The costs of a public health infrastructure for delivering parenting and family support
Introduction
Ineffective and harsh parenting has been linked to child maltreatment and a variety of other undesirable outcomes and constitutes an important public health problem (Berger & Brooks-Gunn, 2005). These outcomes include disruptive behavior and conduct disorder as well as other child behavioral and emotional problems (Dishion and Andrews, 1995, Hawkins et al., 1992, McCord, 1988, Patterson et al., 1989). These childhood problems, as well as the long-term sequelae of child maltreatment, in turn hinder school performance and relationships with peers and adults. These problems reinforce each other and compromise these children's functioning over time, substantially increasing their risk for substance use, delinquency, academic failure, and risky sexual behavior (Ary et al., 1999, Dishion and Andrews, 1995, Hawkins et al., 1992, Patterson et al., 1989).
Child maltreatment specifically as well as children's behavioral and emotional problems associated with problematic parenting collectively exerts an enormous toll on society. Child maltreatment results in costs associated with utilization of administrative services and systems (e.g., child protective services, foster care, judicial system), child treatment services (e.g., healthcare, mental health, educational systems), long-term impact (e.g., psychological and health problems in adulthood), and next generation victimization. Although much uncertainty exists about the cost of child maltreatment and its consequences, Prevent Child Abuse America estimated costs associated with child abuse and neglect in the U.S. to be over $94 billion per year (2001 dollars). Children's behavioral and emotional problems and, in particular conduct disorders, generate costs associated with harm to the youths themselves and other members of society (e.g., victims of crime) and exceed $400 billion per year for the U.S (Miller, 2004).
Given the enormous costs associated with both child maltreatment and children's behavioral and emotional problems, the savings stemming from effective preventive interventions are potentially quite large. A particularly promising vehicle for prevention of both child maltreatment and child behavioral/emotional problems can be found in evidence-based parenting interventions. The most effective parenting interventions for prevention of behavioral/emotional problems in young children are derived from social-learning, functional analysis, and cognitive-behavioral principles (McMahon and Kotler, 2004, Prinz and Jones, 2003, Sanders et al., 2004, Taylor and Biglan, 1998). Various studies have demonstrated that such programs improve parenting-skills and children's behaviors (Barlow and Stewart-Brown, 2000, Prinz and Dumas, 2004, Sanders et al., 2004, Taylor and Biglan, 1998, Webster-Stratton, 1984, Webster-Stratton, 1998, Webster-Stratton et al., 1989), and those effects have been replicated across different studies, investigators, and populations (Sanders, 1999). Multiple best-practice lists identify such interventions as exemplary. These parenting-skills interventions are associated with large effect sizes (Serketich & Dumas, 1996); and those effects often generalize to a variety of home and community settings (McNeil, Eyberg, Eisenstadt, Newcomb, & Funderburk, 1991) and are maintained over time (McMahon, 1999, Sanders et al., 2000, Webster-Stratton et al., 1989).
Although effective, such programs are not accessible to many. To improve access, a public health approach to improving parenting is required. Reducing the prevalence of children's behavior problems will require that a large proportion of the population be reached with effective parenting strategies (Biglan, 1995). An example of a public health approach to parenting is the Triple P Positive Parenting Program system (Sanders, 1999). Triple P is one of the few multi-level, population-based parenting interventions with sufficient empirical support to warrant implementation at the population level. Triple P is unique in that this package of interventions is conceptualized and organized on a population basis and was designed for broad dissemination. The program includes multiple levels of parenting support that allow each family to receive the “minimally sufficient” dose or level of programming (Sanders, 1999). This approach holds out the promise of implementing the program on a broad scale in a cost-effective manner. The strength of evidence and public health promise is so strong that the United Kingdom's National Institute of Clinical Excellence (NICE) judged the program cost-effective and recommended that it be made available to all families in the United Kingdom through the National Health Service.
Using data from a unique population trial in South Carolina, this article estimates the costs of building a public health infrastructure for delivering a multi-level parenting and family support intervention. The study provides an excellent opportunity to examine the dissemination of Triple P in previously unexposed communities. These analyses estimate the costs of implementing an infrastructure for delivering Triple P throughout the community. These costs correspond to the resources required to train the appropriate number of providers with the necessary skills. The number of providers and therefore the amount of training provided was determined for a hypothetical community of roughly 100,000 families with young children (ages 0 to 8).
Section snippets
Prior research
The Triple P system enhances parental competence, prevents dysfunctional parenting practices, and promotes better teamwork between partners, thereby reducing behavioral and emotional problems in children and adolescents. The program includes five levels of increasing intensity and narrowing population reach. Level 1 is a media and communication strategy targeting all parents. Level 2 is a 1–2 session intervention; Level 3 is a more intensive but brief 4-session primary care intervention; Level
Triple P System Population Trial
The population in the U.S. Triple P System Population Trial (TPSPT) includes all families in the nine counties who have at least one child under the age of 8 years (Prinz & Sanders, 2007). The trial involves 18 South Carolina counties ranging in population from 50,000 to 175,000. These counties were matched in nine pairs based on child maltreatment prevalence, population size, and poverty. One county in each pair was randomized to county-wide dissemination of the Triple P system; the other
The costs of universal intervention
The primary inputs into the media campaign involved the salary of and office space for the media consultants; two mass mailings and a parent newsletter. The materials themselves had been created earlier as part of ongoing intervention development and delivery (Table 1).
The required information on the amounts and costs of inputs used (such as postage) were available on financial records for the program. (We estimated the costs of office space using the difference between the on-campus and
Discussion
These results suggest that the costs of building a public health infrastructure for improving parenting throughout a community are rather modest. On a per-child basis, these costs are less than $12 per child. For a relatively modest investment, the core infrastructure can be created to implement an evidence-based, public health intervention such as Triple P. Given the extremely high societal costs of child and family problems (and the strong evidence base for the Triple P program), such an
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