Results

Objective 1: Which strategies and elements of a comprehensive approach to positive parenting are covered, how and to what extent?

Population health strategies

Survey respondents provided information about 138 positive parenting activities. This objective sought to discover whether all strategies and elements of a comprehensive approach to positive parenting are provided to all age groups. The percentages of activities which target parents of children in specific age groups are presented in Figure 1. The total number of activities (138) was used as the denominator. Percentages total more than 100, as activities can target multiple age groups. Most positive parenting activities target parents with children between 0 and 7 years of age.

The strategies for positive parenting and the percentage of activities which include them are presented in Figure 2. Again, the total number of activities (138) is used as the denominator, and activities may incorporate multiple strategies. Over 48% of activities use intervention with families and individuals, parent skills training, or supportive environments as strategies, and fewer than 25% use parenting information campaigns or policy and community action.

Table 2 presents positive parenting activities in KFL&A, broken down by population health strategy and by the age of the children targeted by the activity. Each number in the table represents a code for a specific activity. The key to these codes is presented in Appendices F and G. All age groups are covered by each of the population health strategies.

In a survey of 2554 Canadian parents, Invest in Kids^{13 (p 48)} asked what types of resources, programs and services they valued and used. Parents reported they valued 'general public resources' such as playgrounds and libraries the most. For example, 87% of mothers classified playgrounds as 'very important' and 90% reported using playgrounds. Another category that scored highly was 'child focused/informal programs', such as playgroups and parent-child programs. These two categories would be classified in Table 2 as "Supportive Environments". 'Issue/role improvement programs' such as parenting classes or workshops were rated comparatively poorly, with 48% of mothers reporting that they thought that parenting workshops were important, but only about 12% reported attending them.^{13 (pg 48)} 'Issue/role improvement programs' would be classified in Table 2 in the "Parent Skill Building" category. The importance which parents ascribed to strategies in the Invest in Kids survey is reflected in the number of interventions in Table 2. 

Note: Each number represents an individual activity. See Appendices F and G for activity names and their corresponding numbers.

Elements of positive parenting

Positive parenting elements and the percentage of activities which use them are presented in Figure 3, using the total number of activities (138) as the denominator. Multiple elements can be promoted in a single activity. "Warm or nurturing parenting" and "practicing a child centered approach" were positive parenting elements incorporated into more than 83% of the activities.

Table 3 presents activities in the KFL&A area, broken down by element and age group. Each number in the table represents a code for a specific activity, as provided in Appendices F and G. Many of the programs in our community reported that all six elements of positive parenting are embedded in their programs and resources. "Warm or nurturing parenting" and "practicing a child-centered approach" were reported to be used most often. This data may be helpful if the community decides to adopt key messages across different agencies. It shows that although there are 132 unique programs offered across our community, many have similar parenting ideals and messaging.

No element is missing at any of the age levels, although there are many more activities covering age groups 0-3 and 4-7 than older children or the prenatal period.

Note: Each number represents an individual activity. See Appendices F and G for activity names and their corresponding numbers.

Further description of positive parenting activities in KFL&A

Cost

Most of the positive parenting activities using interventions or parent skills training as strategies were provided with no fee to participants (83.2%). There was a fee with no subsidy for 4% of the activities (Table 4).
In the 2011 survey of Canadian parents reported by Invest in Kids,13 mothers reported that cost was the largest barrier to accessing programs and resources. Cost was the third highest rated barrier for fathers, for whom insufficient time to attend activities was the greatest barrier.

Personnel

Categories of training or professional status of the leaders and planners of positive parenting activities and the percentage of agencies led or planned by them are presented in Figure 4, using the total number of agencies (44) as the denominator. Agencies can provide multiple activities, using a variety of leaders or planners. Child and youth workers, community workers, early childhood educators, nurses, social workers and teachers were reported frequently by survey respondents. Psychologists or behavioural therapists led about 10% of activities. Psychiatrists led fewer than 5%.

The highly varied backgrounds, education and areas of specialty among those offering parenting support in our community may enrich the extent of knowledge and training available to parents, but it also means that facilitators will be offering different viewpoints and levels of expertise. For this reason, the promotion of key messages for parents across the agencies in our community may be an important way to ensure consistent information and approaches to parents, while each facilitator continues to offer a specific program within his or her specialized role.

Impetus for the development of activities

The drivers influencing the development of the positive parenting activities are presented in Figure 5, using the total number of activities (138) as the denominator. Several drivers may have informed the development of a single activity. Literature researches, perceptions of client need based upon community and staff input, and staff experience most often informed the development of activities. Included in the "other" category are provincial protocol, ministry initiative, innovative thinking, basic research, best practice, committee input, other organizations or agencies, and the specific needs of parents, children, youth, and priority populations.

Table 5 presents the drivers of activities by the strategies they used. No obvious relationship between these variables was evident.

Media Channels used in Parenting Information Campaigns

Thirty-four parenting information campaigns were identified by survey respondents; the media channels used in the campaigns are presented in Table 6. The total number of activities using parenting information campaigns (34) was used as the denominator in the calculation of percentages. The channels used most often used were pamphlets, e-mail, posters and electronic newsletters.

* Four media campaigns identified by survey respondents indicated the combined category of channels "pamphlets, posters, billboards, newspaper ads, etc.". These activities were included in the pamphlets total only.

Included within the "other" category are websites, bus ads, newsletters, and kindergarten open houses. Social media campaigns such as Facebook and Twitter were used by 44.1% of the parenting information campaigns; none of the campaigns used blogs.

While many agencies are using technology and the internet to reach parents, pamphlets and posters are still the strategies used most frequently; email has become an important method of distributing these. Pamphlets and posters can be efficient in providing information to parents with whom agencies have contact; for example, parents attending a program may see a poster or pick up a print resource. However, parents who are not engaged in programming or are not looking for specific information may have limited access to posters and print resources. The internet, radio and social marketing tools allow agencies to provide information to parents on a more universal level, as parents do not need to be present "in person" to receive it. Public Health Ontario reports that 95% of Canadians under the age of 55 have access to the internet, so access to internet should not be seen as a barrier.¹⁴

Priority populations served by positive parenting activities in KFL&A

Objective 2: Which priority populations are covered by activities for each population health strategy?

Twenty-two priority populations were identified by survey respondents. A comparison of these with priority populations indentified prior to environmental scan is shown in Appendix H. All but one of the previously identified priority populations were identified by survey respondents, the exception being single parent families. Respondents identified victims of violence, families experiencing bereavement, parents of children with emotional problems, families with substance abuse, parents in crisis, military families, alternate parents (eg. foster parents, grandparents, other relatives acting as parents), parents of multiples and families within certain geographic areas as priority populations. A generic group, "parents of high risk children" was also identified. Additional priority populations were defined by the age group of the children.

The Ontario Public Health Standards defines priority populations as 'those populations that are at risk and for which public health interventions may be reasonably considered to have a substantial impact at the population level'.^{3 (p 16)} For purposes of analysis, priority populations defined by either respondents to the survey or a priori by KFL&A Public Health were considered to be priority populations. "Children with emotional difficulties" are combined with "children with special needs", as this group was heterogeneous with respect to diagnosis. Age groups, although target groups for particular programs, were not considered to be priority populations in analysis both because age does not confer risk in and of itself, and because subsequent analyses were done by age. It is noteworthy that the geographic areas defined as "target" or catchment areas are so considered because they are areas of social and material deprivation. In some analyses, therefore, they are combined with "low-income" groups.

The final analysis used all priority populations identified by either the responding agencies or by KFL&A Public Health, with the exception of pre-defined age groups. The result was twenty-one priority groups. These groups are listed in each of Tables 7a through 7e, along with "universal" programs which are included at the end of the tables. Although universal programs do not target a priority group, they were included in the table because they are accessible to everyone, and therefore to any priority population.

The Invest in Kids Canadian survey gauged parental knowledge of child development, parent confidence, and use of positive parenting vs. negative parenting. The results found that all parents were in need of positive parenting support - regardless of income or education level. For this reason, universal programs and messages that target every parent are very important. This finding was supported by a literature review completed in the first phase of research:

'The simple fact that the vast majority of parents and children who will need special support are not found in high-risk groups - and are not identifiable in advance by traditional socio-demographic criteria - is a powerful argument to shift some of our resources and efforts to broader approaches.'^{16 (p 28)}

In 2010, Michael Marmot introduced the idea of proportionate universalism in his review entitled "Fair Society, Healthy Lives". This concept encourages the provision of programs and services that target those most at risk, while also offering universal messages and programs to capture all parents, regardless of risk status:

'Focusing solely on the most disadvantaged will not reduce health inequalities sufficiently. To reduce the steepness of the social gradient in health, actions must be universal, but with a scale and intensity that is proportionate to the level of disadvantage. We call this proportionate universalism.'1^{6 (p 15)}

Tables 7a to 7e represent positive parenting activities by the age groups and priority populations they target, according to population health approach. Again, activities are identified by number; the key to activities and agencies is provided in Appendices G and F.

Where agencies used policy and community action to achieve positive parenting messaging, most were targeting all children and parents. Very few policies and very little community action are directed to priority populations.

Again, many parenting information campaigns target a universal audience. Some are directed to families of children with special needs or in defined geographic areas.

Although many activities directed to providing supportive environments target all parents and children, there are agencies working towards providing supportive environments for almost all target groups, and particularly for families of children with special needs, high risk children, and military families. Certain geographic areas, such as the area in the northern section of Kingston, also provide supportive environments for positive parenting.

Parent skills training is provided almost universally to the identified target groups. Agencies did not identify parent skills training specifically for children experiencing bereavement, parents in rural areas, parents who are new to Canada or fathers, although universal programs would be open to these families. It is possible that there are gaps in rural areas for activities which incorporate parent skills training.

Agencies identified that they provided interventions with individuals and families to almost all target groups, with the exception of parents in rural areas, parents who are new to Canada, first-time or single parents, alternate parents or fathers. However, it is assumed that universal programs would be available to these groups. It is possible that, in rural areas, interventions with individuals and families are lacking.

In summary, all priority populations are targeted by at least one of the agencies, most by activities using multiple population health strategies.

Objective 3: Are positive parenting activities located where those who need them are?

Vulnerable children identified by EDI scores

Figures 6 and 7 show the location of positive parenting activities in relation to quintiles of the Early Developmental Index (EDI) as a measure of distribution of vulnerability of children. Figure 7 is identical to Figure 6, but shows in more detail the activities clustered in the southern part of the counties. There appear to be programs in all areas, and particularly in areas of greater social deprivation.

Low-income families

Figure 8 is a map of the locations of positive parenting activities for low-income priority populations in Kingston and surrounding area. Again, the majority of these are in areas of greater social deprivation. The map shows only the southern part of the counties because no activities targeting low-income populations specifically were indentified in the northern areas. In these areas, universal activities (as shown in Figure 6) are available to all parents.