Preparing the Field for Feasibility Testing of a Parenting Intervention for War‐Affected Mothers in Northern Uganda

• Author: Verena Ertl,Achan Laura,Claudia Catani,Marion Forgatch,Christopher Mehus,Frank Neuner,Elizabeth Wieling,Julia Möllerherm,Cigdem Yumbul
• DOI: http://doi.org/10.1111/famp.12189
• Published date: 01 June 2017
• Date: 01 June 2017

Preparing the Field for Feasibility Testing

of a Parenting Intervention for War-Affected

Mothers in Northern Uganda

ELIZABETH WIELING*

,†

CHRISTOPHER MEHUS*

CIGDEM YUMBUL*

JULIA MO

¨LLERHERM

‡

VERENA ERTL

†,‡

ACHAN LAURA

†

MARION FORGATCH

§

FRANK NEUNER

†,‡

CLAUDIA CATANI

†,‡

In this article, we discuss the successful implementation of an adapted evidence-bas ed

parenting intervention for families affected by two decades of war in Northern Uganda.

The adaptation and adoption of such interventions to support mental health and family

functioning is widely endorsed by prevention scientists and considered a priority in global

mental health. The preparation and early adoption phases of engaging with a highly

vulnerable community affected by war trauma are documented in this paper along with a

discussion of the steps taken to adapt a parenting intervention for cultural and contextual

fit. This study is a component of an overall program of research aimed at reducing the

long-term negative effects of war on parenting practices and childhood outcomes, which

have considerable implications for preventing mental, neurological, and substance-use

disorders. The processes described here cover a 4-year period culminating in the implemen-

tation of the nine-session Enhancing Family Connection intervention piloted with a group

of 14 mothers. The lessons in cultural adaptation have been valuable and the feasibility

results promising for further testing the intervention.

Keywords: Implementation and Dissemination Science; Parenting; Prevention; War

trauma; Uganda

Fam Proc 56:376–392, 2017

Intergenerational transmission of family violence, substance abuse, and harsh parenting

are only a few of the related consequences of war and organized violence on family and

community functioning (Catani, Jacob, Schauer, Kohila, & Neuner, 2008; Olema, Catani,

Ertl, Saile, & Neuner, 2014; Saile, Neuner, Ertl, & Catani, 2013). Our workgroup, Victim’s

Voice (vivo; vivo.org), has collaborated in current and postconflict communities for over a

*Family Social Science, University of Minnesota, St. Paul, MN.

†

Victims Voice International (vivo.org), Gulu, Uganda.

‡

Department of Psychology, Bielefeld University, Bielefeld, Germany.

§

Oregon Social Learning Center, Implementation Sciences International Incorporated, Eugene, OR.

Correspondence concerning this article should be addressed to Elizabeth Wieling, Department of Family

Social Science, University of Minnesota, St. Paul, MN 55108. E-mail: lwieling@umn.edu.

We acknowledge and thank all project participants and vivo Uganda for making this study possible.

376

Family Process, Vol. 56, No. 2, 2017 ©2015 Family Process Institute

doi: 10.1111/famp.12189

decade, primarily providing treatment for posttraumatic stress disorder (PTSD). One of

these communities is Northern Uganda, the setting of a brutal civil war between the rebel

Lord’s Resistance Army led by Joseph Kony and the Ugandan government that lasted

nearly two decades through 2006.

Over a decade of clinical involvement and research in this community revealed a critical

need for parent- and family-level interventions in addition to PTSD treatment to address

the sequelae of relationally maladaptive, albeit contextually normative, responses to pro-

longed exposure to traumatic stress. The parenting intervention we called Enhancing

Family Connection (EFC) was developed in response to the expressed needs of families in

Northern Uganda to fit their cultural and contextual characteristics. All parenti ng compo-

nents of EFC were adapted from the Parent Management Training, Oregon model (PMTO;

Patterson, 2005) evidence-based intervention. Additional EFC content areas included

psychoeducation on the individual and relational effects of traumatic stress as well as

sessions on the intergenerational transmission of violence, substance abuse, and other

risk-taking behaviors. Wieling has worked with researchers at the Oregon Social Learning

Center for nearly 14 years and has been trained extensively in PMTO. Wieling received

federal funding and was mentored by Forgatch to culturally adapt the intervention to

immigrant Latino/a families in the United States and has adapted the intervention to

several trauma-affected cultural groups.

In this article, we present the processes our research workgroup undertook to assess for

community-level need and desire for a parenting intervention. We also document the ini-

tial development of the program, evaluation of the promise of effectiveness with this popu-

lation, and testing the feasibility of the manual and training program. These efforts are all

part of the preparation and early adoption processes necessary to establish effective imple-

mentation and sustainability (Forgatch, Patterson, & Gewirtz, 2013). A full elaboration of

descriptive quantitative and qualitative findings of the feasibility study are reported in

another publication (Wieling et al., 2015).

TRAUMATIC STRESS RELATED TO WAR AND THE PARENT–CHILD

RELATIONSHIP

Although one can readily identify signs of resilience in communities that have experi-

enced war and trauma, it is also true that these communities see lasting negative effects

on individuals and families. After civil war and the tsunami in Sri Lanka, increased expo-

sure to war and increased alcohol use by fathers predicted higher levels of child-reported

abuse (Catani et al., 2008). In Northern Uganda, exposure to trauma is associated with

family violence and substance use and children report that their worst traumatic experi-

ences are related to family violence above exposure to war violence (Saile et al., 2013;

Olema, Catani, Ertl, Saile, & Neuner, 2014). Following the war in Bosnia, maternal men-

tal health predicted child adjustment (Smith, Perrin, Yule, & Rabe-Hesketh, 2001) and a

qualitative postintervention study conducted with 125 Bosnian refugees in the United

States documents drastic changes in family roles and relationships (Weine et al., 2004). In

a sample of 200 Gulf War veterans in Kuwait, fathers’ PTSD symptoms positively related

to children’s depression scores; children’s anxiety, depression, and abnormal behavior

were all related to fathers’ combat experience and mothers’ PTSD, anxiety, and depression

(Al-Turkait & Ohaeri, 2008). Catani et al. (2008) found that even following war and tsu-

nami, 14% of children reported an experience of family violence as the most distressing

experience of their lives. Siegel (2013) argued that indeed neuroscience research supports

the saying that “violence begets violence” and that children who witness parental violence

are at high risk for repeating family violence in their own adult intimate relationships.

Two recent studies support this hypothesis. In a qualitative study of 25 Burundian former

Fam. Proc., Vol. 56, June, 2017

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