Implementing a Parent Education Intervention in Colombia: Assessing Parent Outcomes and Perceptions Across Delivery Modes

Abstract

Knowledge and identification of autism spectrum disorder (ASD) are increasing in Latin America, yet there are limited resources available to help families of children with ASD. For this study, researchers adapted and tested a parent educational program created for Latino immigrant parents of children with ASD in the United States to the needs of parents of children with ASD in Colombia. Parents were randomized into two intervention delivery modes, one led by parents and the other by students. All measures were self-reported by parents (n = 20). Parents improved in understanding their child’s strengths and needs and frequency of using evidence-based strategies. Parents in the student-led group reported significantly lower depressive symptoms between baseline and follow-up. In focus groups, parents expressed satisfaction with the intervention and described ways they were using the information. This study demonstrated promising results to improve the experience of parents of children with ASD in Colombia.

Keywords

autism spectrum disorders parent training multicultural issues

Autism spectrum disorder (ASD) is estimated to affect about 1% of the world population (Elsabbagh et al., 2012). However, prevalence rates vary by country and many middle and low-income countries do not have surveillance systems in place to monitor the prevalence of ASD, often because it is lower on the scale of public health priorities (Baxter et al., 2015). Contributing to this challenge, ASD markers and diagnostic methods are based on observations of behaviors, which makes it more challenging to assess actual prevalence. Although only a few prevalence studies have been conducted in Latin America, initial work in this area have found lower rates of ASD compared with the United States and other high-income countries: 0.17% in Venezuela (Montiel-Nava & Peña, 2008), 0.27% in Brazil (Paula, Ribeiro, et al., 2011), and more recently, 0.87% in Mexico (Fombonne et al., 2016).

Similar to the limited number of prevalence studies, there has been limited research conducted on the experiences of individuals with ASD and their families and how it is diagnosed and treated in Latin America. For example, in Costa Rica, a study that examined geographic clusters and the diagnosis of ASD found that like studies in the United States, ASD diagnosis tended to cluster in high-income districts (Schelly et al., 2015). This finding surprised the authors, who had assumed that because of the availability of universal health care in Costa Rica, receiving a diagnosis of ASD might be more equitable. These authors theorized that higher-income parents may prefer to pay for a private physician due to long wait times to see a physician in the public health care system and can thus be referred for an ASD diagnosis faster (Schelly et al., 2015). A study that focused on the age of diagnosis of ASD in a clinical sample in Venezuela (Montiel-Nava et al., 2017) found that the mean age of children when parents first expressed concerns about their child’s development was under 2 years old, which is comparable to studies in the United States (Jang et al., 2014; Magaña et al., 2013). The average age of diagnosis in the Venezuelan sample was about 54 months, which is similar to the rates among Latinos in the United States and higher than the rates among non-Latino Whites (Daniels & Mandell, 2014; Magaña et al., 2013). The authors of this study highlighted the importance of ASD awareness and educational programs in Latin American countries (Montiel-Nava et al., 2017). Regarding attitudes about ASD by professionals in Latin America, mental health professionals in Brazil are reported to adhere to a psychoanalytic tradition, and there is disagreement between professionals and parents about how to respond to ASD (Block & Cavalcante, 2012; Rios & Costa Andrada, 2015). Professionals in Brazil lean toward seeking to understand the social and psychological origins of symptoms among children with ASD and often shun the label of autism, while parents have advocated for following recommendations from Western countries, including diagnosing ASD early and providing access to evidence-based treatments and services (Block & Cavalcante, 2012; Rios & Costa Andrada, 2015). This may present tension between parents and professionals on how to respond to children with ASD. Only two other Latin American studies related to ASD were found, both based in Brazil; one that focused on child characteristics of ASD and one that focused on a parent training program (Czermainski et al., 2014; Santos et al., 2015). Overall, there is limited research on ASD in Latin America.

This limited but growing body of research about ASD in Latin America demonstrates that there is an emerging awareness of ASD in this region. Despite increased awareness, many Latin American countries do not have the fiscal or organizational infrastructure to meet many of the complex needs of individuals with ASD and their families (Mercadande et al., 2009) and this is the case in Colombia, the focus of the current study. One approach some Latin American countries are taking is to hold research and policy meetings about ASD to promote networking, research, and work on autism issues (Paula et al., 2011). The Colombian Health System took this approach and formed a task force that began discussions about formal diagnostic services for children with ASD in 2014 (Colombian Ministry of Health, 2015). The task force noted that there is a lack of research, diagnostic tests, trained professionals, and appropriate services for children with disabilities, and especially for ASD. As a result, the Colombian Ministry of Health (2015) announced the dissemination of clinical guidelines for the diagnosis and treatment of children with ASD. These clinical guidelines were created in response to the pressure from families of children with ASD who were looking for diagnostic services when they suspected developmental problems and the option of receiving applied behavior analysis and other services when their children were diagnosed with ASD (Colombian Ministry of Health, 2015). The guidelines focus on early detection and comprehensive services to children and families similar to the advocacy interests of parents in Brazil.

As in other low- and middle-income countries, resources for disability services are scarce in Colombia. The Colombian health care system is based on insurance and a family’s ability to pay for services. There is a public health insurance program for low-income families; however, there are inequalities in access to diagnostic and treatment services (Moreno-Angarita, 2011). While low-income families can access services like occupational and speech therapies for their children, the quality of services is fragmented and uneven (Magaña, Tejero-Hughes, et al., 2019). Middle- and high-income parents are more likely to pay out of pocket for better quality services similar to practices in Costa Rica (Schelly et al., 2015). In this context, it is important to develop and adapt interventions and programs that are low cost and easy to implement to make them accessible to more families.

Parent training programs have been shown to be effective in improving both parent and child outcomes among children with ASD and their parents (Bearss et al., 2015) and typically are lower cost than other types of interventions. Parents are with their children the majority of the time and can be taught to use evidence-based strategies during natural child and family routines, thus increasing the exposure of these strategies to the child. Parent training is generally more cost-effective than is providing therapists to conduct time-intensive and complex interventions. International organizations such as the World Health Organization (WHO) are recognizing the importance of developing parent training interventions that can be taught by nonprofessionals as they may be more feasible in countries that lack resources (Salomone et al., 2018). Parents Taking Action (PTA) is a parent training program focused on psychoeducation about ASD and is designed to be delivered by peer leaders (parents of children with ASD) and has been tested with Latino immigrant populations in the United States (Magaña, Lopez, et al., 2020).

Description of the Intervention and Adaptation in Colombia

PTA was created in the United States for Latino immigrant parents and was tested in three major U.S. cities. The PTA program is focused on empowering parents of children with ASD by providing them with knowledge about ASD and evidence-based strategies to help their children develop and learn. In the original program design, a promotora de salud (community health worker), who is also a Latino parent of a child with ASD, delivers PTA. The promotoras receive about 32 hr of training on the educational information discussed in the program. The promotoras then engage other parents in the educational program through 14 weekly home visits that last about 2 hr each. Each session is culturally tailored to consider Latino cultural values and norms. A manual and supplemental video, audio, and written materials guide the program. Session topics include understanding child development and ASD diagnosis, an overview of evidence-based interventions for children with ASD, advocacy skills, learning evidence-based strategies to address particular markers of autism, reducing parental stress, and talking about ASD with others. Parents participating in the program also received a resource folder of programs and services in their area. A pilot study using this model found the program to be both practical and beneficial for families (Magaña et al., 2017). Results from a randomized control trial of the intervention found that parents in the intervention group were more confident in using evidence-based strategies and used evidence-based strategies more frequently than the control group (Magaña, Lopez, et al., 2020).

Due to its success in the United States, there was interest in offering the program in Bogota, Colombia. Subsequently, PTA was adapted for implementation with families of children with ASD in Bogota through a collaboration of investigators at the University of Illinois at Chicago and the Universidad Nacional de Colombia. Investigators obtained approval through their institutional review boards at both universities.

The adaptation of the PTA program began with the Colombian team reviewing the Spanish versions of existing manuals and materials to suggest changes based on the Colombian context. Next, the Colombian research team shared the materials with professionals who work with children with ASD in Colombia for their feedback. Adaptations of PTA included changing some of the vocabulary to align with the Spanish words used in Colombia and removing chapters on advocacy and navigating the service system, which was specific to a U.S. context. The Colombian team did not recommend many changes because the curriculum was already developed for parents of Latin American descent, and the topics were ones that parents were asking for: information on evidence-based approaches. Changes to the intervention protocol included extending the age range of the child because children were identified with ASD even later than Latino children in the United States (the original protocol age criterion was 2–8 years old).

In addition, the Colombian partners urged the team to use professionals to deliver the program rather than parent promotoras. Their rationale was that it was not common to use nonprofessional peers to offer medical or scientific information and parents may expect this type of information to come from professionals. The U.S. team felt that the peer aspect was an essential part of the intervention because of the peer support and shared experiences that the promotora offered. However, these researchers realized that the immigrant context in the United States is distinct from the Colombia context; immigrant parents are isolated due to language barriers and cultural differences and look forward to sharing information with peers about a host of matters they have in common. In Latin America, parents are not cultural outsiders but may be isolated because they have a child with a disability. As a result, both teams decided on a compromise in the study design that would test each delivery model; parents were randomized to receive the intervention from a parent promotora or from a professional student promotora (students who were studying to be speech and language therapists). See Magaña, Tejero-Hughes, et al. (2019) for more details about the adaptation process.

The purpose of the study was to compare results from two methods of delivery for the intervention to determine whether one mode was more useful than the other for parents in Colombia, and to ascertain the perceptions of parents about their experiences in the intervention. The study was designed to answer the following research questions:

Research Question 1: Do parents participating in the intervention improve on outcomes from pre and post-tests?

Research Question 2: Are there differences in intervention results across the two delivery methods?

Research Question 3: What were the perceptions of the parents of the intervention?

Method

Participants

Parents/family caregivers

We recruited parents or primary family caregivers of children with ASD from the most recognized inclusive public school focused on services for students with autism in Bogota, Colombia. There are no special education programs in public schools in the country, which limits the options for parents. Generally, public schools serve low-income children as middle- and higher-income children are able to access private schools. Because of the inclusive nature of this public school, parents from diverse socioeconomic backgrounds sent their children with ASD to this school. Our Colombian partner had a relationship with the school and the school invited eligible parents to an information session to inform parents of the study and to enroll them. Twenty-five parents/caregivers agreed to participate in the study at this information session, gave their informed consent prior to their participation, and were randomized into two groups based on who delivered the intervention, parent promotoras (PP) or student promotoras (SP). Although all parents/caregivers began the intervention, 20 completed the intervention with the other five withdrawing over the course of the program due to scheduling conflicts. Parents/caregivers included 17 biological mothers of the child, two grandmothers, and one father (to be parsimonious, we will refer to them as parents throughout).

Table 1 shows parent and child demographics by intervention group. There were no significant differences between the two groups of parents or children on demographic variables. The majority of parents completed a high school education, 25% had a bachelor’s degree, and 20% had an advanced degree. About half of the families had low incomes. More than half (55%) of the parents were employed: 20% were employed full-time and 35% were employed part-time. Parents average 40 years of age and 55% of them were married or living with a partner. About half of the parents reported they had either fair or poor health.

Table 1.

Baseline Characteristics and Results for Study Outcomes by Group.

Characteristic	SPG^a (M ± SD)	PPG^a (M ± SD)	Critical test score^b
Parent & child characteristics
Parent age	40.8 ± 10.8	37.9 ± 5.9	0.7
Years of education	14.2 ± 4.3	15.5 ± 4.8	0.6
Child age	8.7 ± 1.7	8.6 ± 1.4	0.1
Age of child (in months) when atypical development was noticed	16.3 ± 10.4	11.6 ± 8.7	1.09
Number of typical developmental services	1.6 ± 1.8	1.4 ± 1.5	−0.3
	Frequency (%)	Frequency (%)
Married or living with someone	5 (50)	6 (60)	0.2
Low income	4 (40)	6 (60)	0.8
Child gender (male)	8 (80)	7 (70)	0.3
	M ± SD	M ± SD
Parent outcomes
Understand child’s strengths & needs	11.1 ± 3.2	11.2 ± 3.8	0.06
Know your rights	8.4 ± 4.9	9.7 ± 5.2	0.6
Help child develop & learn	13.1 ± 2.8	12.8 ± 3.7	−0.2
Have support systems	11.8 ± 5.53	14.7 ± 4.8	1.3
Access community	15.2 ± 5.5	16.8 ± 5.5	0.7
Total family outcome score	59.6 ± 12.3	65.2 ± 18.6	0.8
Efficacy in using strategies	31.6 ± 3.3	33.4 ± 5.5	0.9
Frequency of using strategies	35.4 ± 5.3	37.2 ± 7.5	0.6
Depressive symptoms	25.7 ± 13.5	25.8 ± 13.1	0.02

Note. SPG = student promotora group; PPG = parent promotora group.

n = 10. ^bt test for continuous variables and Pearson chi-square test for discrete variables.

With respect to child demographics, 76% of the children were male and the average age of the child was 10.6 years (ranging between 7 and 13). All of the children had a diagnosis of ASD which was confirmed by the school’s psychology department. Children were receiving between 1 and 2 services at baseline. These services typically consisted of occupational therapy, speech therapy, or integral therapy (integrating different types of therapies).

Instruments

Demographic variables

Parents were asked demographic questions at baseline including parent’s date of birth, education, employment, status, marital status, and physical health status. Child characteristics included the date of birth, gender, diagnosis, and the number and type of services received. The following were outcome variables we examined at baseline and after the intervention. Table 1 includes comparisons of demographics and outcome variables by intervention group. There were no significant differences in between groups on any of these variables.

Parent empowerment

The Family Outcome Scale (FOS) was used to measure parent empowerment (Bailey et al., 2008) and contains 24 questions in five domains: understanding the child’s strength and needs; knowing your rights and advocating for the child; helping the child develop and learn; having support systems; and accessing the community. Respondents answered questions on a 5-point Likert-type scale ranging from 1 (not at all) to 5 (completely). This measure has been validated with Spanish-speaking populations (Olmstead et al., 2010). Items were summed within each of the five subscales (domains), and all items were summed for the overall family outcomes scale. A higher score indicates greater levels of family empowerment. Cronbach’s alphas for the individual subscales for the present study at baseline were .70, .65, .75, .75, and .58 respectively; and .85 for all 24 family outcome items. These statistics indicate that the subscales have fair levels of internal consistency (with the exception of accessing the community which is not as strong), while the overall scale has good internal consistency.

Efficacy in using intervention strategies

This measure was developed for the original pilot study of PTA to assess caregiver confidence in using the strategies that were taught in the intervention and consists of 10 items (Magaña et al., 2017). Sample items include “I feel confident setting the stage for leaning for my child,” and I feel confident immediately rewarding my child for positive behaviors.” Respondents answered questions using a 4-point Likert-type scale ranging from 1 (strongly disagree) to 4 (strongly agree). Items were summed and higher scores indicate higher levels of efficacy in using intervention strategies. Cronbach’s alpha for the present sample at baseline was .73. This indicates fair internal consistency.

Frequency in using intervention strategies

Developed for the original pilot study of PTA, this measure assessed the frequency of using evidence-based strategies and consists of 14 items (Magaña et al., 2017). Sample items include “How often do you immediately reward your child for positive behaviors?” and “How often do you use modeling to show your child what you want him or her to do?” Respondents answer questions using a 4-point Likert-type scale ranging from 1 (never) to 4 (always). Items were summed, higher scores indicate using strategies with greater frequency. Cronbach’s alpha of this measure for the present sample at baseline was .81. This indicates good internal consistency.

Depressive symptoms

The Center for Epidemiological Studies Depression Scale (CES-D) was used to assess the frequency of depressive symptoms over the past week (Radloff, 1977). It contains 20 items using a Likert-type scale ranging from 1 (rarely) to 4 (most of the time). The CES-D has been validated for use with many populations including Latinos (Cho et al., 1993). The Cronbach’s alpha of this measure for the present sample at baseline was .92, indicating a strong level of internal consistency.

Parent focus group interview

The parents participated in focus group interviews at the University that comprised three to four parents in each focus group with each only including parents from the same treatment group (PP or SP). Focus group interviews are well suited for exploring the experiences parents had during the intervention since it allowed for parents to interact with each other and encourages them to build off of each other’s experiences (Barbour, 2008). In addition, focus group interviews are frequently conducted with culturally diverse groups as can be empowering and provide a means for the initial explorations of perceptions related to a topic (Huer & Saenz, 2003). The U.S. bilingual researchers who conducted the interviews were not acquainted with the parents, and parents were assured that their responses would remain confidential. Each focus group interview lasted about an hour and began with a brief overview of the purpose of the meeting. The interview consisted of six questions with follow-up probes that began with parents providing information about their child and continued with them discussing their experiences during the intervention and possible impacts and their perceptions of the intervention. The interviewers took notes and completed a spider diagram that was used to keep track of the discussion and ensure everyone had opportunities to respond. The interviews were digitally recorded and transcribed verbatim.

Procedures

Promotora training

The U.S. and Colombian team conducted the promotora training in Spanish in the university setting of the Colombian partner. We completed about 28 hr of training over a 6-day period for 4 to 5 hr of training per day. In addition to the four promotoras, professionals in the community (speech therapists, psychologists, and teaching staff) also attended many of the training sessions. Our Colombian partner felt it was important to include these professionals as they could be community partners who would help us recruit families and add community credibility to the program implementation.

Enrollment and intervention

Before beginning the intervention, each parent completed a baseline questionnaire through an interview conducted by a Colombian research assistant. After completing the baseline questionnaire, families were randomized into two groups: a parent promotora group (PPG) and a student promotora group (SPG). Both groups received 12 in-home sessions with the goal of meeting weekly, but due to scheduling situations and other factors, sometimes a session had to be rescheduled for another week. Promotoras primarily worked with a parent who agreed to be part of the study, but occasionally the spouse or child would also attend the training sessions.

Post-intervention data collection

When the parent completed the intervention, they completed the post-questionnaires by telephone, which were administered by a Colombian research assistant. The post-questionnaires included the same measures conducted at baseline. The parents were also asked about their interest in participating in a focus group interview. Fifteen parents agreed to be interviewed at the end of their participation in the intervention. Parents who agreed were scheduled to come to the University and were interviewed by the U.S. team. To encourage participation, parents were provided with lunch at the focus group. Four focus groups were scheduled with three to four families attending each. These focus group interviews were conducted by two U.S. bilingual researchers, one who took the lead asking the questions and the other who took notes and asking follow-up probes for clarification.

Data Analysis

To determine whether parents improved in outcomes over the course of the intervention, we used paired-sample t tests to analyze pre- and post-test outcome changes for the overall sample, and by each intervention group. We report findings with a p value of less than .05 to be significant. We also reported effect sizes using Cohen’s d, which can be more meaningful in interpreting differences (Sullivan & Feinn, 2012). A small effect size is considered to be .2, medium .5, and large .8 (Cohen, 1988). To conduct a more rigorous test to determine whether differences by intervention group were significant, we used repeated measures analysis of variance (RM-ANOVA). In other words, the paired-sample t-test comparisons of the two intervention groups can give us an idea of how the two groups may differ between pre- and post-test, but the RM-ANOVA can confirm whether these differences between groups are significant.

We also used qualitative analysis procedures to determine the perceptions of the parents regarding the intervention and their experiences with it. Grounded theory was utilized as the investigators viewed themselves as the primary instruments of the data collection and in data analysis using an inductive stance to derive meaning from the data (Creswell & Guetterman, 2019). In using this framework, we sought out to explore the families’ experiences following the implementation of the intervention by using open questions in a focus group to have a deeper understanding of the families’ perceptions. This theory was identified as an ideal framework, as we analyzed the data without any preconceived notions, as we did not have a relationship with the families, educational systems in Colombia, or with the intervention itself. The interview transcripts and notes were analyzed using thematic analysis by group (PPG or SPG) (Braun & Clarke, 2006). Using a constructivist, grounded theory (Glaser & Strauss, 1999), we summarized and reorganized notes, read and listened to interviews, drafted memos, coded data, compared and contrast codes, negotiated codes, developed themes from the codes, and created matrixes of the identified themes (Charmaz, 2014; Maxwell, 2013; Saldaña, 2016). We worked through this process using collaborative online documents and regular research meetings and continued to negotiate until we agreed on the final themes. During this process, we also identified quotes from the transcripts that exemplified the themes and represented the range of perspectives. All the qualitative analysis was done in Spanish with quotes later translated to English for dissemination.

Results

Parent Outcomes Between Baseline and Follow-Up

Table 2 shows means, standards deviations, t test, and effect sizes between pre- and post-test of the overall sample. We found that for the overall sample, parents reported an increase in understanding their child’s strengths and needs, greater frequency in use of strategies, and fewer depressive symptoms between pre- and post-test, and these differences were statistically significant. The significance level and effect size for parent-reported frequency in the use of strategies was particularly strong. It should be noted that all of the outcomes had better scores at post-test than at baseline. While not statistically significant, moderate effect sizes were found for the overall family outcome scale and helping the child develop and learn. Small effect sizes were found for knowing your child’s rights, accessing the community, and efficacy in using strategies.

Table 2.

Overall t Tests for Study Outcomes.

Parent outcomes	Pre-test	Post-test	t ²	ES
Understand child’s strengths & needs	11.1 ± 3.4	13.4 ± 2.8	−2.7*	0.73
Know your rights	9.05 ± 5.0	10.1 ± 5.3	−0.7	0.21
Help child develop & learn	12.9 ± 3.2	14.4 ± 2.3	−1.9	0.53
Have support systems	13.2 ± 5.3	14.9 ± 5.1	−1.9	0.33
Access community	16.0 ± 5.4	16.9 ± 4.1	−0.8	0.19
Total family outcome score	62.4 ± 15.6	69.9 ± 14.6	−1.9	0.50
Efficacy in using strategies	32.5 ± 4.5	34.5 ± 5.7	−1.5	0.39
Frequency of using strategies	36.3 ± 6.4	43.4 ± 5.4	−4.9***	1.19
Depressive symptoms	26.1 ± 12.8	19.1 ± 11.7	2.6*	0.54

Note. Means and standard deviations reported; ES = effect size.

p < .05. ***p < .001.

Do pre- and post-test results vary by intervention group?

When examining pre- and post-test results by promotora group, we found that there were differences in change over time by group. Table 3 shows the results of paired-sample t tests by promotora group. PPG parents improved significantly in self-reported ratings of understanding the child’s strengths and needs. While not statistically significant, there was a moderate to large effect size for parent-reported frequency in using strategies, and small effect sizes for helping the child develop and learn and the total family outcome score. SPG parents significantly improved in self-reported ratings on several outcomes including helping the child develop and learn, having support systems, and frequency in using strategies. Furthermore, SPG parents reported significantly fewer depressive symptoms, while there was no significant change in depressive symptoms for PPG parents.

Table 3.

Paired Sample t Tests for Study Outcomes by Group.

Parent outcomes	SPG^a		t ²	ES	PPG^a		t ²	ES
Parent outcomes	Pre-test	Post-test	t ²	ES	Pre-test	Post-test	t ²	ES
Understand child’s strengths & needs	11.1 ± 3.2	13.2 ± 3.0	−1.5	0.69	11.2 ± 3.8	13.7 ± 2.7	−2.3*	0.77
Know your rights	8.4 ± 4.9	10.8 ± 6.7	−0.9	0.01	9.7 ± 5.2	9.5 ± 3.7	0.1	0.04
Help child develop & learn	13.1 ± 2.8	15.0 ± 1.3	−2.4*	0.87	12.8 ± 3.7	13.9 ± 3.0	−0.8	0.33
Have support systems	11.8 ± 5.5	14.9 ± 6.2	−2.5*	0.56	14.7 ± 4.8	15 ± 3.9	−0.2	0.07
Access community	15.2 ± 5.5	16.5 ± 4.3	−0.7	0.26	16.8 ± 5.5	17.4 ± 4.1	−0.4	0.12
Total family outcome score	59.6 ± 12.3	70.4 ± 16.4	−1.8	0.74	65.2 ± 18.6	69.5 ± 13.3	−0.8	0.26
Efficacy in using strategies	31.6 ± 3.3	35.5 ± 6.4	−1.7	0.76	33.4 ± 5.5	33.5 ± 5.0	−0.07	0.02
Frequency of using strategies	35.4 ± 5.3	44.5 ± 5.6	−7.7***	1.68	37.2 ± 7.5	42.3 ± 5.3	−2.0	0.78
Depressive symptoms	25.7 ± 13.5	13.2 ± 10.3	2.8*	1.03	25.8 ± 13.1	24.9 ± 10.4	0.4	0.07

Note. Means and standard deviations reported. SPG = student promotora group; ES = effect size; PPG = parent promotora group.

n = 10.

p < .05. **p < .01. ***p < .001.

To determine whether the differences in pre- and post-test change by group that we observed were significant, we conducted an RM-ANOVA. We found that time by group (see Table 4, Time × Group column) was significant for depressive symptoms but not for the other outcome variables. Specifically, this indicates that the reduction in self-reported depressive symptoms was significant for the SPG parents but not for the PPG parents. The difference between pre- and post-test (see Table 4, Time column) controlling for intervention groups was significant for understanding child’s strengths and needs, frequency in using strategies, and depressive symptoms, which was consistent with findings presented in Table 2.

Table 4.

Repeated Measures ANOVA for Parent Outcomes.

Parent outcomes	df	Time		Time × Group
Parent outcomes	df	F	η²	F	η²
Understand child’s strengths & needs	1	6.8*	0.27	0.05	0.003
Know your rights	1	0.5	0.27	0.7	0.380
Help child develop & learn	1	3.7	0.17	0.3	0.010
Have support systems	1	3.9	0.18	2.6	0.130
Access community	1	0.6	0.03	0.08	0.005
Total family outcome score	1	3.7	0.17	0.7	0.036
Efficacy in using strategies	1	2.2	0.11	2.02	0.100
Frequency of using strategies	1	25.8***	0.59	2.05	0.100
Depressive symptoms	1	8.2**	0.31	5.5*	0.230

p < .05. **p < .01. ***p < .001.

Experiences of Parents

Most parents expressed a positive experience with the program and their promotoras. Five major themes emerged from the data: a sense of personal growth, increased advocacy, comfort with the program design, positive changes in their child, and confidence in offering suggestions to others. Regardless of what promotora group parents were in, the majority of parents expressed a sense of personal growth after participating in the program. However, parents working with the parent promotoras felt they learned how to advocate more. These parents also felt that the way the program was set up was helpful. The parents working with student promotoras reported more changes in their child’s behavior and felt that they could offer other families of children with ASD support and suggestions. In the following sections, we use pseudonyms for participants rather than their real names as we further explore these themes.

Personal growth

Fourteen of the parents reported personal growth from participating in the program. In general, the parents indicated that the program helped them learn about themselves and about their child in a way that helped improve their quality of life. For example, Sandra learned from her student promotora to place demands on her child. She states, “She has helped me to place demands on my child because we wouldn’t demand anything from him.” Yessenia learned from her parent promotora to understand her child’s needs. Yessenia explained that she “felt more relaxed and open to be able to understand him because I didn’t fully understand him, I didn’t understand what he wanted or needed when he would throw himself on the floor and tantrum.” Yessenia is happy that she now understands her son. The parents, generally, felt that they were able to learn about what ASD was and how to help their child.

Advocating

As a result of the parents learning more about ASD and strategies to help them cope with challenging behaviors, parents learned to advocate for the needs of their children, with their families, society, and from the government agencies providing services to their child. Eleven of the families reported some form of advocacy for their child. For example, when asked why her child was ill-behaved by strangers while out in public, Josefina learned how to respond in a way that created awareness about ASD. When her family was hesitant to use picture exchanges as part of her child’s communication, Alma explained to them, “the day I am not here, you are not going to understand what is wrong with him or what he wants. We need these to know what he needs.” Likewise, Elsa helped her husband to be more soft-spoken with their daughter to reduce her anxiety and behaviors.

Program design

Parents attributed many of the successes they experienced to the way the program was set up. One parent, Estela, felt that the program “manual was very complete” and that a lot of information was covered in 12 sessions. However, it was not just the information that the families had in the manual. Working alongside their promotora was also helpful for the parents. When Yessenia was stressed out and did not know what to do with her child, she would call her promotora, who was also a parent of a child with ASD, and her promotora would give her advice on “how to explain things to my child” and Yessenia was able to relax after that. Monica’s promotora also helped her learn many skills and encouraged her to try the different activities outlined in the program. Monica admitted she was hesitant to try some of them, but with some coaching she would do them and she said, “it went well, it went really well with my child.”

Changes in the child

The parents also reported changes in their child as a result of their participation in the intervention. Changes ranged from behavioral, to communicative, and social. Sandra and Alicia both reported changes in their children’s behaviors. Alicia reported that the “tantrums he has while out in public aren’t so difficult to handle anymore, because he rarely has them anymore.” Before starting the program, Alicia noted that her child’s tantrums were difficult to manage as he was “an aggressive child with great force that sometimes I couldn’t move and could also hit.” Sandra also felt that the program “helped me, more than anything, to control the difficult behaviors” of her child. Estela, on the other hand, found success in toilet training her child. Using motivation as a strategy, her child now says “bathroom” when she needs to use the bathroom. Maria noted a change in her child’s vocabulary and her ability to understand her child. For example, if the child wants juice, Maria makes him say “juice” and that is how she has come to “understand him more because before, I didn’t understand him.”

Suggestions for others

Finally, 11 of the families noted that as a result of their participation in the intervention, they felt comfortable offering suggestions and advice to others, either about how to interact with their child or about ASD in general. Norma noted that talking to her family members about how to interact with her son helps her “reinforce the behaviors,” which is very helpful to her. She also felt that helping them understand how to interact with her son decreased their rejection of her and her son and feels more welcomed at family parties. Isabel was going to share the program materials with her mom and her sister, who help watch her child. She notes that her mom and her sister are “part of my inner circle, are the ones that need to know more” about ASD and how to work with her child. Rosa also shared the videos with her older daughter and said, “Pay attention so that you are aware, for when you have kids because I didn’t recognize the signs in his behavior when he was six, seven months old.” The advice went beyond immediate family members for some parents. Monica talked to a mom at her child’s school about the program and shared the activities she would do with her child. The mom would do the activities too and then they would chat about them. Elsa discussed with the child’s teacher what she learned and tried to suggest using pictures to help teach her child and would create them and send them to school. At first, the teacher “used the activities, but then did not like using them.”

Discussion

In this study, we examined the implementation of a parent education intervention for parents of children with ASD in Bogota, Colombia. The quantitative results demonstrate evidence of significant improvement in parent-reported outcomes in various domains and the qualitative findings show improvement in child outcomes as well. Overall, parents were satisfied with the intervention and discussed many examples of how they were able to implement the information learned.

In the quantitative findings, parents across promotora groups improved significantly in self-reported ratings of understanding their child’s strength and needs, frequency of using the evidence-based strategies, and depressive symptoms. While not significant statistically, there were moderate effect sizes for the family outcomes scale and helping their child develop and learn. Scores on all outcomes showed improvement after the intervention and all of them showed at least small effects. Smaller effect sizes were found for knowing their child’s rights, and accessing the community; however, these elements were not emphasized during the intervention as it was decided during the adaption process that the policies and services are very different in Colombia than they are in the United States. Therefore, the advocacy sessions were removed from the Colombia adapted version.

The findings varied based on promotora type. Only parents in the SPG showed a significant decrease in depressive symptoms while parents in the PPG did not. One explanation may be found in theories of coping and what aspects of coping each type of promotora may be tapping. Problem-focused coping typically involves taking steps to resolve a problem, while emotion-focused coping involves activities such as venting, avoidance, and minimization (Lazurus & Folkman, 1984). Research on parents of children with ASD shows that problem-focused coping is related to lower depressive symptoms and stress, while emotion-focused coping is related to higher levels of distress (Dabrowska & Pisula, 2010; Smith et al., 2008). It may be that SPs were more problem-focused in their approach by teaching them skills to work with their children and PPs were more emotion-focused by emphasizing shared experiences of challenges they faced. The reduction in depressive symptoms for the SPG indicates a significant clinical difference from a score in the clinical depression range of 26.1 to a score below that range of 13.2. The cutoff for being at risk for clinical depression is 16 (Radloff, 1977). Parents in the SPG reduced in depressive symptoms to below clinical levels. Further study is needed to understand better what the SPs did that may have contributed to reduced depressive symptoms.

Only parents in the SPG improved on the self-reported subscale of helping the child develop and learn. Perhaps previous training of the SPs in their academic program focused on child language development and intervention contributed to these findings. Likewise, only parents in the PPG improved in understanding their child’s strengths and needs. It may be that given the experience as a primary caregiver, the PPs are more able to identify the child’s strengths and specific needs. It was interesting that the parents in the PPG did not experience the same improvements in increasing their support systems as the parents in the SPG did, since this appears to be a relationship-based measure and not a skills-based measure. Perhaps parents in the SPG found the teaching of these skills by the SPs were more reliable since the students were viewed as professionals. Profesionalismo or professionalism is a cultural value often adhered to in a Latino cultural context that values professional opinions over nonprofessional ones (Zea et al., 1994). This preference for professionals was observed in the Colombian researchers’ urging to use students in addition to parents as interventionists in the study.

Parents in both groups increased their self-reported frequency of use of evidence-based strategies. While PPs and SGs likely differed in their approach to teaching these strategies, we believe that just learning about these strategies and how to implement them with their child would result in a higher frequency of their use. Interestingly, parents in neither promotora group increased in their efficacy of their use of these strategies. Perhaps it may take more time for the parents to become comfortable using these strategies, and a longer follow-up (perhaps 12–18 months) would be necessary to measure their efficacy with these new skills.

For a more conservative analysis, we examined whether the baseline and follow-up differences between groups were significant and found that the only outcome that was significant was depressive symptoms. In other words, only the SPG reported a reduction in depressive symptoms. Because the number of depressive symptoms was quite high among this population at baseline, it is important to pay attention to how the SPs may have contributed to this reduction in future research.

Limitations

There were several limitations to the current study’s methods and procedures. These limitations limit the generalizability of the findings of the study. First, there is a notably small sample size (n = 20) for this study. A larger sample size would increase the ability to detect group differences and effects in the data. Second, all parents received the intervention; there was no control group. This study is not a randomized control trial, so it cannot make causal inferences about the effects of the intervention. However, a strength of the study is that it examined two different delivery methods using randomization. Third, as discussed previously, all data from the study comes from self-report by the parents. Self-report data are limited by memory and bias and cannot capture all the variables needed to make certain claims. Fourth, due to the small sample size, we were not able to examine pre- and post-effects by factors such as the child’s level of autism and age, and family socioeconomic status (SES).

Overall, this study showed the success of parent and student-led interventions for parents of children with ASD in Colombia, specifically through increasing parents’ engagement with evidence-based behavioral strategies and decreasing their symptoms of depression. This study shows that peer education interventions can be effective even with parents of older children, which is ideal for places and populations where a diagnosis of autism occurs later in childhood.

Future applications of peer education interventions in Latin America should consider adding a professional or student component, as this aspect of the intervention showed different and interesting findings compared with the parent-led group. While the peer component also showed different and positive outcomes, a professional-led component corresponds well with Latin American cultural contexts and can be used to enhance peer education programs in certain contexts such as in Colombia.

This intervention was especially useful for the Colombian context because of its ability to be implemented affordably. Labor from student practitioners and peers is more economically advantageous than using professionals and allows families in Colombia to receive valuable strategies and information that they may not otherwise be able to afford or be exposed to.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported by the UIC Center for Global Health and the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) Grant 90RT50320-01-00.

ORCID iD

Sandra Magaña

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