Ladnaan - an Evaluation of a Parent Support Program for Somali Parents
Condition: Mental Illness
MeSH terms: Mental Disorders
Study type: Interventional

Summary: 
      The aim of this project is to evaluate the effectiveness of a culturally adapted parenting
      support program for Somali parents living in Sweden on children's and parent´s mental health.
      In recent years the Somali population in Sweden has increased and is currently one of the
      largest groups among ethnic minorities. Most of the Somali people have arrived as refugees
      and have experienced war, trauma and conflict. Research shows that migration to a new social
      context/society is challenging for a family and may together with previous experiences of
      war, separation, create stress and mental illness. This leads to consequences such as family
      violence, child abuse, relational problems, drug problems and school problems for children.
      There is a vast knowledge on the association between parents' mental health, positive
      parent-child relationship and children's health and well-being. Previous studies have shown
      that parenting programs aimed to support parent-child relationship and/or improve parental
      skills have positive effects on parental mental health and on children's behavior. Most
      municipalities in Sweden offer their residents a structured parenting program, but these
      programs do not reach those of ethnic minorities. Studies show that parenting programs mainly
      target parents who can speak Swedish fluently and that the parenting programs are not yet
      culturally adapted.
    

Detailed description: 
      In recent years the Somali population in Sweden has increased and is currently one of the
      largest groups among ethnic minorities in Sweden (http://www.scb.se). Most of the Somali
      people living in Sweden have arrived as refugees and they have experienced war, trauma and
      conflict. Research shows that migration to a new social context/society is challenging for a
      family and may together with previous experiences of war, separation, create mental
      ill-health (Bhugra, 2004; FoU, 2008). According to several studies, refugee families have
      poorer health and low social status compared to the native Swedish (Bhugra, 2004). Previous
      studies reported that both parents and children who have experienced war and conflict suffer
      from stress and are at risk for mental ill-health. This stress leads to various consequences
      such as family violence, child abuse, relational problems between parents and children, drug
      problems and school problems for children (Ajdukovic, et al., 1993; James, 1997; Schimtz, et
      al., 2003). Experience of war and conflict has further shown to have a negative impact on
      parent's ability to care for their children (Jack, 2000).

      There is a vast knowledge on the association between parents' mental health, positive
      parent-child relationship and children's health and well-being (e.g. Bremberg, 2002).
      Previous studies have shown that parenting programs aimed to support parent-child
      relationship and/or improve parental skills have positive effects on parental mental health
      and on children's behavior (Lindsay et al., 2011; Bjorknes et al., 2013; Stewart-Brown et
      al., 2011). For example, parents who have participated in parenting programs report feeling
      less worried, stressed and depressed (Lindsay, et al., 2011; Marcynyszyn, et al., 2011,
      Phelan, et al., 2012; Stewart-Brown, et al., 2004). Hence, by supporting parents in their
      role as parents, improvements can be seen in both parents' and children's health and
      well-being.

      According to the Swedish governmental national strategy, parents should be offered support
      and knowledge on how to strengthen their parenting role (Reports, 2008). Almost all the
      municipalities in Sweden offer their residents a structured parenting program. However, these
      parenting programs do not reach all residents in the municipalities, especially those of
      ethnic minorities (Fabian, et al., 2006; Fabian, et al., 2004), due to language barriers and
      lack of information about existing parenting programs to the ethnic minorities. Studies show
      that parenting programs mainly target parents who can speak Swedish fluently and that the
      parenting programs are not culturally adapted (Kling, et al., 2010). Other international
      studies emphasize that single or young parents, families with low socioeconomic status or who
      live in deprived areas, have low attendance and high drop out of parenting program (Byrne, et
      al., 2013; Stewart-Brown, et al., 2011).

      Attempts have been made to culturally adapt parenting programs both in USA, Australia and in
      Norway. According to (Cardona et al., 2012) cultural adaptation needs to comprise aspects of
      language, culture and context. In a study by Bjorknes, et al. ( 2013), the cultural
      adaptation made included not to have mixed groups with both mothers and fathers and to
      deliver the parenting program with help the of "link workers" of Somali and Pakistani
      background. While many Somali parents in Sweden do not attend or have no information about
      the parenting programs that exist in their municipality, the number of participating families
      might increase substantially if these programs are offered in Somali and are culturally
      adapted to Somali families' needs.

      Aim The aim of the study is to evaluate the effectiveness of a parenting support program on
      parents' and children's mental health.

      Research questions:

        1. What are the effects of the parenting support program on children's mental health?

        2. What are effects of the parenting support program on parents' mental health and parents'
           self-efficacy?

        3. What is the cost effectiveness of the intervention? Methodological approach: A
           randomized controlled trial will be conducted with one intervention group (i.e.
           provision of the Connect parenting program) and one control group (i.e. 'usual
           activities) consisting of Somali parents living in Borlänge Municipality. When
           applicable, both parents will be randomized together as one family.

      Intervention: the intervention consists of Connect, an already established and scientifically
      evaluated parent program. The program is based on attachment theory and focuses on the needs
      of the child/youth and the parent from an attachment perspective. Connect is a 10 week
      program, which addresses nine different principles on child development, parent-child
      relationship and challenging interaction. Parents meet together in small groups with a
      maximum of eight families together with group leaders for one hour sessions each week. In
      relation to this, parents are offered some beverages and snacks half an hour before the
      session. Both parents will be invited to the parenting program participation. The
      intervention will be held in Somali language by group leaders of Somali background. In total
      eight group leaders will be recruited and receive four days of Connect training course by
      Connect instructors. Instructors will give also mentorship during parenting program. The
      program will be proceeded by two sessions (6 hours) on cultural specific challenges, which
      will be based on the results from the qualitative study (I).

      Setting and data collection: Parents will be recruited from the Social services and Somali
      associations in Borlänge. Several information meetings will be held in different facilities
      within the social services and Somali associations. Parents who are eligible and give their
      consent to participate will be asked to fill in the baseline data. Baseline data will be
      collected before randomization. The intervention will be evaluated by a semi-structured
      questionnaire. Outcome measures will be collected two and six months after the program has
      ended in the intervention group, with similar data collection times in the control group. The
      questionnaires will be translated into the Somali language. They will be filled out by the
      same parent throughout the study. If both parents participate the intervention their data
      will pooled if their answer is about the same child. The questionnaires will be answered at a
      time and location chosen by parents/children, during whom a Somali speaking researcher/person
      will be present in order to support parents/children in filling out the questionnaires if
      problems arise (e.g. when parents are illiterate). Outcomes: Primary outcome is improved
      children's mental health. Secondary outcomes are, improved parents' mental health, and
      parents' self-efficacy. The questionnaire will include information about the
      socio-demographic factors and is based on validated instruments.

      Sample size and analyzes: A power analysis was conducted to determine the required sample
      size. When comparing two independent sample means, with alpha set at 0.05, and power at 0.80,
      we need a total sample of 128 children (I: 64 C: 64) to detect a medium difference (d =.5).
      These groups will be expanded to 75 per group (a total sample of 150 children) since we
      expect 20% loss during the follow up. Intention-to-treat will be used. This means that
      analyses will include all randomized parents in the groups to which they were randomly
      assigned, regardless of their adherence with the entry criteria, regardless of the treatment
      they actually received, and regardless of subsequent withdrawal from treatment or deviation
      from the protocol. The specific statistical analysis used with each outcome variable will be
      determined by the distribution of the outcome variables. Intergroup comparison will be made
      between the control group and intervention group.

      Significance A number of studies show that many evidence-based parenting programs improve
      parental skills and parental mental well-being. Parents perceived to be less stressed,
      depressed and that they have more confident in their parenting role after undergoing
      parenting program. By evaluating the effectiveness of a culturally appropriate parenting
      program to Somali parents living in Sweden the project is attempting to contribute to the
      wellbeing of both children and parents with Somali background. The result will be used to
      inform stakeholders and policy makers and hopefully be used in other municipalities in
      Sweden. Furthermore, the results will be disseminated through international conferences and
      publication in international open-access journals
    

Intervention name(s): Parent support program
Intervention type(s): Behavioral
Intervention description(s): Parent support program
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Supportive Care
Keywords: Mental Health; Children; Parent support program; Somali families; Sweden