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

A stakeholder perspective on the necessary conditions for successfully implementing parenting interventions in Botswana

Background

Encouraging positive parenting practices through evidence-based interventions is vital for the achievement of SDG target 16.2, which aims to eradicate all forms of violence against children while promoting their safety and mental wellbeing. As low- and middle- income countries increasingly adopt parenting programs, policymakers and implementers face the challenge of efficiently transporting, adapting, and implementing them across multiple settings.

Purpose

This study seeks to evaluate the real-world experiences, challenges, and best practices in implementing parent support programs in Botswana.

Method

A series of interviews with program implementers and stakeholders from governmental and non-governmental organizations were conducted. Key informants from governmental and non-governmental institutions were recruited through purposive and snowball sampling and 17 practitioners participated in the study. Data collection was carried out through online Zoom video conferencing at a convenient time and location for participants.

Findings

The findings indicate several factors that contribute to the successful implementation of parenting programs in Botswana, including (a) enabling factors such as supportive policies, regulations and guidelines, (b) innovative factors such as capacity building, program adaptation and mixed method program delivery, (c) bridging factors through collaborations with skilled organizations, and (d) intra-organizational factors such as organizational resources, program sustainability, and support for program staff.

Conclusion

No single organization or strategy can sustainably foster positive parenting support in Botswana. Instead, a collective and collaborative learning approach is necessary to develop lasting and scalable solutions.

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.

A structured approach to applying systems analysis methods for examining implementation mechanisms

BACKGROUND

It is challenging to identify and understand the specific mechanisms through which an implementation strategy affects implementation outcomes, as implementation happens in the context of complex, multi-level systems. These systems and the mechanisms within each level have their own dynamic environments that change frequently. For instance, sequencing may matter in that a mechanism may only be activated indirectly by a strategy through another mechanism. The dosage or strength of a mechanism may vary over time or across different health care system levels. To elucidate the mechanisms relevant to successful implementation amidst this complexity, systems analysis methods are needed to model and manage complexity.

METHODS

The fields of systems engineering and systems science offer methods-which we refer to as systems analysis methods-to help explain the interdependent relationships between and within systems, as well as dynamic changes to systems over time. When applied to studying implementation mechanisms, systems analysis methods can help (i) better identify and manage unknown conditions that may or may not activate mechanisms (both expected mechanisms targeted by a strategy and unexpected mechanisms that the methods help detect) and (ii) flexibly guide strategy adaptations to address contextual influences that emerge after the strategy is selected and used.

RESULTS

In this paper, we delineate a structured approach to applying systems analysis methods for examining implementation mechanisms. The approach includes explicit steps for selecting, tailoring, and evaluating an implementation strategy regarding the mechanisms that the strategy is initially hypothesized to activate, as well as additional mechanisms that are identified through the steps. We illustrate the approach using a case example. We then discuss the strengths and limitations of this approach, as well as when these steps might be most appropriate, and suggest work to further the contributions of systems analysis methods to implementation mechanisms research.

CONCLUSIONS

Our approach to applying systems analysis methods can encourage more mechanisms research efforts to consider these methods and in turn fuel both (i) rigorous comparisons of these methods to alternative mechanisms research approaches and (ii) an active discourse across the field to better delineate when these methods are appropriate for advancing mechanisms-related knowledge.

Integrating intimate partner violence prevention content into a digital parenting chatbot intervention during COVID-19: Intervention development and remote data collection

BACKGROUND

Intimate partner violence (IPV) is a serious public health issue which experienced a sharp incline during the onset of COVID-19. Increases in other forms of violence, such as violence against children (VAC), have also been linked to the pandemic, and there have been calls for greater prevention efforts that tackle both forms of violence concurrently. The COVID-19 crisis has highlighted the urgent need for evidence-based and scalable violence prevention interventions that target multiple forms of family violence. Parenting programmes have shown promising results in preventing various forms of family violence, including IPV and VAC, and have recently experienced an expansion in delivery, with digital intervention formats growing. This paper describes the development and evaluation of the IPV prevention content designed and integrated into ParentText, a chatbot parenting intervention adapted from Parenting for Lifelong Health programmes.

METHODS

The ParentText IPV prevention content was developed using the Six Steps in Quality Intervention Development (6SQuID) framework. This involved targeted literature searches for key studies to identify causal factors associated with IPV and determining those with greatest scope for change. Findings were used to develop the intervention content and theory of change. Consultations were held with academic researchers (n = 5), practitioners (n = 5), and local community organisations (n = 7), who reviewed the content. A formative evaluation was conducted with parents in relationships (n = 96) in Jamaica to better understand patterns in user engagement with the intervention and identify strategies to further improve engagement.

RESULTS

Using the 6SQuID model, five topics on IPV prevention were integrated into the ParentText chatbot. Text-messages covering each topic, including additional materials such as cartoons and videos, were also developed. The formative evaluation revealed an average user-engagement length of 14 days, 0.50 chatbot interactions per day, and over half of participants selected to view additional relationship content.

CONCLUSIONS

This article provides a unique contribution as the first to integrate IPV prevention content into a remotely delivered, digital parenting intervention for low-resource settings. The findings from this research and formative evaluation shed light on the promising potential of chatbots as scalable and accessible forms of violence prevention, targeting multiple types of family violence.

Translating research to usual care of children with sickle cell disease in Northern Nigeria: lessons learned from the SPRING Trial Team

OBJECTIVES

Evidence-based practice for stroke prevention in high-income countries involves screening for abnormal transcranial Doppler (TCD) velocity and initiating regular blood transfusions for at least 1 year, followed by treatment with hydroxyurea. This practice has not been transferred to low-resource settings like Nigeria, the country with the highest global population density of SCD. Following a multi-center randomized controlled trial among children with SCA in northern Nigeria, screening for stroke and initiation of hydroxyurea was established as standard of care at the clinical trial sites and other locations. We aim to describe the critical steps we took in translating research into practice for stroke prevention in SCA in Nigeria. Guided by the PRISM framework, we describe how we translated results from a randomized controlled trial for primary prevention of stroke in children with sickle cell anemia into usual care for children with SCA in Kaduna, Nigeria.

RESULTS

Findings from this study demonstrate the importance of organizational support and stakeholder involvement from the onset of a clinical trial. Having the dual objective of conducting an efficacy trial while simultaneously focusing on strategies for future implementation can significantly decrease the lag time between discovery and routine practice.

Prevention of child mental health problems through parenting interventions in Southeastern Europe (RISE): study protocol for a multi-site randomised controlled trial

BACKGROUND

Childhood adversities, such as poor parental practices, exposure to violence, and risk behaviours strongly impact children's future mental and behavioural problems. Adversities affect families living in disadvantaged environments and low- and middle-income countries (LMICs) to a greater extent than in high-income countries. Parenting programmes are an effective way to alleviate them, although their outreach and scalability is still limited in LMICs.

METHODS/DESIGN

A multi-site randomised controlled trial will be conducted in North Macedonia, Republic of Moldova and Romania to test the efficacy and cost-effectiveness of an optimised version of the promising Parenting for Lifelong Health Programme for Young Children (PLH-YC, 5 sessions), against a standard lecture on parenting issues (control group, 1 session). At least 864 participants who report having children between 2 and 9 years old who display elevated levels of behavioural difficulties will be randomised on a 1:1 basis to the intervention and control groups. The primary outcome will consist of parent report of child oppositional aggressive behaviour. Post-test (four months) and follow-up (12 months) assessments will provide information on short- and longer-term effects of PLH-YC compared to the parenting lecture in the control group.

DISCUSSION

This randomised trial will test the efficacy of PLH-YC in alleviating child behavioural problems and assess the cost-effectiveness, transportability across three different cultural contexts, and potential for scalability of the programme.

TRIAL REGISTRATION

ClinicalTrials.gov ., Registration number: NCT04721730 ( https://clinicaltrials.gov/ct2/show/NCT04721730 ). Registered 13.01.2021.

COVID-19 and the Acceleration of Behavioral Parent Training Telehealth: Current Status and Future Directions

The SARS-COV-2 (COVID-19) pandemic and associated social distancing guidelines have accelerated the telehealth transition in mental health. For those providing Behavioral Parent Training (BPT), this transition has called for moving sessions that are traditionally clinic-based, active, and directive to engaging, supporting, and treating families of children with behavior disorders remotely in their homes. Whereas many difficulties accompany this transition, the lessons learned during the current public health crisis have the potential to transform BPT service delivery on a large scale in ways that address many of its long-standing limitations. We describe both challenges and opportunities and consider the possibilities inherent in a large scale BPT service delivery model capable of increasing the reach and impact of evidence-based treatment for all families.

Engaging community voices to assess Kenya's strengths and limitations to support a child maltreatment prevention program

BACKGROUND

Preventing child maltreatment is a global mission of numerous international organizations, with parent support programs as the critical prevention strategy. In Kenya, 70 % of children are at risk of experiencing abuse and neglect, most often by their parents. Yet, there is a lack of evidence-based parent support programs, and a limited understanding of Kenya's capacity and infrastructures (e.g., policies, funding, service agencies) to support and sustain such programs.

OBJECTIVE

The purpose of this study was to assess systematically Kenya's strengths and limitations to implement a parent support program using a mixed-methods study design.

PARTICIPANTS AND METHODS

Twenty-one community stakeholders from Kenya completed the World Health Organization's (WHO) Readiness Assessment for the Prevention of Child Maltreatment to understand Kenya's preparedness to undertake a prevention program. In addition, 91 participants (e.g., parents, community health workers, community leaders) took part in focus group discussions or individual interviews to understand existing support networks around parenting programs.

RESULTS

Kenya's overall 'readiness' score was comparable to the other countries that completed the WHO survey. The survey results revealed Kenya's strengths and limitations across the ten readiness dimensions. Several themes emerged from the focus groups and interviews, including the diverse sources of support for parents, specific programs available for parents, and gaps in services offered.

CONCLUSIONS

The results document ways to build upon Kenyan's existing strengths to facilitate implementation of an evidence-based prevention program. These results also highlight the significant need to understand local context when adapting parenting programs for low/middle income countries (LMICs).

A Multi-Sectoral Approach Improves Early Child Development in a Disadvantaged Community in Peru: Role of Community Gardens, Nutrition Workshops and Enhanced Caregiver-Child Interaction: Project "Wawa Illari"

Background: Multi-dimensional monitoring evaluation and learning strategies are needed to address the complex set of factors that affect early child development in marginalized populations, but few studies have explored their effectiveness.

Objective: To compare improvement of health and development of children 0–3 years between intervention communities (IC) and control communities (CC) from peripheral settlements of Lima. Sequential interventions included: (1) home and community gardens, (2) conscious nutrition, and (3) parenting workshops following the International Child Development Program (ICDP).

Methods: Interventions were delivered by community health promoters (CHPs) using a “step-by-step” learning system. Both IC and CC were monitored before the interventions began, at 8 and 12 months (n = 113 IC and 127 CC children). Data were collected on household characteristics, diet, food security, health indicators (history of diarrhea and respiratory infections, hemoglobin, intestinal parasites, anthropometry), caregiver-child interactions and stress, and achievement of Pan-American Health Organization age-specific developmental milestones. Stepwise multiple logistic regressions were used to determine if the interventions affected food insecurity, as well as motor, social/cognitive and language delays.

Results: At baseline, 2.6% were categorized as “suspected developmental delay” and 14.2% were on “alert for development delay.” Food insecurity, diarrhea and respiratory infections were lowered following the interventions. Through the “step-by-step” approach, caregivers in IC gained skills in gardening, conscious nutrition and parenting that reduced the risk of food insecurity [Adjusted Risk Ratio = 0.20 (95% CI: 0.08–0.51)] and language delay [0.39 (0.19–0.82)] but not motor or social/cognitive delay. Use of a multiple micronutrient supplement decreased the risk of motor delay [0.12 (0.03–0.56)], but more pets were associated with higher risk of motor [3.24 (1.47–7.14)] and social/cognitive delay [2.72 (1.33–5.55)], and of food insecurity [1.73 (1.13–2.66)].

Conclusion: The combined interventions delivered by CHPs helped to mitigate the impact of adversity on food insecurity and language delay. Additional improvements may have been detected if the interventions had continued for a longer time. Our results indicate that control of infections and pets may be needed to achieve measurable results for motor and social/cognitive development. Continuous monitoring facilitated adjusting implementation strategies and achieving positive developmental outcomes.

Reframing implementation science to address inequities in healthcare delivery

BACKGROUND

Research has generated valuable knowledge in identifying, understanding, and intervening to address inequities in the delivery of healthcare, yet these inequities persist. The best available interventions, programs and policies designed to address inequities in healthcare are not being adopted in routine practice settings. Implementation science can help address this gap by studying the factors, processes, and strategies at multiple levels of a system of care that influence the uptake, use, and the sustainability of these programs for vulnerable populations. We propose that an equity lens can help integrate the fields of implementation science and research that focuses on inequities in healthcare delivery.

MAIN TEXT

Using Proctor et al.' (12) framework as a case study, we reframed five elements of implementation science to study inequities in healthcare. These elements include: 1) focus on reach from the very beginning; 2) design and select interventions for vulnerable populations and low-resource communities with implementation in mind; 3) implement what works and develop implementation strategies that can help reduce inequities in care; 4) develop the science of adaptations; and 5) use an equity lens for implementation outcomes.

CONCLUSIONS

The goal of this paper is to continue the dialogue on how to critically infuse an equity approach in implementation studies to proactively address healthcare inequities in historically underserved populations. Our examples provide ways to operationalize how we can blend implementation science and healthcare inequities research.

Teaching GenerationPMTO, an evidence-based parent intervention, in a university setting using a blended learning strategy

BACKGROUND

Despite the large number of evidence-based practices (EBPs) ready for implementation, they are the exception in usual care, especially for ethnic minority patients, who may not have access to trained health professionals. Providing EBP training as part of a graduate curriculum could help build the pipeline of professionals to provide quality care.

METHODS

We conducted a before-after study to determine whether we could implement a blended learning strategy (BL; i.e., in vivo and online training) to teach an EBP in university settings. Feasibility in this pilot was operationalized as knowledge acquisition, satisfaction, fidelity, acceptability, and usability. Using GenerationPMTO as the EBP, our aim was to train graduate students enrolled in Psychology, Social Work, and Family Therapy programs in the EBP in one academic year. Two therapists from a community agency were also students in this pilot. A total of 13 students from five universities were trained in the intervention. Adaptations were made to the intervention and training strategy to optimize training fidelity. Focus groups were conducted with the students to capture their perspective about the training.

RESULTS

Students demonstrated significant knowledge acquisition from baseline (Mean = 61.79, SD = 11.18) to training completion (Mean = 85.27, SD = 5.08, mean difference = - 23.48, 95% CI = - 29.62, - 17.34). They also reported satisfaction with the BL format, as measured by teaching evaluations at the end of the course. Instructors received acceptable fidelity scores (range of 7-9 in a 9-point scale). Qualitative findings from focus groups showed support for acceptability and usability of BL training.

CONCLUSIONS

BL training in university settings can be conducted with fidelity when provided by appropriately trained instructors. BL that integrates EBP and adaptations may be uniquely applicable for training providers in low-resource and ethnically diverse settings. The BL enhanced knowledge of GenerationPMTO was acceptable and usable to students, and was delivered with high instructor fidelity to the training model.