PRO-YOUTH TRIAL: Protecting Youth from Interpersonal Violence via Implementation of the Strengthening Families Programme 10-14 in Panama

In Central America, interpersonal violence can significantly reduce adolescents' opportunities for becoming happy and healthy adults. It is estimated that an adolescent is involved in 82% of all homicides in Central America. Interpersonal violence not only puts their lives at risk; it affects their health and their academic performance. Research suggests that healthy family functioning is one of the most important factors that can protect adolescents from violence. For this reason, for over 5 years the United Nations Office on Drugs and Crime (UNODC) has invested in implementing the Strengthening Families Programme for adolescents 10 to 14 years old (SFP 10-14) in several countries across Central America as a prevention strategy.

SFP 10-14 is delivered in seven group sessions in which both the adolescent (10 to 14 years old) and their parents take part in workshops and activities to build family strengths such as communication and assertive discipline. Research suggests that building these skills, before problems occur, protects adolescents from engaging in risky behaviour, and thus from difficulties later in life. The hub of UNODC's efforts in the last 5 years has been Panama, with close working relationships established between NGO's, education, health and policy. Moreover, members of our research team have conducted a series of preliminary studies in Panama. These include qualitative evaluations of parent's experience after participating in SPF 10-14 in Panama, which are now published.

In this project we aim to build on previous efforts and test implementation of SFP 10-14 widely across high-risk townships in Panama. We have chosen Panama as our laboratory given its strong governmental support, its role as the existing hub for SPF 10-14 in Central America, and the presence of a local investigator with expertise in the topic. Panama's growing rates of interpersonal violence make this issue a pressing local policy priority, with 1 in 3 deaths of those between 10-14 years old due to interpersonal violence.

We will test whether SPF 10-14 leads to a reduction in indicators of risk for families that take part, compared to those who simply receive usual care provided in their communities. We will also look at how the programme is implemented in order to identify the best ways to establish and maintain sustainability. Finally, we will measure the economics of implementation.

The project represents a strong partnership between academic institutions in the United Kingdom, a research centre in Panama, UNODC, and the Panamanian Ministries of Health and Education, and builds upon existing working and research relationships. Findings will have the potential to impact policies beyond Panama given that UNODC has strong and well-established links in this region.

Objective: This study assesses implementation of the Strengthening Families Programme for adolescents 10-14 years old (SFP 10-14) in Panama.

Design: This is a cluster randomized controlled implementation trial. A total of 28 sites will be randomly allocated to implementation of SFP 10-14 or services as usual. Families (N = 840) will be assessed at baseline, post-intervention, 6 months, and 12 months after baseline. Outcomes will be youth externalizing difficulties as measured by the Child Behaviour Checklist (CBCL). Other outcomes will be youth pro-social competencies (Normative Beliefs Scale), family functioning (Family Relationship Index), parental discipline (Children's Report of Parent Behaviour Inventory & Parenting Scale), parental stress (Depression Anxiety Stress Scale), substance misuse (SFP 10-14 scale), academic performance (school grades), delinquency (Self-report Delinquency Scale), and gang involvement (Jamaica Survey of Gang Involvement).

Process Evaluation: Recruitment, attendance, fidelity, and receipt will be measured. Key influences on intervention implementation will be explored, such as interaction between the intervention and local context. Finally, potential sustainability of the intervention beyond the trial will be assessed. Process data will be collected by 1) monitoring recruitment, attendance, group composition, and staff numbers, 2) fidelity ratings of sessions by facilitators and research assistants, 3) and qualitative interviews with facilitators, trainers, families and adolescents to explore barriers/facilitators to implementation, variations across sites and time, and systems/structures needed for sustainability.

Economic Evaluation: Costs and consequences associated with implementation of the intervention will be identified. Service use information will be gathered with a 3-month recall period. Within-trial cost-effectiveness analysis will be performed and Incremental Cost Effectiveness ratios will be estimated.

Our project directly impacts families, adolescents and communities; participating sites; national government and local scientific community.

Impacting Families, Adolescents and Communities: In this project, 420 adolescents in implementation townships will have free access to an evidence-based family-skills training programme. We have budgeted for wide advertisement of the intervention in order to recruit families universally, including those who do not currently access health/educational services regularly and may be at higher risk. Currently, there are no family-skills training programs publicly available for adolescens in Panama. Conducting this project and gathering scientific data will optimize implementation of SFP 10-14 and increase likelihood that the intervention is eventually scaled up across the country (including in SAU townships). We will set up community advisory forums (CAFs) to strengthen community networks, and seek advice/engagement from members of townships where the project will take place (e.g. political societies, NGOs).

Impacting Participating Sites for Adoption: Adoption of the intervention in health/educational sites will be highly dependent on staff engagement and motivation. An Implementation Consultant will be in charge of liaising with local managers and local operative staff (i.e. facilitators and trainers) throughout the project to ensure smooth implementation. Data from our process evaluation will help us identify barriers and facilitators to implementation and how the intervention interacted with specific contexts (i.e. sites). These data will be fed back to sites at the end of the project to prompt sustained adoption.

Impacting National Government for Scaling Up: MINSA and MEDUCA are committed to sustain implementation efforts and we have designed this project to increase the chances of it being successful. (i) We will invest in developing local capacity by training health staff as local trainers of facilitators. After the trial, these trainers, already embedded in existing services, will be ready to train and supervise SFP 10-14 staff across the country and potentially Central America. (ii) We have chosen an evidence-based intervention with low implementation costs which has already been through a process of cultural adaptation. The main on-going costs of SFP 10-14 are materials (i.e. manuals for facilitators, posters). Similar evidence-based interventions require paying developers expensive fees for materials, including shipping from overseas. As a result of previous investments by UNODC, SFP 10-14 materials are now available in electronic versions with developers' approval for local printing, making implementation less costly and highly sustainable for LMICs. Our Pathways to Impact shows how we will work with policy makers to facilitate scaling up after the project is over, including formal meetings at the start and end of the project, and written policy briefings. UNODC are highly committed to the worldwide use of family-skills programmes as a foundational plank for prevention of crime and substance misuse. The physical presence of UNODC in Panama long term increases the likelihood that these pathways will be followed up by our partners after funding is over.

Impacting the Scientific Community for Economic Development in Central America: The Panamanian government recognises the impact of research in economic development for LMICs and is investing in developing scientific capacity. The violence research laboratory led by co-PI Mejia exemplifies a policy driven development increasing links between academic excellence and policy to improve health. Through training local investigators and developing a research hub the project provides a focus for exchange of academic knowledge locally and internationally. The research has direct impact in building infrastructure to contribute towards the country's scientific, economic and societal development.