Anne Arundel County Department of Health is responsible for improving the health of the 550,000+ lives residing in Anne Arundel County.  The county lies between Washington and Baltimore and borders over 533 miles of coastline with areas that are rural and suburban.

The Strengthening Families Program (SFP) is an evidenced-based, 14-week program for parents/caregivers and children ages 6-16. The goal is to build healthy, positive family relationships with objectives to assist parents/caregivers improve family communication, provide effective discipline and improve children’s behavior. SFP helps children/teens to develop better communication and social skills, solve problems, resist peer pressure and learn the consequences of substance use.

In March 2020, the cycles that were running were halted due to COVID. Because program participants expressed interest in continuing the program, a plan was devised to continue the sessions via Zoom, with approval from the SFP program developer. As a result, the program restarted in May. 

Before March, SFP was offered in two schools:  one in North County, and one in Annapolis. A family dinner was offered, then a 1-hour group session for English speaking parents, Spanish speaking parents, teens, children and 0-5 years old. After that, a 30-minute family session was held. In the virtual format, a family dinner was delivered to each household between 5-6pm. From 6-6:15pm, families were welcomed and presented a PowerPoint presentation including homework assignments. Then a 30-minute  group session was offered to each parent group and the teenager group. After that, another 30-minute group session for the children ages 6-11, followed by a 15-minute family session.

In the original format, this program provides transportation, program supplies, a family dinner and incentives for attendance.  When the program went virtual, these crucial components were maintained as much as possible. Families either received a gas card or transportation provided by Uber Health to get their supplies including curriculum books, markers, 2 board games per family, poster boards, etc. Furthermore, each family received pizza delivered to their home on the day of each session.     

Many of the health inequities that already existed before this crisis have been exacerbated for low income, at-risk families. They have experienced greater financial hardship; job, food and house insecurity; and a decline in mental health. The SFP provided emotional support, in addition to providing a set of practical tools to implement to improve their family relationships.  Connections were also made to food pantries, relief assistance programs, recovery services, holiday gift drives, and mental health services.

The first fully virtual cycles finished in December, 2020.  Pretest and post tests were coducted on each cycle. Anecdotally, our families reported that SFP provided emotional support, and increased a sense of community. Families reported they are able to share experiences, help one another learn parenting skills and improve their family relationships.

There are a variety of complex problems to address during this pandemic. Prevention programs and services need to be engaging and supporting the most important stakeholders and primary producers of health within the US: families and households.

The Strengthening Families Program (SFP) is an existing in person evidence based practice that needed to be adapted during COVID into a virtual platform while also keeping to the fidelity of the model.  SFP is a family skills training class that involves parents and children working together to form stronger bonds and healthier relationships. SFP is designed to reduce environmental risk factors and improve protective factors. Its overall goal is to increase personal resilience to drug use and other risky behavior in high-risk youth.

SFP believes in the critical role of families. The wellbeing of a nation depends on strong and loving families. Parenting is an important component in multi-component prevention programs. A root cause of substance misuse is dysfunctional family relationships. Parents teach values and habits, good or bad, by their actions and by their words. SFP promotes:

• The importance of one caring adult

• Opportunities to help others

• Social skills for home and away

• Self-discipline

• Communication of family expectations, including drugs and alcohol

• Parents’ help with critical life decisions

• Resiliency skills: the ability to recover readily from illness, depression, or adversity

The SFP targets the identified population through partnerships with the  Anne Arundel County Public Schools (Social workers, pupil personnel workers, guidance), substance use and mental health treatment providers, Department of Social Services, Department of Juvenile Services, District Court, Circuit Court, Drug Court, and Crisis Response. Participants can also self-refer via Anne Arundel County Dept of Health website.  Families are screened to ensure appropriateness for the services.

Anne Arundel County Department of Health began providing SFP in 2003.  From the beginning, it was well received by the community and other stakeholders which has led to increased funding and cycles provided.  Since 2013, SFP has served over 1500 county residents.

The science based program has helped to improve children’s behavior, mental outlook and grades, and it has helped to reduce their aggressive and violent actions.  Follow up studies found reductions in the participant’s substance use up to five years after they graduated from the program. 

While this program is not a new one to the Department of Health, the adaptation to a virtual platform while maintaining the integrity of the program was new and innovative.   Families who were participating in the cycles when COVID-19 hit were the ones to suggest a virtual platform.  This was in response to the schools going to virtual classrooms.  The SFP Supervisor immediately reached out to the developers for approval.  Once this was granted, the program was quickly and creatively adapted to resume the cycles in process as well as set the groundwork for additional cycles as transmission rates in the county continued to necessitate the need to discontinue non-urgent in person services.

As outlined in the prior section, a paid professional Zoom account was purchased.  The SFP Supervisor developed the plan for implementation with input from stakeholders.  Strategies were developed to address the many foreseen as well as developing challenges with technology, transportation and the family meal.  The prevention administrative assistant worked hard developing partnerships with food establishments to ensure the timely delivery of meals to each family for every session.  Safe practices with social distancing were put in place in order to provide families with their gift cards and supplies.  Pick up appointments held outside for those with transportation.  For those without transportation, SFP staff either delivered to the homes or arranged Uber Health transportation.

Anne Arundel County has witnessed a resurgence of positive cases which has delayed the schools from returning to normal onsite operations.  Most agencies since March 2020 have been providing services remotely and/or using telehealth.  The ability of our prevention team to continue a multi component program that has been such a positive resource for critical families in need has been truly remarkable.  While the continuation of a virtual platform for SFP in the future when the pandemic has ended is still unknown, the knowledge that has been gained through the use of technology has opened doors for consideration in future programming.

The main goals of continuing to offer the Strengthening Families Program (SFP) interrupted by the pandemic via Zoom were:

1) To offer practical, evidence-based tools for families dealing with the stresses cause by family relationships and the pandemic;

2) To provide emotional support; and

3) To connect families to available services and programs related to food, job and housing insecurity, mental health, recovery programs.

The timeline below describes the steps taken to implement and finish the 2 (two) school cycles of the SFP, spring 2020, that were interrupted by the pandemic.

April 2020:

Get a Zoom account

Assign SFP Facilitators for each of the 2 cycles

Estimate costs to offer the remaining program via Zoom with the maximum number of families that can participate (look at funds available in existing program budgets)

Prepare a schedule for the remaining sessions of the program and email the families 

Prepare a Program Requirements and Rules to be sent out to the SFP Participants

Prepare a consent form to be sent to SFP Participants

Invite Families to participate via text message, phone call or email

Prepare a list of participating families

Provide the Site Coordinator with training for Zoom

May 2020

Schedule a Zoom meeting with Facilitators to explain the Program structure via Zoom

Conduct demonstration with all SFP Facilitators to test the Program via Zoom

Drop off SFP Books to families to be used during the program

Find restaurants in each area that can deliver food for families on each program date

Start offering the program via Zoom to the SFP Participants

Monitor attendance; mail gift cards according to the program policies

June 2020

Prepare an agenda for the graduation and invite a guest speaker

Hold Graduation via Zoom

We had to do a cost analysis to estimate the number of families/participants we would be able to accept. The program costs involve salaries for 9 Facilitators, $30 Walmart cards for each 4 sessions of participation, program supplies and food. We had an increase in our food costs, to ensure each family received a family dinner in their homes, on the day of each session. We estimated we could accept 10-15 families per cycle.

During the months of July and August 2020, we received applications via email, or families called us so we completed applications over the phone. Each family’s need was then assessed, in terms of technology available to participate in the program (internet services and devices available), transportation to receive program supplies and incentives, number of household members to ensure enough food was delivered.

Moreover, we worked as a team in which Facilitators and the Program Supervisor ensured all participants received their books and supplies prior to the program start. Due to COVID, we also included in our supplies reusable masks to each participant. Some participants drove to our office and received their supplies, respecting social distancing protocols and mask use, and received a gas card to assist with transportation costs. Others with lack of transportation had their supplies delivered to their door. We also ensured the same process to give them their gift cards, incentives for attendance. 

All the information described above was sent to families either via email or text messages, in English and Spanish, considering we had Spanish speaking families participating. In addition, every announcement during the program was made in English and Spanish, as our Program Supervisor and some of the Facilitators are bilingual.

Other than the families, community stakeholders did not have a major role in changing the program to a digital format. The transition was accomplished in-house with the Department of Health staff.

We had to contact and email our promotional flyers and application forms to our partners. We contacted via email the following agencies: Department of Social Services, Department of Correction, more specifically the Parole Department, as some inmates are required to take parenting classes as part of condition of release, Mental Health Services providers, Anne Arundel County Public Schools Bilingual Facilitators and School counselors, non-profit organizations, among others. In addition, we also sent out information to other programs within the Department of Health, such as Adolescent and Family Services, Peer Support Program, as they are also a source of referral.

During our fall 2020 cycles, our families started to express their needs, and we connected them to services and programs. For instance, there were families that needed substance use disorder programs for their teenagers. We then connected them to Peer Support services within the Department of Health, so they could assist the families to access recovery services. We also send lists of Food distribution sites in the county. Furthermore, some of our families lost their jobs, faced food insecurity, among other hardships and we sent them links to apply for relief assistance programs.

An unexpected partnership that formed through the pandemic and transition to an all-virtual program, was that the Strengthening Families Supervisor partnered with a Registered Nurse to offer a program called “Hands Off Faces” to SFP participants.  The program provided education on how viruses are spread and tips to prevent the spread of COVID.  

The innovative partnership of the Hands Off Faces program benefited the process because it offered families a resource that they had been lacking.  Offering it through a trusted source, SFP, lent credibility to the information given and gave the SFP participants a safe space to learn and share their concerns.

The strategic partnership of Hands Off Faces, connection to Recovery Support services through the Department of Health, and utilization of other County agencies to recruit families all helped to increase health equity.  These partnerships ensured that the families that were recruited were most in need and once they entered into the program, each family was linked to the appropriate services for their unique situation. 

We presented a PowerPoint presentation, before each session, with pictures of the submission of their homework assignments. Those assignments consisted of: having a family meeting and completing a meeting template, playing a game with their children, doing a project together, among others. Our families reported gratitude for the program, in which they had the opportunity to learn different skills, connect to other families, in times in which we feel lonely and isolated. They also shared their experiences with other families, reporting to develop a sense of community. In addition, after 14 weeks together, Facilitators and families reported a sense of pride and accomplishment for committing to the 14 weeks of the program.

Participants were provided with access to transportation through Uber Health or provided gift cards to pick up supplies.  Family dinner was delivered directly to the house and games were provided to encourage interaction for the “family dinner”, a vital component of the program that fosters family unity.

We gave the opportunity for families to apply for the program over the phone, understanding the difficulties for low income, at risk, and often minority populations to access a computer and printer during COVID.

During our sessions, we decided to hold the parents group first, then the children’s group afterwards, and not at the same time as we used to do at our school sites. We had to adapt to our families reality, considering that the children would be using the same device as their parents. We learned that our teenagers had their own cell phones, so they could have a virtual session at the same time as their parents.

 Strengthening Families Program is an evidence-based, family intervention program. In implementing it via live video conference, via Zoom, during COVID, we had keep the integrity of the program while adapting to an ever changing pandemic, and to the new needs of our families.

We strengthen partnerships with other government agencies, mental health providers, and non-profit organizations to be able to do outreach for SFP, and to target the low income, at risk families that most need SFP. Our families were disproportionately affected by this pandemic. Many of the services and programs were halted during this pandemic, and SFP became a source of emotional support and also of valuable information on available resources.

 We had to do a cost analysis, to estimate the number of families/participants we would be able to accept. The program costs involve salaries for 9 Facilitators, $30 Walmart cards for each 4 sessions of participation, program supplies and food. We had an increase in our food costs, to ensure each family received a family dinner in their homes, on the day of each session. We estimated we could accept 10-15 families per cycle. 

We provided transportation or even delivered supplies to families at their homes, to provide program supplies to all.

We connected our families, based on their needs, to services and programs available to them to support them during COVID.

We provided support to our Facilitators, so they felt comfortable and able to facilitate SFP via Zoom.

In a post pandemic world, we foresee the possibility of offering a cycle virtually. This type of format removes some barriers for participation, and provides the opportunity for many at risk-individuals to be able to learn the skills taught in this program, in the comfort of their home. In addition, we must be prepared to respond to any other event that might happen in the future that would prevent us from offering this program in person.  

The goal of primary prevention efforts, such as the SFP, is to prevent disease or injury from occurring. During this pandemic, low income, at risk families were disproportionately impacted by COVID. By providing practical tools for families to improve their relationship, SFP during pandemic assisted our families to build protective factors against substance abuse and other risky behaviors. In addition, SFP became a source of support, information and connection to services and programs available to support our families during COVID.   

We implemented principals of Quality Improvement in this practice. First, we establish a culture of quality. The SFP Supervisor had meetings prior to each session with Facilitators, to ensure they had the tools they needed to follow the curriculum, county’s policies and provided the best experience to our families. In addition, the SFP supervisors watched the sessions in each virtual group for a certain period of time, and provided feedback to each facilitators in a after session meeting. Based on group observations, SFP Supervisor provided feedback to Facilitators to determine and prioritize potential areas for improvement. Furthermore, we are in the process to collect the post surveys from the families, and will use this data to improve our program for the next cycles.