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Concept Note: Impact Evaluation of Nadie es Perfecto,
a Program to Improve Parenting Skills in Chile
Emanuela Galasso (DECPI), Pedro Carneiro (UCL), Miguel Cordero (MOH-Chile)
Background
Parenting practices are key determinants of the physical and socio-emotional health of
children, and parental education interventions are potentially an important strategy employed to
improve parenting practices. Rapid social and lifestyle changes, increased female labor force
participation, increased hours at work for both parents, and the gradual disappearance of the
extended family as a traditional source of informal support, are increasing the pressures on
parenting practices of families living in the so-called emerging economies.
Parents play a critical role in fostering the development of children, and this particularly
important in the early years. Healthy development in a child’s earliest years sets the stage for a
strong development throughout the life span (not only in terms of health outcomes, but also
cognitive and noncognitive skills, as suggested in Currie, 2009). There is evidence that parenting
and the home environment accounts for a significant fraction of the preschool cognitive
achievements (Schady, Paxson 2007) and school test-score gaps among different socioeconomic
groups (Todd, Wolpin 2007). Parents, however, do not always have access to adequate help and
information to support them in making decisions that can assist in fostering healthy child
development. This problem is especially important among the poor.
A recent LANCET comprehensive review of strategies to promote child development (Engle
et al 2007) lists a few parenting and parent-child interventions to conclude that parenting
programs combined with home visits and/or that involve direct opportunities for skill building
and practices with the children are more effective than providing information to parents in
enhancing child development outcomes. Evidence from Bangladesh (Aboud 2007, Hamadani et
al 2006) suggests that both types of programs improve maternal knowledge, but only those
combined with direct demonstrations and interaction with children showed significant gains
child development scores. Extending our evidence on the relative effectiveness of such programs
in other settings and with varying modalities of service delivery (community based vs
individualized interaction) is however of critical policy importance, as they are associated with
substantially different costs and potential for scalability in low and middle income settings.
Furthermore, parenting interventions are often proposed as a tool for improving child
outcomes, and an example is Nobody's Perfect, the Canadian program on which Nadie es
Perfecto (NEP hereafter) is based on. There is very little evidence based on rigorous impact
evaluations on this topic, and it is important to document how and under what circumstances
maternal knowledge translates into improved behavioral change in parenting practices and how
these benefits are in turn passed on to their child.
“Nobody’s Perfect” the most widely disseminated parenting program in Canada, is one
example of this research-practice gap. Canada has championed the development and provision of
this type of intervention. An existing combined qualitative and quantitative evaluation (Chislett
and Kennet 2007; Skrypnek and Charchun 2009) found that Nobody’s Perfect contributes to
improvement in a number of parental outcomes that are potentially associated with superior child
outcomes. The evaluation shows a decrease in negative or punitive practices, and improved
parental ability to cope with parenting stressors, problem solving ability and perceptions of social
support.1 Yet, the evaluation fails to rigorously examine whether these changes in parenting
practices translate into gains in terms child development outcomes. There is now a significant
opportunity to address this problem as the Chilean government is committed to launch a major
evaluation of Nobody’s Perfect (or Nadie Es Perfecto). The government of Chile has selected
this Canadian parenting intervention within their new nationwide early childhood policy, Chile
Crece Contigo and it is planning to gradually roll it out within the country.
The aim of this rigorous evaluation is to understand whether parenting programs are
successful in enhancing child development. We plan to allow variation in the intensity of the
intervention to test how the relative cost-effectiveness of different delivery mechanisms and feed
back into the design of the program during its scaling up phase. In doing so, we aim to go be
beyond the results of the impact evaluation and uncover the mechanisms by which a parenting
program may or may not affect child development.
Description of the Intervention
Nobody’s Perfect is a parenting education program that has been developed Public Health
Agency of Canada. It was introduced in the early 1980s in a few locations, and since 1987 it has
been offered in the whole country. It targets mainly parents with children aged 0 to 5 who live in
poor and isolated conditions. It is expected that the program leads to:
1. an increase in participants’ knowledge and understanding of their children’s health,
safety and behavior;
2. a positive change in the parenting skill of participants in relation to their children’s
health, safety and behavior;
3. an improvement in participants’ confidence and self-image as parents;
4. an improvement in participants’ coping skills as parents; and ,
5. and increase in self-help and mutual support among parents
The innovative approach builds on parents’ existing knowledge and capacities through group
discussion and problem-solving learning activities. Facilitators create opportunities for change
through building trusting relationships with parents and creating groups characterized by mutual
support.
Approaches to parenting that use teaching and reasoning in disciplining children rather than
punitive approaches are associated with to superior child outcomes (Dooley & Stewart, 2007;
Fletcher, Walls, Cook, Madison, & Bridges, 2008; Gershoff, 2002; Lansford et al., 2005).
The basic Nobody’s Perfect parenting program is composed of 6 to 8 group-based parent
education sessions. The group sessions are lead by a trained facilitator. The program employs
adult education strategies to enhance participation and learning. This entailed encouraging
participation, building on strengths, and limited use of didactics. Participating parents identify
1
These results are in line with a meta analysis of Triple P-Positive programs (Nowak and Heinrichs, 2008), which
suggest positive effects of such programs on parenting skills, child behavior problems and parental well being, with
stronger effects in more intensive formats of the intervention. Yet, little is known about the role of parenting
programs in enhancing child development outcomes.
2
preferred parenting topics which are then emphasized in the sessions by the facilitator. The basic
topics will include: (i) positive attending to your child, (ii) use of non-physical disciplinary
strategies, (iii) importance of monitoring for safety, (iv) child nutrition, (v) approaches to
enhance attachment, (vi) management of basic health concerns, (vii) strategies of self care (for
the parent), and (viii) creating a stimulating/learning environment. Each of the set themes has (a)
clear learning objectives (key messages), (b) in-session hands-on activities, (c) set learning
materials for the facilitators, and (d) home-work activities.
Group discussions will be supplemented by parent education booklets that are provided to
participants. Five of the booklets are a component piece of the Nobody’s Perfect parenting
program that provide basic points about parenting of young children with an easy reading level
and brightly illustrated. The booklets are also available on the Chile Crece Contigo website.
In health centers that will not receive the program, the Child Health National Program
considers non-structured parent education sessions in primary care around different topics:
respiratory disease prevention, oral health, home accidents prevention, basic care for new born,
and others. These topics are covered by a nurse or other primary care professionals. These
sessions are of universal coverage (100% of health centers and nearly 60% of the children in the
target group (DEIS data, 2009). Nobody's Perfect will be added to a selected set of centers over
and above this unstructured parental education. Therefore the comparison we will do is between
clinics where the Nobody's Perfect (or its intensive version) is offered on top of already existing
activities (not only unstructured parental education, but also some direct stimulation of children
offered already in half the clinics), and those where Nobody's Perfect is not offered and only the
already existing set of activities is available.
I. Primary Research Questions
The main research questions are the following:
 Does a structured parenting program promote improvement in knowledge and behavioral
change in parenting practices?
 Does the intervention improve the mental health of the mother? Does it translate in
reduced parental stress?
 Does the improvement in parenting practices translate into detectable changes in child
development outcomes, ranging from health, to cognitive and socio-emotional
development?
 What is the value added of increased intensity to the basic parenting program on
knowledge, parenting and child development outcomes? (The exact nature of ‘intensity’
is discussed at more length in the description of the intervention).
II. Outcome indicators
We will focus our study on children ages 0 to 5. Messages regarding health, early stimulation
and enhancing attachment are likely to be critical for the younger age group while sessions
relating to behavioral issues, discipline will be more likely to apply to children above one/one
and half years, once children are walking and start exploring the world. We extended the focus
on the 0-2 to be able to measure the impact of the intervention on a wider range of behaviors and
outcomes.
The direct testing of children will conform to the guidelines on protocols and informed
consent by the national IRB committee (Comite de Etica de Investicaciones con Humanos,
Servicios de Salud).
3

Child Development outcomes
o Young children (0-3.5 years): We plan to use the Bayley Scales of Infant
Development administered by a trained rater. The test identifies the child
development competencies and deficits across five major developmental domains:
cognitive, language, socio-emotional, and fine and gross motor development and
adaptive behavior. The Bayley scale also includes an examiner assessment aimed at
measuring executive function. An adaptation of this scale has been widely used in
Chile. A team member of this evaluation from the Psychiatric Department of the
University of Chile has recently participated in the training and field work
supervision of a large clinical trial using the Bayley’s (Rojas et al 2007). The
evaluation team will also draw from the administrative data on the history of scores
on the Escala de Evaluacion de Desarrollo Psicomotor (EEDP) that has been normed
for Chile and used within as a screening device within the health visits (more on this
below);
o Older children (3.5-6 years): We will focus on a subset of domains of child
development that have been linked to school readiness and subsequent performance
in school:
 Vocabulary will be measured using the Test de Vocabulario en Imagines
Peabody (TVIP), the Spanish version of the Peabody Picture Vocabulary
Test (PPVT).
 Attention and speed of processing: the proposed instrument is the Leiter-R.
 Socio-emotional development: the proposed instrument is the Achenbach
Child Behavior Checklist
 Executive function: the choice of the instrument is currently under
discussion, allowing for experimentation during the pretest (Backward
Digit Span and Stroop test).

Parenting and home inputs: To assess family milieu and well-being as well as the quality
of the mother-infant relationship we will use an abbreviated version of the Home
Observation for Measurement of the Environment (HOME), infant version, containing 6
sub-scales and 45 items (Caldwell and Bradley 1984). This is an instrument designed to
assess the quality and quantity of support for cognitive, social and emotional
development that is available to a child through the home environment. It has been
widely used in studies in the UK, US.
It has been translated and used in Chile (Bulnes et al 1979, Tippie 2003). A Parent-Child
Interaction Scale included in the Canadian National Longitudinal Survey of Children and
Youth (NLSCY) will also be pre-tested (Johnson and Mash 1989).

Maternal mental health and psychosocial well-being: The team will also rely on the
expertise of the local psychologists at the U. of Chile to adapt measures of maternal selfefficacy and Parenting Sense of Competence Scale (Ohan et al 2000).
Maternal mental health will be measured using:
o the Center for Epidemiologic Studies Depression Scale (CESD) which captures
symptoms of clinical depression,
o a measure of psychosocial distress used in Mexico and Chile in the context of the
evaluation of large scale conditional cash transfer programs.
4
Another key dimension arising from qualitative reports in Canada and preliminary
structured interviews in Chile relates to the parental perceived sense of social support
arising from the group interaction. Parental social support, problem-solving, and ability
to cope with stress have all been found to impact quality of parenting (e.g., Cochran &
Niego, 1995; Crnic & Low, 2002).

Administrative data: The survey data will also be merged to detailed administrative data
on each child-mother pair. Crece Contigo has a unique feature of a longitudinal follow-up
of each child (apoyo al desarrollo biopsicosocial), with key administrative data on
maternal pregnancy, birth outcomes and health visits linked for each child in the
Integrated Social Information System (on line platform information system used for
social protection programs in Chile). We will be therefore able to access retrospective
history on risk factors and health outcomes for each child by collecting information on
the personal national identification number. An informed consent will be administered to
parents to be able access the health records of their children in the health clinics. In
particular, the following key retrospective outcomes will be obtained from the clinical
folder for each child:
o Maternal outcomes:
 EPsA: Evaluacion psicosocial abreviada – screening test applied during
prenatal checkups to detect multiple psychosocial risks2
 EPDS: Edinburgh Postnatal Depression Scale– early screening for
postnatal depression at 2 and 6 months of age of the child.
o Child outcomes:
 Anthropometrics data: birthweight, head circumference, weight, and
length of the infant examined using standard measures at birth, 8 weeks,
and at the final follow-up assessment. These indices are measured
regularly as part of a national program monitoring the growth and
development of infants.
 Protocolo de Neurodesarrollo: screening for neurodevelopment between 0
to 2 months.
 Massie/Campbell Scale of Mother-Infant Attachment applied at 4 and 12
months.
 EEDP: Escala de Evaluación de Desarrollo Psicomotor (0-24 months old)
applied at 8 and 18 months 3 and TEPSI: Test de Desarrollo Psicomotor
(2-5 years old) administered at 36 months of age. Both are screening
measures of language, social, coordination and gross motor delays
developed in Chile and normed for the Chilean population. There is also a
reduced version of the EEDP (pauta breve) administered at 1, 12, 21 and
24 months.
In addition, basic socio-economic characteristics of the family can be obtained from the Ficha
de Proteccion Social, the main targeting instrument of social programs in Chile, which captures
socio-demographic information, employment, income and incidence disability and health shocks.
2
The tests detects the following risk factors: presence of depressive symptoms or history of depression, reported or
suspected physical abuse, single parent, substance abuse.
3
The EEDP is re-administered at 10 and 21 months if there are signs of delays during the previous test results. The
TEPSI is re-administered at 42 months if there are delays are detected in its previous tests results.
5
More in-depth socio-economic characteristics will be measured with a light household survey
instrument, with special attention to time use and expenditures in children.
Finally, we will attempt to collect data on the characteristics of health facilities and of
program facilitators, using a combination of administrative and survey data. We plan to add a
facilitator questionnaire, collecting demographic and socio-economic background information
and proxies for their experience and ability for engage groups.
Detailed cost information about the program will be collected in conjunction with the
Ministry of Health. A critical component of the evaluation will be a cost-benefit analysis of the
intervention.
III.
Methodology
This program is to be implemented nationally in Chile but at present it does not exist yet
anywhere. The target population of clinics includes basic family health care, rural health clinics,
urban health clinics and health establishments with minimal service complexity: this corresponds
to about 600 clinics in Chile, covering 342 municipalities.
The evaluation will follow an experimental design, using the health clinic as the unit of
randomization. The gradual roll-out of the program is necessary because of implementation
constraints4, and it is not an imposition of the evaluation (rather, it is an opportunity we take
advantage of). The fact that the set of clinics chosen for the early and late stages of the roll-out is
done using a lottery is an imposition of the evaluation.
Therefore, in an initial stage, a set of health clinics (nationally representative) will be
randomly chosen from the universe of health clinics where the program will be first
implemented. The first group covers about 2/3 of the health clinics in Chile.
Within the first set of clinics, two equal size randomized arms will be implemented:
Group A: Basic NEP – parenting only, as currently designed
Group B: NEP with increased intensity: two extensions are under discussion with the program
team and are of interest in light of its learning potential for scaling up:
a. NEP basic program with two added group sessions that include with play and
direct interaction with children;
b. Basic NEP that holds constant the number of sessions but includes observation of
video-materials.
Group C: The remaining clinics (about 1/3) in group two will not be able to receive the program
for a year and will form the control group.
In larger health centers which have more than one facilitator, we will also experiment with
variation within centers, by introducing encouragement protocols for certain age groups, such as
those under the age of two.
Children (and their respective household) attending these clinics will be assessed at baseline
(before the program is implemented) and one year after implementation. Follow-up funding for a
medium term assessment three years after implementation will be sought at a later stage.
4
Mainly driven by the time it needs to train the facilitators.
6
Power size calculations
With 100 health clinics in treatment A, 100 clinics in B, and 100 health clinics in the control
group, if we sample 5 mother/children pairs per clinic, assuming an intra-cluster correlation of
0.2, it is possible to detect an effect across pairs of alternatives of 0.2376 standard deviations in
the Bayley's test using a 5% level of significance (and power of 80%). Under these power
calculations suggest that we should survey at least 500 households in the each of the treatment
groups and 500 households in the control group, which accounts for 1,500 households in total.
One potential problem with this calculation is that participation in the program is voluntary, and
therefore, it is likely that even though a program is offered in a clinic, less than 100% of the
mothers take it up. Based on the take-up of other education programs offered in Chilean clinics
on a voluntary basis, we believe we can predict a take-up rate of 50% to 80%, which would
imply increasing this sample size by 25% to 100% (1 to 5 mother child pairs per center).
IV.
Evaluation Team
Emanuela Galasso is Senior Economist at DECRG. She has extensive experience in evaluation
of social programs. Especially relevant for this proposal is her evaluation of a nutrition and child
development program in Madagascar. Pedro Carneiro is Associate Professor at the Department
of Economics, University College London. He is an expert in the economics of child
development and the evaluation of social programs.
Miguel Cordero is responsible for managing the health components of Chile Crece Contigo at
the Chilean Ministry of Health. He also has experience in the evaluation of health programs,
having conducted a randomized control trial to measure the impact of an intervention to
ameliorate maternal post-natal depression in Chile, measuring impacts both on mothers and
children alike.
Other members of the evaluation team include:
- Cecilia Moraga: National Coordinator of Nadie es Perfecto, Ministry of Health
- Paula Bedregal, Associate Professor, Universidad Católica de Chile, Departamento de
Salud Pública
- Alejandra Guerrero: Clinical psychologist at the Universidad Católica de Chile
- Rodrigo Herrera and Paula Castro, Evaluation Unit within the Social Division in the
Ministry of Planning
V.
Detailed Description of Funding Request Justification and Timeline
The primary funding source for the intervention is the Chilean Government. The World Bank is
involved with a technical assistance loan (P114774) that supports the strengthening the scaling
up of the social protection system within the Ministry of Planning (MIDEPLAN). The universal
early childhood policy, Chile Crece Contigo, is an integral part of the social protection strategy
in Chile. One of the objectives of the loan is to strengthen the system of monitoring and
evaluation of social programs.
The adaptation of Nobody's Perfect to Chile is already done and the program is to be rolled out
in the near future, as the implementation of different components of Chile Crece Contigo evolves
over time. The implementation of Nobody's Perfect will be, as much as possible, coordinated
with the evaluation efforts, for which these funds will be essential. Therefore, as much as
7
possible, we will try to delay the roll out of the program until funding for the evaluation is
secured, if funding can be secured in the short run.
Timeline:
June 2010: baseline, with the immediate roll out of the program afterwards
December 2010: baseline survey
June 2011: follow-up survey
December 2011: evaluation report
Budget:
A) low case scenario (1,500 households)
Unit
Weeks
A. Staff salaries
B. Consultant fees
International Consultant (for the intensive component)
Research Assistant/Field Coordinator (Local)
Local consultant 1 (local psychologist Bayley's)
Local consultant 2 (local psychologist)
C. Travel & Subsistence
Staff - International airfare
Staff - Hotel & Per Diem
International airfare - Field Coordinator
Hotel & Per Diem - Field Coordinator
International airfare - International Consultant
D. Data Collection Baseline
Data type 1: Household/Individual
Data type 2: Direct cost of the Tests
Pre-test and adaptation of the tests
V. Other
Report preparation
Total Evaluation Costs
Funds from other sources
Funds requested from SIEF
Rate/unit
days/units
Days
Days
days
500
200
200
200
7
80
60
20
Trips
Days
Trips
Days
Trips
1,500
100
1,500
100
1500
1
20
1
50
1
Indiv.
Total
Total
70
1,500
17,500
15,000
6000
USD
0
35,500
3,500
16,000
12,000
4,000
11,500
1,500
2,000
1,500
5,000
1,500
137,500
105,000
17,500
15,000
6000
190,500
190,500
B) high case scenario (3,000 households)
Unit
Weeks
A. Staff salaries
B. Consultant fees
International Consultant (for the intensive component)
Research Assistant/Field Coordinator (Local)
Local consultant 1 (local psychologist Bayley's)
Local consultant 2 (local psychologist)
C. Travel & Subsistence
Staff - International airfare
Staff - Hotel & Per Diem
International airfare - Field Coordinator
Hotel & Per Diem - Field Coordinator
International airfare - International Consultant
D. Data Collection Baseline
Data type 1: Household/Individual
8
Rate/unit
days/units
Days
Days
days
500
200
200
200
7
80
60
20
Trips
Days
Trips
Days
Trips
1,500
100
1,500
100
1500
1
20
1
50
1
Indiv.
70
3,000
USD
0
35,500
3,500
16,000
12,000
4,000
11,500
1,500
2,000
1,500
5,000
1,500
260,000
210,000
Data type 2: Direct cost of the Tests
Pre-test and adaptation of the tests
V. Other
Report preparation
Total Evaluation Costs
Funds from other sources (tbd)
Funds requested from SIEF
Total
Total
9
35,000
15,000
35,000
15,000
6,000
6,000
313,000
113,000
200,000
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