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Lachman a parenting programme to reduce child maltreatment

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Development of a parenting programme to reduce risk of child maltreatment in South Africa (pilot randomised controlled trial) - presentation by Jamie Lachman in Oxford seminar series on Children and Youth in a Changing World

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Lachman a parenting programme to reduce child maltreatment

  1. 1. Development of a parenting programme to reduce risk of child maltreatment in South Africa Pilot Randomised Controlled Trial Lachman, Cluver, Ward, Hutchings, Gardner, Wessels, Kelly, & Mlotshwa Children and Youth in a Changing World A University of Oxford inter-departmental seminar series
  2. 2. I was involved in the development, implementation, training, and supervision the Sinovuyo Caring Families Programme. I am not a parent. Disclosure
  3. 3. Sinovuyo Caring Families Project – PLH for Young Children 2-9 COLLABORATIVE+ RESEARCH SA Gov't Development, Health, Education Research, policy, and clinical practice working together
  4. 4. RESEARCH TEAM University of Oxford: Centre for Evidence Based Intervention Associate Professor Lucie Cluver (Principal Investigator) Professor Frances Gardner (Co-investigator) Jamie Lachman (Co-investigator) University of Cape Town: Department of Psychology Associate Professor Catherine Ward (Principal Investigator) Inge Wessels (PhD Student) Bangor University: Department of Psychology Professor Judy Hutchings (Co-investigator)
  5. 5. Early stages of intervention research Medical Research Council Framework for Complex Social Interventions (Craig et al 2008)
  6. 6. Phase 1: Program development - Step 1: Determining problem theory, existing evidence-base, theory of change - Step 2: Formative research in Cape Town - Step 3: Local/cultural adaptation - Step 4: Manual development - Step 5: Facilitator training
  7. 7. Step 1: Problem theory Caregiver Factors Child Abuse Child Factors Poor Parent- Child Rela onships Social Factors
  8. 8. Who are these parents?
  9. 9. Identifying the evidence-base • Lots of evidence in HICs – Barlow 2006, Mikton and Butchart 2009, Furlong 2012 – PMT-O, Triple-P, Incredible Years, PCIT, etc. • Limited evidence in LMICs, especially for families with children ages 2 to 9 (Knerr, Gardner & Cluver; 2013) • Challenges importing evidence (Mikton 2012) – High costs of established programmes – Generalizability of evidence-based approaches
  10. 10. Theory of Change: How evidence-based parenting programmes work
  11. 11. Evidence-based parenting programmes Different brands, same ingredients/components...but do they (Orobio de Castro) work in South Africa?
  12. 12. Step 2: Formative research in Cape Town - Research Aims - Challenges and coping strategies of parents - Cultural applicability of evidence-based principles and approaches - Feasibility issues in implementing parenting programmes - Methods: - Semi-structured focus groups - In-depth interviews - 97 parents; 29 service providers - Consultation with experts and community based organisations - Thematic analysis
  13. 13. Formative research results - Challenges facing parents: - Financial stress - Child behavior problems - Crime/violence in community - Absence of fathers - Core Themes/Needs: - Issue of RESPECT (communication, behavior) - Relationship building with children - Keeping children safe in community - Stress reduction techniques - Corporal punishment used widely BUT parents expressed desire for alternative methods “I beat my child because I don’t know what else to do...”
  14. 14. Step 3: Local adaptation • Culturally specific content/delivery to support learning – Introduction of principles through stories – Emphasis on communal aspects of parenting – Linking “Respect” to specific child behaviour (i.e. – household rules) – Expanded notion of “Play” to include Special Time • Additional content to address stress and safety – Mindfulness based stress reduction techniques – Child safety and communicating about HIV/AIDS and poverty • Additional support to promote participation and engagement • Fundamentally similar to existing evidence-based parent management training programs from HICs
  15. 15. Step 4: Manual Development • Prevention AND Early Intervention – At-risk families in low-income communities – Children with clinical levels of behaviour problems – Available to ALL caregivers responsible for child’s wellbeing • Group-based approach – 12 weekly group sessions – Home visits to support learning • Low-cost delivery – Paraprofessional facilitators – Illustrated stories and SMS’s – Creative Commons License – Free to use
  16. 16. Problem Solving Nonviolent Discipline Instruction Giving and Household Rules Using Praise and Rewards Special Time for You and Your Child Establishing Parent Goals Building a Rondavel of Support© for You and Your Child Sunshine of Positive Attention Thatch Roof: Limit Setting and Discipline Mud Walls: Positive Parenting Naming Feelings and Actions
  17. 17. Step 5: Facilitator training • Community facilitators – Parents with basic ECD training – Experience facilitating groups • Initial training in facilitation methods – Understanding core parenting principles – Collaborative approach to facilitation – Observation skills and problem solving • Additional training, mentorship, and supervision – Participation in programme prior to facilitation – Training in session content – Ongoing supervision using video playback, role-plays, and group problem-solving
  18. 18. 1. Feasibility of conducting a randomised controlled trial in low-income contexts in South Africa? 2. Feasibility of delivering evidence-informed parenting programme? 3. Preliminary efficacy in reducing risks related to child maltreatment?
  19. 19. Study design • Feasibility Pilot RCT • Intention to treat analysis • 1 : 1 intervention to wait-list control group • Baseline and immediate post-test • Participants • Recruitment in Khayelitsha from local NGO • IsiXhosa speaking parents of children ages 3 to 8 • > 10 on Eyberg Child Behaviour Inventory Problem Scale • Available for weekday morning sessions
  20. 20. Sample characteristics (n = 68 parent-child dyads) Mean parent age 42 years Parent gender (female) 98% Mean child age 5 years Child gender (female) 49% Relationship to child (mother) 59%
  21. 21. 29% Multiple risk factors for abuse 34% 43% 82% 97% 79% Familial HIV/AIDS Intimate Partner Violence Parent Abused as Child Not Matriculated Unemployed Experience Hunger 5 or More Days in Past 30 Days
  22. 22. Outcomes: Evaluation Feasibility • Study recruitment/retention • Randomisation procedures (i.e. blinding & contamination) • Outcome measure reliability • Response rates
  23. 23. Results: Evaluation Feasibility • Recruitment/Retention – 76% recruited (68/96) – 97% for self-report (66/68) – 88% for observational assessments (60/68) • Randomisation Procedures – 5.9% reported compromised blindness – Low contamination • Reliability high on all measures – Self-report: α > .75 except nonviolent discipline (.20) – Observational assessments: r > .70 except child positive behaviour • Response rate – Total: 2.8% missing values – Observational assessments (12% baseline; 10% post-test)
  24. 24. Outcomes: Programme Feasibility • Enrolment/ Attendance/ Engagement • Programme fidelity • Programme acceptability • Participant satisfaction surveys
  25. 25. Results: Enrolment/Attendance/Engagement • Programme enrolment: 82% (56/68) – 98% female caregivers, 97% unemployed – Dropout: employment, relocation, childcare • Attendance: 8.6 sessions (71%) – 64% went to 9 or more sessions • Engagement: 91% of assigned activities • Enrolment/Attendance factors – SMS boosters, home visits – Childcare, public transportation – Behaviour of facilitators – Missed sessions: illness, grant disbursement, bad weather, alcohol
  26. 26. “Ever since I came here, I have noticed that we are close. She has developed much love for me. She hugs me and always likes to spend time with me”
  27. 27. Results: Programme Fidelity • Programme fidelity – 93% of manualised activities implemented • Facilitating of parenting skills – Limit setting skills required more time to deliver – Initial challenge in understanding Time-Out principles • Delivery improved over time – Additional training each session – Supervision using videos supported delivery
  28. 28. “If you are dealing with a group, they can feel when you are not sure about something. But now at least we have that confidence of okay we gonna do it...so even they feel like this is okay, we can do it.... We were more competent.”
  29. 29. Results: Weekly Participant Satisfaction Item Mean score over 12 sessions out of total score of 5 Feeling supported by the group leaders 4.87 Understanding of session content 4.85 Helpfulness of session content 4.91 Sharing of thoughts and experiences 4.90 Helpfulness of group practices (role-plays) 4.95 Ability to do home practice 4.71
  30. 30. Results: Final Participant Satisfaction Overall satisfaction score: M 94.2, SD 5.2 (n = 47*) Item Weighted score out of 100 Met goals and expectations 89.1, SD 8.4 Format of delivery 94.9, SD 10.3 Appropriateness of parenting skills 95.9. SD 6.7 Evaluation of group leaders 98.6, SD 3.1 Supportiveness of group 83.1, SD 20.3 Desire to meet in a group after program 83.3% of respondents
  31. 31. Results: Cultural Acceptability • High satisfaction of programme delivery and content • Overall reported positive change • Challenges with some parenting skills • Strong acceptability of delivery format
  32. 32. “I’ve learned to sit down with my child, to communicate, to read stories, and maybe sometimes on the weekends, we go out. So, I spend a lot of time with my child.”
  33. 33. Outcomes: Preliminary Efficacy • Data collection methods – Self-report using cellphones – Video observation coding of parent-child interaction • Primary outcomes – Harsh parenting – Positive parenting – Child behaviour problems • Secondary outcomes – Parental depression: Beck – Parenting stress – Social support – Intimate partner violence
  34. 34. Results: Preliminary Efficacy • Multiple imputation for missing data • No significant differences at baseline • ANOVA: Parent self report – Medium effect for positive parenting – Small effects for reduced child behaviour problems, stress, and social support (non-sig) • ANOVA: Observational assessments – Medium effect for increased child-led play – Medium effect for decreased child positive behaviour – Small effect for increased child negative behaviour
  35. 35. Parent-Report Positive Parenting Frequency Scale 21.50 25.35 20.12 20.02 27.00 25.00 23.00 21.00 19.00 Sig increase in positive parenting: F = 8.74, p < .01 Cohen's d = 0.68, 95% CI 0.19 to 1.17 17.00 Baseline Post-test Intervention Control
  36. 36. Observed Child-led Play 0.65 0.91 0.55 0.49 Sig increase in child-led play: F 4.80, p < .05 Cohen's d = 0.52, 95%, CI 0.04 to 1.00 1.00 0.90 0.80 0.70 0.60 0.50 0.40 Baseline Post-test Intervention Control
  37. 37. Parent-Report Child Behaviour Problems Intensity 120.59 111.41 99.78 122.56 125.00 120.00 115.00 110.00 105.00 100.00 Sig decrease in child behaviour probs: F = 1.45, p > .05 Cohen's d = 0.26, 95% CI -0.22 to 0.74 95.00 Baseline Post-test Intervention Control
  38. 38. Observed Frequency of Child Positive Behaviour 17.95 15.48 13.49 10.03 Sig decrease in child positive behaviour: F 5.38, p < .05 Cohen's d = -0.55, 95%, CI -1.05 to -0.07 19 17 15 13 11 9 Baseline Post-test Intervention Control
  39. 39. • Feasibility Discussion – High programme and evaluation feasibility – Randomisation possible in low-resource contexts – Attendance and fidelity rates and comparable to HIC • Preliminary Efficacy – Positive parenting improved – Parent-report vs. Observation for Child behaviour – No change in harsh parenting or other measures
  40. 40. Discussion: Limitations • Small sample size • Representativeness and insufficient power • No fathers or working people • First run of programme: inexperienced facilitators • Outcome measures valid? • No long-term follow-up
  41. 41. Discussion: Future recommendations • Programme revision – Some evidence-based principles may require additional sessions and/or time – Increase accessibility and inclusion – Programme fidelity requires extensive training, supervision, and logistical support • Evaluation approach – Larger sample size and longer-term follow-up – Validity of outcome measures – Quality of delivery and relationship to outcomes
  42. 42. Next Steps: Efficacy Study (2014-2015) • Revised programme in early 2014 • Multisite RCT trial in Nyanga and Khayelitsha (n=290, 12 month follow-up) • Subgroup analyses (i.e. HIV/ violence/ disability) • Mediators and moderators • Component research • Parenting for Lifelong Health with World Health Organization and UNICEF
  43. 43. THANK YOU!!! The John Fell Fund and the Clarendon Fund National Lottery Trust Distribution Fund And all the research assistants, volunteers, group facilitators, project managers, and other unsung heroes! Ilifa Labantwana World Health Organisation
  44. 44. References • Barlow, J., Johnston, I., Kendrick, D., Polnay, L., & Stewart-Brown, S. (2006). Individual and group-based parenting programmes for the treatment of physical child abuse and neglect. Cochrane Database of Systematic Reviews, 3, 1-20. • Bernal, G. (2006). Intervention development and cultural adaptation research with diverse families. Family process, 45(2), 143-151. • Campbell, N. C., Murray, E., Darbyshire, J., Emery, J., Farmer, A., Griffiths, F., Guthrie, B., Lester, H., Wilson, P., & Kinmonth, A. L. (2007). Designing and evaluating complex interventions to improve health care. BMJ (Clinical research ed ), 334(7591), 455-459. • Castro, F. G., Barrera, M., Jr., & Holleran Steiker, L. K. (2010). Issues and challenges in the design of culturally adapted evidence-based interventions. Annual review of clinical psychology, 6, 213-239. doi: 10.1146/annurev-clinpsy-033109-132032 • Coley, R. L., & Hoffman, L. W. (1996). Relations of parental supervision and monitoring to children's functioning in various contexts: Moderating effects of families and neighborhoods. Journal of Applied Developmental Psychology, 17(1), 51-68. • Craig, P., Dieppe, P., McIntyre, S., Nazareth, I., Petticrew, M. (2008). Developing and evaluating complex interventions: the new Medical Research Council guidance. British Medical Journal, 337, a1655. • Furlong, M., McGilloway, S., Bywater, T., Hutchings, J., Smith, S. M., & Donnelly, M. (2012). Behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years. Cochrane Database Syst Rev, 2, CD008225. • Hutchings, J., Gardner, F., Lane, E. (2004). Making evidence-based intervention work. In D. Farrington, C. Sutton & D. Utting (Eds.), Support from the Start: Working with Young Children and their Families to Reduce the Risks of Crime and Antisocial Behaviour. London: DFES. • Kaminski, J. W., Valle, L. A., Filene, J. H., & Boyle, C. L. (2008). A meta-analytic review of components associated with parent training program effectiveness. Journal of Abnormal Child Psychology, 36(4), 567-589. doi: 10.1007/s10802-007-9201-9
  45. 45. References • Knerr, W., Gardner, F., & Cluver, L. (2013). Improving positive parenting skills and reducing harsh and abusive parenting in low- and middle-income countries: a systematic review. Prevention Science, 14(4), 352-363. • Kumpfer, K. L., Alvarado, R., Smith, P., & Bellamy, N. (2002). Cultural sensitivity and adaptation in family-based prevention interventions. [Research Support, U.S. Gov't, P.H.S.]. Prevention Science, 3(3), 241-246. • Lau, A. S. (2006). Making the case for selective and directed cultural adaptations of evidence-based treatments: Examples from parent training. Clinical Psychology-Science and Practice, 13(4), 295-310. • Meinck, F., Cluver, L. D., Boyes, M. E., & Mhlongo, E. L. (2014). Risk and protective factors for physical and sexual abuse of children and adolescents in Africa: A review and implications for practice. Trauma, Violence, & Abuse. doi: 1524838014523336. • Mikton, C. (2012). Two challenges to importing evidence-based child maltreatment prevention programs developed in high-income countries to low- and middle-income countries: Generalizability and affordability. In H. Dubowitz (Ed.), World perspectives on child abuse¬ (Vol. 10, pp. 97). Aurora, CO: International Society for the Prevention of Child Abuse and Neglect. • Mikton, C., & Butchart, A. (2009). Child maltreatment prevention: a systematic review of reviews. Bulletin of the World Health Organization, 87(5), 353-361. • Millar, S. L., & Donnelly, M. (2014). Promoting mental wellbeing: developing a theoretically and empirically sound complex intervention. Journal of Public Health, 36(2), 275-284. doi: Doi 10.1093/Pubmed/Fdt075 • Parra Cardona, J. R., Domenech-Rodriguez, M., Forgatch, M., Sullivan, C., Bybee, D., Holtrop, K., Escobar- Chew, A. R., Tams, L., Dates, B., Bernal G. (2012). Culturally adapting an evidence-based parenting intervention for Latino immigrants: the need to integrate fidelity and cultural relevance. Family Process, 51(1), 56-72. • Reid, J. B., & Patterson, G. R. (1989). The Development of Antisocial-Behavior Patterns in Childhood and Adolescence. European Journal of Personality, 3(2), 107-119.

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