J.27 Impact Evaluation Family Counseling PM.pdf

August 2019

An Evaluation of Proponte Más:

A Honduran Secondary Prevention Program Technical Report

AN EVALUATION OF PROPONTE MÁS:

A HONDURAN SECONDARY PREVENTION PROGRAM

TECHNICAL REPORT

USAID PROJECT:

Award No. AID 522-TO-16-00001

AUTHORS:

Charles M. Katz, PhD

Hyunjung Cheon, M.S.

Scott H. Decker, PhD

CENTER FOR

VIOLENCE

PREVENTION AND

COMMUNITY

SAFETY

ARIZONA STATE UNIVERSITY

Phoenix, Arizona, USA

August 2019

ACKNOWLEDGEMENTS:

This document was made possible through the generous support of the people of the United States of America through the United States Agency for International Development under Award No. AID 522-TO-16-00001. The contents of this document are the sole responsibility of the authors and do not necessarily reflect the views of the United States Government, Proponte Más or ASU. The authors would like to thank Robyn Braverman and Guillermo Céspedes for their leadership and support throughout the project and Axel Rivera for all of his assistance on matters related to data collection and interpretation. We would also like to thank Eric Hedberg for his methodological and statistical advice and Cher Stuewe-Portnoff for her copy editing of the manuscript.

UNA EVALUACIÓN DE PROPONTE MÁS:

UN PROGRAMA HONDUREÑO DE PREVENCIÓN SECUNDARIA 1

CONTENTS

INTRODUCTION

RISK FACTOR APPROACHES TO UNDERSTANDING PROBLEM BEHAVIOR

THE USE OF FAMILY-BASED INTERVENTIONS TO RESPOND TO PROBLEM

BEHAVIOR

THE NEED FOR EVIDENCE-BASED PROGRAMMING IN CENTRAL AMERICA

AND THE CARIBBEAN

THE PRESENT STUDY

THE SETTING

ORIGINS OF PROPONTE MÁS

PROGRAMMATIC APPROACH

TECHNICAL DESIGN

THE IMC DIAGNOSTIC TOOL

DATA AND METHODS

DATA

MEASURES

PROCESS MEASURES

OUTCOME MEASURES

INDEPENDENT VARIABLE

CONTROL VARIABLES

ANALYSIS

POWER ANALYSIS

ANALYSIS PLAN

PROCESS EVALUATION RESULTS

REFERRAL

ELIGIBILITY

RETENTION

DOSAGE

IMPACT EVALUATION RESULTS

PART 1: CHANGE IN RISK STATUS

CHANGE IN PROGRAM ELIGIBILITY

CHANGE IN DIAGNOSTIC SCALE SCORES

PART 2: DIRECT EFFECTS

OUTCOMES FOR CHANGE IN FAMILY ADAPTABILITY AND COHESION

OUTCOMES FOR CHANGES IN REVISED IMC RISK AND PROTECTIVE

FACTOR SCORES

OUTCOMES FOR CHANGES IN DELINQUENCY

INFORME TÉCNICO2

PART 3: INDIRECT EFFECTS

CHANGE IN OVERALL RISK FACTOR SCORE AS A FUNCTION OF

CHANGE IN FAMILY ADAPTABILITY AND COHESION

CHANGE IN DELINQUENCY AS A FUNCTION OF CHANGE IN RISK AND

PROTECTIVE FACTORS

PART 4: SPLIT-SAMPLE ANALYSES

BY SEX: FEMALE VS. MALE

BY AGE: 12 YEARS OLD AND YOUNGER VS. 13 YEARS OLD AND OLDER

BY GANG MEMBERSHIP: NON-GANG VS. GANG

CONCLUSIONS

REFERENCES

APPENDIX A

APPENDIX B: KEY TERMS

UN PROGRAMA HONDUREÑO DE PREVENCIÓN SECUNDARIA 3

INTRODUCTION

The use of risk factors coincides closely with the application of public health models to the understanding of a wide variety of forms of behavior.

This has become a versatile conceptual platform, in no small part due to its direct applicability to policy and program questions and the emergence of what is known as “prevention science.” The versatility of risk factor approaches can be demonstrated in a number of ways. First, the range of behaviors that such a methodology has been applied to is robust. Diseases such as heart attacks, strokes, diabetes and hypertension can be understood and responded to with risk factor approaches. In addition to health-related issues, concerns about achievement, whether in school, employment sectors or relationships, can be understood with the application of risk factors. Of particular value for the current evaluation, a risk factor approach can be applied to the understanding of behaviors with deleterious consequences–for instance, drug and alcohol abuse, risky sexual behaviors, and involvement in violence, crime and delinquency.

Indeed, risk factor approaches to involvement in crime and delinquency have proliferated across the past three decades, and they now are a major theoretical and policy orientation in the understanding of violence, gangs, property crime and other forms of illegal and antisocial behaviors (Maguire, Wells, and Katz, 2011).

In addition to the vitality of the risk factor approach, as evidenced by its widespread substantive focus, the use of this model is not linked with a specific country or continent.

Examples of research, policy or practice involving risk factors can be found in North America (the United States and Canada), Europe and the United Kingdom (England and Scotland, Belgium, Cyprus, Germany, Netherlands, Norway), Australia, and Central and South America (Brazil, Honduras, El Salvador, Colombia). Within the US, risk factor approaches have been used in tribal groups, at the city, county and state levels, within detention and penal institutions, and in programs that serve girls, children of incarcerated parents, and pregnant teens. The Center for Disease Control and Department of Justice (Ritter, Simon, and Mahendra, 2014), as well as the Substance Abuse and Mental

Health Services Administration have applied the risk factor model to the multiple complex issues they each deal with. The approach is meant to articulate well with current best practices in re-entry and prevention and intervention, and it is used consistently with “risk/needs/responsivity” approaches to dealing with delinquents, offenders, and inmates returning from prison.

The current evaluation has been undertaken to assess the impact of Proponte Más’ family based intervention on youth and families (i.e., Result 1), a promising intervention designed to deal with crime and delinquency by addressing prominent risk factors for problem behavior.

Proponte Más was in part developed based on and inspired by the Los Angeles’ Gang Reduction Youth Development model (GRYD), an evidence-based risk reduction program. The comprehensive nature of GRYD made it a particularly strong candidate for replication in part or whole. Note that this sort of programming is not common in Latin American settings; to our knowledge, ours is the first assessment of the impact of an intervention program focused on risk factor reduction in Central America.

In fact, although many policymakers and researchers have emphasized the scope and magnitude of the violence problem in Central America, little research has been conducted on what may effectively address the problem in the region. Several recent reports have reviewed the literature on the state of research and evaluation pertaining to violence and the response to violence in Central America, but these reports have essentially just shed light on how very few high-quality evaluations of violence reduction programs exist (Abt and Winship, 2016; Jaitman and Guerrero Compeán, 2015). Recent literature reviews on risk factor based programs reported that there have been no systematic reviews or meta-analyses of evaluations of violence reduction programs in the region; they concluded that this is the result of very little experimental or high quality quasi-experimental research on violence reduction having been conducted in Central America (Abt and Winship, 2016). Collectively, INFORME TÉCNICO4 these reports (Abt and Winship, 2016; Jaitman and Guerrero Compeán, 2015; Santiso et al., 2017; Muggah and Aguirre, 2013) identify only two experimental studies on violence reduction: one on the effectiveness of police patrol on reducing violence in Colombia (García, Mejía, and Ortega, 2013) and the other on the effectiveness of electronic monitoring on recidivism in Argentina (Di Tella and Schargrodsky, 2013).

In the sections below, we present our foundation for the current evaluation as well as our results. We begin by reviewing risk factor approaches to understanding youth problem behaviors, including crime and delinquency, and family-based intervention programs previously used in Central America. Next, we describe our understanding of the context in which the Proponte Más program was implemented, including the particular municipalities where it was introduced.

We then present our evaluation methodology with its rigorous study design, a randomized control trial (RCT).1 We conclude with a discussion of evaluation results and their implications.

RISK FACTOR APPROACHES TO

UNDERSTANDING PROBLEM BEHAVIOR

The risk factor approach is applicable to a number of different domains. This versatility is one reason for its widespread use in dealing with crime and delinquency–it is grounded in the focus of research and programmatic attention on some selected combination of individuals, families, peers, schools and neighborhoods. Considerable research attention is being given to the development and use of sophisticated measures of risk and protective factors, applying solid psychometric measurement methods. This includes careful examinations of the construct and predictive validity of measures of risk factors in low- and middle-income countries

1 An RCT is regarded as the gold standard in evaluation design. Despite this, it is seldom used owing to the difficulty of implementation and the reluctance of program administrators to deny treatment to individuals who, it is believed, would benefit from such programming. One recent study indicated that the majority of the public favors the universal implementation of non-researched, non-tested policies and does not approve of randomized experiments.

For example, about 50% of respondents reported that randomization is inappropriate or that it is unethical to randomize treatment assignment to determine what works (Meyer et al., 2019).

(Murray et al., 2018). Although a disproportionate number of the studies being examined are from China, oriented towards public health and the use of medical diagnostics, researchers are finding considerable overlap in the measurement qualities of the scales associated with risk and protective factors in diverse countries. (Notable exceptions are measures of early physical health on delinquency.) Similarly, Hawkins, Catalano, and Miller (1992) have identified a number of studies in international contexts that used a risk and protective factor approach for identifying not only risk, but also its amelioration.

Among the strengths of the risk factor approach is that it identifies protective factors in addition to factors that may promote harm. This balanced approach provides opportunities for interventions that build on strengths of individuals, families, institutions and communities that can promote success. Such a balanced approach helps to avoid the stigma often attendant to working in poor or disadvantaged communities. It creates a greater sense of hope for individuals and communities, as well as for service providers. In addition, working to enhance community strengths and resilience reduces the magnitude of the challenges faced by individuals who live and work in these communities.

Considerable progress has been made in the study of these factors in the United States, Canada and Europe. Several recent meta-analyses of more than 50 studies concluded that the relationship between risk factors and involvement in delinquency was invariant across the collection of studies (Assink et al., 2015; Jolliffe et al., 2017).

That is, there was a strong positive association between the number of risk factors associated with youth and their involvement in delinquency.

Although variations in the types of risk factors placing a youth at risk are substantial, academics and practitioners are generally in consensus that risk factors for delinquency and crime are consistently associated with at least five domains:

neighborhood, school, family, peer and individual.2 Individual factors such as gender and age have a

2 Each domain is independent, but the risk factors associated with each are not mutually exclusive.

UN PROGRAMA HONDUREÑO DE PREVENCIÓN SECUNDARIA 5

strong influence on delinquency, while important family risk factors include poor family management practices and history of parental criminal behavior.

Peer risk factors include having delinquent peer associations and membership in a gang. School risk factors associated with delinquency include poor academic performance and poor school attendance, among others. Neighborhood risk factors such as neighborhood disadvantage and neighborhood levels of crime are also associated with delinquency.

The past three decades of research on delinquency prevention and intervention have been plagued by the failure to address primary and secondary needs of youth and to implement successful programming. This points to a mismatch between the needs of youth served and the services that many programs have delivered. This is likely due to a fundamental failure to understand the needs of at-risk youth, including those already involved in delinquency or crime. The reasons for this are widely debated; often, the impulse simply to “do something” and reliance on outdated intervention models are cited as primary causes.

Regardless, this situation calls for a data-driven and data-led approach to programming, characterized by careful assessment across multiple domains of behavior, including both risks and resiliency or protective factors. Such assessments would more accurately characterize both the challenges that youth face and the strengths they bring to the task of transitioning from adolescence to adulthood.

The key is to institute data-driven methods for identifying a youth’s problems (e.g., deviance, delinquency, school achievement, substance abuse) and individual and family strengths, and then tailoring interventions responsive to those specific conditions. Data for problem identification can come from any number of sources, such as secondary records from schools, neighborhood groups, family members and, most importantly, the youth themselves. This type of information can provide a solid foundation for building effective interventions. This risk factor approach to date has been most closely aligned with efforts in the United States. It remains to be determined whether and how well such an approach (adapted to regional culture and structures) might translate to low- and middle-income nations

THE USE OF FAMILY-BASED

INTERVENTIONS TO RESPOND TO

PROBLEM BEHAVIOR

The family has become a key point of entry and intervention for responding to youth violence and other problem behaviors. Prior research has documented that parents and their children bidirectionally influence family culture, management, communication and structure. On one hand, poor parenting skills are associated with negative child outcomes, such as alcohol and drug use, delinquency, school problems, and other high-risk behaviors (Weisman and Montgomery, 2019;

Knerr, Gardner, and Cluver, 2013). On the other hand, child aggression is associated with hostility and conflict between parents or parents and children within the home, which increases harsh and negative parenting and promotes a reciprocal cycle of aggression and hostility (Knerr, Gardner, and Cluver, 2013). The family is seen as the primary means of child socialization and, as such, it can serve as either a risk or protective factor in youth development (Simons et al., 1998). It is generally accepted that dysfunctional families model and provide opportunities for problem behavior, while functional families model and provide opportunities for positive and prosocial behavior (Development Services Group, 2014). Therefore, family-based interventions in general have become a common strategy for preventing and intervening in youth problem behavior, but are rare in Honduras.

Today, a wide variety of family-based intervention programs are available. Most focus on identifying and building upon family strengths to address youth misbehavior, developing coping skills and strategies, providing skills-building training for parents and children, identifying patterns of family interaction and setting goals for improving these, and motivating children and parents to reframe problems and act with positive enthusiasm (Development Services Group, 2014). Several family-based interventions have been evaluated in developed nations and were found to have positive impacts when addressing issues such as violence (Maalouf and Campello, 2014), gangs (Thornberry et al., 2018), drug use (Hartnett et al., 2017), and teen suicide and depression (Diamond et al., 2010). The body of literature is deep enough that multiple systematic literature reviews and meta-

INFORME TÉCNICO6

analyses have been completed, substantiating the positive effects of family-based intervention on youth outcomes such as delinquency (Farrington and Welsh, 2003).

Family-based intervention programs are increasingly implemented in developing nations to address systemic social and health problems (Maalouf and Campello, 2014). This has, in part, been a consequence of their successful implementation with high-risk participants and effectiveness in achieving desired outcomes elsewhere (Knerr, Gardner, and Cluver, 2013). The programs have rarely been evaluated in developing nations in general or in Central American nations, specifically. The United Nations Office on Drugs and Crime conducted one of the few examinations of family-based intervention in low- and middle-income countries, examining SFP and Families and Schools Together (FAST) programs and their impact on violence in nine low and middle-income nations, including Honduras.

No control group was used; however, pre/post-test data suggested both programs were effective for reducing violence, demonstrating strong potential for use in low and middle income nations. The evaluations were necessarily limited by the lack of a control group and a small convenience-based sample (n=188 across nine nations). Regardless, the authors concluded that family-based interventions were a promising strategy for developing nations.

They recommended conducted a RCT as the next essential step for determining the programs’ likely effectiveness in low- to middle-income nations (Maalouf and Campello, 2014).

THE NEED FOR EVIDENCE-BASED

PROGRAMMING IN CENTRAL AMERICA

AND THE CARIBBEAN

Over the last two decades, violence has grown in a number of countries in Central America, including El Salvador, Guatemala, Honduras. Some of this violence is associated with proximate causes, but much of it has deeper roots and is imbedded in distal causes associated with inequality, economic distress, culture, and institutional weaknesses (Rodgers and Baird, 2014).

When combined with the relative instability of several nations in the Central American region, it is clear from the review above that there are many risk factors and not enough protective factors. This strongly underscores the need for evidence-based prevention and intervention throughout the area.

Honduras is an especially important site for such efforts given its geographic and economic position in the region, and its historically high levels of violence. Violence serves to disrupt the socializing power of parents, neighborhoods, schools, and institutions such as the labor market and family.

Violence reduces labour market opportunities of those living in violent neighbourhoods because it limits resident’s access to jobs and limits the capacity of neighbourhoods to support and generate local business. Community violence also erodes family functioning through its negative effect on family communication and family conflict.

It also increases family fear of victimization, results in increased familial isolation, and reduces the financial resources available to the family. Youth exposed to violence are also less connected school, which results in poorer school performance and increased likelihood of dropping out of school.

Individuals living in high violence communities also experience reduced trust and cooperation with social institutions and the limited resources that are available are expended on the police, courts, and corrections rather than human development and support (Moser and van Bronkhort, 1999;

Vincent, 2019). An intervention that balances risk and protective factors, and built upon a solid understanding of them, could be an important stabilizing influence in the lives of Honduran youth.

Unfortunately, little research has been conducted in Central America where delinquency and violence are high; of the research that has been conducted, results have been inconsistent.

Along with the lack of analysis on the causes and correlates of problem behavior in Central America, there is a dearth of knowledge about what works in response to the risks faced by youth in these nations (Abt and Winship, 2016; Jaitman and Guerrero Compean, 2015). The lack of evidence-based programming (i.e., prevention, intervention, and suppression) in Central America stems from multiple sources. First, Central America generally lacks the strong criminological foundations needed for understanding its patterns of criminal justice and delinquency. Second, the history of programming

UN PROGRAMA HONDUREÑO DE PREVENCIÓN SECUNDARIA 7

in the region is quite checkered, as the typical response to most problems of crime and disorder has been based in suppression. That is, crackdowns by police (and occasionally the military) that include round-ups, extensive use of incarceration, and surveillance have been the predominant crime control efforts in the face of growing crime and violence. A focus on intervention and prevention has emerged in the past twenty years (Alvarado, Muggah, and Aguirre, 2015), but there is still a lack of balance between suppression-based and prevention/intervention-based efforts.

Third, much of the intervention/ prevention effort has its locus outside the region.

Often such efforts are led by groups that provide development funding, such as USAID, UNDP, OAS and the World Bank (Muggah and Aguirre, 2013).

In fact, external agencies provide about 70% of the funding for citizen security in the region. In those few instances where organizations with sophisticated research designs have conducted data-driven, intervention/prevention-focused programming, few if any were required to assess their programs’ effectiveness. Of more than 1,350 violence reduction programs sponsored by international development agencies since the late 1990s, more than 57% were not evaluated at all, repeatedly missing out on the chance to identify best practices in violence reduction. (See Alvarado et al., 2015). Large international development organizations often do not require implementers to participate in evaluations to determine what works. As such, the present study represents an opportunity to assess the results of a data-driven, locally focused intervention program with a rigorous research design.

THE PRESENT STUDY

This report contains the evaluation results of the implementation of Result 1 of Proponte Más, a secondary prevention program sponsored by USAID in Honduras. The report contains five sections. The first section discusses the program’s setting, origins and family-based model. The next section describes the research design, including sampling and recruitment, data, measures and analysis. The third and fourth sections present the results of our process and impact evaluations, and the last section discusses the implications of those results.

THE SETTING

Over the past several years, Honduras has experienced some of the highest rates of homicide in the world. In 2011, that rate was 86.5 homicides per 100,000 population. The homicide problem has begun to subside substantially, but as recently as 2017, the nation still ranked as one of the most violent in the world with 43.6 homicides per 100,000 population (https://iudpas.unah.edu.

hn/observatorio-de-la-violencia/boletines-del-observatorio-2/boletines-nacionales/cite).

In 2014, USAID completed the Honduras Country Development Cooperation Strategy, calling for resources to target the densely populated urban communities at greatest risk for violence. In Honduras, these included 14 intervention zones comprising 216 communities located in the two largest municipalities: Tegucigalpa, the nation’s capital and largest city, and San Pedro Sula, the Honduran industrial center and second largest city. It also included three other municipalities:

Choloma, La Ceiba and Tela. As shown in exhibit 1, each of the five municipalities has had a homicide rate above the national average since 2015.

INFORME TÉCNICO8

ORIGINS OF PROPONTE MÁS

Proponte Más is an evidence-informed secondary prevention program. Its roots are found in several of the most prominent responses to delinquency and other problem behaviors. The Comprehensive Strategy developed by the Office of Juvenile Justice and Delinquency Prevention (OJJDP) influenced the development of the precursor to Proponte Más. The Gang Reduction and Youth Development (GRYD) response to gangs in Los Angeles, founded on principles established in the OJJDP comprehensive model, was a milestone in the development of risk reduction programs.

GRYD took the Comprehensive Strategy to a new level, integrating youth development as a key component in the response to gangs (Kraus et al., 2017). By doing so, GRYD promoted the development of prosocial opportunities and skills as an integral part of a successful response to gangs and delinquency. Proponte Más leveraged the Los Angeles experience with GRYD by incorporating youth development and family strengthening as central elements of its response to at-risk youth in Honduras.

In 2012, the City of Los Angeles and USAID signed an agreement that led to their sharing violence prevention and intervention best practices; and in in 2013, a pilot test in Honduras was carried out to demonstrate proof of concept. (known as Proponte). Subsequently USAID awarded funding in December 2015, and Proponte Más was operational by January 2016.

Shortly thereafter, regional offices opened, staff received training, and potential participants were referred to the program. YSET-I assessments were completed in September 2016 with the first cohort of participants.

A post-hoc evaluation of the first cohort of Proponte Más program participant data showed that the program for secondary group participants was implemented with a high degree of fidelity but fell short of full implementation with tertiary program participants. Findings of the impact evaluation, which relied on regression discontinuity, suggested that the program had a modest but significant effect on reducing risk factors and delinquency (Katz et al., 2017).

Based on lessons learned during the first cohort, program plans for the second cohort were refined, and Proponte Más staff worked with the evaluation team to develop and implement a more rigorous evaluation process applying the principles of a randomized control design. Referrals for second cohort program participation began in August 2017, risk factor assessments were completed by February 2018, and program implementation took place between March and September 2018. IMC-R assessments were completed in September 2018.

The results of the evaluation of the second round of program implementation (second cohort) are provided in this report. In the next section, we discuss the program’s approach, technical design and activities.

YSET/IMC Instrument Glossary YSET-I/IMC-I. The first YSET/IMC taken by youth following referral. Used to determine program eligibility, and used by the evaluation team as the pretest.

YSET-R/IMC-R. The second YSET/IMC taken by youth. Administered 6 months following program implementation. Used by the evaluation team as the post-test.

Exhibit 1: Homicide rates per 100,000 inhabitants by year and municipality

Municipality 2013 2014 2015 2016 2017

La Ceiba 140.7 95.6 157.25 120.83 181.5

Tela 94.7 74.2 93.47 48.7 100.3

San Pedro Sula 193.4 143.8 173.6 107.02 166.4

Choloma 68.7 61.5 78.3 92.7 94.5

Distrito Central 86.0 81.1 88.2 82.3 99.9

Nationwide 73.64 67.17 59.44 59.1 43.6

Source: https://app-iudpas.unah.edu.hn/participacionciudadana/Denuncias/mapa_oficial

UN PROGRAMA HONDUREÑO DE PREVENCIÓN SECUNDARIA 9

PROGRAMMATIC APPROACH

The primary goal of Proponte Más is to reduce the risk factors for problem behavior associated with youth ages 8 to 17 in Honduras.

Proponte Más’ approach to attain this goal is structured around the achievement of five results:

Result 1. Increased the number of youth and families receiving secondary prevention services, Result 2.

Increased the number of eligible youth and families accessing additional support services in targeted locations, Result 3. Cadre of family counselors established in targeted communities, Result 4.

Alternative justice measures strengthened, and Result 5. Community-based secondary prevention model established.

The program’s approach is closely linked to the IMC beta diagnostic instrument, which was used (formerly known as the YSET) to identify youth who, with their families, were eligible to receive violence prevention services in targeted areas. The IMC beta relied on nine risk factor scales, described below. Family counselors, certified in the administration of the IMC beta and family interventions, were assigned to the youth and their families. The Proponte Más model posits that it is necessary to work with the entire family, to provide individual and group interventions and to link members to community services, for the purpose of reducing risk factors and increasing protective factors for the youth and their families.

Family-based intervention, based on a theory of change, attempts to modify relational sequences, family dynamics and family cohesion, using behaviors as a lever to create cooperation and change.

TECHNICAL DESIGN

The Proponte Más technical design provides youth and their families with six months of family-based interventions, divided into seven phases (see exhibit 2). Youth and their families are guided through each phase by the assigned family counselor, who emphasizes achievement of specific goals determined by the participants’ IMC beta assessment and family context. Each phase takes about 30 days to complete.

Phase 1: Referral and Collaboration:

includes the behavioral description of the problem identified by the referral source, if there is one;

the behavioral description of the caretaking signing the informed consent; the information generated by the IMC beta diagnostic and; the information generated by the FACES diagnostic. to identify the youth’s risk factors. Youth who are possess 0 to 3 risk factors are assigned to a primary (no- or low-risk) group, while those with 4 to 9 risk factors are assigned to a secondary (moderate or high-risk) group

Phase 2 Building Agreements: includes an agreement with the family that identifies behaviors that the family and the counselor will work on.

Phase 3: Redefining: incudes shifting the emphasis of the intervention from one that requires an individual problem formulation and solution to one that includes the horizontal and vertical family.

Phase 4: Celebrating Changes: includes, a celebration of efforts that ideally bring together as many members of the horizontal and vertical family as possible;

Phase 5 Integrating: Includes incorporation of emotional resources and program resources that the leadership identifies.

Phase 6: Next Level Agreements: Includes meeting with the leadership of the family and establishing a set of rules that will guide the process of supervision in the family.

Phase 7: Re Evaluation: Includes a re evaluation of the index youth using the IMC, and an evaluation of the family using FACES. At this time treatment ends.

INFORME TÉCNICO10

As an intervention based on family systems theory and practice, the program’s strong theory of change identifies the family as the key change agent for moderating risk factors. Cespedes and Herz (2011: 9) state that the theory of change is predicated on the prior work of Bowen (1993), Kerr and Bowen (1988), Fisch, Weakland, and Segal (1982), Minuchin and Fishman (1981), and Walsh (2003, 2006, 2009), all of whom…

…encourage[d] multigenerational family “connectedness;” reinforcing parental/ caretaker authority; using of positive and effective problem-solving skills at the individual, family, and community levels; and helping youth self-differentiate from the gang culture through alternative, positive activities and positive connections to positive, supportive family members and/or other adults…

Therefore, stronger interventions are those in which family members engage in changing the behaviors and risk factors of youth. The goal is to shift the way the family functions such that it reduces embeddedness with delinquent peers and addresses other risk factors. Because the family is viewed as the “medicine” or crucible of change, it is crucial that Proponte Más counselors accurately assess family strengths and weaknesses as they lay out a treatment plan. This points to the critical role of the IMC. At the heart of the intervention is the goal of creating long-term, vertical, perhaps even multi-generational family cohesion.

THE IMC DIAGNOSTIC TOOL

The IMC emerged from the Gang Risk of Entry Factors (GREF) and Youth Services Eligibility (YSET) assessment tools, which were originally developed by Karen Hennigan and her colleagues in Los Angeles. The GREF was first used in the GRYD (the secondary gang prevention program that addresses high-risk youth in Los Angeles.)

The assessment goal was to identify youth at high risk for gang joining. A systematic review of the gang literature was performed to identify “a subset of factors that have consistently been empirically related to gang affiliation…favoring evidence from studies with rigorous research designs” (Hennigan et al., 2014: 109). The risk assessment tool’s architects relied on two systematic literature reviews to identify pertinent risk factors for gang joining. The first was Klein and Maxson’s (2006) review of gang research from the United States, Exhibit 2: Phases of Family- Centered Interventions

APPLICATION OF IMC

D

IA

G N

O

ST

IC

IN

T

ER

V

EN

T

IO

N ST

R

AT

EG

IE

S D

O

SA

G E

Establishing Agreements (month 1 of service)

Redefining (Service month 2)

Celebrating Changes (Service month 3)

Integrating (Month 4 of service)

Next Level Agreements (Month 5 of service)

Re - Evaluating (Month of service)

NOT ELEGIBLE ELEGIBLE

Referral & Collaboration

INTERVENTIONTRANSFER

OTHER PROGRAMS

HORIZONTAL STRATEGY:

Problem Salving Strategies

VERTICAL STRATEGY:

Multi Generational-Strenghs Based Genograms

Meeting of Strategic Team (1 for Phase)

Family Meetings (2 for Phase)

Individual Meetings (1 for Phase)

All interventions are conducted through a family systems theory and practice lens.

IDENTIFICATION OF

POTENTIAL PARTICIPANTS

APPLICATION OF IMC

ABILITY TOOL, FOR ADOLESCENTS AND YOUTH

PHASE 1

PHASE 2

PHASE 3

PHASE 4

PHASE 5

PHASE 6

PHASE 7

UN PROGRAMA HONDUREÑO DE PREVENCIÓN SECUNDARIA 11

Canada and Europe; the second was Krohn and Thornberry’s (2008) review of longitudinal gang research in about a half a dozen American cities, Montreal, Canada, and Bergen, Norway.

The literature reviews suggested seven risk factors for gang association: (1) cumulative exposure to stressful life events, (2) problem behavior associated with impulsivity, risk taking, and oppositional, aggressive or externalizing behavior, (3) delinquent beliefs, (4) weak parental supervision, (5) negative peer influence, (6) peer involvement in delinquency, and (7) early involvement in delinquency. Hennigan et al. (2014:

110) emphasized that no single risk factor predicted gang joining; rather, it was the accumulation of multiple risk factors that was associated with gang joining.

Based on these findings, the research team created scales that included items that had previously been used in the United States, Canada, and Europe to operationalize these same constructs (see Klein and Maxson, 2006; Krohn and Thornberry, 2008). The instrument was initially pilot tested with youth in Los Angeles to assess each item’s readability. Adaptions were made to improve the respondent’s comprehension of each item (Hennigan et al., 2014). Hennigan et al. (2015) later tested the validity of the YSET using a high-risk sample of 11- to 16-year-olds, again in Los Angeles.

The analysis indicated that all males identified as high risk (i.e., possessing four or more risk factors) using the YSET had also self-reported being a gang member. Likewise, 81 percent of male former gang members and 74 percent of males who associated with a gang were identified as being at high risk.

(The YSET was also found to be a valuable tool to assess relative levels of risk among females, although the relationship was not as strong, due in part to the relatively small number of female gang members in the sample.). Following the first cohort of program implementation in Honduras, the YSET was revised to include additional items, discussed further below, and was renamed the IMC. IMC stands for Instrumento de Medicion de Comportamientos or in English, Behavior Measurement Instrument.

Proponte Más used the IMC to identify at-risk youth and their families, who would receive prevention services in the targeted communities.

Family counselors, YSET certified, administered the risk assessment tool (assuring that youth were assessed by counselors other than the one who would later be assigned to their family). The YSET relied on nine risk factor scales related to those identified earlier by Hennigan et al. (2014). The scales include antisocial tendencies (7 items), weak parental supervision (5 items), critical life events (7 items), impulsive risk taking (4 items), neutralization of guilt (6 items), negative peer influence (3 items), peer delinquency (5 items), influence of gangs in the family (2 items), and crime and substance use (16 items). Each risk factor scale was constructed using Proponte Más’s scale development protocol (Hennigan, 2017). Items included in each scale, response categories and descriptive statistics are presented below (exhibit 3).

The core premise of the Proponte Más’ secondary prevention through the Prevention and Intervention Family Systems Model is that youth and their families will be selected for program participation based on level of risk, as identified with the IMC. Youth (and their families) are assigned to one of two levels: the primary risk group includes those with 0 to 3 risk factors, and the secondary risk group includes those with 4 to 9 risk factors.

INFORME TÉCNICO12

Exhibit 3: Scales and items distribution (n=4495)

Factors and Items # of items Range Mean SD Response Categories

Antisocial Tendencies 7 I am kind to others 1-5 2.03 1.21 1=always…5=never

I respect the feelings of others 1-5 1.84 1.20 1=always…5=never

I get angry easily 1-5 3.39 1.49 1=never…5=always

I am obedient 1-5 2.67 1.32 1=always…5=never

I threaten others to get what I want 1-5 1.39 0.94 1=never…5=always

People “blame me” for lying or cheating 1-5 2.53 1.52 1=never…5=always

I take things that don’t belong to me 1-5 1.30 0.77 1=never…5=always

Weak Parental Supervision 5 When I go out, I let my parents or guardians know where I am going 1-5 1.91 1.36 1=always…5=never

My parents or guardians ask me where I am going when I leave the house 1-5 1.46 1.03 1=always…5=never

My parents or guardians know who I am with when I’m not at home or school 1-5 1.93 1.39 1=always…5=never

My parents or guardians know who my friends are 1-5 1.84 1.30 1=always…5=never

I feel that my parents or guardians care about what I do 1-5 1.61 1.18 1=always…5=never

Critical Life Events 9

In the last year, have you...

…failed a grade in school? 0-1 0.19 0.39 0=no, 1=yes

…been expelled or suspended from your school due to disciplinary reasons? 0-1 0.09 0.28 0=no, 1=yes

…had a girlfriend/boyfriend for the first time this year? 0-1 0.35 0.48 0=no, 1=yes

…broken up with/ended a relationship with a boyfriend/ girlfriend or been broken up with by a boyfriend/ girlfriend?

0-1 0.30 0.46 0=no, 1=yes

…fought or had a problem with a friend? 0-1 0.53 0.50 0=no, 1=yes

…tried “hanging out” with a new friend group? 0-1 0.64 0.48 0=no, 1=yes

…felt forced to abandon school for any reason? 0-1 0.26 0.44 0=no, 1=yes

…has someone close to you died or been seriously hurt due to an accident or illness? 0-1 0.48 0.50 0=no, 1=yes

…has someone close to you died (or was murdered) due to violence? 0-1 0.26 0.44 0=no, 1=yes

Impulsive Risk Taking 4

Sometimes I like to do dangerous activities for fun 1-5 2.59 1.26 1=strongly disagree…5=strongly agree

Sometimes I find it exciting to do things that could get me in trouble 1-5 2.59 1.23

1=strongly disagree…5=strongly agree

I frequently do things without thinking if I’ll get in trouble or not 1-5 2.72 1.26

1=strongly disagree…5=strongly agree

I like to have fun when I can, even if I’ll get in trouble for doing them later on 1-5 2.96 1.30

1=strongly disagree…5=strongly agree

UN PROGRAMA HONDUREÑO DE PREVENCIÓN SECUNDARIA 13

Factors and Items # of items Range Mean SD Response Categories

Neutralization of Guilt 6

It is okay to lie if it keeps my friends from getting in trouble with their parents or with the police 1-5 2.55 1.16

1=strongly disagree…5=strongly agree

It is okay to lie to someone to keep myself from getting in trouble with them 1-5 2.50 1.14

1=strongly disagree…5=strongly agree

It is okay to steal something if someone is rich and can easily replace it 1-5 1.96 0.81

1=strongly disagree…5=strongly agree

It is okay to steal small items from a store without paying because stores have a lot of money and this does not affect them

1-5 1.91 0.80 1=strongly disagree…5=strongly agree

It is okay to hit others if others hit me first 1-5 3.03 1.31 1=strongly disagree…5=strongly agree

It is okay to hit people if it’s for my own defense 1-5 3.39 1.26 1=strongly disagree…5=strongly agree

Negative Peer Influence 3 If your friends were getting in trouble in your home, would you continue being their friend? 1-5 2.23 0.76 1=definitely no…

5=definitely yes

If your friends were getting in trouble at school, would you continue being their friend? 1-5 2.19 0.72 1=definitely no…

5=definitely yes

If your friends were getting in trouble with the police, would you continue being their friend? 1-5 1.95 0.55 1=definitely no…

5=definitely yes

Peer Delinquency a 5

During the last six months, how many friends have… …stolen something? 1-5 1.43 0.83 1=none…5=all

…attacked someone? 1-5 1.42 0.87 1=none…5=all

…sold marijuana or other illegal drugs? 1-5 1.09 0.43 1=none…5=all

…used illegal drugs? 1-5 1.21 0.67 1=none…5=all

…belong to or have joined a gang or “mara”? 1-5 1.09 0.47 1=none…5=all

Influence of Gangs in the Family 2 Including all of the people that you consider part of your family; how many family members think that you will most likely join a gang one day?

0-4 0.39 0.98 0=0, 1=1, 2=2, 3=3, 4= 4 or more

Currently, how many of your family members are in a gang? 0-4 0.32 0.82 0=0, 1=1, 2=2, 3=3, 4= 4 or more

INFORME TÉCNICO14

Factors and Items # of items Range Mean SD Response Categories

Crime and Substance Abuse 16

In the last six months… ...consumed alcohol or smoked cigarettes? 0-1 0.14 0.35 0=no, 1=yes

...used marijuana or other illegal drugs? 0-1 0.04 0.21 0=no, 1=yes

…skipped class? 0-1 0.17 0.38 0=no, 1=yes

…avoided paying for a movie, taxi or bus? 0-1 0.12 0.33 0=no, 1=yes

…broken or destroyed something on purpose that was not yours? 0-1 0.13 0.33 0=no, 1=yes

…carried a hidden weapon around for protection? 0-1 0.02 0.16 0=no, 1=yes

…illegally painted a wall or building – done “graffiti?” 0-1 0.08 0.28 0=no, 1=yes

…stolen something of low value? 0-1 0.13 0.33 0=no, 1=yes

…stolen something of high value? 0-1 0.01 0.11 0=no, 1=yes

…entered or tried to enter a building to try and steal something? 0-1 0.01 0.09 0=no, 1=yes

…hit someone with the intention of hurting them? 0-1 0.12 0.33 0=no, 1=yes

…attacked someone with a weapon? 0-1 0.01 0.10 0=no, 1=yes

…used a weapon or physical force to get money from someone else? 0-1 0.00

0.06 0=no, 1=yes

…participated in fights with youths from other neighborhoods? 0-1 0.08 0.27 0=no, 1=yes

…participated in gang fights? 0-1 0.01 0.11 0=no, 1=yes

…sold marijuana or other drugs/helped others sell drugs? 0-1 0.01 0.10 0=no, 1=yes a = responses for those reported that they do not have a group of friends were coded “none” for all the items in peer delinquency factor.

MEASUREMENT AND SCORING OF IMC FOR

PROGRAM ELIGIBILITY

Data collected through Proponte, the 2013 pilot test demonstrating the programs proof of concept, were used to determine the cut point for the respondents’ level of risk (United States Agency for International Development, 2016). The cut points for each scale, by age, are presented in exhibit 4. In the pilot study, cut points reflected each respondent’s relative level of risk compared with other respondents enrolled in the study (n=327). Respondents who scored from the 1st to the 25th percentile of a scale were labeled as OK.

Respondents scoring from the 26th to the 49th percentile were labeled as close. Those scoring from the 50th to the 70th percentile was assigned a 1; those from the 71st to the 89th percentile were assigned a 2; those from the 90th to the 99th percentile were assigned a 3, and those in the greater than 99th percentile were coded as 4.

Each scale then was recoded into a dichotomous variable. Those who were labeled OK or close were categorized as not at risk (0).

Those at or above the 50th percentile, coded as 1 or higher, were categorized as at risk. An additive scale was created that represented the respondents’ cumulative level of risk, ranging from 0 to 9. As noted above, respondents identified with the IMC as not at risk (0-3 risk factors) were placed in the primary group (i.e., referred to the program, but assessed as no- or low-risk, therefore ineligible to receive services). Primary group members’ individual demographic data were collected and included in selected analyses.

Respondents identified as having four or more risk factors were categorized as at risk, and as such were eligible for services; they were placed in the secondary group.

UN PROGRAMA HONDUREÑO DE PREVENCIÓN SECUNDARIA 15

Exhibit 4: Cut points by risk factor

Cut Point

Risk Factors Risk Level Age 12 and younger (n=2,317) Age 13 and older (n=2,178)

Antisocial Tendencies Not at risk 7 thru 16 7 thru 18

At risk 17 and over 19 and over

Weak Parental Supervision Not at risk 5 thru 11 5 thru 11

At risk 12 and over 12 and over

Critical Life Events Not at risk 0 thru 3 0 thru 4

At risk 4 and over 5 and over

Impulsive Risk Taking Not at risk 4 thru 12 4 thru 13

At risk 13 and over 14 and over

Neutralization of Guilt Not at risk 6 thru 16 6 thru 17

At risk 17 and over 18 and over

Negative Peer Influence Not at risk 3 thru 6 3 thru 6

At risk 7 and over 7 and over

Peer Delinquency Not at risk 5 thru 7 5 thru 7

At risk 8 and over 8 and over

Family Gang Influence Not at risk 0 thru 1 0 thru 1

At risk 2 and over 2 and over

Crime and Substance Abuse Not at risk 0 thru 2 0 thru 3

At risk 3 and over 4 and over

Note: The age selection process was determined at baseline (pretreatment period).

DATA AND METHODS

Youth who lived in the fourteen intervention zones located within five municipalities in Honduras were referred to the program and then assessed with the IMC, after which their eligibility for programming was determined by Proponte Más. Of 4,495 youth assessed, 944 were found though the IMC to be at risk for four or more risk factors, qualifying them to receive program services. Within each intervention zone, as previously noted, the 944 eligible youth were then randomly assigned to the treatment group or the control group. A total of 463 youth with their families were assigned to the treatment group;

481 were assigned to the control group. Of those assigned to treatment, 33 dropped out before the program started and another 58 dropped out during program participation, leaving a total of 372 (80.3%) for analysis. Of the 481youth assigned to the control group, 75 dropped out prior to the post-test, leaving 406 (84.4%) for analysis. (See exhibit 5.)

INFORME TÉCNICO16

Exhibit 5: CONSORT Flow Diagram

Randomized (n=944)

ENROLLMENT

ALLOCATION

FOLLOW-UP

ANALYSIS

Assessed for eligibility (n=4,495)

Allocated to treatment group (n=463) Received allocated intervention (n= 430) Did not receive allocated intervention (n= 33); Reasons: Changed mind prior to start (n=13), Medical problem (n=1), Not enough time to participate (n=2), moved out of intervention zone (n=17).

Discontinued intervention (n=58) Reasons: Changed mind (n=16) Not enough time to participate (n=14), migrated out of country (n=9), moved out of intervention zone (n=11), medical problem (n=3), other (n=5)

Analysed (n=372) Excluded from analysis (give reasons) (n=0)

Allocated to control group (n=481)

Lost to follow-up (n=75) Reasons: Changed mind (n=18), Not enough time (n=8), migrated out of country (n=11), other (n=8), not located (n=4), moved out of zone (n=26).

Analysed (n=406) Excluded from analysis (give reasons) (n=0)

Excluded (n=3,551) Not meeting inclusion criteria (n=3,383) Declined to participate (n=168)

About 66% of the treatment group and 62% of the control group were male; the mean age of males in both groups was about 12 years old. Roughly, 87% of treatment youth and 84% of control group youth were enrolled in school.

Less than 80% of youth in both groups had both parents present in the home; 18.59% of treatment youth and 19.7% of the control group lived with a single mother or female figure. Only a small number of youth in the treatment and control groups lived with a single father or no parent at all.

We compared the treatment and control groups in terms of gender, age, school status, parental presence and neighborhood of residence, and found no significance differences between the groups (see exhibit 6).

Exhibit 6. Demographic Characteristics of treatment and control groups (n=778)

Treatment Group (T0; n=371) Control Group (C0; n=406) n % n % sig.

Gender

Male 246 66.13 251 61.82

Female 126 33.87 155 38.18

Agea (mean & s.d.) 12.3(2.5) 12.5(2.5)

Currently in school 323 86.83 341 83.99

UN PROGRAMA HONDUREÑO DE PREVENCIÓN SECUNDARIA 17

Treatment Group (T0; n=371) Control Group (C0; n=406) n % n % sig.

Parental presence

Mother and father/female and male figure 291 78.45 314 77.34

Single mother/female figure 69 18.59 80 19.70

Single father/male figure 9 2.42 8 1.97

No parent/adult guidance 2 0.54 4 0.99

Zone

San Miguel 25 6.72 25 6.16

Carrizal 30 8.06 33 8.13

Predregal 18 4.84 20 4.93