It is a recurring problem that even when agencies are persuaded to adopt evidence-based programs, they can’t get the right people to implement them. They struggle to engage parents in parenting programs, and parents find such programs difficult to use. The result is empty chairs, wasted money, blighted lives, a failure to replicate findings from efficacy trials, and frustration all round. So what can be done? This question was addressed in a paper by Nick Axford, from the Social Research Unit, Dartington, UK.

He described a randomized trial of the Incredible Years BASIC parenting program in six children’s centers in a large conurbation in England. The trial needed 144 children aged four years old who scored above the “high need” cut-off on the Total Difficulties score of the parent-completed Strengths and Difficulties Questionnaire. They could come via open access events at centers, and or through invitations to local partner agencies to refer families.

There were 2,913 children of that age living in the six catchment areas. A city-wide survey in 2007 showed that 15 per cent of these children fell into the “high need” category – 437 potential clients. How well did the centers do at finding them?

The recruitment process started in spring 2009, with Incredible Years groups scheduled to take place during autumn 2009. By the end of the year only 85 of the eligible children had been recruited – far lower than anticipated.

Some centers did better than others. Forty five per cent of eligible children were identified in Northfield compared with only six per cent in Uppertown. The targeting was best in Eastfield (40 per cent of those referred met the threshold) and worst in Midtown (17 per cent).

Most centers struggled to find eligible families, despite, in many cases, assurances at the outset by center managers that reaching the target would be straightforward because they were already serving such families. What went wrong?

Interviews with service providers, and a survey of parents and other agencies highlighted several problems. To start with, responsibility for recruitment work was at best contested and at worst unclear. Center staff felt that they did not know who was referring whom and in some cases did not accept that recruitment was their responsibility.

The publicity materials were criticised for using negative language and poor quality images, and for providing limited information about the program, including venue, time and incentives to attend.

Centers lacked sufficient capacity to implement the program and provide the necessary assistance to enable and encourage parents’ attendance – making phone calls or home visits, and providing transport, crèche, refreshments and interpreting.

Some providers had negative perceptions of the program. They were concerned that it targeted parents – and therefore risked being stigmatizing – and that it adopted a “one size fits all “approach, limiting scope for professional discretion.

Partner agencies also reported being reluctant to make referrals for fear of raising families’ hopes only to see them dashed if they ended up in the control group.

This meant that providers were unenthusiastic, which undermined recruitment efforts. Target group families simply didn’t hear about the program. Then, once it started, drop-out was high, at least early on.

As all good researchers do, the team consulted the literature. This showed that because vulnerable families are often known to many different practitioners in various agencies, and practitioners are naturally reluctant to refer families to a new service, the only way to connect them with a new service is through extensive communication and collaboration.

It showed that failure to invest time in engaging families and ensuring practitioners have the high level of interpersonal skills to relate well to vulnerable families will make it hard for a parenting program to get off the ground.

Further, parents simply won’t use services that aren’t simple to use. Services need to fit in with the rhythms of modern life, for example by holding evening sessions for parents who work. Some parents will need help getting to venues and most will expect help with childcare.

Other lessons were that parents won’t use a parenting program if they cannot see the need or likely benefit, or if they feel anxious or threatened, and that extra effort is also needed to make services accessible to parents and families who are poor, educationally disadvantaged or from minority ethnic backgrounds.

Returning to the field, the team invested more time and energy in briefing partner agencies about Incredible Years and helping them understand that it was going to be useful to parents.

A new recruitment pack was compiled and distributed, and thumbnail sketches of hypothetical eligible children were used to help local staff understood the screening criteria.

Extra money was paid to providers to cover refreshments, crèche and interpreting, and centers received an additional payment for high recruitment and retention rates.

A series of outreach events were held in residential areas and public spaces frequented by families with young children, including supermarkets and parks.

It still took another 12 months to recruit enough families, but some important lessons emerged:

• Lots of children and families who need parenting programmes don’t get them, and they won’t unless the people responsible for commissioning and providing them act to make them more accessible.
• If parents are not engaged in programs, the programs won’t work.
• Providers need to be engaged first if parents are to be engaged.
• There should be a clear recruitment process and everyone involved should be trained.
• There should be investment in recruitment and retention, which should also be incentivized.
• Parents must be approached because they cannot be expected to come forward themselves.
• Relationships should be built by visiting and calling, and visiting and calling again.
• Parents should be made to want to attend programs, and it should be made easy for them to do so.
• Creativity is needed.
• Recruitment is nothing without retention.
• Aims should be high but realistic: life gets in the way of the best intentions.