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 .

Behavioral activation for live-in migrant home care workers and care recipients in Israel: a pilot study.

In a growing global trend, individuals are migrating to other countries to live with and care for older adults with dementia. Although this trend addresses the geriatric workforce shortage, workers and older adults often experience distress. In a pilot study in Israel, six migrant care workers participated in a six-week group intervention in which they learned to increase valued, enjoyable activities for themselves and the older adult with whom they lived (behavioral activation). After the intervention, workers reported that they increased activities for themselves and the older adult and were satisfied, and quality of life and sense of achievement showed medium and large effect sizes, respectively. Participants suggested adapting the intervention to an online format for greater access. Although findings are tentative, the study points to promising strategies for migrant home care workers: focusing on the worker and older adult and offering online interventions.

'It provides practical tips, practical solutions!': acceptability, usability, and satisfaction of a digital parenting intervention across African countries.

The parenting evidence base is well established, and the question is how best to transfer the evidence to an app. App-based interventions could expand access to evidence-based parenting support; however, current provision lacks rigorous evidence, shows low user engagement, and is primarily for commercial gain. This study aimed at testing the feasibility and acceptability of ParentApp for Teens, an open-source, mobile parenting intervention application based on the Parenting for Lifelong Health Teens programme targeting parents of teens. The objective was to gather feedback from users on the relevance, acceptability, satisfaction, and usability of ParentApp for Teens across contexts in Africa, and subsequently, use the feedback to improve the app experience for target users. Caregivers and their adolescents aged 10-17 years, from nine different countries, were purposefully selected for user testing. The study involved 18 caregivers participating in the programme by using the app for 13 weeks and providing feedback on it through remote, semi-structured interviews that explored the app's acceptability and usability. Adolescents of six caregivers were also interviewed. Data were analysed thematically. Participants expressed a high level of satisfaction with the app's content and described it as easy to use and useful. However, views on the app's animated characters varied. Although effectiveness was not a primary aim of the user testing, several caregivers commented that they perceived their participation in the study had helped to enforce positive parenting skills in themselves. Adolescents' data supported the caregivers' reports of less harsh parenting and improved relationships between caregivers and their children due to the caregivers' participation in the study. Findings indicate the app could be relevant and acceptable in participants' communities, but possible barriers to its uptake may be lack of android smartphones, lack of data for app download, and inability of non-literate caregivers to read the content.

Mediation pathways for reduced substance use among parents in South Africa: a randomized controlled trial.

BACKGROUND: Substance use is a major public health concern worldwide. Alcohol and drug use have increased during recent decades in many low- and middle-income countries, with South Africa, where this study was conducted, having among the highest rates in the world. Despite existing evidence on the effectiveness of family-based interventions in reducing substance use among parents and caregivers in low- and middle-income countries, little is known about the mechanism of change that contributes to the reduction. This study investigated mediators of change in a parenting programme (Parenting for Lifelong Health [PLH]) on reducing substance use among parents and caregivers of adolescents through three potential mediators: parental depression, parenting stress and family poverty. METHODS: The current study used a pragmatic cluster randomized controlled trial design. The total sample comprised 552 parent and caregiver of adolescents M = 49.37(SD = 14.69) who were recruited from 40 communities in South Africa's Eastern Cape. Participants completed a structured confidential self-report questionnaire at baseline and a follow-up test 5 to 9 months after the intervention. Structural equation modeling was conducted to investigate direct and indirect effects. RESULTS: Analyses indicated that the effect of the PLH intervention on reducing parental substance use was mediated in one indirect pathway: improvement in parental mental health (reduction in parental depression levels). No mediation pathways from the PLH intervention on parental substance use could be associated with parenting stress or family poverty. CONCLUSIONS: The findings of the study suggest that intervention approaches targeting mental health among parents and caregivers have promise for reducing parental substance use. These findings emphasize the need to create supportive environments and systems for parents who suffer from emotional strain and mental health problems, particularly within families experiencing adversity. TRIAL REGISTRATION: Pan-African Clinical Trials Registry PACTR201507001119966. Registered on 27 April 2015. The trial can be found by searching for the key word 'Sinovuyo' on the Pan-African Clinical Trials Registry website or via the following link: http://www.pactr.org/ATMWeb/appmanager/atm/atmregistry?_nfpb=true&_windowLabel=BasicSearchUpdateController_1&BasicSearchUpdateController_1_actionOverride=%2Fpageflows%2Ftrial%2FbasicSearchUpdate%2FviewTrail&BasicSearchUpdateController_1id=1119.

"Home Is Where My Couch Is": The Role of Possessions in the Process of Moving and Adjusting to Continuing Care Retirement Communities.

We examined the role of possessions in the process of moving and adjusting to continuing care retirement communities (CCRCs). Totally, 59 CCRC residents in 12 CCRCs were interviewed. We categorized three main types of residents: "I want it all," "I want it that way," and "I want to break free." Each type experienced differently the role that objects play in (a) the reasons for moving, (b) choosing a CCRC and a specific apartment, (c) organizing one's belongings in preparation for relocation, and (d) adjusting to the new apartment. Most residents were attached to their belongings and reported having great difficulty leaving them behind. Our findings suggest that while older adults should be given every possible opportunity to make their own choices about their belongings, it is also necessary to balance between the desire to maintain continuity with their past, and the limited space of a CCRC apartment.

Child-Parent Relationship Therapy with Extra-Familial Abused Children.

Sexual abuse by a perpetrator outside of the family is the most prevalent form of child sexual abuse. It is associated with serious consequences for both the child and his family. Surprisingly, however, the issue of extra-familial sexual abuse has received very little research and clinical attention. The purpose of the current study was to explore the effectiveness of Child-Parent Relationship Therapy (CPRT), which uses nondirective play therapy tools, among parents of extra-familial abused children and their parents. In order to do so, data was collected from 51 parents who participated in CPRT, at three points in time: pretreatment stage, at the beginning of the first meeting; and in the post treatment stage. The data included the parents' reports via three questionnaires: Parenting Stress Inventory (PSI), Compassion Fatigue Self-Test (CFST), Child Behavior Checklist (CBCL). Overall, the results indicated a decrease in internalizing and externalizing symptoms among the children, as well as in parenting stress and in parental secondary trauma symptoms. This study contributes to the literature on interventions with victims of extra-familial child abuse and their parents. Specifically, the results highlight the benefits and importance of involving both parents and children in therapeutic interventions for victims of extra-familial child sexual abuse, with particular emphasis on the benefits of Child-Parent Relationship Therapy.

A systematic review and meta-analysis of interventions designed to prevent or stop elder maltreatment.

BACKGROUND: elder maltreatment is a major risk for older adults' mental health, quality of life, health, institutionalisation and even mortality. OBJECTIVES: to perform a systematic review and meta-analysis of interventions designed to prevent or stop elder abuse. METHODS: Studies that were posted between January 2000 and December 2014, written in English, specifically designed to prevent or stop elder maltreatment were included. RESULTS: overall, 24 studies (and four records reporting on the same participants) were kept for the systematic review and the meta-analysis. Studies were broadly grouped into three main categories: (i) interventions designed to improve the ability of professionals to detect or stop elder maltreatment (n = 2), (ii) interventions that target older adults who experience elder maltreatment (n = 3) and (iii) interventions that target caregivers who maltreat older adults (n = 19). Of the latter category, one study targeted family caregivers, five targeted psychological abuse among paid carers and the remaining studies targeted restraint use. The pooled effect of randomised controlled trials (RCTs)/cluster-RCTs that targeted restraint use was significant, supporting the effectiveness of these interventions in reducing restraint use: standardised mean difference: -0.24, 95% confidence interval = -0.38 to -0.09. INTERPRETATION: the most effective place to intervene at the present time is by directly targeting physical restraint by long-term care paid carers. Specific areas that are still lacking evidence at the present time are interventions that target (i) elder neglect, (ii) public awareness, (iii) older adults who experience maltreatment, (iv) professionals responsible for preventing maltreatment, (v) family caregivers who abuse and (vi) carers who abuse.

Improving the Cooperation Rate of Older Adults and Their Caregivers in Research Surveys.

BACKGROUND: Recruiting older adults, their family members and their home care workers as participants in research studies is particularly complicated. This might be due to medical or cognitive problems of the older adult as well as the high workload and shortage of time experienced by caregivers. The present study compared the contribution of two different versions of an advanced letter followed by two different versions of a recruitment phone call to the cooperation rate of older adults, family caregivers and home care workers in a face-to-face survey. METHODS: A quasi-experimental design was used to compare the contribution of the different types of appeal. A total of 2,014 caregiving units (composed of an older adult, a family member and a home care worker) were randomly sampled from a list of Israeli long-term care insurance beneficiaries. 74.32% of the sampled caregiving units were eligible to participate in the study. The first group of participants received formal and succinctly phrased written and oral appeals - an advanced letter followed by a recruitment phone call. The second group of participants received the original formal and succinctly phrased advanced letter, but a revised recruitment phone call that included a more personal approach, the provision of broader information about the study and the avoidance of words with a possible negative connotation. The third group of participants received both a revised advanced letter and a revised recruitment phone call. RESULTS: Using the succinctly phrased written and oral appeals, we had a cooperation rate of about 50% for the entire caregiving unit. Using a revised advanced letter and a revised recruitment phone call yielded an increase of 20-25% in the cooperation rate for the entire caregiving unit. Using the revised recruitment phone call and the original advanced letter yielded an increase in the cooperation rate only among migrant home care workers. CONCLUSION: This study showed that by changing the format of appeal we can increase the cooperation rate of older adults and their caregivers in a research survey. This study also pointed out the importance of the advanced letter.

A hybrid digital parenting programme to prevent abuse of adolescents in Tanzania: study protocol for a pragmatic cluster-randomised controlled trial.

BACKGROUND: Evidence-based parenting programmes have strong evidence in preventing and mitigating violence, but in-person programmes are challenging to deliver at scale. ParentApp is an open-source, offline-first app-based adaptation of the Parenting for Lifelong Health for Parents and Teens programme to promote playful and positive parenting, reduce risks for sexual violence victimisation, and prevent violence against adolescents. This study aims to evaluate the effectiveness and cost-effectiveness of ParentApp compared to an attention-control group. METHODS: This study is a two-arm pragmatic cluster-randomised controlled trial to test whether ParentApp reduces adolescent physical abuse, emotional abuse, and sexual violence risks and victimisation at 1 month and 12 months post-intervention. Caregivers of adolescents aged 10-17 years and their adolescent children (N = 2400 caregiver-adolescent dyads) will be recruited in urban and peri-urban communities in the Mwanza region of Tanzania. A total of 80 study clusters will be stratified and randomised (1:1) to the intervention group, who will receive ParentApp with support through a WhatsApp group, or to an attention-control group, who will receive a water, sanitation, and hygiene app. Quantitative data will be collected through outcomes questionnaires with caregivers and adolescents, administered at baseline, 4 months post-baseline, and 16 months post-baseline, as well as through routine implementation data and ParentApp engagement data. Qualitative data will be collected through individual interviews and focus groups with caregivers, adolescents, and implementing partner staff. DISCUSSION: App-based interventions have the potential to expand access to evidence-based parenting support, but currently lack rigorous evidence in low- and middle-income countries. This is the first known randomised control trial of a hybrid digital parenting programme to prevent the abuse of adolescents in low- and middle-income settings. TRIAL REGISTRATION: The trial was registered on the Open Science Framework on 14 March 2023, registration: OSF.IO/T9FXZ .

Screening and Priority-Setting to Determine Home- and Community-Based Aging Services for Older Floridians.

The National Aging Network serves millions of older Americans seeking home- and community-based services, but places others on waitlists due to limited resources. Little is known about how states determine service delivery and waitlists. We therefore conducted a process evaluation and analyzed data from one five-county Area Agency on Aging in Florida, where an algorithm calculates clients' priority scores for service delivery. From 23,225 screenings over 5.5 years, clients with higher priority scores were older, married, living with caregivers, and had more health problems and needs for assistance. Approximately 51% received services (e.g., meals/nutrition, case management, caregiver support), 11% were eligible/being enrolled, and 38% remained on waitlists. Service status was complex due to multiple service enrollments and terminations, funding priorities, and transfers to third-party providers. More research is needed regarding how other states determine eligibility and deliver services, potentially informing national standards that promote optimal health in older Americans.

Longitudinal Analysis of Mortality for Older Adults Receiving or Waiting for Aging Network Services.

OBJECTIVES: For older adults screened by an Area Agency on Aging (AAA) in the National Aging Network, we aimed to examine the 12-month mortality rate for wait-listed callers compared with those who received services within 12 months, and to assess whether the mortality rate differed according to how quickly they received services. DESIGN: The design was a longitudinal analysis of 3 years of AAA administrative data, using survival analysis. SETTING: The data source was administrative data from an AAA spanning a five-county region in west central Florida. PARTICIPANTS: All older adults (age 60 y and older) screened for service eligibility from July 15, 2013, to August 15, 2015, who completed initial screening during the study period were included (N = 6288). MEASUREMENTS: The outcome was mortality within 12 months of the initial screening. Covariates included demographics, caregiver status, health status, access to healthcare, and AAA service status. RESULTS: In the first survival analysis, the strongest predictor was waiting for services compared with receiving services; waiting increased the odds to die vs not to die by 141%, after controlling for health status and other covariates. In the second survival analysis, those who received services within 0 to 3 months had a higher mortality risk compared with those who received services within 6 to 9 months or 9 to 12 months. CONCLUSION: Older adults placed on aging service waiting lists may be at a greater risk of mortality within 12 months than those receiving services. Given that rapid receipt of services was less protective than receiving services later, those prioritized to receive services quickly may be at very high risk of adverse outcomes. Findings raise the possibility that aging services may lower mortality, although additional services may benefit those waiting long periods for services, as well as those eligible for services rapidly. Research is needed to replicate and extend these findings. J Am Geriatr Soc 68:519-525, 2020.

Violations of workers' rights and exposure to work-related abuse of live-in migrant and live-out local home care workers - a preliminary study: implications for health policy and practice.

BACKGROUND: Home care workers work in an isolated environment, with limited supervision and guidance which makes them more prone to abuse and exploitation. While past research focused mostly on the well-being of care recipients, this study aimed to shed light on the care workers' daily reality and explore if and how boundaries of professional care work are blurred. Our primary aim was to assess the working conditions and the prevalence of abuse and exploitation among live-in migrant home care workers and live-out local home care workers. METHODS: A random stratified sample of Israeli older adults aged over 70, who are entitled by law to home care services was used to recruit 338 migrant live-in home care workers and 185 local live-out home care workers to a face-to-face survey. The participants were asked about their relationship with the care recipient and their exposure to violations of workers' rights and work-related abuse. RESULTS: Almost all the participants reported exposure to certain workers' rights violations. Among the migrant live-in care workers, it was found that 58% of them did not receive any vacation days besides the weekly day-off, about 30% reported not get even a weekly day-off on a regular basis, and 79% did not get paid sick days. Local live-out care workers also suffered from a high prevalence of exploitation - 58% did not get any vacation days besides the weekly day-off, and 66% did not get paid sick leave. 20% of the local live-out care workers, and 15% of the migrant live-in care workers did not receive a signed contract. A smaller portion (7.4% among migrant care workers, 2.5% among local care workers) reported work-related abuse. When compared to local workers, migrant home care workers were more vulnerable to some worker's rights violations, as well as emotional abuse. CONCLUSION: These findings are disturbing, as work-related abuse and exploitation affect not only the well-being of the care worker but also the health of the care recipients, as the quality of care provided deteriorates. At the public policy level, more significant attention and regulation of the home care industry is needed. The frequency and the nature of home visits made by home care agencies must be changed. Also, home care workers should be offered emotional support.

Whom Do Migrant Home Care Workers Contact in the Case of Work-Related Abuse? An Exploratory Study of Help-Seeking Behaviors.

Migrant home care workers constitute an "invisible" and vulnerable group in society, as they work in isolation in the homes of frail older adults. Past research has shown that this population is particularly vulnerable to work-related abuse. The aim of the present study was to explore the help-seeking behaviors of migrant home care workers who were exposed to work-related abuse. Overall, 187 Filipino home care workers completed a self-report questionnaire regarding four types of work-related abuse (sexual, physical, emotional, and exploitation), help-seeking strategies (i.e., formal and informal reporting), and reasons for not disclosing abusive incidents. A total of 56.7% reported some type of abuse. Of these, less than half reported the abuse, mostly informally to family and friends. None reported the abuse to the police. Main reasons for not disclosing the abuse were fears that things would get worse and the belief that it will take too much time and effort. The findings demonstrate that migrant home care workers are highly vulnerable to work-related abuse but are not likely to report work-related abuse and put an end to the cycle of abuse and violence. This calls for the development of further policy and interventions to protect this already vulnerable population.

Live-In Versus Live-Out Home Care in Israel: Satisfaction With Services and Caregivers' Outcomes.

PURPOSE OF THE STUDY: The present study provides a preliminary examination of the relationship between the type of home care services (live-in vs. live-out; i.e., round the clock vs. several hours per week), the caregiver's satisfaction with services, and the caregiver's burden, distress, well-being, and subjective health status within the conceptual framework of caregiving outcomes proposed by Yates and colleagues (Yates, M. E., Tennstedt, S., & Chang, B. H. [1999]. Contributors to and mediators of psychological well-being for informal caregivers. Journal of Gerontology: Psychological Sciences, 54, P12 -P22. doi:10.1093/geronb/54B.1.P12). DESIGN AND METHODS: A random stratified sample of family caregivers of older adults more than the age of 70 who receive live-in (442) or live-out (244) home care services through the financial assistance of the National Insurance institute of Israel was selected. A path analysis was conducted. RESULTS: Satisfaction with services was higher among caregivers under the live-in home care arrangement and positively related to well-being. Among caregivers, live-in home care was directly associated with higher levels of subjective health and indirectly associated with better well-being via satisfaction with services. IMPLICATIONS: The present study emphasizes the potential benefits of live-in home care services for caregivers of older adults who suffer from high levels of impairment and the importance of assessing satisfaction with services as a predictor of caregivers' outcomes.