UK Phase I study

HEALTH EDUCATION RESEARCH

Vol.22 no.4 2007 Pages 547–560 Advance Access publication 13 October 2006

Cultural accommodation of the Strengthening Families Programme 10–14: UK Phase I study

Debby Allen, Lindsey Coombes and David R. Foxcroft* Abstract Social and cultural differences between the United States and the United Kingdom mean that positive results from US prevention programmes may not translate to the United Kingdom. The Strengthening Families Programme 10–14 (SFP10–14) has been evaluated in a large Phase III randomized controlled trial in rural Iowa in the United States and shown to be effective for delaying alcohol and drug initiation. This paper reports the first stage of the adaptation and evaluation of the SFP10–14 for the United Kingdom through a process of cultural accommodation of the SFP10–14 materials and format. Themes that emerged in nominal group and focus group research with young people and their parents indicated that changes to the US SFP10–14 materials needed to consider language, narrators, realism, acceptability of exercises/games, perceived religiosity and ethnic representativeness. However, not all changes reflected straightforward cultural differences, as adaptations were also required to improve the quality and to update the material, indicating that cultural accommodation does not necessarily imply cultural diversity.

School of Health and Social Care, Oxford Brookes University, Marston Campus, Jack Straws Lane, Marston, Oxford OX3 OFL, UK *Correspondence to: D. R. Foxcroft. E-mail: [email protected]

Introduction Alcohol and drug misuse Figures from the Department of Health [1] suggest that substance use and misuse among young people in the United Kingdom remains a considerable cause of concern, with prevalence estimates remaining steady over the past few years. Twenty-one percent of pupils (schoolchildren aged 11–15 years) had taken drugs in the last year in 2003, slightly up from 20% in 2002 and 2001. Twelve percent of pupils had taken drugs in the last month in 2003, the same proportion as in 2002 and 2001. Nine percent of pupils aged 11–15 years were regular smokers in 2003, down from 10% in 2002. The proportion of pupils who drank in the last week was 25% in 2003, no significant change from the previous year (24% in 2002) [1]. Young people may suffer significant adverse consequences of alcohol and drug misuse [2]. Less severe physical problems include intoxication and infection, but deaths related to substance misuse arise from accidents, suicide and violence [3]. Although it is difficult to determine the precise risk of premature deaths for substance misusers, it has been estimated that substance misusers aged 15–19 years are 16 times more likely to die than those of a similar age in the general population in England and Wales [2]. Commonly reported psychosocial consequences include arguments with families and friends, financial difficulties and problems at school [4]. Among young people, between 30 and 50% of those with psychiatric disorders, especially disruptive behaviour disorders, have substance-misuse problems. One-third of divorces,

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doi:10.1093/her/cyl122

D. Allen et al. 40% of domestic violence and 20% of child-abuse cases are associated with substance misuse [5].

The Strengthening Families Programme for youth aged 10–14 years Although very many drug education/prevention programmes have been developed, inadequate evaluation is a consistent problem [6–8]. Within the United Kingdom, the first Annual Report and National Plan—Tackling Drugs to Build a Better Britain [9] identified the importance of parental involvement in helping to prevent young people using illicit drugs and alcohol. The report observed that much more needs to be done in conjunction with parents to make a real impact in the area of drug prevention. While there are several prevention programmes that do involve parents, the Strengthening Families Programme 10–14 (SFP10–14) has in recent years been shown to be an effective intervention, in high-quality randomized controlled trials, for delaying the onset of drug, alcohol and tobacco use among young people in Iowa in the United States. The SFP10–14 (directed at children between the ages of 10–14 years and their parents) is a videobased programme that includes parents/guardians and children learning together. Several theoretical models have influenced the development of the SFP10–14: the biopsychosocial vulnerability model [10], a resiliency model [11, 12] and a family process model linking economic stress and adolescent adjustment [13]. The biopsychosocial vulnerability model offers a framework that suggests that family coping skills and resources (such as effective family management, conflict resolution/problem-solving skills and communication skills) buffer family stressors (such as family conflicts and financial stress). The approach assumes a developmental perspective, with the family exerting relatively more influence on young adolescents than older adolescents. The resiliency model has a greater focus in families on protective processes that are associated with basic resiliency characteristics in young people. It includes seven coping or life skills: emotional management skills, interpersonal social skills, reflective 548

skills, academic and job skills, ability to restore self-esteem, planning skills and problem-solving ability. The family process model relates objective economic stress to parents’ perceptions of increased economic pressure. This perceived pressure is, in turn, linked to increased parental depression and demoralization, leading to greater marital discord and more frequent disruptions in successful parenting. The family process model indicates that the disrupted parenting adversely affects adolescent adjustment. Taken together, these models support familyrisk-focused and youth resiliency approaches to prevention using strategies to reduce or buffer the known, overlapping precursors of conduct and substance-use problems in adolescents that originate in the family. The strategies also help youth build protective coping skills through positive rather than negative behaviours. The SFP10–14 authors [14] have incorporated empirically supported techniques for improving family management practices and youth skill enhancement to address selected risk and resiliency factors, based on Adlerian concepts of parent education and social learning approaches to skill development. The programme aims to facilitate parents to learn to increase desired behaviours in children by using attention and rewards, clear communication, effective discipline, alcohol and substance-use education, problem solving and limit setting. Similarly, it aims to enable children to learn effective communication, understanding feelings, coping with anger and criticism, stress management, social skills, problem solving, resisting peer pressure, consequences of substance use and compliance with parental rules [11, 15, 16]. The long-term goal of the SFP10–14 is reduced substance misuse and behaviour problems during adolescence. Other objectives include improved parental nurturing and limit setting skills, improved communication skills for both parents and young people and development of young people’s prosocial skills. The risk and protective factors for parents and youth that are addressed in each session are shown in Table I. A recent Cochrane Collaboration Systematic Review, commissioned by the World Health

Strengthening Families Programme Table I. Risk and protective factors (source: [14]) Session

Session 1 Session 2

Session 3

Factors addressed Protective

Risk

Positive future orientation, goal setting and planning, supportive family involvement Age-appropriate parental expectations, positive parent–child affect, empathy with parents Emotional management skills, family cohesiveness

Demanding/rejecting behaviour, poor communication skills Harsh and inappropriate discipline, poor child–parent relationship

Session 4

Youth reflective skills, empathy with parents, pro-social family values

Session 5

Cohesive, supportive family environment; consistent discipline; meaningful family involvement; empathetic family communication; social skills; peer-refusal skills Positive parent–child affect, clear parental expectations regarding substance use, interpersonal social skills, peer-refusal skills Positive parent–child affect, reinforcement of risk reduction skills addressed in the programme, reinforcement of protective factors and youth assets Pro-social peer interaction skills, effective stress and coping skills Conflict resolution skills, positive marital interaction Cohesive, supportive family environment; empathy with parents; consistent discipline

Session 6

Session 7

Booster Session 1 Booster Session 2 Booster Session 3

Booster Session 4

Positive marital interaction, family cohesiveness, peer-refusal skills

Organization and the UK Alcohol Education and Research Council, reported the SFP10–14 to be an effective and promising prevention intervention [6, 17] over the longer term for the primary prevention of alcohol misuse in young people. There is also good evidence from primary research for the effectiveness of the SFP10–14 for behaviours other than alcohol. Compared with youth in the randomized control group, those in the SFP10–14 group showed significantly delayed initiation of alcohol, tobacco and marijuana use [16]; lower frequency of alcohol and tobacco use [16] and lower levels of

Harsh, inconsistent or inappropriate discipline; poor communication of rules; child aggressive or withdrawn behaviour Poor parental monitoring; poor, harsh, inconsistent or inappropriate discipline; youth antisocial behaviours Indulgent or harsh parenting style, family conflict, negative peer influence

Poor school performance, negative peer influence Poorly managed adult stress, poor social skills in youth

Ineffective conflict management skills, poorly managed adult stress Peer conflict and aggression, hostile family interactions Harsh and inappropriate discipline, poor child–parent relationship, poor communication of rules Ineffective conflict management skills, negative peer influence, inappropriate parental expectations

overt and covert aggressive behaviours and hostility in interactions with parents [18].

Cultural accommodation of the SFP10–14 Although such evaluations are encouraging, there is not yet sufficient evidence for their effectiveness to warrant wide-scale implementation [6, 19, 20]. Similarly, concern has been raised regarding the cultural applicability of prevention programmes that have been developed in the United States [6, 19, 20]. This may be simply attributable to language or colloquial differences or, more 549

D. Allen et al. importantly, the social context driving the development and content of such programmes may be very different in the United States, even when programmes such as the SFP10–14 focus on cultural universals in the form of specific parent and youth attributes and interactions. Therefore, an important test of the cross-cultural value of the SFP10–14 is to deliver and evaluate the programme in other countries and cultural settings. A recent study from Phoenix, AZ, USA [21], has shown that a multicultural version of a substanceuse prevention programme tested in middle schools was at least as effective as culturally targeted and specific versions of the prevention programme. This is an important finding because culture-specific programmes may be less appropriate for culturally diverse settings. However, it is naive to think that one can simply use the US SFP10–14 materials and format without making any sort of cultural accommodation: the challenge is to adapt the material and format without compromising theoretical and conceptual integrity and therefore potential effectiveness. The goal of cultural accommodation in prevention services is the integration of the cultural context within the design and delivery of the prevention programme. Cultural accommodation aims to minimize the cultural distance between the prevention materials and approach and the target groups [22–24] and includes the following issues: (i) culture-relevant language, colloquialisms and examples; (ii) culturally accepted norms of role behaviour; (iii) culture-relevant definitions of undesirable behaviour and (iv) culturally and context-appropriate systems and service providers. The challenge with the testing of the SFP10–14 in the United Kingdom therefore was first to adapt the programme materials and format as part of an ongoing evaluation of this complex prevention intervention. The UK Medical Research Council (MRC) [25] has issued guidance on the development of evaluations of complex interventions. The first step in evaluating a complex intervention is to establish the theoretical basis that suggests that your intervention should have the effect you expect it to have. If a particular intervention to be evaluated is already widely practiced, a theoretical phase may well not 550

be essential; the health service already has what is considered a clear understanding of the ‘mechanisms of action’ of an intervention that is nevertheless to be evaluated. As there is already a good theoretical basis for the SFP10–14, it was not considered appropriate to revisit this phase of the development and evaluation of the SFP10–14 for use in the United Kingdom. The MRC report [25] states that the next step in evaluating a complex intervention is to develop an understanding of an intervention and its possible effects (Phase I). ‘‘‘Modelling’, for example, computer simulations or economic modelling, refers to the possibility that this phase is paper based’’ for clarity. It may also include qualitative testing through focus groups, preliminary surveys, case studies or small observational studies. The first step in our adaptation and testing project was to undertake a Phase I cultural accommodation study to ensure that the SFP10–14 materials and format were culturally relevant to general UK audiences. We anticipated that our Phase I qualitative research would identify several areas where the US SFP10– 14 materials and format should be revised for use in a general UK cultural context. Subsequent phases in the evaluation of complex interventions include exploratory trials, definitive trials and post-implementation surveillance, Phases II, III and IV, respectively. These later phases will form the basis of future scientific reports and papers.

Aims of the Phase I research To adapt and model the adapted SFP10–14 materials and approach with parents and young people in the United Kingdom.

Method Ethics approval was obtained from the Oxford Brookes University Research Ethics Committee. There were two parts to the Phase I study: a nominal group technique was used to build consensus on initial adaptations to the US SFP10–14 materials and focus groups assessed both the

Strengthening Families Programme original US SFP10–14 materials and the revised UK SFP10–14 materials to provide a second assessment of the US material and to comment on whether the changes made in the UK version were necessary and/or useful.

Nominal group technique for consensus development An advisory group was established to guide the researchers on initial adaptations to the US SFP10– 14 materials, involving prevention workers, parents and youth with prior experience of the SFP10–14 in the United Kingdom. Prevention workers in Greenwich (London) and Barnsley, UK, had been delivering the SFP10–14 using the original US materials in the absence of UK-relevant materials. Facilitators from these two settings were approached and asked to join the advisory group. In addition, parents/caregivers and young people who had participated in the programme at the two sites were sent information letters about the project and the advisory group and asked if they would like to participate in the research. Purposive sampling [26] was used to target a small number of participants who were representative of the families who had attended the SFP10–14 sessions in Greenwich and Barnsley. Nine families were approached to participate in the research and we received five positive responses: four mothers, two fathers and five young people agreed to join the advisory group. The advisory group was established with the remit to meet on one occasion only, with further contact by letter. A nominal group technique was used to collect data. Nominal groups are thought to generate better quality ideas than other interacting groups and reach consensus more quickly than using a Delphi technique (this is a postal questionnaire method using open-ended questions in order to obtain the ideas or attitudes of a number of people anonymously without the necessity of organizing a meeting) [27–29]. This was an important factor as there were large amounts of material to be reviewed. The advisory group was asked to review the US SFP10– 14 materials and generate a list of positive features and areas for improvement. A ‘round robin’ re-

cording of ideas was undertaken until all ideas were exhausted and duplicates eliminated. The advisory group was then asked to generate ideas and discussion about each member’s list of items and to reach a consensus on adaptations to be made. The group decision was the pooled result of individual opinions. The process was recorded and the completed list of adaptations was sent to all participants to check for accuracy and agreement. The US SFP10–14 materials were then revised according to the agreed lists of adaptations.

Focus groups Focus group meetings were held in schools in four different geographical locations in the United Kingdom: Barnsley, Chester, Oxford and Peterborough. The sites were selected purposively guided by time and resources. Selection of a representative subsection of schools in the United Kingdom was not possible in this phase of the research study (and even if selection of such a representative sample was attempted, the sample size would be likely to be so large as to preclude the kind of intensive analysis we were seeking in the study). We based our sample selection of schools on a number of factors: that the school settings were accessible and were able to respond reasonably readily and quickly, that the schools provided access to families from a variety of cultural and socio-economic (SES) backgrounds and that the schools were based in different geographical locations. While we would not claim that the sample of schools selected in the study was representative of the population of schools in the United Kingdom, we would argue that it is relevant and findings may be generalizable when considered alongside other cultural adaptation studies, especially those carried out in the United States. One focus group was facilitated at each of the four sites and the group met on one occasion only. The purpose of the meetings was to model the UKadapted SFP10–14 materials and approach with individuals and groups who were consistent with the target population. The focus groups comprised parents/guardians and youth aged 10–14 years from schools that agreed to participate at each of the four 551

D. Allen et al. locations. Contact was made with a key person at each school to help facilitate the organization of the focus group; generally, this was the deputy head teacher. Of the four schools that were initially approached to participate in the research, one did not respond to the information letter and one declined to participate. Two further schools in the same geographical areas were then approached and consent was obtained. Information sheets and invitation letters were sent to all families who had a child within the target age-band. Potential participants were encouraged to contact members of the research team for further information about the research and their contribution. A total of 300 letters were sent out (between 60 and 90 from each school). The average response at each site was between 31 and 35%. Random sampling [26] was used to identify eight families from each site. The target of eight families was greater than required to allow for potential nonattendance. Following the return of reply slips, participants were contacted by telephone to allow introductions and to generally welcome and thank people for their response. It also gave an opportunity to establish a convenient date/time that would allow people to plan their diary to attend the focus group. If families decided at this point they could not/did not wish to continue, a further family was contacted until we received eight positive responses. From a potential 32 families who agreed to participate, we had 13 families who did not arrive for the focus group meeting. The composition of the four focus groups is summarized in Table II. Most of the parents in the focus groups were in the 30- to 40-year age group and comprised a mixed SES group. In Barnsley, Peterborough and Chester,

several parents were in low-income groups with children receiving free school meals. In Oxford, all parents were employed and most in white-collar jobs. Correspondingly, the educational background of parents in Barnsley, Peterborough and Chester was predominantly below university level, whereas in Oxford, the parents were a mixed group of degree-educated and professionally trained participants. Barnsley is in the north of England and the participants were drawn from a deprived area. Peterborough is in the east of England and the participants were drawn from a deprived area. Chester is in the north-west of England and is a fairly affluent area though the participants were drawn from a relatively less affluent part of the city. Oxford is in the southeast of England and participants were from a fairly affluent area. The focus group participants were predominantly white apart from the Peterborough group which included two African-Caribbean participants. At the start of each focus group, we showed some small clips from the US SFP10–14 videos. This was to enable participants to get a flavour of the original materials. Participants were then asked how they found the excerpts they had viewed. Following this, the revised (SFP10–14 UK) video materials were presented, and once again, the group were invited to give their views. The focus groups were taperecorded. The tapes were transcribed and a content analysis of transcriptions was undertaken. Content analysis produces a relatively systematic and comprehensive summary of the data as a whole [30]. In this project, the content analysis was used to address the question of what adaptations were required in the US SFP10–14 material. At the end of each focus group, participants were thanked and offered a gift voucher for £10.

Table II. Composition of focus groups

Group Group Group Group

552

1 2 3 4

(Barnsley) (Peterborough) (Oxford) (Chester)

Mother

Father

Male youth 10–14 years

Female youth 10–14 years

4 3 4 3

1 (foster father) 1 (stepfather) 2 1

1 2 2 4

3 1 3 0

Strengthening Families Programme

Results Nominal group technique The adaptations to the US SFP10–14 materials suggested through the nominal group technique are summarized below. These are characterized as general changes and video-specific changes because the SFP10–14 predominantly uses video materials to guide the programme.

General changes (all materials)  The language in all materials should be sensitive to varied cultural backgrounds (UK minority ethnic groups, regional accents, different class and educational backgrounds).  Idiomatic US language should be translated to UK-relevant terms.  The frequent use of ‘he/she’ in the text of the programme manual should be avoided.  The religious connotations in all materials should be removed, e.g. change ‘creed’ (perceived as a religious word) to ‘motto’ (a nonreligious word).  There will be a need to provide literacy support to some SFP10–14 participants as there is a marked emphasis on writing in the programme.

Video-specific changes  Videos will require re-shooting to improve the quality and also because the US vignettes did not reflect ‘real-life’ situations in the United Kingdom.  Use real-life settings for the vignettes rather than studio-based settings with artificial backgrounds.  Improve the quality of the acting in the videos.  Use families that participants can more easily identify with.  Change the background music (‘US version is dated and boring’).  Update narrator dress style (e.g. clothes of narrators are dated).  Consider using ‘voice-over’ narration instead of ‘onscreen’ narrators.

 Ensure clear narration—US narrators tended to talk too fast.  Change tone of narration—it was felt that much of the vocal tone of the US videos tended to be admonishing and moralizing.  Avoid bad language in videos.

Focus groups The focus groups were first asked to comment on the original US SFP10–14 material and then, by comparison, to comment on the adapted UK SFP10–14 material. Several themes emerged in a content analysis of discussions relating to the original US SFP10–14 material: use of language in the videos, video narrators, realism of vignettes, acceptability of exercises/games and perceived religiosity. These are described below.

Use of language in the videos Participants identified with the situations presented in the US SFP10–14 materials and recognized similar behaviours and situations from their own experience. However, some participants commented that they found the language of the US videos rather old-fashioned and overly sentimental—‘very American’. All four groups raised issues of language. Specific number of statements on language by group: Group 1 = six, Group 2 = four, Group 3 = seven and Group 4 = six. It needs to be less flowery (language), more realistic. They say ‘I love you’ in almost every other sentence: people in the UK don’t do things like that. (Mother, Group 1) They also had some issues related to the language used by the US actors and narrators. These concerns were mainly about the difficulty in listening to and understanding programme content. Some participants felt that it was necessary to concentrate very hard to understand what was happening in the vignettes presented and what the narrators were saying about these. The following are some of the participants’ comments: You really have to listen hard to follow what was being said. (Mother, Group 1) 553

D. Allen et al. The American accents made it hard to understand. [Youth (male), Group 2] One of the actors said ‘shift your butt’ and they kept going on about ‘shopping malls’ and things. And basketball isn’t a major sport here. (Father, Group 2) One participant observed that listening to the US speakers on the videos tended to cause the listener to lose concentration: You shut off after about five minutes. (Mother, Group 3) I started to nod off listening to their voices. (Father, Group 3) Their accents were really distracting and by the end you’d forgotten what they were talking about. (Mother, Group 4) I was trying so hard to hear what they were saying, rather than just taking it in. (Father, Group 4) On a similar note, some participants found the language of the commentary on the videos rather laboured and circumlocutory: You feel like saying—give it a rest! Get to the point! (Mother, Group 4) Some participants thought that the way of addressing issues with young people suggested by the programme was too indirect and that UK parents preferred a more candid approach. One participant commented about the issue of homework: The Americans tend to skirt around the issue ... you just need to get the message across. Parents don’t talk to each other like that. (Father, Group 1)

Video narrators The videos used in the original US SFP10–14 employ two narrators (a man and a woman) to present information and provide continuity between different components of the programme. All four groups raised issues of video narration. Specific number of statements on video narration by group: 554

Group 1 = six, Group 2 = five, Group 3 = eight and Group 4 = five. Participants reported that they perceived the narrators as being rather patronizing in the way they presented material. In addition, they thought the narrators’ attire was somewhat dated. One participant commented that the narrators were Sitting there in very much the lecturing position, it all added to that feeling of how authoritative they would be, rather than the message you would want to be delivering. (Foster father, Group 1) Another participant said I thought they were talking down to you, as though you didn’t know anything. (Mother, Group 3) Comments regarding the clothing of the narrators included That jumper was very 1980s! (Mother, Group 4)

Realism of vignettes The US SFP10–14 used a number of video-based vignettes to illustrate the topics of the programme. In the videos, actors in a studio setting perform most of the vignettes as it was thought that the studio setting would reduce issues such as identification of social class and wealth implicit in many real-life settings. However, the focus group participants found that the original US SFP10–14 videos seemed rather artificial, and that the situations portrayed did not seem real. All four groups raised issues with the vignettes used in the videos. Specific number of statements on vignettes by group: Group 1 = four, Group 2 = four, Group 3 = five and Group 4 = six. One bit had two dads talking about parenting in a studio with a black background with a tool box in the foreground. Why was that there? It was obviously a false situation. (Father, Group 3) It would be better if the people were like in a room at our house. [Youth (female), Group 3] Some of the scenes had sofas and chairs in them like it was someone’s living room, but it wasn’t.

Strengthening Families Programme Why couldn’t they just have used a real living room? (Mother, Group 4)

creed at the end of each session. For example, the youth creed states

The participants agreed that it was possible to understand what the underlying message of the vignettes was, although it was important not to be distracted too much by issues such as characters playing parts in the videos and the set used in filming.

We are strong young people with a great future. We are making good decisions so we can reach our goals.

Acceptability of exercises/games Participants also commented on the other materials used in the programme, particularly the exercises/ games. Once again, all four groups raised issues on the exercises/games used in the programme. Specific number of statements on exercises/games by group: Group 1 = five, Group 2 = four, Group 3 = six and Group 4 = five. While some participants felt that UK families would not like to participate in this part of the programme (due to embarrassment), others felt this was not the case. One mother was a teacher who also worked with a youth centre; she observed that once people started to participate in such games they generally became very enthusiastic. We do this thing called ‘tunnel of love’. You make an arch with your arms and as the person goes through you each say something really positive about them. You should see the beam on their faces. Brilliant. (Mother, Group 1) Some of the games seem a bit childish, like the one where you go round making noises ‘beep beep’. But the kids seem to like them though. (Father, Group 2) The games bring families together. I like the way they start with minimal touch and then they build up to holding each other gently. (Mother, Group 4) I’d give it a go and join in yes—it looks like fun. [Youth (male), Group 4]

Perceived religiosity associated with creeds The US SFP10–14 uses a creed at the end of every session. There is a youth creed, a parent creed and a family creed and each group recite the relevant

Although all groups referred to the use of creeds, among three of the groups there was a negative reaction to their use. Specific number of statements on creeds by group: Group 1 = seven, Group 2 = four, Group 3 = eight and Group 4 = seven. Among those who objected, the following reasons were cited: It seems very old fashioned. (Mother, Group 1) It is not very British, we don’t do that sort of thing. (Father, Group 3) Me, no way, I would be out of there! [Youth (female), Group 3] I’m not sure I would like that. It seems a bit religious. (Mother, Group 4) However, one parent noted that the concept of having a creed was understandable as they were being used as ‘affirmations’. Nonetheless, the same parent qualified his statement, adding I can see Americans doing it and feeling it would be an important part to take away with them and remember, but the British are terribly self-conscious. (Stepfather, Group 2) Some individuals within groups were more favourable in their response to the use of creeds, but felt it would be more appropriate to call them mottos, as this would take away potential religious interpretations and would be more appropriate to families today. I think, if it was said like a rap it would be good, then I’d do it. [Youth (male), Group 10)] We have Scouts and Guides and things, they all have Promises the children learn don’t they? It’s no different to that really. (Father, Group 3) Overall, the results presented above generally supported the results from the nominal group technique. 555

D. Allen et al. The focus groups were then asked to examine the adapted UK SFP10–14 materials and to comment on and discuss the revised material in the context of the original US videos that they had just seen. Several themes emerged in a content analysis of discussions relating to the revised UK SFP10–14 material: video narrators, presentation and setting for the videos, realism of vignettes and ethnic representativeness. These are described below.

Video narrators Participants found the adapted videos more realistic and ‘life-like’. Following feedback from the nominal group work, the onscreen narrators had been replaced with a voice-over reading of the script while a still image from the following scene was displayed onscreen. Male and female voice-over narrators were used. The idea of using a voice-over was unanimously supported, with participants enthusiastically commenting on how much this improved the original US materials. All four groups commented favourably on the narration. Specific number of statements on narration by group: Group 1 = seven, Group 2 = six, Group 3 = eight and Group 4 = seven. Participants expressed the view that it helped you to focus on the scenario that was to follow. It is much better to listen to someone speaking, as opposed to having two individuals talking ‘at you’ as in the US videos. (Foster father, Group 1) The new videos seem less preachy. (Mother, Group 4) It is so much better, much easier to follow what’s going on. [Youth (male), Group 4] In addition to this, participants particularly like the different UK regional accents of both the narrators and the actors used in the scenes.

scenes were shot in real locations, both inside and outside the home setting. All four groups gave positive feedback on the changes that had been made to the presentation and setting for the videos. Specific number of statements on presentation/ setting by group: Group 1 = seven, Group 2 = five, Group 3 = eight and Group 4 = six. It was felt the use of realistic and varied locations was a great improvement: Much better than contrived studios: it works much better. (Mother, Group 1) The videos are much more real. I liked the use of real rooms to act out the scenes. (Father, Group 2) The actors were a lot easier to understand and identify with. [Youth (female), Group 2] The groups felt you could understand them better, they were more modern and generally the scenarios were more realistic. There was a discussion about a kitchen scene because some participants’ felt it was too ‘posh’ and could ‘put people off’, while others felt that it would not really be a problem: I wish I had a kitchen like that! (Mother, Group 2) The first couple ‘seemed posh’. The scene in the kitchen ... they had wood floors. (Mother, Group 3) But it isn’t real and we watch soaps and things, I don’t think it matters. (Mother, Group 4) While the kitchen was admired, participants felt it essential that some scenes reflected homes that were much smaller and less perfect or it could mean that people did not identify themselves with the families being shown: You risk people not being able to identify with it. (Father, Group 4)

Presentation and setting for the videos The UK videos were felt to be more engaging than the US version, and it was also easier to understand the actors. Following clear feedback on this issue from the nominal group work, we had ensured that 556

Realism of vignettes All four groups discussed the realism of the vignettes in the adapted materials. Specific number of statements on realism of vignettes by

Strengthening Families Programme group: Group 1 = four, Group 2 = three, Group 3 = six and Group 4 = four. Some participants observed that there should be more shouting and answering back by youth to their parents. However, other participants disagreed, saying You are trying to see how to achieve a successful outcome rather that just how bad it can be. (Father, Group 1) I think it is really good when you see someone getting it not right, we can all relate to that, I wanted to know how the end would be ... it’s a good strategy. (Mother, Group 3) It’s about the principle of what helps rather than how awful kids can be. (Mother, Group 4) It’s much more like real life things happening, more real. [Youth (male), Group 4] The groups all felt that the adapted materials were of a good standard and clear to understand. One participant (who was a foster parent) asked about the intended dissemination of the SFP10–14 (UK), commenting that it should be readily available to the general public as a whole: To help everyone get through the teenage years. (Foster father, Group 1)

Ethnic representativeness The issue of ethnicity was only raised by one group, but was felt to be of such importance within that group that we felt it necessary to make further changes to the video vignettes. Although we had included some mixed race families among the actors in the first UK video vignettes, none of the actors were Asian, as one of the participants observed: We have a big Asian population here, yet none of the actors are Asian, and that’s what I noticed. (Mother, Group 3) Generally, the group felt that it was vital that the video scenarios reflected a cross-section of the community, and they liked the fact that different regional accents were used.

Discussion The nominal group technique and focus group discussion results presented constitute Phase I of an ongoing programme of research to adapt and test the US SFP10–14 for use in the United Kingdom. The results from the nominal group meeting and subsequent focus group meetings provided useful information on whether and how the original US SFP10–14 materials should be adapted for use in the United Kingdom, while at the same time retaining essential ingredients of the effective US programme. This nominal and focus group study has led to the development of newly revised programme materials, now referred to as SFP10–14 (UK), that will be used in Phase II research. In terms of cultural accommodation [22–24], this study has considered the following issues: (i) culture-relevant language, colloquialisms and examples: the study has clearly shown the importance of revising the material for language, colloquialisms and examples. Language revisions were required both for narration and for specific tasks such as creeds; colloquialisms were removed and exercise and game activities were revised for the UK cultural context; (ii) culturally accepted norms of role behaviour: overall, the nominal and focus group studies did not identify discrepancies in normative role behaviours between the US prevention materials and the UK context. This implies that the norms used and modelled in the US SFP10– 14 prevention programme are appropriate to the United Kingdom. The only exception was some ambivalence over standing up in a group and reciting the creed or motto together, with an indication that the UK audience would feel less comfortable with displaying such positive affirmation behaviours in a group setting; (iii) culturerelevant definitions of undesirable behaviour: similarly, the nominal and focus group studies did not identify discrepancies in definitions of undesirable behaviour. No comments were made in group interviews regarding implicit definitions used in the US SFP10–14 material within specific topics on limit setting, on alcohol and drug misuse or on 557

D. Allen et al. antisocial behaviour; (iv) culturally and contextappropriate systems and service providers: focus group participants were recruited through schools so this framed their understanding of how the programme would be delivered in the United Kingdom. No comments were made to suggest that schools would be an inappropriate setting for the delivery of the programme in the United Kingdom. On the contrary, it was suggested in one focus group that the programme should be widely available through schools. One of the other issues that arose in the nominal group work was related to literacy skills. The SFP materials include games and exercises, which make the assumption that participants will have the level of literacy skills to enable them to participate. In some sessions, young people and adults are asked to read out scenarios from cards. The concern about literacy levels was given further credence during the organization of one of the focus groups. We were informed by the deputy head teacher in a school hosting the group that one of the people who had heard about the research and was interested in participating had confided that she could not read or write. Sensitive and discreet support enabled this participant to join the focus group. This incident raised awareness of the need for researchers and facilitators involved in this type of work to be alert to potential difficulties faced by participants. It does not mean that people will not be able to participate, but rather that facilitators will need to be alert to potential problems faced by participants and to offer sensitive and discreet help and support on some occasions. This illuminates the need for the selection of individuals with appropriate skills to act as facilitators and also that programme facilitators should undergo a period of training to prepare them to deliver the programme in the United Kingdom. In the focus group feedback, participants had identified the need for actors in the scenarios to be representative of different ethnic groups. One of the teachers the project team worked with observed that the area in which the school was situated had a high Asian population. There was an identified substance-misuse problem among the youth but 558

there was also strong denial among the Asian community of any such problem. The teacher felt that there was a need for an adapted version of the SFP10–14, aimed particularly at the Asian population, taking into account their very different and specific cultural needs. However, other professionals felt that it would be better to adopt a model of inclusion and not to separate parents and young people by cultural identity. This highlights an issue of importance for future research: would versions of the SFP10–14 for particular ethnic groups be more effective than generic, but ethnically sensitive, versions? Themes that emerged in nominal group and focus group research with young people and their parents regarding the adaptation of the SFP10–14 for use in the United Kingdom were language, narrators, realism, acceptability of games, perceived religiosity of creeds and ethnic representativeness. Interestingly, although this Phase I study aimed to identify those aspects of the US SFP10–14 that were culturally inappropriate for the United Kingdom, the results have not permitted a clear conclusion to be drawn for two, related, reasons. The first is that the research identified changes that needed to be made because of place issues, in other words differences between the United States and the United Kingdom, but also because of time issues because the US material was developed and produced in the mid-1990s [11, 14] with inevitable contrasts with contemporary language, fashion and style. Our research was not able to distinguish adaptations required for time or for place issues. The second reason is that changes were also identified because of perceived quality deficiencies in the original material, for example having realistic settings for the vignettes as opposed to artificial studio-based scenes. In conclusion then, although we are confident that we have achieved an appropriate cultural accommodation of the SFP10–14 prevention programme to the United Kingdom, we cannot state that all the changes made to the original US material were in fact cultural adaptations. Rather, the changes reflected a combination of perceived time, place and quality discrepancies between the US prevention materials and the

Strengthening Families Programme implicit expectations of a UK version of the same prevention materials as articulated through this research project. The Phase I study also highlighted the need for careful selection and training of SFP10–14 facilitators and raised the question of differential effectiveness among different ethnic groups, or the need for cultural specificity in prevention programmes, although, as stated earlier, the current evidence on this question is inconclusive—with at least one study indicating that multiculturalism in prevention programmes is not a disadvantage [21].

Acknowledgements The UK Alcohol Education and Research Council and the UK Home Office funded this Phase I study with additional funding from Diageo GB (London) for the adaptation of video materials. The original US SFP10–14 was developed at the Iowa State University of Science and Technology. Oxford Brookes University has subsequently received additional funding from Diageo PLC (London) to develop and test the SFP10–14 in the United Kingdom and other European countries.

Conflict of interest statement None declared.

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