Developing an Educational Parenting Skills Package to Parents Undergoing Substance Abuse Treatment for Preventing Addiction among Adolescents: A Study Protocol Based on Social Marketing Approach.

BACKGROUND: Developing an educational parenting skills package for parents with substance abuse may be effective in preventing the same problem in their adolescents. Social marketing is one of the approaches facilitating the preparation of educational content for this purpose. Social marketing is a regular and planned process focusing on customers and their needs for encouraging a target group to exhibit a particular behavior or adopt a specific idea. This study protocol aims to use the social marketing approach to prepare an educational parenting skills package for the parents undergoing substance abuse treatment to prevent addiction in their adolescents.
METHODS: An educational parenting skills package will be designed and validated by a combination of qualitative research (descriptive phenomenology), scoping review, and Delphi study based on social marketing approach (4 Ps = product, price, place, promotion). The package will be prepared in four phases including educational need assessment, ranking the identified educational needs, determining the suitable health education constructs, and modeling and developing the educational content based on the identified constructs. The designed educational package will be validated from the perspective of the target group (parents undergoing substance abuse treatment) and experts.
CONCLUSION: Developing educational packages based on a scientific health education approach and mainly the Social Marketing Assessment and Response Tool (SMART) model with an emphasis on market analysis or marketing mix (4 Ps = product, price, place, promotion) can prove effective in attracting the audience and promoting the target activities.

Introduction

Addiction and substance abuse are highly complex health problems that affect almost all human societies.1,2 Adolescence is an important phase of life regarding the initiation of high-risk behaviors, because adolescents are self-centered and unaware of behaviors’ consequences.3 Adolescents undergo intense emotional and personal changes in which parents’ negative response to these changes causes emotional damages.4 Family issues are known to be strongly associated with the incidence of substance abuse. In addition, substance abuse disrupts the cohesion of the family and the functions of its members.5 Some important family factors put children at risk for substance abuse including a poor relationship with parents, the absence of concerned adults, the ineffective role of parents, and a chaotic home setting.6 When an adolescent’s relationship with parents, especially the mother, is accompanied by negative emotions, this relationship can affect the child’s relationships in other areas, also leading to substance abuse.7 People with an addiction problem often have a deficiency in life skills and perform poorly in problem-solving and parenting; also, they have defective attributional styles. Poor parenting techniques such as insufficient monitoring and supervision, ineffective disciplinary actions, and poor relationship are also associated with the occurrence of substance abuse among young people.8 Brook et al. have hypothesized that emotional attachment to parents, social learning, and intrapersonal characteristics affect the susceptibility of adolescents to substance abuse.9 Considering the role of parenting in the occurrence of substance abuse, the development of educational packages and programs for improving parenting skills may be effective in preventing the onset of substance abuse, especially in adolescence. The first step in developing such a program to prevent early-onset substance abuse in adolescents is to prepare suitable educational packages. One of the approaches facilitating the preparation of such educational content based on customer orientation is the social marketing approach. This approach can be described as a regular and planned process focusing on customers and their demands to encourage a target group to exhibit a certain behavior or adopt a specific idea.10,11 The idea of social marketing was first introduced in 1971 by Philip Kotler, who founded the principles of this subject by combining the concepts of social change, commercial marketing, and advertising. According to Storey et al, social marketing principles can be used to sell ideas, attitudes, and behaviors to society.12 In social marketing, the goal is to use the principles and techniques of commercial marketing to draw the attention of a target group and encourage them to perform a desirable social behavior or stop an undesirable behavior in such a way that the new attitude becomes the norm.13-15 One of the available models for developing social marketing is the Social Marketing Assessment and Response Tool (SMART) model. In this model, the social marketing process is divided into seven phases: preliminary planning, audience analysis, channel analysis, market analysis, materials development and pretesting, implementation, and evaluation. The present study applies the market analysis or marketing mix component. The marketing mix is a key concept in social marketing which encompasses all measures that manufacturers or service providers take to systematically affect the market demand for a product or service. The marketing mix is also known as 4 Ps which refers to four levels of marketing including product, price, place, and promotion.16-18 The purpose of this study is to design and validate a social marketing-based educational parenting skills package for the parents undergoing substance abuse treatment to prevent addiction in their adolescents.

Methods

This research is a combination of a qualitative study (descriptive phenomenology), scoping review, and Delphi study (classic Delphi and fuzzy Delphi) to develop an educational parenting skills package for the parents undergoing substance abuse treatment to prevent addiction in their adolescents. This package is based on the social marketing approach with a focus on marketing mix (4 Ps = product, price, place, promotion). This research will be performed in four phases in the addiction treatment clinics of North Khorasan Province, Iran, from April 2020 to April 2021 (Figure 1).

Figure 1

Study phases

Phase 1: Educational needs assessment

This phase involves identifying the required parenting skills, existing barriers, suitable places for education, available communication channels, and appropriate educational methods from the perspective of parents undergoing substance abuse treatment, adolescents, experts, and policymakers based on social marketing mix.

This phase consists of the following seven stages:

Stage 1: Qualitative educational needs assessment of parents

The researchers will conduct a qualitative study based on the social marketing approach and with the needs assessment objective on the parents undergoing substance abuse treatment to determine the required parenting skills, the existing barriers, suitable places, communication channels, and methods for education or promotion. Inclusion criteria for parents are: undergoing substance abuse treatment, having at least an adolescent child (12-20 years old), and being able to express their experiences and views. The samples will be selected by the purposive and snowball sampling method. The sampling process will continue until saturation. In addition, the data will be collected through focus group discussions or in-depth semi-structured interviews. Focus group discussions and interviews will be transcribed verbatim then will be coded using MAXQDA 10 software. The analysis will be performed based on Colaizzi’s 7-step method including reading carefully all the descriptions to get familiar with the data, extracting significant statements, extracting concepts from these significant statements, arranging meanings into categories, clusters of themes, and themes, developing an exhaustive description incorporating all the themes produced in step 4, converting complete descriptions of the phenomenon into a real and concise description, and finally, validating the findings by interviewing with participants to clarify the ideas obtained.19-21 For the sake of the trustworthiness of qualitative data, four criteria proposed by Guba and Lincoln will be used.22 These four criteria include credibility (in-depth interviews in multiple sessions and situations, the researcher's constant obsession and involvement in the data, use of different methods to collect data, the selection of variant participants with different characteristics, review of writings by participants, and the control and supervision of the researchers on all stages of the study), dependability (complete recording of decisions and activities, re-coding of interviews and comparison of two codes, and use of observer review), transferability (accurate and purposeful description of the study method, external review of research results to judge whether there are similarities between research results and their own experiences), and confirmability (in addition to the researcher check and confirming the interviews, codes, and extracted categories by the members of the research group).21-24

Stage 2: Qualitative educational needs assessment of the young children

The researchers will carry out a qualitative study based on the social marketing approach with the needs assessment of adolescents. Inclusion criteria for adolescents are: aging 12 to 20 years, having parents with substance abuse, and being able to express their views and experiences. The samples will be selected by the purposive and snowball sampling method. The sampling process will continue until saturation. Besides, the data will be collected through focus group discussions or in-depth semi-structured interviews. Focus group discussions and interviews will be transcribed verbatim then will be coded using MAXQDA 10 software. The analysis and the trustworthiness will be performed as similarly as stage 1.

Stage 3: Qualitative educational needs assessment of the relevant experts

The researchers will perform a qualitative study based on the social marketing approach with the need assessment objective on the experts with relevant scientific and executive backgrounds (psychology, psychiatry, social work, professional doctorate, health education and health promotion, medical education) in order to determine the required parenting skills, the barriers to gaining these skills, the suitable places to learn these skills, and the suitable methods to gain more information about these skills. In this stage, the data will be collected through in-depth semi-structured interviews. The samples will be selected by the purposive and snowball sampling method. The sampling process will continue until saturation. In addition, the data will be collected through focus group discussions or in-depth semi-structured interviews. Interviews will be transcribed verbatim then will be coded using MAXQDA 10 software. The analysis and the trustworthiness will be performed as similarly as stage 1.

Stage 4: Qualitative educational needs assessment of the relevant policymakers

The researchers will conduct a qualitative study based on the social marketing approach with the need assessment objective of relevant policymakers (Iran’s State Welfare Organization, Ministry of Health, Ministry of Education, and Ministry of Labor, Social Affairs, and Social Services) in order to determine the required parenting skills, the barriers to gaining these skills, the suitable places to learn these skills, and the suitable methods to gain more information about these skills. In this stage, the data collection will be performed through in-depth semi-structured interviews. The sampling process will continue until saturation. In addition, the data will be collected through focus group discussions or in-depth semi-structured interviews. Interviews will be transcribed verbatim then will be coded using MAXQD 10 software. The analysis and the trustworthiness will be performed as similarly as stage 1.

Stage 5: Educational needs assessment using the Delphi method

Step 1- Setting the goals of the Delphi study (classic Delphi): This step involves determining the educational needs of the parents undergoing substance abuse treatment about parenting skills, the barriers preventing parents from acquiring these skills, the suitable places to acquire these skills, and the suitable communication channels and educational methods for this purpose.

Step 2- Selecting the participants: This step involves using the purposive and snowball sampling method to find and enroll people with expertise in addiction prevention and treatment and people with relevant scientific and executive background in educational institutions and organizations (psychology, psychiatry, social work, professional doctorate, health education, and health promotion) for participation in the Delphi technique. Ultimately, 30 people will be selected to participate in this technique.

Step 3- Designing and distributing the first-round questionnaire: The first-round questionnaire will consist of open-ended questions (these questions will be about identifying the required parenting skills, existing parenting barriers, suitable places for education, and appropriate educational methods) designed based on the marketing mix format through consultation with experts. The questionnaires will be distributed through e-mail.

Step 4- Designing and distributing the second-round questionnaire: Second-round questionnaire will be distributed among the first round’s participants. In these questionnaires, the participants will be asked to answer the questions with "Yes", "No", or "I am not sure". The purpose of these questionnaires is to determine the areas on which respondents are in agreement or disagreement. Analyses will be performed using descriptive statistics [mean, median, standard deviation (SD)], with 70% consensus considered as strong, 50% consensus considered as moderate, and 30% consensus considered as poor and unacceptable.25,26 Items with moderate consensus will be assessed in the third round.

Step 5- Designing and distributing the third-round questionnaire: At this step, participants will be asked to review the answers, reconsider their opinions and judgments, if needed, and state their reasons for not agreeing with others. This process will continue until reaching a consensus among at least 70% of participants.25,26

Stage 6: Scoping review with the educational needs assessment objective

The purpose of this stage is to review the literature related to the parenting skills of parents undergoing substance abuse treatment and addiction prevention in adolescents of these parents. For this review, the researchers will search for studies published in Persian and English. This search will be performed for relevant keywords in titles, abstracts, and Medical Subject Headings (MeSH) and subheadings. The databases will be Medline, Embase, Scopus, Web of Science, PubMed, Google Scholar, Scientific Information Database (SID), and Iran Medex. Scoping review steps include identifying the research question, identifying relevant studies, study selection, charting the data, and collating, summarizing, and reporting the results.27

Stage 7: Summarization of the identified educational needs by the expert panel

The identified educational needs in the previous six stages will be discussed and summarized by an expert panel consisting of 15 experts with relevant scientific and executive backgrounds (psychology, psychiatry, social work, professional doctorate, health education and health promotion, and medical education). The output of this stage will be a list of educational needs of the parents undergoing substance abuse treatment in relation to parenting skills, the barriers to acquiring these skills, and the suitable locations, communication channels, and education methods for this purpose.

Phase 2: Ranking of educational needs in relation to parenting skills

In this phase, parenting skills, existing barriers, preferential educational locations, and appropriate educational methods identified in phase one are ranked in two rounds by 20 experts, who will be selected by the purposive and snowball sampling method, with relevant scientific and executive backgrounds (psychology, psychiatry, social work, professional doctorate, health education and health promotion, and medical education). In the first round, a closed-ended questionnaire will be designed in the form of a Likert scale with 5 options (very low, low, medium, high, very high). This questionnaire will be given to the experts to answer after that the fuzzy and de-fuzzy values will be determined. Then, the results in the second round will be provided to experts again. Finally, the rank and importance of each item will be finalized.28,29

Phase 3: Developing educational content

Stage 1: Identifying health education structures related to needs by Delphi

In this stage, based on the required parenting skills and barriers to parenting that were identified in the previous stages, in three rounds, the structures of related health education models for developing appropriate content in the field of parenting and determining appropriate educational methods will be identified. In the first round, 30 health education and health promotion experts who will be selected by objective sampling and snowball sampling will be asked to announce the structures of health education models appropriate for parenting with an open-ended questionnaire. After collecting their comments and removing duplicates, the second-round questionnaire will be compiled in a closed way with a three-choice Likert scale (yes, no, not sure) and will be provided to experts. According to experts, items with a consensus of 70% and above and items with a consensus of 30% to 50% will be reviewed and ranked in the next round, and items with a consensus below 30% will be removed.

In the third round, again, to determine the importance of structures, the questionnaire will be designed as a Likert scale with 5 options (very low, low, medium, high, very high) and experts will be asked to answer them; then, the fuzzy and de-fuzzy values will be calculated by summarizing the experts' comments, and finally, the importance and rank of each structure will be determined.25,26,28,29

Stage 2: Developing the educational content

In this stage, the researcher will use the findings of phase 1 (educational needs assessment), phase 2 (ranking of educational needs), and the first stage of phase 3 (constructs from health education models and theories) to create a draft of parenting skills educational package for the parents undergoing substance abuse treatment to protect their adolescent children against substance abuse, and then develop the educational guidelines accordingly.

Phase 4: Validation of the developed education package

The developed parenting skills educational package will be evaluated by experts as well as the target group (parents who are quitting substance abuse).

Step 1- Validation by experts

Educational package by 15 experts (professional doctorate, psychology, psychiatry, health education, and health promotion), based on criteria such as transparency and clarity of content, adequacy of content, the usefulness of content, acceptability of content, attractiveness, non-contradiction of content, the relevance of content to the target group, the proportionality of content in each section, and accuracy of the materials will be reviewed and evaluated; also, necessary corrections will be made.

Step 2- Validation by the target group (parents quitting substance abuse)

Educational package by 15 members of the target group (parents under the treatment of substance abuse) based on criteria such as transparency and clarity of the content, adequacy of the content, usefulness, acceptability of the content, attractiveness, and the issues raised by experts after compiling the content will be reviewed and evaluated; necessary corrections will be made as well.30

Discussion

This study aimed to develop an educational package for improving the parenting skills of the people undergoing substance abuse treatment to protect their adolescents against addiction, through a scientific process based on rigorous educational needs assessment (qualitative study, Delphi method, scoping review, and expert panel) in the framework of marketing mix and health education models and theories. The first step in developing a parenting education program to prevent early-onset substance abuse in the adolescents of these parents is to prepare suitable educational content for this purpose. This cannot be done without a framework or model for staged evidence-based planning. Over the years, researchers have developed various models and methods to develop, plan, and evaluate health education and promotion programs. One of these methods is the social marketing approach, which responses appropriately to the mentioned needs. In addition to its constituent elements, this approach defines a series of concepts known as marketing mix, including product (behavior or suggestion that is expected to be accepted by the target audience), price (what the customers pay to get the product), place (the path by which the product or service reaches the customer), and promotion (how people become aware of the product or behavior). It has been shown that social marketing can be used as a novel approach in the development of health education and promotion programs to enhance the ability of participants and to increase the sense of democracy and the value of the audience (customers). In other words, using this approach to health education to change the socially-accepted norms (behaviors, beliefs, attitudes, etc.) will be more effective than using the traditional approaches to health promotion, which often pay less attention to the target audience. Moreover, in the past, many health education programs were designed with a top-down approach involving health professionals to identify health-related problems and design the goals, content, methods, and interventions. However, the social marketing-based method involves a bottom-up approach to develop educational programs focusing on encouraging behavioral change through customer-orientated methods.31-34

After assessment of educational needs based on the social marketing approach and ranking the identified needs by the Delphi technique, the next step is to determine the health education constructs that help us recognize the related constructs through the determined barriers and problems in acquiring parenting skills that can be used in the development of educational content for the purpose of the study. In the end, evaluation is performed from the perspectives of experts as well as the target group, i.e., the parents undergoing substance abuse treatment.

Conclusion

The development of an educational package based on scientific health education methods and especially, the social marketing approach, can prove effective in attracting the target audience and promoting the target activities.