Strengthening a Culture of Prevention in Low- and Middle-Income Countries: Balancing Scientific Expectations and Contextual Realities

Parenting for Lifelong Health for Young Children in Montenegro: Preliminary Outcomes, Dissemination, and Broader Embedding of the Program

The quality of parenting program implementation significantly affects the extent to which a program is delivered effectively as well as the likelihood of it becoming embedded in everyday services. The group based Parenting for Lifelong Health for Young Children (PLH-YC) program for parents of children aged 2-9 years was developed specifically for implementation in low- and middle-income contexts, has been tested in five randomized trials, and incorporates a number of strategies to encourage fidelity of delivery. This paper reports on the introduction of PLH-YC to Montenegro, including initial work to engage government agencies and service providers, adapt the program and, following initial evidence of effectiveness, implement strategies to promote effective delivery and embed the program. Following program adaptation and initial facilitator training, eight groups were run, supported with resources and supervision and independently evaluated. The successful pilot led to program training accreditation by national professional agencies and a series of steps to successfully further embed it into routine settings in Montenegro, including by recognizing the program in national policy documents. This led to further facilitator trainings, now numbering 97 facilitators and the certification of ten coaches and two trainers. By the end of 2023, 1278 parents, across 13 municipalities (half of all municipalities in Montenegro) and a range of service providers, have received the program. The paper describes the project phases and key fidelity components that underpinned the successful introduction and embedding of the program in Montenegro. The plan has resulted in Montenegro having its own domestic resources to continue to implement the program effectively and further plan for widespread dissemination.

Parenting practices and interventions during the COVID-19 pandemic lockdown: an exploratory cross-sectional study of caregivers in Brazil, Mexico, and the United States

INTRODUCTION

The COVID-19 pandemic led countries' governments to rapidly establish lockdowns and social distancing, which altered family routines and the quality of family relationships worldwide.

OBJECTIVES

This exploratory cross-sectional study aimed to identify the impacts of the social distancing and lockdown in parenting practices of caregivers from Brazil, Mexico, and the USA, and to analyze the continuity of parenting intervention support for children and their families at the beginning of the pandemic in these countries.

METHODS

The sample consisted of 704 caregivers of children (286 from Brazil, 225 from Mexico, and 193 from the USA) who answered an online survey about parenting practices before/after quarantine, caregiver/child routines, feelings related to quarantine, changes in everyday life since the beginning of the COVID-19 pandemic, contact with health professionals, and sources of parenting information.

RESULTS

Data indicate that caregivers from the three countries experienced similar parenting practices during this time, and did not report significant changes before and after the lockdown. They sought information about parenting predominantly via social media. Those receiving previous mental health care perceived the transition from in-person to telehealth services during the pandemic as feasible and acceptable.

CONCLUSION

This study will be helpful for clinicians and parents to contextualize their practices amid long-standing effects that the COVID-19 pandemic can have on children and their families during and post-pandemic from multiple cultural backgrounds.

Using a Design Thinking Approach to Develop a Social Media-Based Parenting Program for Parents of Children With Attention-Deficit/Hyperactivity Disorder: Mixed Methods Study

Background: Parenting programs have proven effective in improving the behavior of children with attention-deficit/hyperactivity disorder (ADHD). However, barriers such as job and transportation constraints hinder parents from attending face-to-face therapy appointments. The COVID-19 pandemic has further exacerbated these challenges. Objective: This study aimed to develop and test the feasibility of a social media-based parenting program for parents of children with ADHD, considering both the pre-existing challenges faced by parents and the additional barriers imposed by the COVID-19 pandemic. Methods: This study used a 5-stage design thinking process, encompassing empathizing with parents, defining their needs, ideating innovative solutions, prototyping the program, and testing the program with parents. Qualitative interviews were conducted with 18 parents of children with ADHD to understand their unique needs and values. Brainstorming techniques were used to generate creative ideas, leading to the creation of a prototype that was tested with 32 parents. Participants' engagement with the program was measured, and posttraining feedback was collected to assess the program's effectiveness. Results: Parents of children with ADHD encounter specific challenges, including managing impulsive behavior and difficulties in emotion regulation. The social media-based parenting program was delivered through the LINE app (Line Corporation) and consisted of 7 modules addressing topics related to ADHD management and effective parenting strategies. The program exhibited a high completion rate, with 84% (27/32) of participants successfully finishing it. Program provider-participant interaction peaked during the first week and gradually decreased over time. Qualitative feedback indicated that the program was feasible, accessible, and well received by participants. The LINE app was found to be convenient and helpful, and participants preferred content delivery once or twice per week, expressing acceptance for various content formats. Conclusions: This study emphasizes the significance of adopting a human-centered design thinking approach to develop parenting programs that cater to the unique needs and values of parents. By leveraging social media platforms, such as LINE, a parenting program can overcome the challenges posed by the COVID-19 pandemic and other constraints faced by parents. LINE offers a viable and feasible option for supporting parents of children with ADHD, with the potential for customization and widespread dissemination beyond the pandemic context.

A culturally adapted parenting intervention for the Chilean context: Qualitative indicators of participant satisfaction and contextual and cultural relevance

Parent training (PT) interventions constitute an empirically demonstrated alternative to promote effective parenting practices and prevent child behavioral and mental health problems. However, the dissemination of evidence-based PT interventions across Latin America remains scarce. This qualitative study had the primary objective of evaluating the level of acceptability of a culturally adapted version of the PT intervention known as GenerationPMTO^© , adapted for the Chilean context. According to qualitative reports provided by 24 Chilean caregivers exposed to the culturally adapted parenting intervention, the intervention was perceived by caregivers as useful for their parenting practices, as well as contextually and culturally relevant. Current qualitative findings indicate that the culturally adapted PT intervention holds promise for larger dissemination in the Chilean context.

Culturally adapting an evidence-based parenting intervention for the Chilean context: Balancing fidelity, context, and cultural relevance

The dissemination of evidence-based parent training (PT) interventions remains extremely limited in Latin American countries. This is concerning when considering the high prevalence of child maltreatment associated with punitive parenting practices across countries in the region. Furthermore, efforts to disseminate PT interventions must be conducted by adhering to the core parenting components that have established effectiveness for such interventions, while ensuring contextual and cultural relevance for focus populations. In this manuscript, we describe the cultural adaptation of an evidence-based PT intervention in the context of Chile. This initial phase of adaptation was informed by the theoretical tenets of the Ecological Validity Model of cultural adaptation (Bernal et al., J. Abnorm. Child Psychol., 23, 1995, 67). According to findings from a qualitative thematic analysis conducted with five interventionists in training, therapists perceived that the intervention's core components were relevant to Chilean caregivers who participated in the parenting program. Interventionists also provided specific suggestions to enhance the intervention's contextual and cultural relevance. This investigation illustrates the importance of culturally adapting evidence-based interventions according to comprehensive cultural adaptation frameworks, prior to engaging in large-scale dissemination of adapted interventions in Latin American contexts.

The Feasibility, Acceptability, and Utility of Mantente REAL: the Culturally Adapted Version of keepin' it REAL for Mexico

A binational team of investigators culturally adapted, implemented, and tested the efficacy in Mexico of keepin' it REAL, a US-designed prevention intervention for youth. This article reports on the social validity of the adapted intervention by assessing its feasibility, acceptability, and utility, as perceived by participating middle school students, teachers/implementers, and school administrators. Middle schools (N = 36) were randomly assigned to (1) the culturally adapted version for Mexico (Mantente REAL), (2) the original intervention from the USA (keepin' it REAL) translated into Spanish, or (3) a control condition (treatment as usual). Adult and child feedback about the adapted and original versions of the intervention indicate that both are feasible to implement in the Mexican context. Implementation fidelity was equally high for both versions of the manualized intervention. Students, however, were more satisfied with the culturally adapted version than with the non-adapted version. They reported gaining more knowledge, finding it more acceptable, applicable, and authentic, and they reported discussing the program with their family and friends more often. The findings support the feasibility of engaging classroom teachers to implement manualized prevention programs in Mexico. These findings also advance prevention science by documenting the importance of cultural adaptation as a means to increase students' identification with and acceptability of efficacious school-based interventions. The article discusses the practice, policy, and future prevention research implications of the findings for Mexico and their potential generalizability to other middle- and lower-income countries.

A South-to-South Cultural Adaptation of an Evidence-Based Parenting Program for Families in the Philippines

Rates of child maltreatment are higher in low- and middle-income countries due to risk factors such as social inequities, economic adversity, and sociocultural norms. Given the evidence showing the effectiveness of parenting interventions to prevent child maltreatment, this study embarked on a cultural adaptation of an evidence-based parenting program with the eventual goal of integrating it within a nationwide conditional cash transfer program for low-income Filipino parents with children aged 2-6 years. We document the systematic adaptation of the Parenting for Lifelong Health for Young Children program that was developed and tested in South Africa, for low-resource Filipino families using the heuristic framework for the cultural adaptation of interventions. We underscore the merits of conducting a multistage top-down and bottom-up process that uses a participatory approach among cultural insiders and outsiders to develop a parenting intervention that reflects the contextual realities and cultural values of end users. The adapted program, Masayang Pamilya Para sa Batang Pilipino, is the product of a delicate and deliberate effort to balance Filipino childrearing goals and values with the scientific evidence on components of parenting interventions known to promote positive parenting and prevent child maltreatment.

Commentary on the Culture of Prevention

Despite significant progress in prevention science over the past 30 years in developing evidence-based interventions and policies, there has not been equal success in attracting support from policymakers and gaining acceptance by communities. In recognition of this gap, the editors of Prevention Science put out a call to scientists to help clarify and define the concept of a “culture of prevention.” Such a culture would influence the creation of an infrastructure for implementing and sustaining the most effective strategies informed by research. The journal call stated a culture of prevention was a “general orientation or readiness of a group of people… to address problems by using a preventive, rather than a reactive approach.” This commentary examines the concept demonstrated in the array of papers presented here in which the “culture of prevention” is applied in different contexts—occupational safety and health, substance use, school, governmental, community, around problem behaviors, and violence. It is important to note that the papers represent perspectives and experiences from several countries, including some cross-national experiences providing an international framework. While a final definition awaits further research, the commentary summarizes important elements that might constitute that evolving definition and pave the way for the implementation of more effective prevention programming.

Combining parenting and economic strengthening programmes to reduce violence against children: a cluster randomised controlled trial with predominantly male caregivers in rural Tanzania

Introduction

Parenting programmes may reduce the risk of violence against children and improve child well-being. However, additional economic support may be necessary in highly deprived rural communities in sub-Saharan Africa. Furthermore, delivering programmes within farmer groups may increase male caregiver recruitment and engagement.

Methods

A parallel cluster randomised controlled trial examined the combined and separate effects of parenting and economic strengthening programmes on reducing violence against children aged 0–18 years in farming communities in Tanzania (n=248 families; 63% male caregivers). Eight villages were randomly assigned to four conditions (2:2:2:2): (1) 12-session parenting programme (n=60); (2) agribusiness training (n=56); (3) parenting and agribusiness combined (n=72); (4) control (n=60). Parent-report, child-report and early childhood observation assessments were conducted at baseline, mid-treatment and post-treatment. Primary outcomes were child maltreatment and parenting behaviour. Secondary outcomes included corporal punishment endorsement, parenting stress, parent/child depression, child behaviour, economic well-being and child development.

Results

At post-treatment, parents and children receiving the combined interventions reported less maltreatment (parents: incidence rate ratio (IRR=0.40, 95% CI 0.24 to 0.65; children: IRR=0.40, 95% CI 0.17 to 0.92). Parents reported reduced endorsement of corporal punishment (D_w=−0.43, 95% CI −0.79 to 0.07) and fewer child behaviour problems (D_w=−0.41, 95% CI −0.77 to 0.05). Parents in parenting-only villages reported less abuse (IRR=0.36, 95% CI 0.21 to 0.63) and fewer child behaviour problems (D_w=−0.47, 95% CI −0.84 to 0.11). Parents in agribusiness-only villages reported fewer child behaviour problems (D_w=−0.43, 95% CI −0.77 to 0.08) and greater household wealth (D_w=0.57, 95% CI 0.08 to 1.06). However, children in agribusiness-only villages reported increased physical abuse (IRR=2.26, 95% CI 1.00 to 5.12) and less positive parenting (D_w=−0.50, 95% CI −0.91 to 0.10). There were no other adverse effects.

Conclusion

Parent training may be the active ingredient in reducing maltreatment in farmer groups with majority male caregivers, while agribusiness training programmes may have unintended negative consequences on children when delivered alone. Locating parenting support in existing farmer groups can engage much higher proportions of fathers than stand-alone programmes.

ClinicalTrials.gov: NCT02633319

Parenting in the Midst of Adversity: Tailoring a Culturally Adapted Parent Training Intervention According to the Parenting Experiences of Mexican-Origin Caregivers

Although parent training (PT) interventions are considered the gold standard for preventing externalizing behaviors in children and youth, their dissemination in low-income Latina/o immigrant communities continues to be scarce throughout the United States (US). An alternative to address this gap in service delivery consists of implementing culturally adapted PT interventions characterized by cultural and contextual relevance. Thus, the main objective of this qualitative study was to document salient immigration-related experiences, as well as parenting needs and challenges, as reported by 30 low-income Mexican-origin immigrant caregivers residing in an urban setting in the Southern United States. The research methodology was guided by the tenets of the Thematic Analysis approach, which involved collecting data through a series of focus group interviews. Qualitative research findings highlight the importance of culturally and contextually tailoring adapted PT prevention interventions, prior to their delivery in contexts that differ from those in which interventions were originally adapted. Specifically, parents in the current investigation provided detailed accounts of immigration-related stressors that are highly relevant to inform recruitment procedures, intervention curriculum, and intervention delivery activities.

Evaluating the dissemination and scale-up of two evidence-based parenting interventions to reduce violence against children: study protocol

Background

Eliminating violence against children is a prominent policy goal, codified in the Sustainable Development Goals, and parenting programs are one approach to preventing and reducing violence. However, we know relatively little about dissemination and scale-up of parenting programs, particularly in low- and middle-income countries (LMICs). The scale-up of two parenting programs, Parenting for Lifelong Health (PLH) for Young Children and PLH for Parents and Teens, developed under Creative Commons licensing and tested in randomized trials, provides a unique opportunity to study their dissemination in 25 LMICs.

Methods

The Scale-Up of Parenting Evaluation Research (SUPER) study uses a range of methods to study the dissemination of these two programs. The study will examine (1) process and extent of dissemination and scale-up, (2) how the programs are implemented and factors associated with variation in implementation, (3) violence against children and family outcomes before and after program implementation, (4) barriers and facilitators to sustained program delivery, and (5) costs and resources needed for implementation.Primary data collection, focused on three case study projects, will include interviews and focus groups with program facilitators, coordinators, funders, and other stakeholders, and a summary of key organizational characteristics. Program reports and budgets will be reviewed as part of relevant contextual information. Secondary data analysis of routine data collected within ongoing implementation and existing research studies will explore family enrolment and attendance, as well as family reports of parenting practices, violence against children, child behavior, and child and caregiver wellbeing before and after program participation. We will also examine data on staff sociodemographic and professional background, and their competent adherence to the program, collected as part of staff training and certification.

Discussion

This project will be the first study of its kind to draw on multiple data sources and methods to examine the dissemination and scale-up of a parenting program across multiple LMIC contexts. While this study reports on the implementation of two specific parenting programs, we anticipate that our findings will be of relevance across the field of parenting, as well as other violence prevention and social programs.

Introduction to the Special Issue on "Promoting a Culture of Prevention: an International Perspective"

The primary goal of this special issue is to showcase novel, theory-driven, creative, and rigorous contributions to our understanding of the existence and development of a culture of prevention and readiness to prevent. The term “culture of prevention” is neither a set of practical guidelines nor a leading theory. Instead, it is a multidimensional term representing the general orientation and readiness of a group of people (be it a family, community, school, organization, nation, etc.) to deal with problems using a preventive, rather than a reactive, approach. The COVID-19 pandemic creates an opportunity for taking stock of the worldwide progress in creating a “culture of prevention.” This special issue aims to stimulate this discourse by presenting six studies and three commentaries from international scholars focused on themes and approaches for creating a culture of prevention.

Building a Culture of Prevention: Tasks for Multi-Taskers

Building a culture of prevention presents many challenges, all of which originate from and refer back to both strengths and weaknesses of this effort. In this invited commentary, I provide an overview of these challenges and remaining open questions extracted from the original contribution enclosed in the special issue. Crucial questions that need to be addressed are the use of formal models of a “culture of prevention”; how the interplay of local values, alliances, and co-creational processes can be reflected in other experiences; and evaluation of the culture change itself.

Addressing Immigration-Related Stress in a Culturally Adapted Parenting Intervention for Mexican-Origin Immigrants: Initial Positive Effects and Key Areas of Improvement

Culturally adapted evidence-based parenting interventions constitute a key strategy to reduce widespread mental health disparities experienced by Latinx populations throughout the United States. Most recently, the relevance of culturally adapted parenting interventions has become more prominent as vulnerable Latinx populations are exposed to considerable contextual stressors resulting from an increasingly anti-immigration climate in the country. The current study was embedded within a larger NIMH-funded investigation, aimed at contrasting the differential impact of two culturally adapted versions of the evidence-based parenting intervention known as GenerationPMTO©. Specifically, a sample of low-income Mexican-origin immigrants was exposed either to a culturally adapted version of GenerationPMTO primarily focused on parent training components, or to an enhanced culturally adapted version in which parenting components were complemented by sessions focused on immigration-related challenges. The sample for the study consisted of 103 Mexican-origin immigrant families (190 individual parents). Descriptive analysis and generalized estimating equations (GEEs) indicated that exposure to the enhanced intervention, which included context- and culture-specific sessions, resulted in specific benefits for parents. However, the magnitude of the impact was not uniform for mothers and fathers and differed according to the type of immigration-related stress being examined (i.e., intrafamilial vs. extrafamilial stress). Overall, findings indicate the relevance of overtly addressing contextual (e.g., discrimination) and cultural challenges in culturally adapted interventions, as well as the need to increase precision according to the extent to which immigration-related stressors impact immigrant mothers and fathers in common and contrasting ways. Implications for family therapy practice and research are discussed.

Binational Cultural Adaptation of the keepin' it REAL Substance Use Prevention Program for Adolescents in Mexico

Sharp increases in substance use rates among youth and the lack of evidence-based prevention interventions in Mexico are a major concern. A team of investigators from Mexico and the USA are actively addressing this gap by culturally adapting keepin' it REAL (kiR)-a former US SAMHSA model program-for Mexico. This paper reports on the processes and outcomes of the cultural adaptation of kiR for adolescents in Mexico. Multiple forms of data informed this cultural adaptation, including focus groups with students about gendered and violence experiences with substance use, feedback from teachers who previously implemented the original versions of kiR, lesson fidelity observations, and external expert reviews. The culturally adapted version of kiR integrates Ecological Validity and Cultural Sensitivity Models in the adaptation process. The process encompassed surface structure adaptations, like updating language, graphics, and videos, as well as deep structure adaptation components including cultural norms, attitudes, and beliefs salient among Mexican adolescents. Youth reported receiving alcohol offers from family members, links between substance use and violence, and that shifting gender norms result in more females initiating substance use offers. In adapted kiR activities, students practice navigating substance use offers in these contexts. This approach to cultural adaptation led to a true collaborative between investigators in two countries. This study advances knowledge about how to undertake cultural adaptations of efficacious US-based prevention programs in international settings.

The United Nations Office on Drugs and Crime's Efforts to Strengthen a Culture of Prevention in Low- and Middle-Income Countries

This article discusses how decision-makers can be supported to strengthen a culture of prevention. This article presents an example of the United Nations Office on Drugs and Crime’s (UNODC) work to engage with decision-makers to create readiness, demand, and capacity for evidence-based prevention programming among them, particularly in low- and middle-income countries. First, we utilized two of the UNODC’s data sources to describe the context where the UNODC’s prevention efforts take place. Analysis of the first dataset on prevention activities implemented globally revealed a gap in translating evidence into practice on a global scale. The second dataset consisted of UNODC policy documents mandating and guiding global action to address substance use. The analysis showed that at the level of political frameworks, prevention is gradually gaining more attention but is still frequently left in the shadow of health- and law enforcement-related issues. In addition, these guiding documents did not reflect fully the current scientific understanding of what constitutes an effective prevention response. Against this background, the feasibility of the UNODC’s efforts to bridge the science–practice gap in the field of prevention was discussed by presenting the results from the UNODC’s regional capacity-building seminars focused on the role of monitoring and evaluation in prevention programming. The results showed potential of this capacity building to affect the attitudes and knowledge of targeted decision-makers. Such efforts to increase decision-makers’ readiness and ultimately their endorsement, adoption, and ongoing support of evidence-based preventive interventions should be continued and intensified.

Parenting Programs for Underserved Populations in Low- and Middle-Income Countries: Issues of Scientific Integrity and Social Justice

Research suggests that parenting programs are effective for preventing behavioral and emotional difficulties in children, but a lot more attention needs to be paid to issues of context and culture during the development, testing and implementation of these interventions. The views and needs of underserved and disenfranchised communities in the US and the Global South are often not taken into account for the development and testing of interventions. The successful implementation of evidence-based interventions for vulnerable children and families in underserved and marginalized communities requires careful consideration of how existing paradigms of prevention, evaluation, and implementation science impact issues of social justice and equity. This paper will describe how a team of parenting program researchers has been collaborating with their partners globally in generating local knowledge by balancing the need for rigorous scientific methods with issues of power. Authors from the U.S., Latin America, Africa and Southeast Asia draw on their experiences regarding challenges and successes with issues regarding study design and measurement, the transferability and adaptation of interventions, and the dissemination and implementation of different parenting interventions while placing communities at the center of their efforts through participatory methods. We describe innovative approaches that span the continuum of intervention development, adaptation, optimization, evaluation, implementation, and scale up of different parenting programs for vulnerable children and families across the world. We conclude by offering specific and pragmatic recommendations to increase access of culturally relevant and effective parenting programs in these communities.

Research Needs for Implementing Cancer Prevention and Early Detection in Developing Countries: From Scientists' to Implementers' Perspectives

Implementation of evidence-based cancer prevention and early detection in low- and middle-income countries (LMIC) is challenging. Limited and inappropriate introduction of novel alternatives results in an equity gap whereby low-income populations receive a lower benefit. Implementation research represents an opportunity to foster the adoption and expansion of evidence-based cancer control strategies; however, scientific development in high-income countries does not necessarily fulfill the particular needs of LMIC in the field. A review on the link between implementation research and practice, the tension between theory and pragmatism, the conflict around implementation research methods, and determinants of research priority definition was carried out by considering the perspective of cancer prevention and early detection implementers in LMIC. Basic principles and alternatives to overcome implementation research challenges in these settings are discussed.

Championing Equity, Empowerment, and Transformational Leadership in (Mental Health) Research Partnerships: Aligning Collaborative Work With the Global Development Agenda

Through a narrative synthesis of existing literature on research partnerships, the paper underscores four core values championed in public policy and practice: equity, empowerment, transformational leadership, and treating mental health research as a cooperative inquiry. Building on these values, the author maps the challenges before mental health researchers in forging resilient, egalitarian, and committed Global North-South partnerships within the context of current global development agenda. Reports appraising the UN Millennium Development Goals lament how the goal of developing global partnerships to combat health, gender, and economic inequities has remained under-realized. Emphasis has been placed on the great need to augment Sustainable Development Goals (SDG) in ways where partnership processes would drive development and human rights agenda for the most afflicted, under-resourced, and marginalized in the world. Global North-South partnerships result in fewer lasting benefits to Global South-a regressive trend that is critically analyzed. The need for Global North to adopt ethical and responsible stances while creating/curating new knowledge is discussed. Being responsible is not only imperative for Global North researchers; it is imperative for both North and South researchers to adopt a dialogical approach in clarifying and sharing roles, responsibilities, access, and leadership in developing scholarship and praxis in mental health. The importance of de-centering hierarchies, valuing reciprocity in one another, improving communication, demonstrating empathy, and sharing resources and benefits are found to be key components in the narrative synthesis towards achieving greater empowerment and equity. The paper reflects on the potential problems in engagement and development of de-centered and transformational leadership in partnerships and implications for research ethics in the context of lower-and-middle-income countries. Lastly, the author in a bid to encourage global partnerships suggests that engaging in transparent and bi-directional conversations regarding these issues and realigning research priorities along the four core values will contribute to greater success in research collaborations (across cultural contexts) and more so in the global mental health field.