Applying the WHO-INTEGRATE evidence-to-decision framework in the development of WHO guidelines on parenting interventions: step-by-step process and lessons learnt.

BACKGROUND: Development of guidelines for public health, health system, and health policy interventions demands complex systems thinking to understand direct and indirect effects of interventions within dynamic systems. The WHO-INTEGRATE framework, an evidence-to-decision framework rooted in the norms and values of the World Health Organization (WHO), provides a structured method to assess complexities in guidelines systematically, such as the balance of an intervention's health benefits and harms and their human rights and socio-cultural acceptability. This paper provides a worked example of the application of the WHO-INTEGRATE framework in developing the WHO guidelines on parenting interventions to prevent child maltreatment, and shares reflective insights regarding the value added, challenges encountered, and lessons learnt. METHODS: The methodological approach comprised describing the intended step-by-step application of the WHO-INTEGRATE framework and gaining reflective insights from introspective sessions within the core team guiding the development of the WHO guidelines on parenting interventions and a methodological workshop. RESULTS: The WHO-INTEGRATE framework was used throughout the guideline development process. It facilitated reflective deliberation across a broad range of decision criteria and system-level aspects in the following steps: (1) scoping the guideline and defining stakeholder engagement, (2) prioritising WHO-INTEGRATE sub-criteria and guideline outcomes, (3) using research evidence to inform WHO-INTEGRATE criteria, and (4) developing and presenting recommendations informed by WHO-INTEGRATE criteria. Despite the value added, challenges, such as substantial time investment required, broad scope of prioritised sub-criteria, integration across diverse criteria, and sources of evidence and translation of insights into concise formats, were encountered. CONCLUSIONS: Application of the WHO-INTEGRATE framework was crucial in the integration of effectiveness evidence with insights into implementation and broader implications of parenting interventions, extending beyond health benefits and harms considerations and fostering a whole-of-society-perspective. The evidence reviews for prioritised WHO-INTEGRATE sub-criteria were instrumental in guiding guideline development group discussions, informing recommendations and clarifying uncertainties. This experience offers important lessons for future guideline panels and guideline methodologists using the WHO-INTEGRATE framework.

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.

Research review: Effects of parenting programs for children's conduct problems on children's emotional problems - a network meta-analysis.

BACKGROUND: Specific programs are often implemented for specific child mental health problems, while many children suffer from comorbid problems. Ideally, programs reduce a wider range of mental health problems. The present study tested whether parenting programs for children's conduct problems, and which individual and clusters of program elements, have additional effects on children's emotional problems. METHODS: We updated the search of a previous systematic review in 11 databases (e.g., PsycINFO and MEDLINE) and included studies published until July 2020 with keywords relating to 'parenting', 'program', and 'child behavioral problems'. Also, we searched for recent trials in four trial registries and contacted protocol authors. Studies were eligible for inclusion if they used a randomized controlled trial to evaluate the effects of a parenting program for children aged 2-10 years which was based on social learning theory and included a measure of children's emotional problems postintervention. RESULTS: We identified 69 eligible trials (159 effect sizes; 6,240 families). Robust variance estimation showed that parenting programs had small significant parent-reported additional effects on emotional problems immediately postintervention (Cohen's d = -0.14; 95% CI, -0.21, -0.07), but these effects faded over time. Teachers and children did not report significant effects. Additional effects on emotional problems were larger in samples with clinical baseline levels of such problems. No individual program elements predicted larger additional effects. Of the clusters of elements, combining behavior management and relationship enhancement elements was most likely to yield the strongest additional effects. CONCLUSIONS: The additional effects on emotional problems of parenting programs designed to reduce conduct problems are limited, but some clusters of elements predict larger effects. Our findings may contribute to realistic expectations of the benefits of parenting programs for children's conduct problems and inform the development of programs with wider benefits across mental health problems.

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.

Optimising engagement in a digital parenting intervention to prevent violence against adolescents in Tanzania: protocol for a cluster randomised factorial trial.

BACKGROUND: Violence against adolescents is a universal reality, with severe individual and societal costs. There is a critical need for scalable and effective violence prevention strategies such as parenting programmes, particularly in low- and middle-income countries where rates of maltreatment are highest. Digital interventions may be a scalable and cost-effective alternative to in-person delivery, yet maximising caregiver engagement is a substantial challenge. This trial employs a cluster randomised factorial experiment and a novel mixed-methods analytic approach to assess the effectiveness, cost-effectiveness, and feasibility of intervention components designed to optimise engagement in an open-source parenting app, ParentApp for Teens. The app is based on the evidence-based Parenting for Lifelong Health for Teens programme, developed collaboratively by academic institutions in the Global South and North, the WHO, and UNICEF. METHODS/DESIGN: Sixteen neighbourhoods, i.e., clusters, will be randomised to one of eight experimental conditions which consist of any combination of three components (Support: self-guided/moderated WhatsApp groups; App Design: sequential workshops/non-sequential modules; Digital Literacy Training: on/off). The study will be conducted in low-income communities in Tanzania, targeting socioeconomically vulnerable caregivers of adolescents aged 10 to 17 years (16 clusters, 8 conditions, 640 caregivers, 80 per condition). The primary objective of this trial is to estimate the main effects of the three components on engagement. Secondary objectives are to explore the interactions between components, the effects of the components on caregiver behavioural outcomes, moderators and mediators of programme engagement and impact, and the cost-effectiveness of components. The study will also assess enablers and barriers to engagement qualitatively via interviews with a subset of low, medium, and high engaging participants. We will combine quantitative and qualitative data to develop an optimised ParentApp for Teens delivery package. DISCUSSION: This is the first known cluster randomised factorial trial for the optimisation of engagement in a digital parenting intervention in a low- and middle-income country. Findings will be used to inform the evaluation of the optimised app in a subsequent randomised controlled trial. TRIAL REGISTRATION: Pan African Clinical Trial Registry, PACTR202210657553944. Registered 11 October 2022, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=24051 .

Commentary for Special Issue on Using Baseline Target Moderation to Assess Variation in Prevention Impact: When (and How) to Revise Our Programs.

Developing a better understanding of sources and mechanisms of heterogeneity is a key route to improving outcomes and targeting of preventive interventions. This commentary attempts to draw together findings from eight intervention trials in this special issue, each exploring baseline target moderation (BTM) or baseline target moderated mediation (BTMM). It considers their implications for prevention research and program design, particularly the question of whether they can help us to revise or adapt interventions. The studies cover a range of interventions, targets, and contexts, including parenting, couple, and CBT interventions, for depression, anxiety, conduct problems, or obesity. Some important findings stand out. Where studies found moderator effects, they tended to operate in a "compensatory" fashion, such that greater benefit was found in higher risk groups, suggesting that closer targeting might be warranted. It was rare for harmful effects to be detected for any subgroups. In other respects, patterns of BTM/BTMM findings were quite mixed across studies, suggesting it would be premature to change our interventions based on these trials. Implications of the findings for equity, for "slimming down" and scaling up interventions, and for research are discussed, including the need to combine BTMM with intervention component research, and to accumulate a more robust body of evidence by pooling data across trials.

Does Social and Economic Disadvantage Predict Lower Engagement with Parenting Interventions? An Integrative Analysis Using Individual Participant Data.

There is a social gradient to the determinants of health; low socioeconomic status (SES) has been linked to reduced educational attainment and employment prospects, which in turn affect physical and mental wellbeing. One goal of preventive interventions, such as parenting programs, is to reduce these health inequalities by supporting families with difficulties that are often patterned by SES. Despite these intentions, a recent individual participant data (IPD) meta-analysis of the Incredible Years (IY) parenting program found no evidence for differential benefit by socioeconomic disadvantage (Gardner et al. in Public Health Resesearch 5, 1-144, 2017). However, it did not examine whether this was influenced by engagement in the intervention. Using intervention arm data from this pooled dataset (13 trials; N = 1078), we examined whether there was an SES gradient to intervention attendance (an indicator of engagement). We ran mixed-effects Poisson regression models to estimate incidence rate ratios (IRRs) for program attendance for each of five (binary) markers of SES: low income; unemployment; low education status; teen parent; and lone parent status. The multilevel structure of the data allowed for comparison of within-trial and between-trial effects, including tests for contextual effects. We found evidence that low SES was associated with reduced attendance at parenting programs-an 8-19% reduction depending on the SES marker. However, there was no evidence that this association is impacted by differences in SES composition between trials or by the attendance levels of higher-SES families. The findings underscore the importance of developing and prioritizing strategies that enable engagement in parenting interventions and encourage program attendance by low-SES families.

The development, reliability, and validity of the Facilitator Assessment Tool: An implementation fidelity measure used in Parenting for Lifelong Health for Young Children.

BACKGROUND: The Parenting for Lifelong Health for Young Children (PLH-YC) programme aims to reduce violence against children and child behaviour problems among families in low- and middle-income countries (LMICs). Although the programme has been tested in four randomised controlled trials and delivered in over 25 countries, there are gaps in understanding regarding the programme's implementation fidelity and, more generally, concerning the implementation fidelity of parenting programmes in LMICs. AIMS: This study aims to address these gaps by examining the psychometric properties of the PLH-YC-Facilitator Assessment Tool (FAT)-an observational tool used to measure the competent adherence of PLH-YC facilitators. Examining the psychometric properties of the FAT is important in order to determine whether there is an association between facilitator competent adherence and programme outcomes and, if correlated, to improve facilitator performance. It is also important to develop the implementation literature among parenting interventions in LMICs. METHODS: The study examined the content validity, intra-rater reliability, and inter-rater reliability of the FAT. Revision of the tool was based on consultation with programme trainers, experts, and assessors. A training curriculum and assessment manual was created. Assessors were trained in Southeastern Europe and their assessments of facilitator delivery were analysed as part of a large-scale factorial experiment (N = 79 facilitators). RESULTS: The content validity process with PLH-YC trainers, experts, and assessors resulted in substantial improvements to the tool. Analyses of percentage agreements and intraclass correlations found that, even with practical challenges, assessments were completed with adequate yet not strong intra- and inter-rater reliability. CONCLUSIONS: This study contributes to the literature on the implementation of parenting programmes in LMICs. The study found that the FAT appears to capture its intended constructs and can be used with an acceptable degree of consistency. Further research on the tool's reliability and validity-specifically, its internal consistency, construct validity, and predictive validity-is recommended.

Research Review: The most effective parenting program content for disruptive child behavior - a network meta-analysis.

BACKGROUND: Programs to support parents are the recommended strategy to reduce disruptive child behavior problems. Efforts have been made to demonstrate which program components (i.e., clusters of techniques taught) increase program effects, but these methods fail to account for the fact that components rarely operate in isolation. We examine how combinations of components cluster together to form program types and use network meta-analysis to estimate the relative effects of these program types. METHODS: We updated an existing systematic review of parenting programs for disruptive child behavior and identified 197 randomized trials. We modeled clusters of components in each trial arm and chose the best-fitting model. We subsequently took 20 draws from the probability distribution of the latent class for each arm, entered each draw into a network meta-analysis model and combined findings using Rubin's rules. Combined estimates were bootstrapped to rank the clusters. We estimated main models and separate models for prevention and treatment settings. RESULTS: A five-class solution fit the data best: (1) behavior management; (2) behavior management with parental self-management; (3) behavior management with psychoeducation and relationship enhancement; (4) maximal component loading and (5) no/minimal component loading (i.e. control). In the main model and in treatment settings, all four program types were effective compared to no/minimal components. In prevention settings, only behavior management and behavior management with parental self-management were effective compared to no/minimal components. Probabilistic ranking showed that overall and in treatment settings, behavior management had the largest chance, and in prevention settings, behavior management with self-management had the largest chance, of being most effective compared to no/minimal components. CONCLUSIONS: Programs with more focused content seem more likely to yield stronger effects, and different foci may be needed in treatment versus prevention settings. Next steps include identifying individual family differences in optimal program content.

The Role of Clearinghouses in Promoting Transparent Research: A Methodological Study of Transparency Practices for Preventive Interventions.

Transparency of research methods is vital to science, though incentives are variable, with only some journals and funders adopting transparency policies. Clearinghouses are also important stakeholders; however, to date none have implemented formal procedures that facilitate transparent research. Using data from the longest standing clearinghouse, we examine transparency practices for preventive interventions to explore the role of online clearinghouses in incentivizing researchers to make their research more transparent. We conducted a descriptive analysis of 88 evaluation reports reviewed in 2018-2019 by Blueprints for Healthy Youth Development, when the clearinghouse began checking for trial registrations, and expanded on these efforts by applying broader transparency standards to interventions eligible for an endorsement on the Blueprints website during the study period. Reports were recent, with 84% published between 2010 and 2019. We found that few reports had data, code, or research materials that were publicly available. Meanwhile, 40% had protocols that were registered, but only 8% were registered prospectively, while one-quarter were registered before conducting analyses. About one-third included details in a registered protocol describing the treatment contrast and planned inclusions, and less than 5% had a registered statistical analysis plan (e.g., planned analytical methods, pre-specified covariates). Confirmatory research was distinguished from exploratory work in roughly 40% of reports. Reports published more recently (after 2015) had higher rates of transparency. Preventive intervention research needs to be more transparent. Since clearinghouses rely on robust findings to make well-informed decisions and researchers are incentivized to meet clearinghouse standards, clearinghouses should consider policies that encourage transparency to improve the credibility of evidence-based interventions.

Transparent, Open, and Reproducible Prevention Science.

The field of prevention science aims to understand societal problems, identify effective interventions, and translate scientific evidence into policy and practice. There is growing interest among prevention scientists in the potential for transparency, openness, and reproducibility to facilitate this mission by providing opportunities to align scientific practice with scientific ideals, accelerate scientific discovery, and broaden access to scientific knowledge. The overarching goal of this manuscript is to serve as a primer introducing and providing an overview of open science for prevention researchers. In this paper, we discuss factors motivating interest in transparency and reproducibility, research practices associated with open science, and stakeholders engaged in and impacted by open science reform efforts. In addition, we discuss how and why different types of prevention research could incorporate open science practices, as well as ways that prevention science tools and methods could be leveraged to advance the wider open science movement. To promote further discussion, we conclude with potential reservations and challenges for the field of prevention science to address as it transitions to greater transparency, openness, and reproducibility. Throughout, we identify activities that aim to strengthen the reliability and efficiency of prevention science, facilitate access to its products and outputs, and promote collaborative and inclusive participation in research activities. By embracing principles of transparency, openness, and reproducibility, prevention science can better achieve its mission to advance evidence-based solutions to promote individual and collective well-being.

Preventing child mental health problems in southeastern Europe: Feasibility study (phase 1 of MOST framework).

The prevalence of child emotional and behavioral problems is an international problem but is higher in low- and middle-income countries (LMIC) where there are often less mental health supports for families. Parenting programs can be an effective means of prevention, but must be low-cost, scalable, and suitable for the local context. The RISE project aims to systematically adapt, implement, and evaluate a low-cost parenting program for preventing/reducing child mental health problems in three middle-income countries in Southeastern Europe. This small pre-post pilot study is informed by the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework and tested the feasibility of the intervention, the implementation, and evaluation procedures: Phase 1 of the three-phase Multiphase Optimization Strategy (MOST) for program adaptation. Local facilitators delivered the Parenting for Lifelong Health (PLH) for Young Children program to parents of children aged 2-9 in North Macedonia, the Republic of Moldova and Romania in 2018. Parents completed assessments pre- and post-program. Results demonstrated positive pre-post change for participating families (N = 140) on various outcomes including child externalizing and internalizing symptoms and parenting behavior, in all three countries, all in the expected direction. Program participation was associated with positive outcomes in participating families. Based on the experiences of this pilot study, we outline the practical implications for the successful implementation of parenting programs in the three countries that will inform our next study phases, factorial experiment, and RCT.

El predominio de los problemas emocionales y conductuales de los niños es un problema internacional, pero es mayor en los países de ingresos bajos y medios donde generalmente hay menos asistencia para la salud mental de las familias. Los programas de crianza pueden ser un medio de prevención eficaz, pero deben ser de bajo costo, escalables y adecuados para el contexto local. El proyecto RISE tiene como finalidad adaptar, implementar y evaluar sistemáticamente un programa de crianza de bajo costo para prevenir o reducir los problemas de salud mental infantil en tres países de ingresos medios del Sudeste de Europa. Este pequeño estudio piloto previo y posterior está fundamentado por el marco de Alcance, Eficacia, Adopción, Implementación y Mantenimiento (RE-AIM, por sus siglas en inglés) y evaluó la viabilidad de los procedimientos de intervención, de implementación y de evaluación: Fase 1 de la Estrategia de Optimización Multifase (MOST) de tres fases para la adaptación del programa. Un grupo de moderadores locales impartió el programa Crianza para la Salud Durante Toda la Vida (Parenting for Lifelong Health, PLH) para Niños Pequeños a padres de niños de entre 2 y 9 años en Macedonia del Norte, República de Moldavia, y Rumania en 2018. Los padres completaron evaluaciones antes y después del programa. Los resultados demostraron cambios positivos después del programa para las familias participantes (N = 140) en varias respuestas, entre ellas, los síntomas de exteriorización y de interiorización de los niños y la conducta de crianza, en los tres países, todos en la dirección esperada. La participación en el programa estuvo asociada con resultados positivos en las familias participantes. Sobre la base de las experiencias de este estudio piloto, describimos las consecuencias prácticas para la implementación satisfactoria de los programas de crianza en los tres países que servirán como base para las fases de nuestro próximo estudio, del experimento factorial y del ensayo controlado aleatorizado.

Book-Sharing for Parenting and Child Development in South Africa: A Randomized Controlled Trial.

This study evaluated the impact of a parenting intervention on children's cognitive and socioemotional development in a group of caregivers and their 21-to-28-month-old children in a low-income South African township. A randomized controlled trial compared an experimental group (n = 70) receiving training in dialogic book-sharing (8 weekly group sessions) with a wait-list control group (n = 70). They were assessed before the intervention, immediately following it, and at a six month follow-up. The intervention had positive effects on child language and attention, but not behavior problems, prosocial behavior, or theory of mind. Intervention caregivers were less verbally and psychologically harsh, showed more sensitivity and reciprocity and more complex cognitive talk. This program benefitted parenting and child development and holds promise for low-income contexts.

Feasibility pilot of an adapted parenting program embedded within the Thai public health system.

BACKGROUND: This feasibility pilot of the Parenting for Lifelong Health for Young Children program in Thailand aimed to: 1) explore the feasibility of study evaluation approaches; 2) assess the feasibility of delivering an adapted program; 3) report indicative effects on child maltreatment and related outcomes; and 4) examine intervention content associated with key mechanisms of change perceived by caregivers and facilitators. METHOD: Sixty primary caregivers of children aged 2-9 years were recruited for an 8-week parenting program embedded within the local health system. Mixed-methods approaches included quantitative caregiver-report and observational data from standardized instruments, and qualitative data from individual and group interviews with caregivers and program facilitators. Analyses involved Wilcoxon signed-rank tests, paired t-tests, Friedman's ANOVA, and thematic analysis. RESULTS: Participants reported that most (65%) were grandparents or great-grandparents. Study retention and response rates were high, and enrolled caregivers attended an average of 93% of sessions. Primary outcomes showed caregiver-reported pre-post reductions in overall child maltreatment (d = - 0.58, p < 0.001), as well as reductions in physical (d = - 0.58, p < 0.001) and emotional abuse (d = - 0.40, p < 0.001). Combined caregiver report and observational assessments using the HOME Inventory showed reductions in abusive and harsh parenting (d = - 0.52, p < 0.001). Secondary outcomes demonstrated decreases in child neglect; dysfunctional parenting; poor child monitoring and supervision; parental sense of inefficacy; child behavior problems; daily report on child problem behavior; parent overall depression, anxiety, and stress; and attitudes supporting physical punishment and harsh discipline. There were increases in overall positive parenting, daily positive parenting behavior, as well as HOME Inventory assessments on parent-child relationships. Thematic analyses from interviews and focus group data identified six key program themes associated with strengthened parent-child relationships, reduced child behavior problems, improved attitudes and strategies toward discipline, and improved management of parental stress. CONCLUSIONS: This study represents one of few evaluations to test the feasibility of an evidence-based parenting program embedded within routine public health service delivery in a low- or middle-income country. Findings show preliminary effectiveness in reducing child maltreatment, improvements on 22 of 24 secondary outcomes, and perceived mechanisms of change that support quantitative findings. Prospects are promising for program scalability, pending randomized controlled trial results. TRIAL REGISTRATION: 11/01/2019, ClinicalTrials.gov, ID# NCT03539341 .

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

Relevant initiatives are being implemented in low- and middle-income countries (LMICs) aimed at strengthening a culture of prevention. However, cumulative contextual factors constitute significant barriers for implementing rigorous prevention science in these contexts, as defined by guidelines from high-income countries (HICs). Specifically, disseminating a culture of prevention in LMICs can be impacted by political instability, limited health coverage, insecurity, limited rule of law, and scarcity of specialized professionals. This manuscript offers a contribution focused on strengthening a culture of prevention in LMICs. Specifically, four case studies are presented illustrating the gradual development of contrasting prevention initiatives in northern and central Mexico, Panamá, and Sub-Saharan Africa. The initiatives share the common goal of strengthening a culture of prevention in LMICs through the dissemination of efficacious parenting programs, aimed at reducing child maltreatment and improving parental and child mental health. Together, these initiatives illustrate the following: (a) the relevance of adopting a definition of culture of prevention characterized by national commitments with expected shared contributions by governments and civil society, (b) the need to carefully consider the impact of context when promoting prevention initiatives in LMICs, (c) the iterative, non-linear, and multi-faceted nature of promoting a culture of prevention in LMICs, and (d) the importance of committing to cultural competence and shared leadership with local communities for the advancement of prevention science in LMICs. Implications for expanding a culture of prevention in LMICs are discussed.

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.

Los índices de maltrato infantil son más altos en los países de ingresos medios y bajos debido a factores de riesgo, como las desigualdades sociales, las dificultades económicas y las normas socioculturales. Teniendo en cuenta los datos que demuestran la eficacia de las intervenciones en la crianza para prevenir el maltrato infantil, este estudio inició una adaptación cultural de un programa de crianza factual con el objetivo principal de integrarlo dentro de un programa de transferencia condicional de dinero en efectivo a nivel nacional para padres filipinos de bajos recursos con niños de entre dos y seis años. Documentamos la adaptación sistemática del programa "Crianza para una buena salud durante toda la vida" (Parenting for Lifelong Health, PLH) orientado a niños pequeños que se desarrolló y se probó en Sudáfrica, para familias filipinas de bajos recursos utilizado el marco heurístico para las adaptaciones culturales de las intervenciones. Subrayamos los méritos de llevar a cabo un proceso multietapa descendente y ascendente que emplea un método participativo entre personas conocedoras de las culturas y personas ajenas a ella para desarrollar una intervención en la crianza que refleje las realidades contextuales y los valores culturales de los usuarios finales. El programa adaptado, Masayang Pamilya Para sa Batang Pilipino, es el producto de un esfuerzo comprometido y deliberado de equilibrar los objetivos y los valores de la crianza de los niños filipinos con las pruebas científicas sobre los componentes de las intervenciones en la crianza que promueven la crianza positiva y previenen el maltrato infantil.

Parenting for Lifelong Health for Young Children: a randomized controlled trial of a parenting program in South Africa to prevent harsh parenting and child conduct problems.

BACKGROUND: Parenting programs suitable for delivery at scale in low-resource contexts are urgently needed. We conducted a randomized trial of Parenting for Lifelong Health (PLH) for Young Children, a low-cost 12-session program designed to increase positive parenting and reduce harsh parenting and conduct problems in children aged 2-9. METHODS: Two hundred and ninety-six caregivers, whose children showed clinical levels of conduct problems (Eyberg Child Behavior Inventory Problem Score, >15), were randomly assigned using a 1:1 ratio to intervention or control groups. At t0 , and at 4-5 months (t1 ) and 17 months (t2 ) after randomization, research assistants blind to group assignment assessed (through caregiver self-report and structured observation) 11 primary outcomes: positive parenting, harsh parenting, and child behavior; four secondary outcomes: parenting stress, caregiver depression, poor monitoring/supervision, and social support. TRIAL REGISTRATION: ClinicalTrials.gov (NCT02165371); Pan African Clinical Trial Registry (PACTR201402000755243); Violence Prevention Trials Register (http://www.preventviolence.info/Trials?ID=24). RESULTS: Caregivers attended on average 8.4 sessions. After adjustment for 30 comparisons, strongest results were as follows: at t1 , frequency of self-reported positive parenting strategies (10% higher in the intervention group, p = .003), observed positive parenting (39% higher in the intervention group, p = .003), and observed positive child behavior (11% higher in the intervention group, p = .003); at t2, both observed positive parenting and observed positive child behavior were higher in the intervention group (24%, p = .003; and 17%, p = .003, respectively). Results with p-values < .05 prior to adjustment were as follows: At t1 , the intervention group self-reported 11% fewer child problem behaviors, 20% fewer problems with implementing positive parenting strategies, and less physical and psychological discipline (28% and 14% less, respectively). There were indications that caregivers reported 20% less depression but 7% more parenting stress at t1 . Group differences were nonsignificant for observed negative child behavior, and caregiver-reported child behavior, poor monitoring or supervision, and caregiver social support. CONCLUSIONS: PLH for Young Children shows promise for increasing positive parenting and reducing harsh parenting.

Shared Picture Book Reading Interventions for Child Language Development: A Systematic Review and Meta-Analysis.

Interventions that train parents to share picture books with children are seen as a strategy for supporting child language development. We conducted meta-analyses using robust variance estimation modeling on results from 19 RCTs (Ntotal  = 2,594; Mchildage  = 1-6 years). Overall, book-sharing interventions had a small sized effect on both expressive language (d = 0.41) and receptive language (d = 0.26). They had a large effect on caregiver book-sharing competence (d = 1.01). The impact of the intervention on child language was moderated by intervention dosage, with lower dosage associated with a minimal impact. Child age and caregiver education level were unrelated to child outcome. This review and meta-analysis confirms the promise of book-sharing interventions for enhancing and accelerating child language development.

Parenting Among Mothers Who Experienced Child Sexual Abuse: A Qualitative Systematic Review.

Child sexual abuse (CSA) represents a significant public health problem. While CSA is associated with several adverse outcomes, recent attention has been given to its effect on maternal parenting. Despite a growing literature on this topic, a comprehensive systematic review has not been conducted. Thus, this review aimed to fill this gap. Several search strategies were used, including searches in academic databases. Two reviewers completed screening, full-text review, data extraction, and quality determinations. Extracted qualitative data were synthesized for the 108 studies meeting inclusion criteria. The primary themes emerging from women's accounts of the effects of CSA on their current parenting included abuse of child, breastfeeding, child-rearing practices, coping related to parenting, mother-child relationship, perceptions of child, perceptions of motherhood, and protection of children from abuse. Given the current lack of interventions designed for these mothers, the results of this review may aid in the development of evidence-based interventions.

The Earlier the Better? Individual Participant Data and Traditional Meta-analysis of Age Effects of Parenting Interventions.

Strong arguments have been made for early intervention for child problems, stating that early is more effective than later, as the brain is more malleable, and costs are lower. However, there is scant evidence from trials to support this hypothesis, which we therefore tested in two well-powered, state-of-the-art meta-analyses with complementary strengths: (a) Individual participant data (IPD) meta-analysis of European trials of Incredible Years parenting intervention (k = 13, n = 1696; age = 2-11); (b) Larger, trial-level robust variance estimation meta-analysis of a wider range of parenting programs (k = 156, n = 13,378, Mage  = 2-10) for reducing disruptive behavior. Both analyses found no evidence that intervention earlier in childhood was more effective; programs targeted at a narrower age range were no more effective than general ones.