of the themes contains practical activities during the sessions, learning materials and activities for the home.

Participants are five easy book to use, since its size is like a children's book, contain a clear and simple text, accompanied by drawings of colors and key messages underlined. The five books are named after the five main themes of NEP; Behavioral Safety and Prevention, Parents, Moms, Caregivers, Mental Development, Physical Development, which have been adapted and designed from the books of Canadian parents, specifically to be attractive and non-threatening for people with low literacy levels. The original drawings and contents are adapted to the Chilean culture and physiognomy of the local population. The Chilean edition of books for parents has been approved by Health Canada.

The books contain major issues concerning each topic of relevance to the development of children. Security focuses on preventing accidents, especially in arranging home for it, and first aid; Physical development is on the growth, health and disease, especially on the identification and initial response to common childhood illnesses; Behavior focuses on teaching or guiding children how to behave positively and resolution of common behavior problems at different ages; Mental development focuses on cognitive and emotional development, the importance of play and how to encourage children at different ages, and Fathers, mothers, caregivers focuses on a self-help adults, prevention of domestic violence and strategies to remain a healthy adult.

Additional materials, such as stickers with emergency phone numbers, posters to promote the program, a DVD entertainment with 30 topics covered in the books of NEP and a box of materials for the job of the facilitator to all centers provided providing primary care service NEP.
The "NEP Intensive" version includes sessions Canadian original model adapted to Chile, plus two additional sessions of direct interaction with children and their parents, including the entire group that participated in the first 6-8 sessions. The two additional sessions revolved around language stimulation and the importance of play. The content and additional training sessions were developed with input from a pilot infant stimulation program in Chile (Let's Play with Our Children), developed by the Catholic University. The intensive version of the program aims to strengthen the skills developed in the basic version of the workshop, now through opportunities to model the behavior and the effective exercise of the skills for the game and sensitive interaction with the child.

Nobody's Perfect program in Chile, is one of those early interventions that seek to positively influence parenting skills to parents, and thus positively impact the development of cognitive and non-cognitive skills of children in families with low income. Nobody's Perfect promotes learning through reflection on their own experience and personal situation, and observing their behavior, child behavior and positive parenting strategies. Through exercises with parents based on everyday experience of parenting and its history, this program explores the beliefs, attributions, knowledge, practices, goals and values ​​related to the skills that underlie the parental behavior of participants.
Training team

In 2009 thirty-two potential National Coaches were selected from among workers in the public network of all health services in the country. To become a National Coach, the health worker program facilitator should be first and have experienced the organization of group workshops with parents in primary health care, should also have the support of your direct employer and send a letter of application claiming an interest in being a coach. The thirty-two were trained in two groups of sixteen, directly by a Master Trainer sent by the Agency for Health Canada, and with the direct support of the team of Chile Grows with the Chilean Ministry of Health.

The training of more than 1,700 facilitators in Basic mode Nobody's Perfect nationwide was conducted between late 2009 and early 2010. The training workshop comprised at least 32 hours of training conducted by at least one of 32 national coaches certified by a senior coach of Canada. To be certified facilitator, you need to have completed 3 sets of parents. The training of facilitators incorporates didactic teaching, group discussion, role playing, practicing skills and papers evaluated. Through this training, participants learn to: manage group dynamics, identify potential problems, support parents in developing positive parenting skills and methods to address the behavior of children. A fortnightly monitoring is promoted to maintain fidelity and quality of groups.

Nobody's Perfect Chilean version includes two manualised components: Working with Nobody's Perfect: A Facilitator's Guide (2000), adapted by the Chilean Ministry of Health as Facilitator No Manual is Perfect (2009) and Nobody's perfect: Training Manual (2003) adapted by the Chilean Ministry of Health as "Manual for Trainers Nobody's Perfect" (2010). The first national coaches, the national team of Chile Grows with You, and a nurse head coach of Canada contributed to the adaptation of manuals. The adaptation was approved by Health Canada. A third manual to implement "Nobody's Perfect Intensive" was developed especially for this evaluation.

NEP is a parenting intervention operating in the context of a broader early childhood policy
platform called Chile Crece Contigo (ChCC). The intervention was adapted from the Nobody’s
Perfect program in Canada, a long-running group parenting intervention implemented within the
public health system in Canada. NEP relies on a semi-structured curriculum that promotes
knowledge about child development, parental self-care, positive parenting skills in caregivers, and
the use of non-violent disciplinary strategies, helping caregivers to foster a nurturing home
environment.
NEP targets parents with children aged 0 to 5 who are enrolled in the public health system.
Potential participants are offered participation in the program during the regular health check-ups,
home visits or immunization visits. The intervention can be applied to all parents who are
interested in improving their parental skills, but it is more directly targeted to caregivers who are
particularly vulnerable, such as adolescents, single parents, and geographically or socially isolated
households. Parents in these groups, and other parents who are in need of this type of intervention,
can be identified by the health care provider (doctor or nurse) with whom they interact frequently.
Households at very high risk (children with severe child developmental delays or disabilities, or
high-risk parents with psychiatric problems or intra-household violence) are not considered
eligible for NEP and are instead referred to services with more intensive engagements at the local
level.
The standard program (which we call NEP-Basic, or NEP-B) includes 6 to 8 weekly group sessions
with 6-12 caregivers, facilitated by a trained moderator, and based on a curriculum that promotes
positive parenting skills to improve cognitive stimulation, to manage child behavior with positive
disciplinary strategies, and to improve their parental self-esteem. Each session lasts approximately
two hours. An intensive version (NEP-Intensive, or NEP-I) was developed as part of the study as
an additional evaluation arm. It adds to NEP-B two practical sessions with children in order to give
caregivers the opportunity to interact with their child in a monitored environment and thereby
receive more personalized feedback on their practices.

2011-07-10

2012-04-30

Language (Spanish version of the Preschool Language Scale (PLS-4), Test de Vocabulario en Imágenes (TEVI-R)
Executive Function (Dimensional Change Card Sort (DCCS) task, Leiter-R scale)
Socioemotional Development (BattelleDevelopmental Inventory Screening Test (BDIST II) personal-social scale), Achenbach Child Behavior Checklist (CBCL))

Cognitive stimulation: Family care indicators (FCI), Home Observation Measurement of the Environment (HOME) Short Form
Socioemotional stimulation: Parent Behavior Checklist (PBC)
Parenting beliefs: Parenting Sense of Competence Scale (PSCS), Parental Cognitions and Conduct toward the Infant Scale (PACOTIS)
Parenting style: Ideas about Parenting (IAP)

Our study draws on a representative sample from 162 health clinics nationwide that were selected from a pool of 250 health clinics that had adopted program by the end of 2010, at early stages of the program roll-out (by the end of 2011, more than 600 health clinics had done so). Excluded centers were those that lacked two trained NEP facilitators or there was no management support to implement the group sessions (Figure 3). In close collaboration with the MoH and participating health centers, the research team developed a roster of potential participants at each location in line with NEP's standard recruitment practices. From April to June 2011, facilitators compiled a waitlist of approximately 80 potentially eligible families with at least one child aged 0-5 per health center. Out of them, 45-60 families met the NEP's inclusion and exclusion criteria, and were invited to take part in the study and formally enrolled following an interview with a NEP facilitator. During this session, they received detailed information about the study and were presented with the informed consent form to read and sign. Participation refusal was exceptionally rare.
These waitlists allowed for the formation of three potential groups of 15-20 households within each health center. Inclusion criteria included caregivers with at least one child aged 0-5 years who were willing to improve their caregivers’ parenting skills, and households deemed vulnerable based on psychosocial evaluations conducted during regular health check-ups or identified by health professionals as at risk. Exclusion criteria ruled out families facing severe adversities such as domestic violence, significant mental health issues, and critical child developmental delays or behavioral problems requiring specialized care, who were instead referred to individualized services.
Using these waitlists, we implemented a two-stage randomization process. First, the 45-60 families were randomly assigned to three groups: 1/3 to NEP-B, 1/3 to NEP-I, and the remaining 1/3 to the control group. Second, within each group we restricted the sample size and invited 6 families to be part of the survey data collection. Importantly, families not selected to be part of the study were still invited to attend the NEP sessions. The control group remained on a waitlist until the follow-up survey was conducted and these families continued to receive their usual standard of care at the health center, but no NEP.

Randomization was done through a website dedicated to the recruitment.

households

No

2916 households

2916 households

972 households control, 972 households NEP-Basico, 972 households NEP-intensivo

With an expected 40% participation rate and 10% attrition by the time of the endline survey, our goal is to detect an ITT impact of the program of at least 0.12 SD on different indicators of parental beliefs and practices, and child development.

We present results from a large-scale experimental evaluation of a national parenting program in Chile. The program is low cost: it lasts only 6–8 weeks, and it is administered to groups of eight to 12 parents. It is implemented by the national health system, taking advantage of its existing physical infrastructure and human resources. We find that 3 years after the interventions ends, children whose parents are offered the opportunity to participate in this program increase their vocabulary and socioemotional development scores by 0.1 standard deviations, mirrored by similar improvements in caregiver’s parenting behaviors and beliefs.

Impacts of a Large-Scale Parenting Program: Experimental Evidence from Chile Pedro Carneiro, Emanuela Galasso, Italo Lopez Garcia, Paula Bedregal, and Miguel Cordero Journal of Political Economy 2024 132:4, 1113-1161

https://doi.org/10.1086/727288