Method: Parents of 4-year old pre-kindergarten (preK) children in 9 Baltimore City Public Schools serving a low-income families (>92% low-income; 96% African American or Latino) were given a bank issued debit card and offered up to $230 to participate in the parenting groups at their child’s school; $15 for each 2 hour session attended and $5 for each weekly skill building “homework” assignment completed and submitted. These amounts were based on prior research estimating the opportunity costs for parents to attend a 2-hour parent group session. Group leaders submitted weekly attendance and “homework” completion records electronically within 24 hours of the parenting sessions; incentives were loaded electronically onto parents’ debit cards within 48 hours of the session. Data were collected on attendance, homework assignment completion, quality of parent engagement in the parenting sessions, parents’ motivations for enrolling in the program, importance of cash incentives on their decision to enroll and attend the program, and how cash incentives were used. Parent reports of child behavior problems were also obtained at baseline and post-intervention (3 months later) using the Eyberg Child Behavior Inventory, a standardized measure of child behavior problems. Results were compared with participation rates previously obtained in published validation studies conducted with comparable parent samples.
Results: To date, 213 parents of 4-year old preK students have enrolled in the parenting skills training program (56.5% single-parent households; 70% African American; 67% report annual household incomes <$20,000). Across schools, 80% of parents who enrolled attended at least one parent group session (M attendance= 65% of sessions) and 60% completed weekly homework assignments; a four-fold increase in homework completion rates without CCTs. Although 68% of parents reported that the debit cards influenced their decision to enroll, the most important reasons parents cited for signing up were to “learn better ways to manage my child’s behavior” (94%) and “always looking for ways to be a better parent” (96%). At baseline, 42% of the preschool children had behavior problems in the “clinical range” (defined as scores greater than 1 SD above the mean). At post-intervention, 22% of the children had behavior problems in the “clinical range,” representing a 48% decline in child behavior problems (p<.001). Parents who identified the CCTs as an important motivator for signing up for the program tended to have higher attendance rates (F=2.8, p=.07). The most common reason for not attending parent groups (53.3%) was a change in their work schedule that conflicted with the time of the group session. Observed quality of parent participation during group sessions was high and comparable to results obtained when no CCT’s were provided. Parents used debit cards for food, clothing, gas, school supplies, medicine, and other basic necessities.
Conclusion: The importance of a responsive and nurturing caregiving environment may never be more important than during the first 5 years life when children’s brain architecture is first developing and when most of what children learn centers on the home environment. Promoting healthy caregiving environments, particularly among families struggling with the stress of raising young children in poverty, is an important role for nurses. However, even the most effective interventions cannot work if parents do not participate. The results of this study suggest that CCT programs are feasible, acceptable, and useful for improving parent participation rates in health promoting programs in low-income communities. However, CCT’s remain controversial in the U.S. Features of high impact CCT programs and efforts for sustaining CCT programs in schools will be discussed.