Research in Nursing & Health, 2006, 29, 212–222

Measuring Participation in a
Prevention Trial With Parents of
Young Children
Christine Garvey,1 Wrenetha Julion,1 Louis Fogg,1 Amanda Kratovil,2 Deborah Gross1

1
Rush University, College of Nursing, Rush University, 600 South Paulina, 1080, Chicago, Illinois 60612
2
Rush University Medical Center, Rush University, 600 South Paulina, Chicago, Illinois 60612
Accepted 4 February 2006

Abstract: This paper describes parent participation in a clinical trial of

preventive parent training (PT) targeting low-income parents of young
children. Participation encompassed enrollment, attendance, and engage-
ment. Average enrollment rate was 34.9%, although enrollment rates were
significantly higher in the control (39.1%) than in the intervention (30.6%)
centers. Parents attended an average of 39% of the PT sessions. Higher
attendance was associated with lower parenting self-efficacy, more parent-
reported child behavior problems, and attending the first PT session. Level of
engagement in the PT sessions was related to improvements in parent and
child outcomes. Findings suggest that attendance is linked to parent
perceived need for help and that resources should be focused on ensuring
parent attendance at the first intervention session. ß 2006 Wiley Periodicals, Inc.
Res Nurs Health 29:212–222, 2006

Keywords: participation; parent training; prevention

Parent training (PT) is a widely used strategy for
increasing positive parent behaviors and reducing
negative child behaviors and numerous studies
have demonstrated its effectiveness for preventing
behavior problems in young children (Gross et al.,
2003; Tucker, Gross, Fogg, Delaney, & Lapporte,
1998; Webster-Stratton, 1998). However, no
intervention is effective if parents do not enroll
and actively participate in these efforts. Participa-
tion rates in preventive PT programs are typically
low, particularly among ethnic minority families
from economically disadvantaged communi-
ties (Perrino, Coatsworth, Briones, Pantin, &
Szapocznik, 2001; Spoth, Redmond, Hockaday,
& Chung, 1996; Stein, Bauman, & Ireys, 1991).
Because of these low participation rates, preven-
tion intervention studies have been plagued with
validity concerns secondary to having small
biased samples and diminished power to detect
effects (Coie et al., 1993). The purpose of this
study was to describe parent participation in a
clinical trial of preventive PT targeting low-
income parents of young children. The associa-
tions between parent participation and select
sociodemographic and psychosocial factors and
parent and child outcomes also were examined.
The long-term goal is to increase our under-
standing of why parents do not participate
in prevention programs aimed at promoting
positive parent and child outcomes, to develop

Contract grant sponsor: National Institute of Nursing Research; Contract grant

number: 2 R01 NR04085.
Contract grant sponsor: Sigma Theta Tau Gamma Phi Chapter.
Contract grant sponsor: Rush University College of Nursing Research Resource
Fund.
Correspondence to Christine Garvey
Published online in Wiley InterScience (www.interscience.wiley.com)
DOI: 10.1002/nur.20127

ß 2006 Wiley Periodicals, Inc.

 MEASURING PARTICIPATION / GARVEY ET AL.
cost-effective strategies for raising participation
rates, and to enhance the validity of PT prevention
trials.
Participation was defined in three ways: (a)
enrollment, defined as the percent of parents in the
target population who consent to enter the study
and complete baseline assessments; (b) dose,
defined as the percent of intervention sessions
the parents attend; and (c) engagement, defined as
the degree to which parents actively participate
in the intervention sessions they attend. All three
types of participation are important; they represent
different aspects of the overall construct of
participation. That is, not all parents who enroll
in a prevention study attend, and not all parents
who attend the intervention actively engage in the
sessions. Ideally, the goal is to engage the greatest
number of parents in prevention PT. However,
this ideal is rarely achieved (Spoth, Redmond, &
Shinn, 2000).
Enrollment rates for prevention intervention
trials tend to be low, often ranging from 20% to
25% of the eligible population (Coie et al., 1993),
sometimes even lower. For example, in a study of
the effectiveness of the Effective Black Parenting
Program for inner city African-American fami-
lies, Myers et al. (1992) reported enrollment rates
as low as 13%. Such low enrollment rates can
result in unrepresentative samples that threaten the
validity of study findings.
Why might enrollment rates be so low?
Researchers conducting prevention trials seek to
determine whether an intervention is effective in
preventing problems that have not yet occurred.
For example, children may not have an identified
behavior problem, and parents may not be aware
they are using ineffective or harsh strategies to
discipline their children. Thus, parent motivation
to enroll in a prevention trial is likely to be low if
the perceived need for help is low (Perrino et al.,
2001).
Low-income families struggling with immedi-
ate problems such as inadequate child care, safety
concerns, and insufficient financial and emotional
support are likely to focus their energies on current
crises rather than future worries. Not surprisingly,
low-participation rates have consistently been
linked to socioeconomic disadvantage (Dumas &
Wahler, 1983; Webster-Stratton & Hammond,
1988, 1990). To offset low perceived need for
intervention, particularly among low-income
populations, many prevention trial researchers
have offered costly incentives such as cash, gifts,
and door prizes to parents who enroll in and
attend PT sessions (Guyll, Spoth, & Redmond,
2003).
Research in Nursing & Health DOI 10.1002/nur
213
However, cash, gifts, and prizes may not
increase participation. For example, in one study
(Orrell-Valente, Pinderhughes, Valente, & Laird,
1999), parents were paid $15 for each parent group
attended, but parent attendance averaged only
56% of sessions. In another study (Irvine, Biglan,
Smolkowski, Metzler, & Ary, 1999), parents were
paid $10 for meeting with the recruiter and up to
$30 for attending the intervention. In addition,
door prizes were distributed at each session. Still,
14%–38% of parents never attended the interven-
tion. These results suggest that enrollment and
attendance rates can be difficult to change, even
when monetary incentives are offered. Taken
together, the findings point to the need for more
research to understand why parents choose not to
enroll in or attend preventive PT intervention
trials.
Those parents who do enroll in preventive PT
programs appear to do so because they want
parenting support. For example, some parents who
attend community-based parenting programs tend
to rate their children as having more behavior
problems than parents who do not attend these
programs (Haggerty et al., 2002). Moreover,
researchers have found that the children of parents
attending preventive PT programs have behavior
problem scores comparable to those found in
children referred to outpatient mental health
clinics (Friman, Soper, Thompson, & Daly,
1993). Gross, Julion, and Fogg (2001) found that
most parents enroll in preventive PT because they
want to learn about young children, share
experiences with other parents, and get help
managing difficult child behaviors. It appears that
preventive PT programs do serve the parents they
are designed to serve: those who want to be better
parents, who see the benefits of participation, and
whose children may be at elevated risk for
behavior problems. Nonetheless, many more
parents who might also benefit from preventive
PT never participate, and there is little information
in the literature about why those parents choose
not to enroll or attend.
Enrollment and attendance rates have received
attention in the prevention literature, but much less
is known about the role of engagement as an
indicator of the quality of parent participation in
preventive interventions. Engagement is defined
as a measure of parents’ level of interest and
investment in PT. In two studies researchers have
found significant associations among parent
engagement, attendance rate (Orrell-Valente
et al., 1999), and improvement in intervention
outcomes (Baydar, Reid, & Webster-Stratton,
2003). Although more research is needed, these
214 RESEARCH IN NURSING & HEALTH
studies indicate that parent engagement in the PT
intervention may be an important index of
participation.
In this study, we sought to describe participation
rates and understand how they were linked to
parent and child indicators of risk. We examined
the relationships between participation and par-
enting self-efficacy, parent stress, depressive
symptoms, and child behavior problems (Gross,
Sambrook, & Fogg, 1999; McLloyd & Wilson,
1991; Webster-Stratton & Hammond, 1988). We
also examined the relationship between dose and
demographic variables associated with poorer
child outcomes including parent age, education
level, parity, employment status, economic
disadvantage, and child sex. The relationship
between dose and parent race/ethnicity was
analyzed to determine if attendance differed by
racial/ethnic background. Finally, to determine
whether the length of travel required to attend
the PT group might have affected attendance, we
estimated the distance between parent home
address and the day care center where the PT
groups were conducted.
Five research questions were posed:
1. What was the enrollment rate for parents
eligible to participate in the PT trial?
2. Why did eligible parents choose not to enroll in
the PT trial?
3. Among parents enrolled in the intervention
condition, what was the average dose of
intervention received and what demographic
and parent-child risk factors predicted dose?
4. Among parents enrolled in the intervention
condition, why did some parents not attend the
PT group sessions?
5. Among parents enrolled in the intervention
condition, what was the mean engagement
level and was it linked to improvements in
parent-child outcomes?
METHODS
The current study had a descriptive/correlational
design. The data were collected as part of a larger
NIH-funded randomized clinical trial on the
effectiveness of preventive PT with low-income
families of young children. This study was
approved by the Institutional Human Subjects
Committee. The larger study tested the effective-
ness of a 12-week intervention, called The
Chicago Parent Program, which was developed
in collaboration with a parent advisory group to
ensure it would be relevant for low-income
Research in Nursing & Health DOI 10.1002/nur
families of color with 2–4 years old children.
The intervention consisted of 11 weekly 2-hour
group sessions to watch and discuss a series of
videotaped vignettes depicting parents and chil-
dren engaged in a variety of situations typical of
families with young children. In group discussions
we emphasized empirically supported principles
and strategies for promoting positive child beha-
vior and reducing negative behavior, using the
vignettes as examples of effective and ineffective
techniques. Two months following the 11th PT
group, a booster session was conducted to
reinforce the continuation of program principles
and techniques without the ongoing support of the
weekly parent group. All groups were led by
trained group leaders who used a manual standar-
dizing the protocol for each PT session.
Parents were not paid for attending parent
groups. However, enrolled parents were paid $120
for completing all of the four research assessment
phases ($30 per phase). These four assessment
phases occurred at baseline, post-intervention, and
at 6-months and 1-year post-intervention. How-
ever, only baseline scores were used to address the
research questions pertaining to attendance.
Parent assessments included a series of question-
naires and a videotaped parent-child play session.
If parents remained in the study through the 1-year
follow-up, they received a copy of their video-
taped parent-child play sessions.
All PT groups were conducted on site at the
child’s day care center during weekday evenings.
Free childcare and dinner was provided during
parent groups. Reimbursement for taxi fare home
was offered to parents who did not wish to take
public transportation in the dark after PT groups
ended. These incentives and barrier reduction
strategies were selected based on previous
research supporting their acceptability and effec-
tiveness with low-income parents (Gross et al.,
2001).
Target Population and Sample
Seven licensed day care centers serving low-
income families of 2–4 years old children in
Chicago participated in the larger study. Criteria
for day care center selection included centers: (a)
with over 90% of enrolled families meeting state
income eligibility requirements for subsidized
child care; (b) that were licensed by the Depart-
ment of Children and Family Services; (c) that
served at least 60 children in the target age range;
(d) that could provide the space for the weekly
parent groups; and (e) that were willing to be
 MEASURING PARTICIPATION / GARVEY ET AL. 215

randomized. The 7-day care centers were as- Table 1. Parent Relationship to Child, Educational
signed to one of two equivalent groups that were Level, Race/Ethnicity, Employment Status, Marital
matched on size, racial/ethnic composition, med- Status, and Child Sex by Condition
ian income, and percent single-family households
Intervention Control
and then randomly assigned to the intervention or Group Group
waiting list control condition. Day care center (n ¼ 156) (n ¼ 136)
parents in the waiting list control condition
completed the research measures but were not Variable n % n %
offered the PT intervention. One year later, new
Relationship to child
parents in these centers were recruited to receive
Mother 143 91.7 115 84.6
the intervention. Parents who had previously Father 8 5.1 15 11.0
served in the waiting-list control condition but Foster parent 1 0.6 3 2.2
wished to participate in the PT intervention could Grandparent 3 1.9 2 1.5
do so but only after their follow-up assessments Other 1 0.6 1 0.6
had been completed. Highest educational level
Parent inclusion criteria were (a) being a parent Grade school 6 3.9 9 6.6
or legal guardian of a 2–4 years old child enrolled Some high school 25 16.1 20 14.7
in one of the participating day care centers and (b) High school/GED 42 27.1 32 23.5
being able to speak English. Only one parent and Associate degree 7 4.5 9 6.6
Vocational degree 7 4.5 8 5.9
one child per family were enrolled in the study. If a
Some college 51 33.0 47 34.5
parent had more than one child in the target age College degree 12 7.7 11 8.1
range attending the daycare, the younger child was Graduate degree 5 3.2 0 0
chosen to be in the study. Data were collected from Parent Race/ethnicitya,b
2002 to 2004. African-American 78 50.3 90 67.2
Across all day care centers 858 parents met Latino 62 40.0 37 27.6
inclusion criteria; 292 parents enrolled in the study Multi-racial 2 1.3 3 2.2
(see Table 1). The intervention and waiting-list White (not Latino) 11 7.1 1 0.7
control groups did not differ on informants’ Other 1 0.6 0 0
relationship to the child, parent age, education, Employment status
Full time 80 51.3 86 63.2
employment status, marital status, level of eco-
Part time 26 16.7 19 14.7
nomic disadvantage, number of children, or child In school 15 9.6 11 8.1
sex. However, there were differences by parent Working and in school 18 11.5 7 5.1
race/ethnicity. The intervention group included Unable to work 2 1.3 2 1.5
more Latino and non-Latino White parents while Looking for job 9 5.8 11 8.1
the control group included more African-Amer- Other 6 3.8 11 8.1
ican parents, x2 (5, n ¼ 289) ¼ 16.2, p < .01 Marital status
(three participants did not provide answers to this Married 43 27.6 36 26.5
item). Single 91 58.3 88 64.7
Partnered 16 10.3 9 6.6
Other 6 3.8 3 2.2
Child sex
Variables and Measures Boys 82 52.6 82 60
Girls 74 47.4 54 40.0
Enrollment rates. Enrollment rates were
defined as the percent of parents in the eligible Notes: Numbers vary as some participants did not
population who signed the consent forms and respond to some questions.
a
completed baseline measures. Enrollment rates The intervention group included more Latino and non-
Latino White parents while the control group included
were estimated separately for the intervention and more African-American parents, w2 (5, n ¼ 289) ¼ 16.2,
waiting list control conditions. p < .01.
Reasons for not participating in the study. b
Two parents in the waiting list control group and one
Eligible parents who did not enroll in the parent in the intervention group did not provide race/
ethnicity data.
study were asked to complete the investigator-
developed Non-Participant Questionnaire, a brief
anonymous, survey listing common reasons & Redmond, 2000) and anecdotal accounts from
parents may have chosen not to enroll. Items on parents and teachers. The questionnaire can be
this questionnaire were created by the researchers completed in 3 minutes and is written at a 4th
based on prior research (Gross et al., 2001; Spoth grade reading level.
Research in Nursing & Health DOI 10.1002/nur
216 RESEARCH IN NURSING & HEALTH
Two versions of the Non-Participation Ques-
tionnaire were developed. One version for parents
in the control centers contained 15 items pertain-
ing only to non-intervention aspects of the study
(e.g., ‘‘I was too busy to fill out questionnaires and
be videotaped,’’ ‘‘I did not want to be in a research
study.’’). A second version for parents in the
intervention centers included the same 15 items
plus 5 additional items pertaining to participating
in a weekly parent group (e.g., ‘‘I was too busy to
participate in a program that met for 11 weeks,’’ ‘‘I
do not like to talk about my personal life in
groups;’’ see Table 3). For each item, parents were
asked to rate its importance in their decision not to
participate on a 3-point scale of ‘‘not a reason for
me’’ to ‘‘a big reason for me.’’ Frequencies with
which each item was endorsed were calculated
separately for the intervention and waiting list
control groups.
Dose. Dose was defined as the percent of
11 weekly parent groups attended. The booster
session was not included in the dose estimation
because it was administered after the post-
intervention assessment. PT group leaders kept
weekly attendance records and submitted these
records to the research team.
Reasons for non-attendance. At the post-
intervention assessment parents who enrolled but
missed one or more parent group sessions were
asked the following question: ‘‘There are many
reasons why parents are sometimes unable to
attend the parent group. What are some of the
reasons you were unable to attend the parent
group?’’ Parent responses were recorded verbatim
and later grouped into themes.
Engagement. Engagement was assessed by PT
group leaders at the end of the 11th parent group
session using the Engagement Form. This seven-
item scale measures the degree to which parents
(a) attended to the videotaped scenes; (b) partici-
pated in group discussions; (c) were supportive to
other parents; (d) actively participated in discus-
sions; (e) disclosed personal experiences; (f)
were not resistant to program principles; and (g)
correctly applied program principles on a scale of
1 (not at all) to 4 (most of the time). Scores could
range from 7 to 28 with higher scores indicating
greater engagement. Alpha reliability for this
scale was .87 and inter-rater agreement was .72.
Inter-rater disagreements on parent engagement
ratings generally were within one scale point;
disagreements exceeding one scale point occurred
in only one case.
Parenting self-efficacy. Parenting self-efficacy
was assessed using the Toddler Care Question-
naire (TCQ), a scale for rating parent’s self-
Research in Nursing & Health DOI 10.1002/nur
efficacy in managing a range of tasks and
situations relevant to raising young children
(Gross & Rocissano, 1988). Reliability and vali-
dity of the TCQ has been supported in studies
showing significant associations with knowledge
of child development (Conrad, Gross, Fogg, &
Ruchala, 1992), difficult toddler temperament
(Gross, Conrad, Fogg, & Wothke, 1994), and
improvements following PT (Gross et al., 2003).
Alpha reliability in the current study was .93.
Parent stress. Parent stress was measured
using the Everyday Stressor Index (ESI; Hall &
Farel, 1988). The ESI assesses the extent to which
the parent is worried about problems related to
family, money, parenting, and interpersonal rela-
tionships. Concurrent validity of the ESI has been
supported by its associations with maternal
depression and child behavior in previous studies
with low-income families (Gross et al., 1999;
Hall, 1990). Alpha reliability in the current study
was .87.
Depressive symptoms. Depressive symptoms
were measured using the Center for Epidemiolo-
gic Studies Depression Scale (CESD; Radloff,
1977). Prior researchers have demonstrated that
the CESD is a sensitive measure of depression
(Weissman, Sholomskas, Pottenger, Prusoff, &
Locke, 1977) and correlated with other measures
of depression (Gotlib & Cane, 1989). The alpha
reliability of the CESD in this study was .86.
Travel to attend the intervention. To measure
the distance traveled to attend the intervention, we
used an internet-based site that estimated in miles
the distance between the parent’s home address
and the day care center where parent groups were
conducted. Based on the distribution of the data,
travel miles were grouped into two categories: (a)
3 miles or less and (b) more than 3 miles from the
child’s day care center.
Demographic factors. Demographic factors
included parent age, parent education level, parity,
employment status, economic disadvantage, mar-
ital status, and child sex. Because all families were
considered to have low incomes based on state
eligibility criteria for receiving subsidized child
care, we included a measure of economic disa-
dvantage to differentiate low-income parents
experiencing significant financial difficulties from
those who are able to meet their expenses. Parents
were asked to indicate which of seven possible
events had occurred to them in the past year
including being unable to pay their rent or
mortgage, being evicted from their home, being
unable to pay their utility bills, having their
telephone disconnected because of failure to pay
their bill, having their heat or electricity turned off
 MEASURING PARTICIPATION / GARVEY ET AL.
because they were unable to pay the bill, not
seeking health care because of inability to pay for
health care, and not seeking dental care because of
inability to pay for the dentist bill (Bauman, 1998).
Scores may range from 0 (none have occurred in
the last 12 months) to 7 (all events have occurred in
the last 12 months). Finally, parent racial/ethnic
background was obtained by parent report during
baseline assessments.
Child behavior problems. Child behavior pro-
blems were measured by parent-report and
teacher-report. Parent-reported behavior pro-
blems were assessed using the Eyberg Child
Behavior Inventory (ECBI; Eyberg & Pincus,
1999). This is a 36-item survey designed for
parents of children 2–16 years of age. The ECBI
contains an Intensity Scale measuring the fre-
quency of the problems, and a Problem Scale
measuring the total number of problems reported
by the parent. The validity of the ECBI has been
supported in studies showing its association with
other measures of child behavior problems
(Doctoroff & Arnold, 2004; Koniak-Griffin &
Verzemnieks, 1995). The alpha reliabilities of the
ECBI Intensity and Problem Scales were .91 and
.92, respectively.
Child behavior problems based on teacher
report were measured using the Caregiver-Teacher
Report Form (CTRF), a measure of classroom
behavior problems for children, 1–5 years
(Achenbach & Rescorla, 2000). The CTRF
contains two subscales: the Internalizing Scale
(32 items) representing symptoms of anxiety and
depression and the Externalizing Scale (34 items)
indicative of inattention and aggression. Prior
researchers have shown that the CTRF dis-
criminates clinic-referred from non-referred
children and predicts child behavior problems
in later childhood (Achenbach & Rescorla).
Alpha reliabilities for the Internalizing and Exter-
nalizing Scales in this study were .88 and .89,
respectively.
Procedures
Numerous strategies were used to recruit parents
into the larger study. Recruiters were paid to spend
approximately 10–15 hours per week in their
assigned day care center developing relationships
with parents and teachers while recruiting. The
racial/ethnic backgrounds of the recruiters were
matched with the predominant racial/ethnic back-
ground of the families served in their assigned day
care centers. Flyers advertising the study were
posted in the hallways, sent home with the
Research in Nursing & Health DOI 10.1002/nur
217
children, and included in parent newsletters.
Research team members attended parent and
teacher meetings at each center to describe the
PT study and encourage enrollment.
To collect data from non-enrolled parents, a
research assistant stood at the daycare classroom
doorway and asked non-enrolled parents if they
would complete the anonymous Non-Participation
Questionnaire at that time. Although most parents
completed the form in the presence of the research
assistant, a self-addressed stamped envelope was
provided for parents who were unable to complete
the form at that time. These data were collected
within 2 months following the conclusion of
recruitment in each center.
Data Analysis
Data were analyzed using frequency counts, chi-
square analyses, t-tests, and correlations. The
Engagement Form was developed after the study
began; data are only available for half of the
intervention group parents (n ¼ 78).
RESULTS
What Was the Enrollment Rate for
Parents Eligible to Participate in
the PT Trial?
Among the 7-day care centers, 858 families met
the eligibility criteria, including 348 eligible
families in the waiting list control centers and
510 eligible families in the intervention centers.
The enrollment rate in the waiting list control
centers (39.1%, n ¼ 136) was significantly higher
than in the intervention centers (30.6%, n ¼ 156),
w2 (1, n ¼ 858) ¼ 6.6, p < .01. The final sample
consisted of 292 parents and their children and a
total parent enrollment rate of 34.9%.
Why did Eligible Parents Choose
not to Enroll in the PT Trial?
Sixty-nine percent (n ¼ 147) of eligible parents in
the waiting list control centers and 61.9%
(n ¼ 219) of eligible parents in the intervention
centers who did not enroll in the study agreed to
complete the anonymous Non-Participant Form
assessing the reasons for not enrolling in the PT
trial. As shown in Table 2, at least 10% of the
respondents endorsed four items as ‘‘big’’ reasons
218 RESEARCH IN NURSING & HEALTH

Table 2. Reasons Identified as Important in Parents’ Decisions Not to Enroll in the Study by Condition

Intervention Condition Control Condition

(n ¼ 219) (n ¼ 147)

Reasons for Not Enrolling n % n %

Did not know about study 76 34.7 41 27.9

Too busy to participate in a program for 11 weeks 63 28.7 NA NA
Group conflicted with work/school schedule 60 27.4 NA NA
Family commitments 44 20.1 7 4.8
Too busy to do questionnaires/videotape 36 16.4 61 41.0
Would get home too late after group ended 20 9.1 NA NA
Did not want to be in a research study 17 7.8 19 13.0
Do not like to talk about personal life in groups 15 6.8 NA NA
Did not want to be videotaped 14 6.4 8 5.4
Not sure what I’d have to do/what I’d be asked so 13 6.0 9 6.1
decided not to participate
Not encouraged by center staff to participate 10 4.6 16 10.9
Wanted to participate but recruiter not around 10 4.6 9 6.1
Do not need a program on parenting 10 4.6 NA NA
Was not interested in getting a free videotape of 9 4.1 5 3.4
parent-child play sessions
$120 was not enough for me to participate 6 2.7 2 1.4
Did not know there would be childcare 4 1.8 NA NA
Did not feel I could make a difference in my child’s life 3 0.5 2 1.4
Wanted both children in study but only one was 1 0.5 0 0
permitted to enroll and be videotapeda
Meant to sign up but did not get around to ita 0 0 2 1.4
Did not trust the recruiter 0 0 2 1.4

a
Notes: Other reasons added by parents that were not on the Non-Participant Form.

for not enrolling in the control arm of the study and
five items as ‘‘big’’ reasons for not enrolling in the
intervention arm of the study. Parents in the
control centers most often reported they did not
enroll because they (a) were too busy to complete
the research measures; (b) did not know about the
study; (c) did not want to be in a research study;
and (d) did not feel encouraged to participate by
the day care staff. Parents in the intervention
centers most often indicated they did not enroll
because (a) they did not know about the study; (b)
they were too busy to participate in an 11-week
program; (c) of schedule conflicts; (d) they had
other family commitments that kept them from
participating; and (e) they were too busy to
complete the research measures.
Among Parents Enrolled in the
Intervention Condition, What Was the
Average Dose of Intervention Received
and What Factors Predicted Dose?
Average attendance among the 156 intervention
group parents was 4.3 sessions or 39% of the
Research in Nursing & Health DOI 10.1002/nur
11 weekly parent group sessions. Closer scrutiny
of the dose data show that 32.7% (n ¼ 51) of
parents who enrolled never attended a parent
group and 8.3% (n ¼ 13) attended only one
session. Fourteen percent (n ¼ 21) of the parents
attended all weekly sessions.
At baseline, parents who attended more PT
group sessions had lower parenting self-efficacy
(r ¼
.20, p < .05) and rated their children as
having more behavior problems on the ECBI-
Intensity Scale (r ¼ .19, p < .05). Attendance was
unrelated to baseline parent stress, depression, or
teacher-rated child behavior problems (all ana-
lyses based on two-tailed tests of significance).
Parents living within a 3-mile radius of the day
care center had lower attendance rates (M
dose ¼ 3.5, SD ¼ 3.7) than parents living more
than 3 miles away from their child’s day care
center (M dose ¼ 5.1, SD ¼ 4.5), t(153) ¼
2.3,
p < .05. Dose was unrelated to parent age, parent
educational level, employment status, parity, level
of economic disadvantage, marital status, child
sex, or race/ethnicity.
We analyzed the effect of coming to the first PT
group session on subsequent attendance. Parents
 MEASURING PARTICIPATION / GARVEY ET AL. 219

who attended the first PT group session were 91%
more likely to attend at least two group sessions;
only 8.8% (n ¼ 6) of parents who attended the first
session failed to return for another. In contrast,
among parents who did not attend the first PT
group session, only 28.2% (n ¼ 20) ever attended a
PT group session.
theme was schedule conflicts (63.3%, n ¼ 76).
Family related responsibilities accounted for
another 21.7% (n ¼ 26) of the reasons for their
absence at PT sessions. Four other responses
suggested communication flaws needing to be
addressed by the research team.

Among Parents Enrolled in the

Among Parents Enrolled in the Intervention Condition, What Was the
Intervention Condition, Why did Mean Engagement Level and Was it
Some Parents not Attend the PT Associated With Improvements in
Group Sessions? Parent-Child Outcomes?

Of the 135 parents who missed at least one parent
group session, 89% (n ¼ 120) responded to this
question. As shown in Table 3, the most common
Table 3. Parents’ Reasons for Not Attending Parent
Group Sessions
Reasons for Non-Attendance
Schedule conflicts
Conflict with work schedule
Conflict with school schedule
Conflict with a previously
scheduled event
‘‘That day didn’t work for me’’
Conflicts with family-related
responsibilities
Had a baby
Family illness
Needed to care for other children
Family emergencies
Funeral
Family vacation
Miscommunication Problems
Not informed of day/time group
was meeting
Group leader was too opinionated
Childcare staff could not
manage child
Thought parents were paid for
attending
Child left the day care center
Did not wish to state why they did
not attend
Bad weather
Parent forgot about the group meeting
Parent moved
‘‘Too busy’’ to come
Already knew the information
being presented
Could not recall reason for not attending
Car trouble
Notes: Data represent 130 responses from 120 interven-
tion group parents who completed post intervention
assessments. Parents could give more than one reason.
Research in Nursing & Health DOI 10.1002/nur
The mean engagement score was 23.0 (SD ¼ 4.2,
possible range 7–28), indicating that parents who
attended parent groups were relatively engaged in
the PT group sessions. We examined the degree to
which engagement was associated with number of
PT group sessions attended. We found that
engagement scores were related to attendance
n % (r ¼ .59, p < .001), suggesting that parents who
attend more sessions were also more likely to be
76 63.3
47 39.2
active and involved in the group sessions.
16 13.3 Engagement scores were significantly related to
2 1.7 improvements in child behavior problems as
measured by parents and teachers. Specifically,
11 9.2 engagement was correlated with improvements in
26 21.7 ECBI-Intensity sores (r ¼ .21, p < .05), CTRF
Internalizing scores (r ¼ .21, p < .05), and CTRF
4 3.3 Externalizing scores (r ¼ .21, p < .05). In addi-
10 8.3 tion, engagement was related to improvements
5 4.2
in parent depression scores (r ¼ .21, p < .05).
3 2.5
2 1.7
There was no relationship between attendance
2 1.7 and improvements in child behavior or parent
5 4.2 depression.
2 1.7
1 0.8 DISCUSSION
1 0.8
Participation rates found in this prevention trial
1 0.8 were low but consistent with rates reported in
similar studies. Only 34.9% of eligible parents
5 4.2
4 3.3
enrolled in the study, and of those who enrolled in
the intervention condition, average attendance
3 2.5 was 39% of the PT sessions. Although 7% of
3 2.5 parents attended all 11 weekly sessions, almost
3 2.5 one third of the enrolled parents never attended a
2 1.7 session.
1 0.8 One of the most common reasons parents gave
for not enrolling in the PT study was because their
1 0.8 lives were too busy. All of the parents in the
1 0.8
participating day care centers had low incomes,
and most were single, working parents with
multiple children. It is understandable that these
parents might feel overwhelmed with their current
220 RESEARCH IN NURSING & HEALTH
responsibilities and view participation in a
research study or attendance at a weekly preven-
tion program a low priority. Among parents in the
intervention centers, conflicts with their work or
school schedule also deterred parents from enrol-
ling in the study. Not surprisingly, enrollment
rates were significantly lower in the intervention
centers (30.6%), where greater time commitment
was required of participants, than in the waiting-
list control centers (39.1%). Although numerous
strategies were used to reduce barriers to atten-
dance (e.g., free dinner and child care, on-site
group sessions, reimbursement for cab fare home),
issues related to program duration and scheduling
can be difficult to address without changing the
parents’ life circumstances (e.g., easing demands,
improved economic conditions, increased job
flexibility) or altering the intervention format to
more individualized, but more costly formats
(e.g., home visiting sessions).
Approximately 28% of the parents in the
control centers and 35% of the parents in the
intervention centers said they did not enroll
because they did not know about the study. This
occurred despite what appeared to be widespread
advertisement through flyers, newsletters, group
presentations, and face-to-face interactions with
recruiters. Understanding how best to reach all
eligible parents so they are able to make an
informed choice about participation is a challenge
that needs to be addressed.
Eleven percent of parents in the control
condition centers wrote that they did not partici-
pate because they had not been encouraged by the
staff at their children’s day care center, while only
4.6% of parents offered this as a major reason for
not enrolling in the intervention centers. Research
team members attended parent and teacher meet-
ings at each of the participating centers to describe
the study and encourage participation. However,
staff enthusiasm was noticeably lower in the
waiting list control centers when they learned that
no service was being provided to parents until
1 year later. Although the intent of the waiting list
control condition was to avoid resentful demor-
alization among staff in these centers, they may
have been disappointed nonetheless. As a result,
staff may not have endorsed participation in the
waiting list control centers.
In addition to low enrollment rates, attendance
rates were also low. It might be expected that given
the stressfulness of being a single, low-income,
working parent, attendance would be associated
with parent stress and depression. However, there
was no relationship between parent attendance
and their reported levels of stress and depression.
Research in Nursing & Health DOI 10.1002/nur
Attendance was also unrelated to a number of
demographic variables often associated with
poorer outcomes in this population including
parent age, education, employment status, parity,
marital status, level of economic disadvantage,
and child sex. Moreover, attendance did not differ
by parent’s racial/ethnic group.
Rather, attendance was associated with lowered
parenting self-efficacy and higher rates of parent-
reported child behavior problems. Although the
correlations were modest, the results suggest that
parents participate in preventive PT interventions
because they are seeking help with parenting. This
finding is consistent with other research showing
that parents participate in prevention programs
because they want help, and the costs of attending
are outweighed by the perceived benefits (Perrino
et al., 2001; Spoth et al., 1996).
Parent attendance was not related to teachers’
ratings of the children’s behavior problems in the
classroom. Attendance in prevention PT appeared
to be tied more to the parent’s perception of
the child than to a teacher’s perception. It is
possible that more communication and collabora-
tion between parents and teachers might increase
participation among parents whose children have
higher rates of classroom problems.
Contrary to expectations, attendance was lower
among parents living within 3 miles of their
children’s day care center than among parents
living further away. It is possible that parents who
lived further from the day care center may have
found it easier to stay for dinner and the PT group
than to make the long trip home and make dinner.
Attending the first intervention session appears
to be crucial to continued attendance; 91% of the
parents who attended the first PT session attended
at least two or more group sessions. When parents
did not attend the first session, they were more
likely to never attend the PT group; only 28.2% of
these parents attended any parent groups. It is
possible that parents are too embarrassed to enter a
group that has already started, or that parents who
are ambivalent about attending find it easier to
simply not go. Regardless of the reason, the
finding suggests that resources should be centered
on ensuring that parents know about and attend the
first intervention session.
Schedule conflicts and family related responsi-
bilities were the most common reasons for not
attending at PT groups. However, some parents
described reasons that reflected errors on the part
of the research team. Two parents said they had not
been informed that the group had started, one
parent stopped coming because she felt the group
leader was ‘‘too opinionated,’’ and another parent
 MEASURING PARTICIPATION / GARVEY ET AL.
stopped coming because the day care staff member
caring for her child during the PT group
complained of his unmanageable behavior. All
of these problems could have been avoided
through better communication among the research
team, group leaders, and child-care staff, perhaps
through staff training in communication.
One parent reported that she stopped coming to
PT sessions because she was not being paid to do
so. Although many other preventive PT studies
have included cash, gifts, and prizes to enhance
participation rates (Guyll et al., 2003; Irvine et al.,
1999; Orrell-Valente et al., 1999), we elected not
to include them in this study, based on the concern
that such incentives could not be generalized
beyond the well-funded study. Controlled stu-
dies demonstrating the cost-effectiveness of these
incentives and the amount needed to raise
participation rates are needed to guide decisions
on whether and how much participants should be
paid for attendance. Alternatives to direct cash
incentives might also be evaluated, including child
care co-payment discounts contingent on parent
attendance at group sessions, creating an ‘‘honor
roll’’ of parents who complete the parenting
program, and scheduling the first parent group
meeting in conjunction with another popular event
such a health or job fair to encourage high
participation at the initial session.
The data showed that parents who attended had
high engagement levels, which were significantly
associated with improvements in parent and child
outcomes. That is, parents who were more
engaged in the PT groups attended more sessions
and their children demonstrated greater improve-
ment in their behavior at home and in the
classroom. Parent engagement was also related
to decreases in parent depression. It is interesting
to note that engagement was highly correlated
with attendance, but attendance was not related to
any of these parent-child outcomes. Although the
correlations were modest, the findings lend
support to the validity of parent engagement, over
and above attendance, as an important component
of the construct of participation in preventive PT
interventions. However, more work is needed on
increasing the reliability of the Engagement Scale.
Inter-rater agreement was lower than desired, and
this may have contributed to the modest correla-
tions between parent engagement and parent and
child outcomes. Future researchers should focus
on increasing the clarity of Engagement Scale
items so raters can more accurately discriminate
levels of parent engagement.
The low participation rates found in this study
are consistent with the low adherence rates
Research in Nursing & Health DOI 10.1002/nur
221
clinicians report when recommending behavioral
changes to patients to prevent chronic illness or pre-
mature death (Holland et al., 2001; Meichenbaum
& Turk, 1987). To this end, the data presented here
might simply reflect real life. In the same way that
patients say they know they need to change their
unhealthy behaviors but do not, fewer than 5%
of the non-enrolled parents cited not needing a
parenting program as a reason for not enrolling in
the study. The challenge to prevention researchers
is to devise cost-effective strategies for enhancing
enrollment and attendance in preventive parenting
programs in ways that can be generalized to real
world contexts.
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