Independent evaluation of the Triple P Positive Parenting Program in family support service settings

Independent evaluation of the Triple P Positive ParentingProgram in family support service settingscfs_771 1..12

David McConnell*, Rhonda Breitkreuz† and Amber Savage‡*Professor and Director, Family and Disability Studies Initiative, †Assistant Professor, Human Ecology and ‡Research

Coordinator, Family and Disability Studies Initiative, University of Alberta, Edmonton, Alberta, Canada

ABSTRACT

The Triple P Positive Parenting Program is a multilevel system ofbehaviour-based parenting training and support. The aim of this studywas to determine whether implementation of levels 2 and 3 of theTriple P system, designed for primary care settings, enhances parent,child and family outcomes compared with services-as-usual inAlberta, Canada. The study employed a quasi-experimental, single-blind and post-test-only design. A survey incorporating outcome mea-sures was administered to a sample of 1296 parent-clients. A total of923 parents responded, including 172 parents who had received aTriple P (level 2 and/or 3) intervention during the previous 12 weeks.A significant interaction was found between participation in a group-based parent education programme and receipt of Triple P. Parentswho participated in a group-based parent education programme, andwho received a Triple P intervention reported somewhat higher levelsof need satisfaction than parents who participated in a group-basedparent education programme but who did not receive a Triple Pintervention. No significant difference was found between Triple Pand service-as-usual groups on any secondary outcome measuresincluding parenting stress, positive interaction, family functioningand child problem behaviours.

Correspondence:Amber Savage,Family and Disability StudiesInitiative, Faculty of RehabilitationMedicineUniversity of Alberta3-66 Corbett Hall, Edmonton,Alberta T6G 2G4,CanadaE-mail: [email protected]

Keywords: behavioural familyintervention, parenting programme,primary care, Triple P

Accepted for publication: February2011

INTRODUCTION

Parenting programmes aim to promote healthy childdevelopment by targeting intra- and interpersonaldeterminants of parenting behaviours, includingparent knowledge, skills and resourcefulness, parent-ing stress and family relationships. The Triple P Posi-tive Parenting Program (Triple P) is one of the mostwidely disseminated ‘brands’ of behaviour-basedparenting training. Triple P comprises a multilevelsystem of parenting training and support, which isdesigned to facilitate the matching of interventiontype and intensity to parent and child needs (seeFig. 1). At one end of the Triple P spectrum are mul-timedia strategies aimed at improving parent access tohigh quality parenting information. At the other,Triple P comprises active, multimodal parenting

training with enhancements for high-risk families(Sanders 2008). The aim of this study was to deter-mine whether implementation of levels 2 and 3 of theTriple P system, designed for primary care settings,enhances parent, child and family outcomes com-pared with services-as-usual in Alberta, Canada.

Over the last three decades, there has been a pro-liferation of studies investigating the efficacy ofparenting training programmes. These programmesare heterogeneous, varying in theoretical approach(e.g. cognitive and behaviour-based, attachment andrelationship based); training modality (e.g. centre andhome-based, group and one-to-one instruction);intervention scope (e.g. parent-mediated or multisys-temic); and training intensity (e.g. brief and moreintensive interventions; Layzer et al. 2001). Meta-analytic syntheses of this research have produced

doi:10.1111/j.1365-2206.2011.00771.x

1 Child and Family Social Work 2011 © 2011 Blackwell Publishing Ltd

remarkably consistent findings. These suggest that onaverage, behavioural and non-behavioural parentingtraining and support programmes produce small (i.e.when based on independent clinical observation) tomoderate (i.e. when based on parent self-report mea-sures) but arguably meaningful effects on a range ofoutcomes: parenting knowledge, stress and behavioursand child social-emotional development (Serketich &Dumas 1996; Layzer et al. 2001; Curtis et al. 2004;Maughan et al. 2005; Lundahl et al. 2006; McCartet al. 2006; Barlow et al. 2003; Singer et al. 2007;Kaminski et al. 2008; Dretzke et al. 2009).

Triple P – Positive Parenting Program

A compelling number of studies have found thatTriple P programmes are efficacious. For an anno-tated bibliography of over 60 Triple P trials, seeMcConnell et al. (2010). However, most studies todate have focused on levels 4 and 5, which is thetargeted end of the Triple P service spectrum (e.g.Rogers et al. 2003; Gallart & Matthey 2005; Heinrichset al. 2006), although some promising data on levels 1and 3 are now emerging (e.g. de Graaf et al. 2009;Boyle et al. 2010). Meta-analytic syntheses suggestthat, in general,Triple P outcomes are commensuratewith other well-researched parenting training andsupport programmes (Thomas & Zimmer-Gembach2007; de Graaf et al. 2008a,b; Nowak & Heinrichs2008). Thomas and Zimmer-Gembach (2007)however suggest that more independent evaluationsare needed to confirm the efficacy of Triple P. Eisner(2009) reached the same conclusion observing thatindependent studies of Triple P, although few innumber, have generally found smaller effects, that is,by comparison to developer-led studies.

Triple P (levels 2 and 3)

Levels 2 and 3 of Triple P are designed for use inprimary care settings with parents who are seekingprofessional guidance and support to deal withcommon, discrete child behaviour problems (e.g. tan-trums, whining) and challenging but typical childdevelopmental transitions (e.g. toilet training).Selected Triple P (i.e. level 2) is available in twoformats. The first is a brief, one to two session inter-ventions providing early anticipatory developmentalguidance to parents of children with mild behaviouraldifficulties or developmental issues with the aid of tipsheets and videotapes that demonstrate specificparenting skills. Additionally, selected Triple P can beoffered as a seminar series including three specificpositive parenting topics. The seminars are used topromote awareness of Triple P and as brief and infor-mative sessions for any parent. Each seminar includesa presentation, a question and answer period, distri-bution of a parenting tip sheet and availability of prac-titioners at the end of the session to deal withindividual inquiries and requests for further assis-tance. Primary care Triple P (i.e. level 3) is a narrow-focus four-session intervention designed for childrenwith discrete mild to moderate behaviour problemsand includes active skills training for parents.

Four English language, peer-reviewed and pub-lished evaluations of level 3 Triple P report promisingbut mixed results (Crisante & Ng 2003; Turner &Sanders 2006; de Graaf et al. 2009; Boyle et al. 2010).Turner and Sanders (2006) employed an experimen-tal pre-test post-test design with random assignmentof a total of 30 participants to level 3 Triple P andwaitlist control conditions. Outcomes were mixed. Atpost-test and follow-up, meaningful Triple P treat-ment effects were found on a limited subset ofoutcome measures including some dimensions of self-reported dysfunctional parenting, parent confidenceand adjustment. However, no significant effect wasfound on observational measures of parent and childbehaviours. The study findings suggest that level 3Triple P may be helpful to many parents and families,but the study did not address the question which isarguably of utmost interest to policy-makers and prac-titioners, that is, is level 3 Triple P any more effectivethan existing programmes and practices?

More recently, de Graaf et al. (2009) compared out-comes of level 3 Triple P with existing primary careparenting support services in the Netherlands. LikeTriple P, existing services in the Netherlands are oftenbased on social learning theory may also focus on

Figure 1 Triple P: levels of intervention.

Triple P in family support service settings D McConnell, R Breitkreuz and A Savage


parent–child communication and conflict resolutionand involve the use of video home training. A quasi-experimental, pre-test post-test design with follow-upwas employed. The sample included 87 parents (atbaseline) who received level 3 Triple P and a matchedcomparison group of 42 parents who receivedservices-as-usual. Both parenting training conditionsresulted in small to moderate effects observed at post-test and follow-up: on average, parents in both groupsreported a significant decrease in child problembehaviours and dysfunctional parenting. No signifi-cant difference between conditions was found onpost-test and follow-up measures of child behaviours.However, small but significant differences, in favour oflevel 3 Triple P, were found on measures of parentingstyle and parent self-efficacy. de Graaf et al. (2009)conclude that level 3 Triple P may become the pro-gramme of choice, but further research is needed.

Triple P (levels 2 and 3) pilot in Alberta, Canada

In 2007, Alberta Children and Youth Services(ACYS) implemented a pilot of levels 2 and 3 of theTriple P system in 19 Parent Link centres (PLCs) inthree Child and Family Services Authorities: Calgaryand Area, Edmonton and Area and North CentralAlberta. PLCs began in 2004, and by 2007, all ofthe 46 currently operating PLCs were providing ser-vices. PLCs are family support agencies offering awide range of professional supports and services forparents with young children in the communities theyserve. They are staffed by a variety of professionalsalthough training in early childhood development iscommon. PLCs provide five core services: parenteducation, early learning and care, developmentalscreening, family support and information and refer-ral through non-targeted, community-centred pro-gramming. ACYS limited training in the pilot tolevels 2 and 3 of the Triple P system as these wereseen to provide the levels of intervention that wouldbe most appropriate in the non-targeted, primarycare setting of PLCs. PLCs are expected to integrateTriple P programming into the parent education ser-vices they provide as a replacement for ‘non-evidence-based’ programmes that address similarissues. Triple P International Pty Ltd. was contractedto provide training and accreditation for 60 PLCstaff in level 2 and level 3 in 2007–2008. Staff fromthe PLCs participating in this evaluation receivedTriple P training and accreditation in two waves. Thefirst cohort was trained in Fall 2007, and the secondcohort was trained in Fall 2008. Staff participated in

four consecutive days of training followed by anaccreditation session 6 weeks later.

Study hypotheses

Building on the now substantial body of Triple Poutcomes research, the focus of this study was on thequestion of whether Triple P (levels 2 and 3, hereafterreferred to simply as Triple P) enhances outcomescompared with PLC services-as-usual. The primaryhypothesis was that parents receiving Triple P would,on average, report greater need satisfaction comparedwith parents who receive only PLC services-as-usual.A secondary hypothesis was that parents receiving aTriple P intervention would report lower levels ofparenting stress, more positive parenting behaviours,improved family functioning and fewer child problembehaviours.

It is important to note, we did not hypothesize largeand statistically significant effect sizes for eitherservices-as-usual or Triple P conditions on parentingstress, parenting behaviours, family functioning andchild behaviours. The reason for this is that Triple Pand PLC services are prevention-oriented, workingmostly with normal-risk parents and families. Theseparents, by definition, are unlikely to report high levelsof, for example, parenting stress or child problembehaviours at the outset. Consequently, floor (i.e. ‘theonly way is up’) or ceiling (i.e. ‘the only way is down’)effects may come into play.

METHOD

An independent evaluation of Triple P was under-taken. The authors have no relationship with Triple PInternational, the Triple P programme trainers orfacilitators. The study was funded by the AlbertaCentre for Child, Family and Community Research,which has no formal ties with, or financial interest in,Triple P International. A minimally intrusive, quasi-experimental, single-blind, post-test only, active com-parison group research design was employed. This‘natural experimental’ approach is fitting wheninterventions, and the needs they address, are as het-erogeneous as Triple P and PLC services-as-usual(Petticrew et al. 2005).With this approach, the risk ofselection bias effects is minimized by controlling sta-tistically for potentially confounding factors.

Following Health Ethics Research Board approval(reference B-400908), parent participants wererecruited from 10 PLCs (Triple P pilot sites) whichprovide Triple P to some parents and/or services-as-



usual to others, and 10 PLCs that only offer services-as-usual. Triple P pilot sites were selected to ensurerepresentation of urban and rural areas and PLCsserving aboriginal and immigrant families. Census-tract data were used to match Triple P pilot sitesand services-as-usual PLCs on a range of socio-demographic variables.

To identify potential participants, parents whoreceived a service over a 1-month period, April–May2009, at each of the 20 PLC sites, were invited torecord their name and contact details in a PLC visi-tor’s book with the understanding that they may beinvited to participate in a research project. Informa-tion sheets about the project were available toparents upon request at this time. In an effort tominimize the potential for participant bias, potentialparticipants were informed only that the study aimwas to find out how well PLCs are meeting parentinformation and support needs and to discoverwhich support strategies are working best. Sampledemographic and service profiles are presented inTables 1 and 2.

Data collection

Outcome measures were incorporated into the ‘Sup-ported Parenting Survey’ (or SPS, available from thefirst author). Administration of the SPS was based onthe Dillman method (Dillman 1978). Approximately8–12 weeks after parents recorded their name andcontact details in the PLC visitor’s book, the SPS was

mailed out with a cover letter, consent form, penciland a return postage paid envelope. Approximately 2weeks later, a follow-up postcard was sent to allparents thanking those who had already respondedand requesting a response from those who had not yetresponded. Approximately 2 weeks later, a new coverletter, survey and return postage paid envelope wassent to those who had not yet responded. All respon-dents received an honorarium of $30.00.

Supported Parenting Survey

The SPS incorporated previously validated scales andnew items created for the purpose of this study. Theselection of scales and items was based on three prin-cipal considerations: validity, reliability and parsi-mony. The primary outcome measure was ParentReported Need Satisfaction (PRNS). This proxy pre-and post-measure was based on four items derivedfrom the Client Satisfaction Questionnaire (Turneret al. 1999). The items, each scored on a seven-pointscale, were (i) did you get the type of help you wantedfrom your PLC?; (ii) to what extent did the PLC meetyour needs as a parent?; (iii) did your PLC help you todeal more effectively with your child’s behaviour?; and(iv) did your PLC help you to deal more effectivelywith problems that arise in your family? The internalconsistency of these four items was high (a = 0.861).A total score for PRNS was therefore created bysumming item scores together.

Table 1 Sample demographics

Triple P mean(SD) or %

Services-as-usualmean (SD) or %

Total (n = 923)mean (SD) or %

ParentAge (years) 32.7 (6.1) 31.9 (6.1) 32.0 (6.1)Gender (female) 96.5% 96.5% 96.5%Aboriginal 7.6% 5.7% 6.1%English is a second language 11.0% 7.6% 8.2%No post-secondary education 28.5% 28.2% 28.3%History of special education 13.5% 7.3% 8.5%Disability/health condition 18.0% 16.8% 17.0%Employed 40.1% 42.6% 42.1%

Nominated childAge (years) 3.3 (3.0) 2.6 (2.2) 2.8 (2.4)Disability/health condition 16.9% 13.7% 14.3%

HouseholdSole parent 3.5% 3.3% 3.4%Low income < $40 000 16.6% 15.8% 15.9%Size (persons) 3.9 (0.9) 3.9 (1.0) 3.9 (1.0)Children < 6 years 1.6 (0.8) 1.5 (0.7) 1.5 (0.7)

SD, standard deviation.



Secondary outcomes measures

The Parenting Stress Index-Short Form (PSISF;Abidin 1990) was employed to measure stress relatedto the parenting role. This widely used and well-validated scale consists of 36 items, each with fiveresponse categories. Based on the factor analysis con-ducted by Haskett et al. (2006), PSISF items com-prise two subscales: personal distress and child rearingstress. Combining these two subscales gives a totalscore for parenting stress (i.e. PSISF total).

The National Longitudinal Survey of Childrenand Youth (NLSCY-Cycle 7) Parenting scales wereemployed to obtain measures of two dimension ofparenting 0–1-year-olds (i.e. positive interaction,ineffective parenting), and four dimensions ofparenting 2–11-year-olds (i.e. positive interaction,ineffective parenting, consistent parenting and ratio-nal parenting; Statistics Canada: Special SurveysDivision 2007a,b). Parent participants in this studycompleted these scales with reference to the childthey were most concerned about (i.e. the nominatedchild).

Family functioning was measured by the NLSCYFamily Functioning Scale (NLSCY-Cycle 7; StatisticsCanada: Special Surveys Division 2007a,b).This scalecomprises 12 items, each with four response catego-ries, tapping various aspects of family functioningincluding problem solving, communication, roles,affective involvement, affective responsiveness and

behaviour control. A total family functioning scorewas created by reverse scoring several items with anegative loading and then summing item scorestogether.

Child behaviour for children 3 years and older wasmeasured using the Child Strengths and DifficultiesQuestionnaire (Goodman et al. 2000).This scale con-sists of 25 items, each with three response categories,comprising five subscales: emotional symptoms,conduct problems, hyperactivity, peer problems andprosocial behaviour. A ‘total difficulties’ score iscreated by summing the scores from all of the scaleswith the exception of the prosocial scale. Parents withmore than one child completed this questionnaire forthe nominated child, as above.

Support and service, parent andfamily characteristics

A checklist of potential parent concerns and supportreceived was developed based on the list of topicscovered by the Triple P parenting tip sheets. Parentsindicated whether they had received any supportfrom their PLC with issues to do with their (i) rela-tionship with their partner; (ii) baby/infant; (iii)toddler; (iv) pre-school-aged child; (v) elementaryschool-aged child; (vi) teenager; and/or (vii) personalwell-being. Then, within each of these seven catego-ries, parents identified specific issues or concernswith which they had received support (e.g. sleep

Table 2 Service history, frequency and type/s

Triple P mean (SD) or % Services-as-usual mean (SD) or % All (n = 923) mean (SD) or %

Service frequency* 3.4 (0.9) 3.2 (1.0) 3.2 (1.0)New PLC client† 11.7% 16.7% 15.7%Information/tip sheets 82.5% 65.9% 68.9%One-to-one training 28.7% 11.6% 14.8%Group-based programme 50.9% 31.6% 35.2%Family support 29.2% 15.6% 18.1%Drop in play-group 82.5% 86.7% 85.9%Received support with

Partner relationship 9.3% 5.3% 6.1%Baby/infant 27.3% 25.4% 25.8%Toddler 50.6% 33.0% 36.3%Pre-school child 18.6% 16.0% 16.5%School aged child 14.5% 6.0% 7.6%Teenager 3.5% 1.2% 1.6%Personal well-being 32.6% 22.4% 24.3%

*Number of visits in the past 12 weeks.†First contact with PLC services occurred in the past 12 weeks.PLC, Parent Link Centre; SD, standard deviation.



patterns of an infant, toilet training a toddler, bed-wetting by an elementary school-aged child).

Other survey items were developed to collect dataon service variables, including history (i.e. new orlongstanding client), frequency of contact and type;child variables, including age and health status; parentvariables, including age, gender, language spoken athome, aboriginal identity, educational attainment,special support with learning at school, employmentand health/disability; and household/family variables,including total number of persons living in the house-hold, number of persons < 6 years living in the house-hold, household type and household income.

ANALYSIS

The data were analysed using PASW (SPSS) v. 18(IBM, Chicago, IL, USA). Before data analysis com-menced, a rigorous check was undertaken to ensure thesurvey data were entered accurately. The data werethen screened: data were plotted and visuallyinspected, and the internal consistency reliability of

each scale was examined (see Table 3). The relation-ship between intervention group, PRNS and each ofthe secondary outcomes was then examined. General-ized linear model multivariate analysis of variance(MANOVA) was employed to examine the bivariateassociation between intervention group and eachoutcome (see Table 4). Multiple regression was thenemployed, firstly to screen for interactions betweenservice variables (see Table 5) and then to test theprimary hypothesis (i.e. is receipt ofTriple P positivelyassociated with PRNS?), controlling for potentiallyconfounding variables (see Tables 6 and 7). In testingthe primary hypothesis,PRNS was first regressed on alldemographic and service variables (i.e. the full model).Non-significant ‘predictors’were then dropped and theregression analyses were repeated (i.e. the revisedmodel).

RESULTS

A total of 1296 parents recorded their name andcontact details in the PLC visitor’s book.

Of these, a total of 923 completed the SPS, aresponse rate of 71%. And of these, 172 (18.6%)reported receiving a Triple P intervention. Theresponse rate for the 10 Triple P pilot sites and 10services-as-usual PLCs was 70% (n = 420) and 72%(n = 500), respectively. Notably, the overall responserate from parents accessing aboriginal PLCs was sub-stantially lower at just 28%. This is consistent withprevious research showing that surveys are rarely cul-turally acceptable or appropriate for aboriginal groups(Holmes et al. 2002).

Across all respondents, PRNS was generally high.More than 87% of all respondents indicated that,generally at least, they got the type of help they wantedfrom their PLC, and over 75% indicated that most or

Table 3 Scale reliability and descriptive statistics(n = 923)

Variables M SD Range a

Parent need satisfaction 20.54 4.16 4–28 0.86PSISF total parenting stress 72.66 18.97 36–142 0.92Positive interaction (n = 883)* 21.36 2.68 11–25 0.81SDQ Total child difficulties

(n = 441)†10.92 5.90 0–33 0.81

Family functioning 43.32 6.01 22–52 0.92

*completed if the nominated children was 0–11 years of age.†completed if the nominated child was 3 + years of age.PSISF, Parenting Stress Index–Short Form; SDQ = Strengthsand Difficulties Questionnaire; SD, standard deviation.

Table 4 MANOVA: Triple P vs. services-as-usual on primary and secondary outcomes

MANOVA 1Triple P group Services-as-usual

F (1831)Partial

Eta-squaredMean (SD) Mean (SD)

Need satisfaction 21.54 (4.09) 20.36 (4.09) 10.351* 0.012PSI(SF) total parenting stress 75.15 (19.05) 71.79 (18.27) 4.152 0.005PSI(SF) Personal distress 27.44 (8.28) 26.53 (8.23) 1.534 0.002PSI(SF) Childrearing stress 47.71 (13.03) 45.27 (12.40) 4.765 0.006Family functioning 42.92 (5.23) 43.46 (6.13) 1.034 0.001Positive interaction (0–1 years) 21.16 (2.66) 21.38 (2.64) 0.873 0.001

Wilks’ Lambda F (5827) = 3.714, P < 0.001, Partial Eta-squared = 0.022

*Signifies a statistically significant difference at P < 0.01.PSI(SF) = Parenting Stress Index-Short Form.



all of their needs as parents had been met. Further,more than two-thirds of the parents reported thattheir PLC had helped them, at least ‘somewhat’, todeal more effectively with their child’s behaviour, andmore than one in two indicated that their PLC hadhelped them to address problems that arise in theirfamily.

Parent, child and family outcomes: MANOVAgroup comparisons

Table 4 presents the means and standard deviations forTriple P and service-as-usual groups and the F-teststatistic from MANOVA group comparisons onprimary and secondary outcome measures.The resultsshould be interpreted with caution because potentialconfounders (e.g. group differences in service typesreceived) are not controlled in this analysis. Notwith-standing, a statistically significant difference (P <0.01), in favour of Triple P, was found for PRNS. Noother statistically significant difference was found.

Parent reported need satisfaction: interactionbetween service variables

A statistically significant interaction was foundbetween Triple P and parent participation in group-based parent education for PRNS (see Table 5). Inother words, the effect of Triple P on PRNS varied

depending on whether or not the parent participatedin a PLC (Triple P or service-as-usual) group-basededucation programme. Of course, the reverse is alsotrue: the effect of group-based parent education pro-grammes varied depending on whether parentsreceived a Triple P intervention of some kind.

Parent reported need satisfaction:multivariate analyses

Because of the significant interaction betweenTriple Pand group participation, separate regression analyseswere performed for parents who did and parents whodid not participate in group-based parent education.The findings reported in Table 6 show no significantassociation between receipt of Triple P and PRNS,that is, when parents did not participate in group-based parent education. Notably, higher PRNS in thissubgroup of parents was associated with increasedfrequency of service; receipt of parenting informationincluding handouts and tip sheets and supportaddressing issues to do with the parent’s personalwell-being or issues to do with a toddler. Conversely,lower need satisfaction was associated with havingEnglish as a second language and parental and/orchild disability or chronic health condition.

Table 7 presents the findings from the regressionof PRNS on support, service, parent, child andfamily variables in cases in which parents reported

Table 5 Regression: interaction between Triple P and service variables

Need satisfaction

B SE B b

Constant 16.825 0.598Triple P (Levels 2/3) 0.746 1.475 0.072New PLC client (new in last 3 months) -0.809 0.390 -0.072*Service frequency (no. of contacts) 0.505 0.157 0.119***Parenting information (e.g. tip sheets) 1.363 0.320 0.152***One-to-one training 1.368 0.470 0.120**Group programme 0.936 0.326 0.111**Family support (e.g. community kitchen) 0.815 0.398 0.078*Drop-in playgroup 0.627 0.449 0.053Triple P*new PLC client 0.819 1.061 0.029Triple P*service frequency -0.084 0.415 -0.029Triple P*parenting information -0.468 0.900 -0.042Triple P*one-to-one training -0.094 0.821 -0.005Triple P*group program 1.464 0.701 0.107*Triple P*family support -0.206 0.799 -0.012Triple P*drop-in playgroup -0.539 1.006 -0.048Adjusted R2 0.130F 9.641***

*P < 0.05, **P < 0.01, ***P < 0.001.



participation in a PLC group-based education pro-gramme. The data show that when support andservice variables, parent, child and family characteris-tics were held constant, Triple P was associated withgreater PRNS. In addition, the data show that amongparents who reported participation in a PLC group-based education programme, need satisfaction waspositively associated with receiving support withissues to do with an elementary school-aged child andnegatively associated with parental educational attain-ment and child age. In other words, in this subgroup,parents with higher levels of educational attainmentand parents concerned about an older child tended toreport lower levels of need satisfaction.

DISCUSSION

Whether parents received a Triple P (level 2 and/or 3)intervention or not, most reported high levels of needsatisfaction: PLC services were meeting most parents’needs, and helping parents deal more effectively withtheir child’s behaviours. PRNS was somewhatenhanced when participation in a group-based parenteducation programme was coupled with a Triple Pintervention such as a Triple P group seminar, parent-ing tip sheets and/or one-to-one active skills training.With potentially confounding variables held constant,receipt of Triple P was associated with an increase inPRNS equivalent to 0.190 of a standard deviation in

Table 6 Predictors of need satisfaction when no group-based intervention is received

Need satisfaction

Full model Revised model

B SE B b B SE B b

Constant 14.32 3.168 14.95 0.782Triple P (Levels 2/3) -0.415 0.501 -0.036New PLC client -0.489 0.480 -0.043Service frequency (no. of contacts) 0.616 0.183 0.150*** 0.667 0.165 0.161***Parenting information (e.g. tip sheets) 0.891 0.372 0.103* 1.212 0.353 0.139***One-to-one training 0.862 0.683 0.058Family support (e.g. toy exchange) 0.737 0.490 0.063Drop-in playgroup 0.378 0.572 0.030Issue: relationship with your partner 0.442 0.934 0.021Issue: baby/infant 0.205 0.477 0.019Issue: toddler 0.825 0.404 0.092* 1.212 0.372 0.134***Issue: pre-school-aged child 0.959 0.541 0.082Issue: elementary school-aged child 1.433 0.826 0.078Issue: teenager 3.058 1.809 0.078Issue: personal well-being 1.543 0.483 0.144*** 1.770 0.441 0.163***Parent age -0.001 0.032 -0.001Parent gender – female -0.331 1.042 -0.014Aboriginal status 0.377 0.729 0.022English spoken at home 1.354 0.601 0.101* 2.271 0.547 0.166***Parent educational attainment -0.126 0.158 -0.037Parent history of special education 0.914 0.691 0.056Parent longstanding health condition -1.17 0.466 -0.100* -1.31 0.452 -0.116**Parent employed/working 0.679 0.363 0.080Child age -0.189 0.093 -0.106* -0.095 0.075 -0.053Child longstanding health condition -1.11 0.529 -0.105* -1.07 0.507 -0.088*Sole parent household -1.34 1.473 -0.048Blended family 0.967 1.113 0.060Original family 0.581 0.919 0.047Household income 0.129 0.067 0.087Household size -0.263 0.269 -0.060No. of children < 6 years 0.177 0.339 0.031Adjusted R2 0.158 0.145F (30 486) 4.231*** (8537) 12.544***

*P < 0.05, **P < 0.01, ***P < 0.001.



this subgroup – a small but potentially meaningfuleffect. In the absence of group participation however,there was no significant difference between Triple Pand non-group-based services-as-usual with respectto PRNS.

Precisely why group participation would moderatethe effect of Triple P is unclear. One possibility is thatgroup participation addresses certain needs (e.g.reduces parent sense of social isolation) which in turn,enables parents to benefit more from Triple P trainingand support. However, it may be more accurate to saythat Triple P is enhancing the outcomes of group-based parent education than vice versa. The questionthen is ‘why would Triple P moderate the effects ofgroup-based parent interventions?’ The answer may

lie in the high quality Triple P educational materials,including video resources and tip sheets and/orthe highly structured and systematic nature of theprogramme.

The study findings also suggest that not all parentsare benefiting equally from PLC services. Forinstance, among parents who did participate in agroup-based parent education programme, those witholder children and those with higher levels of educa-tion, on average, reported lower levels of need satis-faction. Notably, most parents in the study and mostparents served by PLCs have young children. It ispossible therefore that parents with older children arenot deriving the same benefit from PLC servicesbecause there is less opportunity for them to mix with

Table 7 Predictors of need satisfaction when a group-based intervention is received

Need satisfaction

Full model Revised model

B SE B b B SE B b

Constant 20.09 3.48 23.356 0.754Triple P (Levels 2/3) 1.203 0.455 0.155** 1.502 0.445 0.190***New PLC client -0.724 0.576 -0.071Service frequency (no. of contacts) 0.043 0.264 0.010Parenting information (e.g. tip sheets) 0.808 0.579 0.082One-to-one training 0.627 0.460 0.080Family support (e.g. toy exchange) 0.260 0.469 0.033Drop-in playgroup 0.609 0.579 0.063Issue: relationship with your partner 0.965 0.679 0.085Issue: baby/infant 0.561 0.437 0.078Issue: toddler 0.365 0.431 0.052Issue: pre-school-aged child 0.274 0.547 0.031Issue: elementary school-aged child 1.973 0.777 0.174* 1.938 0.678 0.172**Issue: teenager 1.873 1.396 0.091Issue: personal well-being 0.842 0.439 0.116Parent age 0.037 0.038 0.065Parent gender – female -0.221 1.161 -0.011Aboriginal status 0.154 0.853 0.010English spoken at home 1.657 1.003 0.093Parent educational attainment -0.385 0.166 -0.143* -0.301 0.148 -0.111*Parent history of special education -0.609 0.642 -0.055Parent longstanding health condition -0.661 0.531 -0.071Parent employed/working 0.587 0.397 0.083Child age -0.233 0.113 -0.168* -0.248 0.085 -0.178**Child longstanding health condition -0.782 0.562 -0.083Sole parent household -2.013 1.532 -0.108Blended family -2.514 1.309 -0.146Original family -0.548 0.913 -0.054Household income 0.112 0.081 0.084Household size 0.063 0.314 0.017No. of children < 6 years -0.099 0.402 -0.019Adjusted R2 0.146 0.063F (30 271) 2.717*** (4311) 6.299***

*P < 0.05, **P < 0.01, ***P < 0.001.



other parents who share their life stage and facesimilar challenges. Alternatively, parents may find thatthe behaviour-based strategies that Triple P and otherPLC programmes teach are more difficult to imple-ment or are less effective for older children. Explain-ing why parents with higher levels of educationalattainment are not deriving the same benefit is moredifficult. It could be that parents with higher levels ofeducational attainment, who typically have higherlevels of parenting knowledge to begin with (Benasich& Brooks-Gunn 1996), are looking for more or differ-ent information and guidance than PLCs are cur-rently offering.

Limitations

The study findings are consistent with previousresearch which has generally found only modesteffects for low-level parenting training and supportinterventions in ‘typically normal risk’ populations(Layzer et al. 2001; Nowak & Heinrichs 2008).Further, the study findings are consistent with thosereported by Turner & Sanders (2006) and de Graafet al. (2009) who also found little or no effect forTriple P (level 3) on secondary outcomes such as childbehaviour. Notwithstanding, this study had two keylimitations. Firstly, participants were not randomlyassigned and consequently, the Triple P and services-as-usual groups may not be equivalent. Any pre-existing group differences could offer a plausiblealternative explanation for the study findings. Tominimize the selection threat to internal validity,participants were drawn from matched Triple P andnon-Triple P PLC sites, and multiple regression wasemployed to control for many potentially confoundingvariables. Another limitation is that a post-test-onlydesign was employed. This design affords less statisti-cal power than a pre-test post-test design. However,post-test-only designs offer several advantages. One isthat they are less onerous for participants. Anotheradvantage is that they circumvent repeat-testing, attri-tion and regression threats to validity.

Conclusion

There is a large and compelling body of evidencesupporting the efficacy of Triple P. However, moststudies have been developer-led, few studies havecompared Triple P with active services-as-usual com-parison groups and only a small number of studieshave evaluated levels 2 and 3 of the Triple P system.The findings of this study suggest that implementa-

tion of levels 2 and 3 of Triple P does not markedlyenhance parent, child and family outcomes comparedwith PLC services-as-usual. A small effect on parentperceived need satisfaction was found, but this wascontingent: the study findings suggest that parentneed satisfaction is enhanced when group participa-tion is coupled with a Triple P intervention. However,no significant between-group differences were foundon secondary outcome measures including parentingstress, parenting practices, family functioning andchild behaviours.

Further research is clearly needed before any firmconclusions can be reached with respect to the effec-tiveness of Triple P (levels 2 and 3). The modestadvantage that Triple P (levels 2 and 3) conferredover services-as-usual in this study raises the ques-tion of whether the dissemination of Triple P (levels2 and 3) is worth the expense. It is however impor-tant to acknowledge that the dissemination of TripleP may have other benefits: Triple P (levels 2 and 3)may add value to family support services in otherways. The dissemination of Triple P may, forexample, result in efficiency gains as high-qualityeducational resources are at hand. The reputationand status of family support agencies may also beimproved if the services provided are perceived to beevidence-based, and this may result in increasedreferrals. A cost–benefit analysis is needed to providepolicy-makers with the additional data they need tomake informed decision with respect to the dissemi-nation of Triple P or other comparable programmesin primary care settings.

ACKNOWLEDGEMENTS

This paper reports findings from an independentevaluation ofTriple P in Alberta, Canada.The authorshave no affiliation with the developers or distributorsof the Triple P programme. The study was supportedby a grant from the Alberta Centre for Child, Familyand Community Research.

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Independent evaluation of the Triple P Positive Parenting Program in family support service settings

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