Legacy for Children™ (Legacy) is a parenting-focused prevention program for socioeconomically disadvantaged families described briefly here and in detail elsewhere (Perou et al., 2012; Robinson et al., 2019). Legacy was specifically designed to promote mothers’ responsibility and investment in their children; facilitate responsive and sensitive parent-child relationships; support mothers as guides in their child’s behavioral/emotional regulation; enhance maternal sense of community; and foster child verbal and cognitive development. Sessions consist of regular group meetings including mother-only time as well as mother-child time which allows participants to practice concepts in a safe, nurturing environment. Through the group process, participants also connect to a network of mothers with children at similar developmental stages to foster a sustainable community of support. The curriculum is built on the philosophy that there is no one “right” way to parent; in fact, there are many positive parenting strategies that support child development. The Legacy program focuses on enhancing the parent-child relationship quality above and beyond any specific parenting behavior. Effectively, mothers are encouraged to feel confident in child-rearing choices and discuss cultural differences in parenting within a safe environment. The developmentally-timed curriculum covers topics ranging from positive parent-child interactions, maternal self-care and stress reduction, to parenting strategies that foster children’s cognitive, language, and social skills (e.g., discipline, literacy promotion, play). Of note, Legacy is not a literacy-specific intervention; Legacy supports the parent-child relationship and the importance of reading and talking with children in whichever language mothers use at home.

RCTs of the two Legacy University of California, Los Angeles [UCLA] and University of Miami curricula demonstrated that program participation was associated with a lower risk of child hyperactive behavior in the Los Angeles cohort, and fewer behavioral concerns and socioemotional problems among children of Legacy participants in the Miami cohort (Kaminski et al., 2013). In addition, Legacy participant children in the Los Angeles cohort had higher IQ and achievement scores six years post-intervention (Perou et al., 2019). To reach a broader population of children, the Centers for Disease Control and Prevention (CDC) has been collaborating with federal and private partners to ascertain Legacy’s feasibility within diverse family-serving systems such as Early Head Start, private ECE, and pediatric primary care (Robinson et al., 2019).

Although Legacy was originally designed and tested with samples of predominantly non-Hispanic black mothers and English-speaking Latina mothers, recognition of the unique needs of Spanish-monolingual Latino families prompted the CDC to translate and culturally adapt the Legacy UCLA curriculum. As the curriculum was originally designed for minority populations and involves non-didactic group discussion allowing for exploration of cultural differences, major adaptations to the curriculum were not expected to be necessary (see the Methods section for a description of the adaptation procedure).

The translation and adaptation process first involved a review of the English curriculum by content experts – including a bilingual staffperson – to flag phrases, examples, or concepts that might require adaptation. These English examples, books, videos, and songs were replaced with Spanish language, culturally appropriate versions determined to convey the same concepts (e.g., repetition and rhyming). Subsequently, a pilot session that captured common themes from the curriculum and was anticipated to present particular translation challenges was selected for translation; this session was iteratively translated until consensus was achieved across the independent translation team, a second team of bilingual translators, and content experts that the translation reflected the original content. The full curriculum was then translated collaboratively by the second team of bilingual translators and content expert team, then finally reviewed, edited, and approved by the original curriculum developers (see Beasley et al., 2017).

Subsequent to the adaptation process, we conducted a cultural congruency program evaluation with Latino bilingual parenting program providers to understand the acceptability, satisfaction, relevance, importance and cultural congruency (i.e., alignment with the unique needs of Latina mothers) of the translated curriculum. Providers discussed the positive attributes of the curriculum and its relevance for Spanish-monolingual mothers. The evaluation also highlighted the importance of tailored engagement and attendance promotion strategies for this population (e.g., convivios or potlucks at the end of a block of sessions, mother-mother socialization opportunities) (Beasley et al., 2017). These data informed further revisions to the Spanish language curriculum and implementation (e.g., inclusion of additional visuals and songs, recruitment through trusted agencies already serving Latino families).

Legacy is being implemented in partnership with Tulsa Educare as a component of their community outreach strategy, consistent with broader strides in the early childhood sector to promote relationship-building with families - particularly those experiencing adversity (U.S. Department of Health and Human Services and U.S. Department of Education, 2016). Participant selection involved convenience sampling of low-income mothers who were pregnant or had newborns and were interested in attending weekly parenting groups. Recruitment efforts included outreach by local service agencies (i.e., community mental health center), Catholic Charities, child care wait lists, and local medical providers. In addition, we set-up advertisements and booths at organizations and businesses frequented by parents in the community. We conducted separate but similar recruitment activities for English-speaking and Spanish-speaking families. To participate in Legacy, mothers had to evidence some type of socioeconomic adversity (e.g., family income below the federal poverty level).

Both the English and Spanish versions of the Legacy UCLA curriculum (herein solely referred to as English and Spanish curricula) are implemented in nine blocks of ten consecutive weekly sessions. The sessions are developmentally-timed for participants approximately seven months pregnant until the mother’s child is approximately three years-old (Perou et al., 2012). Mothers were enrolled in the program as close as possible to the first curriculum session, prenatally if possible, or shortly after their child’s birth if prenatal enrollment was not feasible. The Legacy UCLA curriculum alternates each week between a session for mother-only group discussion and a session for the mother and child to practice the curriculum material (Figure 1). Sessions are typically two hours long. Although the curriculum is specifically designed for mothers or primary female caregivers, broader family participation is encouraged through maternal sharing of materials, special events, and community activities.

Legacy group sessions were facilitated by two leaders in each group, with a total of five group leaders. Within each curriculum language version, one group leader facilitated both groups (e.g., two English or two Spanish groups) so there was consistency across the groups within a curriculum version. The Legacy Spanish groups were facilitated by two native Spanish-speaking group leaders and a bilingual group leader (Figure 1). The bilingual group leader also facilitated one English group so there was also consistency across curriculum versions. All group leaders and their Legacy supervisors attended a 3-day in-person training and participated in bimonthly coaching calls provided by the CDC. On a weekly basis, group leaders completed program monitoring forms and met with onsite supervisors to discuss issues related to program implementation and the group process. Three of the group leaders were staff from the early learning center and two were local university staff. All group leaders had either a Bachelor’s or Master’s degree in a social science field (e.g., social work).

At baseline, mothers reported their sex, age, race/ethnicity, education level, language(s) spoken in the home, employment status, household income, and receipt of public assistance. For their children, mothers reported on their child’s age, sex, and race/ethnicity.

We collected several quantitative measures of parent engagement from both parent and group leader perspectives. In order to capitalize on all available data, we used a last observation carried forward approach (Salkind, 2012) – if a respondent had missing data at the present study’s assessment timepoint, their last observed score closest in time to the present was used for that measure. The parent’s group support/connectedness variable was defined as the parent’s receipt of group support and the parent’s level of connection to the group, and was measured using the Working Alliance Inventory – Short Form (WAI-S). The WAI-S is a questionnaire used in psychotherapy settings to assess therapeutic alliance (i.e., interactive relationship between clients and their therapists) and was developed from an original 36-item instrument (Horvath & Greenberg, 1989). Although Legacy is not implemented by therapists, Legacy group leaders create a safe, open environment for group discussion and trying out new ideas, and support connections between group members similar to elements found in a psychotherapy group intervention. Further, the WAI-S has been increasingly used in similar group parenting programs to examine relationships between group members (Hukkelberg & Ogden, 2013; Morris et al., 2017). The 12-item instrument has a therapist version that was completed by the group leaders at the end of each block in this investigation. Respondents rated each item using a seven point Likert scale from 1 (Never) to 7 (Always). Although these items can be organized into sub-scales to calculate an overall alliance score, we focused on the individual items for this analysis. 7 items in the WAI-S were averaged to calculate an average group support/connectedness score (Cronbach’s α = 0.88).

The parent-group leader relationship variable was defined as the reported quality of the mother’s relationship with the group leader. This construct was measured by parent report in the Parent Satisfaction Survey (PSS) (Perou et al., 2012) and by the group leader in the WAI-S. For example, “how often does the group leader answer your questions about parenting?” is a closed-ended question related to the parent-group leader relationship in the PSS. Parent-group leader items are rated on a Likert scale from 1 (Never) to 4 (Always). The PSS was made available to participants in Spanish or English, and was completed at the end of block five. In order to learn from the distinct perspectives offered by the WAI-S (group leader) and PSS (participants) while avoiding multiple testing, we created composite variables for the parent-group leader relationship in both the WAI-S (11 items, Cronbach’s α = 0.83) and PSS (6 items, Cronbach’s α = 0.72), through averaging relevant items in the respective instruments. Finally, the overall satisfaction with Legacy variable was rated by participants in the PSS with a single item, “how satisfied do you feel with Legacy?”. The satisfaction item is rated from 1 (Somewhat Satisfied) to 4 (Very Satisfied).

Information on barriers and facilitating factors for parent engagement were collected through open-ended responses on the parent-reported PSS and the group leader-reported Parent Engagement Form (PEF). Both forms are used as program monitoring tools for quality assurance in implementing the Legacy program. The PEF contains open-ended questions pertaining to parents’ participation in group, parents’ perceived benefits, parents’ contributions to group, barriers impacting parents’ participation, and efforts to contact parents (Appendix 1). In a previous study, Heggs Lee and colleagues (2018) used factor analysis to determine that the PEF is composed of four consistent factors (parent-child interaction, group alliance, group participation, and social support). The social support and group alliance subscales were predictive of group attendance, while the parent-child interaction subscale predicted later child behavioral outcomes (Heggs Lee et al., 2018). The PSS was developed as a Legacy program monitoring tool based on Patton’s (1990) categorization system (Fraser, Wallace, Dempsey, Reubens, & Hawkins, 2009). To date, the PSS has only been used within the Legacy program to assess participant satisfaction. The PSS contains closed- and open-ended questions regarding mothers’ perceptions of the program content, group leader, and other mothers in the group; challenges impeding attendance; confidence in applying parenting skills targeted by Legacy; and suggestions for program improvement (Appendix 1) (Perou et al., 2012). For PSSs completed by Legacy Spanish participants, open-ended responses were translated into English using recommended cross-cultural qualitative research practices: translation by both a native and non-native Spanish speaker, back translation procedures, and resolution of interpretation discrepancies through discussion between investigators and program implementers (Esposito, 2001).

We described demographic characteristics and compared across the English and Spanish curriculum versions using Wilcoxon rank-sum tests (for continuous variables) and Kruskal-Wallis tests (for categorical variables). We also used Wilcoxon rank-sum tests to compare mean scores of parent engagement measures (group support/connectedness, parent-group leader relationship, and overall satisfaction) between the English and adapted Spanish versions. A non-parametric test of association was selected because variables were not normally distributed, upon assessment via Shapiro-Wilk tests. We handled missing data using available-case analysis, and conducted a supplemental analysis to understand whether respondents who had missing vs. non-missing data for the PSS differed on select sociodemographic characteristics. All tests were two-tailed and considered statistically significant at p values of less than 0.05. Quantitative analyses were conducted in Stata 14.1© (StataCorp, College Station, TX).

Parent and group leader perspectives on barriers and facilitators for parent engagement were coded inductively and deductively, in conjunction with the framework method (Gale, Heath, Cameron, Rashid, & Redwood, 2013; Ritchie & Lewis, 2003), to explore modifiable program barriers and facilitators.

Two investigators (MS and AAR) were the primary analysts for the coding process. MS (a non-native Spanish speaker) and AAR (a native Spanish speaker) are both CDC research staff supporting the implementation support system (e.g., fidelity monitoring) of Legacy, although they are not involved in direct program delivery within communities. Given these investigators’ relationship to the program and this dataset, several steps were taken to augment validity, including developing codes from current evidence and employing a member check procedure with program implementers (described below).

A priori codes were first derived based on existing literature (Butler & Titus, 2015; Fraser et al., 2009; Lakind & Atkins, 2018; Morawska, Dyah Ramadewi, & Sanders, 2014; Whittaker & Cowley, 2012) and extant fields in the PEF and PSS prior to initiating the formal coding process. These codes served as the basis of a preliminary codebook specifying the hierarchy of codes and affiliated sub-codes. The same two investigators independently coded a randomly selected 20% of data fields; inter-coder reliability was calculated via Cohen’s kappa statistic after coding this initial sub-sample. At this first stage, the kappa was 49.6% based on coding comparison queries, indicating a “moderate” degree of agreement (Fleiss, Levin, & Paik, 2004). Investigators discussed discrepancies and made codebook modifications through consensus, before re-coding initial interviews and proceeding to the next phase of coding. After codebook revisions, inter-coder reliability was 70.5% (in the “substantial” range; Fleiss et al., 2004).

The codebook was modified six times to ensure data saturation was achieved (Appendix 2). Both memos generated from the literature (theoretical memos) and memos generated from the data directly (analytic memos) were recorded throughout (Ritchie & Lewis, 2003). Analysts also discussed their assumptions and biases that might affect the coding process to ensure these were addressed, facilitated by a structured vantage point reflection worksheet (available upon request). Once all fields were coded, we used the constant comparative method to capture themes (Bernard, Wutich, & Ryan, 2017).

We then identified recurrent themes of barriers and facilitators within the framework matrix. We ascertained the salience of factors across the Spanish and English curricula and within curriculum using principles of cultural domain analysis. Namely, we (1) examined the degree to which a given code presented in either or both data sources (PEF or PSS) and (2) inspected the frequency with which each code was represented against the number of respondents reporting (Bernard et al., 2017). This enabled us to parse factors into “primary” (factors that emerged with relatively high frequency and converged across group leader and parent report) and “secondary” (factors that emerged with relatively high frequency but surfaced only by one of these reporters) barriers and facilitators. Finally, we shared summarized results with group leaders for both curriculum versions to ascertain the validity of findings using a synthesized “member check” technique (Birt, Scott, Cavers, Campbell, & Walter, 2016).

Baseline demographic data were available on 24 of the Legacy English participants and 28 of the Legacy Spanish participants. We found some mother and child sociodemographic differences across curriculum versions. A low percentage of participants responded to the question on maternal race (18.7%). With regard to ethnicity, 37.6% of participants in the Legacy English curriculum identified as Hispanic or Latino, compared to 100% of mothers in Legacy Spanish. Among those participants who responded, individuals in Legacy English were approximately split racially between white (46.3%) and black (50.3%). The responding Legacy Spanish mothers predominantly identified as white (52.3%) or other (46.2%). Legacy Spanish mothers were primarily 1st generation immigrants with the majority from Mexico and a few mothers from Honduras. Additional sociodemographic characteristics are described in Table 1. We did not observe statistically significant differences across curriculum versions by mother and child age, nor by education level.

A supplemental examination of baseline differences on four demographic characteristics between individuals with missing vs. non-missing data for the PSS indicated that individuals with missing responses reported lower rates of full or part-time employment, compared to individuals with non-missing responses (not shown). We did not observe significant differences between these groups regarding proportion that speak primarily English, monthly household income, or maternal age.

Parents’ group support/connectedness to the group (i.e., the degree of engagement of parents with respect to other parents) assessed by the group leader was high in both English and Spanish curricula, with mean scores of 6.0 (SD: 1.3) and 6.9 (SD: 0.8) on a 7-point scale, respectively. Participants in Legacy Spanish demonstrated significantly higher scores for group support/connectedness (p = 0.011) than the Legacy English participants. No significant differences were identified across curricula for parent-group leader relationship by either the WAI-S (p = 0.482) or PSS measure (p = 0.100). Finally, parents’ report of overall satisfaction with Legacy revealed higher levels of satisfaction among Legacy Spanish compared to Legacy English participants (p = 0.015; Table 2).

Mothers and group leaders in both the English and Spanish curricula mentioned health-related challenges and appointments as a barrier to engagement. Comments in this theme included medical procedures, appointments with providers, and both specific and non-specific health challenges (e.g., “Kids being sick” [Participant, Legacy English]). Health-related challenges were not limited to acute physical conditions. Group leaders mentioned developmental disabilities among one of the mothers’ children and another mother’s self-reported depression as barriers.

A second barrier shared by participants in both curricula were employment challenges. Mothers and group leaders mentioned a range of issues related to mothers’ jobs that inhibited attendance (e.g., “She has attended when work schedule allows” [Group Leader, Legacy English]) or hampered engagement when they did come, due to being late, tired, or distracted. Having an unpredictable or erratic work schedule was cited as a barrier to attendance, as were mothers’ expressions that they were in the process of seeking employment (“Mom has stated that once baby is older she will look for work” [Group Leader, Legacy Spanish]). A handful of participants in the English groups pointed out the scheduling conflicts presented by their job(s), child care, and bringing in their children for the mother-child days; as explained by one parent in an English group:

Not being able to bring my child to Educare AFTER the parenting group meeting does hinder my ability to bring him to the meetings on the mom and child days… This will likely prevent me from attending the group at all within the next block or two.

However, group leaders and mothers both noted that despite job-related barriers, mothers often maintained interest and investment in the program, as evidenced by being responsive and receptive to other components of Legacy (e.g., social media, home visits, telephone call reminders).

Although less common, some mothers across both curriculum versions expressed challenges related to the group leaders, particularly their ability to keep the group on topic and complete the entirety of the lesson. We note that although this facet of the group leaders emerged as a secondary barrier for both curricula, group leader/other staff present characteristics were also a secondary facilitator for Legacy Spanish participants (for additional examples see Table 4c).

In terms of distinctions between programs, some barriers to engagement emerged as unique to Legacy English participants, particularly regarding the geographic distance to site—and affiliated time and effort—needed to attend group sessions on a routine basis and the family responsibilities that mothers had to handle. Several mothers shared that needing to “support [their] family” made it difficult for them to attend at times. General stress and life and challenges were cited as reasons that made it more difficult for mothers to attend and meaningfully engage in groups (for additional examples see Table 3b). Specifically cited challenges included reports of “significant life changes,” “personal dilemmas,” and “[having] a lot on her mind,” although the descriptions left unclear the specific nature of the stressors mothers experienced.

During the member check process, group leaders underscored that transportation access, more specifically, may have been an issue rather than actual distance to site, particularly in this community with limited public transportation. However, group leaders emphasized that mothers were still willing to take on the long distance and time needed to attend. Group leaders described one mother, without her own car, walking several miles with a young child, each way to attend the weekly groups.

The barriers unique to Legacy Spanish participants concerned specific transportation issues and the needs of mothers’ other (non-Legacy) children in their care. Transportation challenges encompassed reports that mothers frequently lacked personal vehicles and often had to carpool, walk, or take the bus to attend Legacy.

The needs of other children in the mothers’ lives also emerged as a key issue for individuals in the Legacy Spanish curriculum. Several respondents talked about how the responsibilities to provide for other children’s educational (e.g., school-related meetings) and health (e.g., doctor’s appointments) needs could have limited attendance as well as impacted a participant’s attention and quality of interaction during meetings. These included both mentions of mothers’ own children as well as children of other relatives the mother was responsible for (e.g., nieces, grandchildren). Several individuals raised the number of children as an issue, and the stress involved in “juggling many roles.”

Some group leaders also noted that a lack of knowledge about available services such as Legacy may have been a challenge for parents to feel comfortable enough to initially attend, although they often noted that this hesitance waned over time. Several mothers described social isolation as an issue that may have presented barriers for attendance— due to a lack of individuals who could support a given mother’s parenting responsibilities or encourage participation in the Legacy group. Finally, group leaders also identified mothers’ current or anticipated enrollment in English as a Second Language classes as a barrier to engagement in Legacy at times (Table 3c).

In both the original and adapted curriculum groups, group leaders and parents often described mothers’ interest in the program topics as beneficial for engagement. Several respondents indicated “learning about parenting” as what first attracted them to the program—as well as for engagement over time. Regarding a Legacy English group participant, one group leader explained,

We have seen a huge shift in this mom. Her original motivation for attending Legacy was ‘something to do.’ Gradually her interest in parenting topics has grown tremendously. Now she attends regularly and stays focused on what she can learn.

Within these expressions of interest, the desire of mothers to improve their parenting skills seemed to be motivating to attend Legacy, based on their own experiences being parented (e.g., “she was parented harshly herself” [Group Leader, Legacy English]) or with other children (e.g., “she wants to parent differently than she did with her older child [since] she was working all of the time” [Group Leader, Legacy Spanish]).

Another prominent facilitator shared across English and Spanish curriculum versions was the presence of other mothers in the group. Group leaders and parents both highlighted the role of other mothers in providing multiple dimensions of social support, specifically emotional support (e.g., “I appreciate the friendships and emotional advice” [Participant, Legacy Spanish]) and opportunities to socialize (e.g., “develop [camaraderie]” [Participant, Legacy English]). Notably, the opportunity to socialize was a more common expression for Legacy Spanish participants, and was occasionally linked to mothers’ lack of a robust social network (Table 4a). For example, one group leader explained that a mother in Legacy “seemed like she needed the social engagement and moral support from the other mothers” after recently having a new baby. Mothers in the group were occasionally described as a challenge, rather than facilitator, to interpersonal dynamics among group members (e.g., “At times they can be overly critical of others and overstep their boundaries” [Group Leader, Legacy English]). However, mothers’ perceptions of other’s challenging behaviors did not emerge as a primary barrier.

Examining factors that emerged distinctly for each curriculum illuminated the role of having other mothers’ children participate in Legacy as a key facilitator for English group participants. Of note, that Legacy provided an opportunity to interact with children at similar developmental stages appeared to be important, evidenced through common mentions of phrases such as being “around other children [their child’s] age” (Participant, Legacy English) and “create relationships with children my [baby’s] age” (Participant, Legacy English) (for additional examples see Table 4b).

For Legacy Spanish, other program-related characteristics were identified as important for engagement. Specifically, the curriculum session materials themselves were influential (e.g., mentions of specific session content such as rule setting and unstructured sessions designed to build sense of community) as were elements of the program design and delivery. Regarding the latter, mothers and group leaders described the dedicated time that mothers were afforded to spend time with their baby during mother-child group days as beneficial. Aspects about the group leader were also deemed influential for Legacy Spanish, although to a lesser extent compared to other program-related features. These characteristics included “patience,” “understanding,” “compassion,” “encouragement,” helping participants feel comfortable, being adequately prepared, and having high-quality information (“[The group leader] always uses research and studies to back up her knowledge, not just opinion” [Participant, Legacy Spanish]) (Table 4c).