The Role of Maternal Depression Symptoms and Maternal Attachment in Predicting Exclusive Breastfeeding: A Multisite Prospective Study.

Background: Previous research shows that 61% of children younger than 6 months in low- and middle-income countries (LMICs) are not exclusively breastfed. Although data on the role of pre- and postnatal depression on breastfeeding exclusivity is mixed, fetomaternal attachment might foster breastfeeding exclusivity. Thus, we tested the potential mediating role of fetomaternal attachment and postnatal depression in the relationship between maternal prenatal depression and exclusive breastfeeding. Materials and Methods: Data were collected as part of a prospective, cross-cultural project, Evidence for Better Lives Study, which enrolled 1208 expectant mothers, in their third trimester of pregnancy across eight sites, from LMICs. Of the whole sample, 1185 women (mean age = 28.32, standard deviation [SD] = 5.77) completed Computer-Aided Personal Interviews on prenatal depressive symptoms, fetomaternal attachment, and socioeconomic status. A total of 1054 women provided follow-up data at 3-6 months after birth, about postnatal depressive symptoms, exclusive breastfeeding, and infant health indicators. Path analysis was used to assess parallel mediation. Results: In the whole sample, the effect of prenatal depression on breastfeeding exclusivity was completely mediated by postnatal depression, whereas fetomaternal attachment did not mediate the relationship. The full mediation effect was replicated individually in Pakistan and Sri Lanka. Conclusions: The study results indicate that prenatal depression symptoms contributed to the development of depressive symptoms after birth, negatively affecting the probability of exclusive breastfeeding. Future research should explore this in early prevention interventions, increasing the chances of healthy child development in LMICs. Considering the mixed results around the sites, it is important to better understand the relationship between maternal depression, fetomaternal attachment and breastfeeding behavior in each site's socio-cultural context.

Factors influencing human papillomavirus vaccination uptake in European women and adolescents: A systematic review and meta-analysis.

OBJECTIVE: Cervical Cancer (CC) lingers as a severe public health issue due to low vaccination coverage and poor screening addressability. Hence, this systematic review explored psychological factors influencing the Human Papilloma Virus (HPV) vaccination uptake in European women. METHODS: As of September 2022, PubMed, EMBASE, Scopus, and Web of Science were systematically searched to include English studies assessing diverse factors influencing vaccination uptake in European women. Only studies comparing vaccinated with unvaccinated women were included. Quality assessment, publication attrition assessment, and sensitivity analyses were performed. RESULTS: Eighteen studies were included, totaling a population of 18,611 participants. Results indicated that knowledge about HPV infection could positively influence vaccination rates with an Odds Ratio (OR) of 1.82 and a confidence interval (CI) between 1.27 and 2.61, showing statistical significance at a Z value of 3.24 with a p-value of 0.001. Neither knowledge about HPV vaccination (OR = 1.39, CI: 0.73-2.65, Z = 1.01, p = 0.31) nor knowledge about CC screening (OR = 1.05, CI: 0.55-1.98, Z = 0,14, p = 0.89) seem to affect vaccination rates. Regardless, intention to undertake CC screening (CCS) showed an OR = 1.68 in favor of the group intending to perform it, with a CI between 1.37 and 2.07, showing statistical significance at a Z = 4.94 and p = 0.00001. Other aspects affecting vaccination uptake were fear of side effects, insufficient information, and belief that chances of being infected are low. CONCLUSIONS: Results demonstrated that diverse aspects could affect the vaccination intent, while personalized interventions focusing on population and country characteristics need to be assembled to mitigate vaccination coverage.

Co-Occurrence of Intimate Partner Violence Against Mothers and Maltreatment of Their Children With Behavioral Problems in Eastern Europe.

This study investigates the co-occurrence of intimate partner violence (IPV) against mothers and their risk of perpetrating child maltreatment (CM) in North Macedonia, the Republic of Moldova, and Romania. Risk factors for IPV, CM, and their co-occurrence were identified. Two samples (N1 = 112, N2 = 701) of mothers with children with behavioral problems were assessed. IPV was reported by 64% of mothers, CM by 96%, and their co-occurrence by 63%. Mothers exposed to emotional IPV reported more physical and emotional CM. Mothers exposed to physical IPV reported more physical CM. Mothers own history of CM and offspring's behavior problems were associated with IPV and CM co-occurrence.

Corrigendum: Illness perceptions of COVID-19 in Europe: predictors, impacts and temporal evolution.

[This corrects the article DOI: 10.3389/fpsyg.2021.640955.].

Who Stays, Who Moves on and the Host Population: A Picture of Adolescents' Perceived Well-Being and Risk Behaviours.

The study aims to evaluate the health profile of first- and second-generation Romanian immigrants living in Italy compared to their adolescent peers in the country of origin (Romania) and the host population (Italian-borns). Analyses were performed on the 2013/2014 Health Behaviour in School-aged Children (HBSC) survey data. Romanian natives showed lower levels of health complaints and higher life satisfaction than Romanian migrants, who were similar to the host population, especially the second-generation ones. A comparable prevalence of being bullied was registered among Romanians, both native and immigrant, with significantly lower levels among Italian natives. Bullying others showed the second-generation migrants share a similar prevalence with the host population. The prevalence of liking school a lot was three times higher among the Romanian natives than among their peers living in Italy. Thanks to the HBSC data, this study is the first to examine the health of adolescent migrants from both the perspective of the host country and the population of origin. The results highlight the need for a more nuanced approach to studying immigrant populations, taking into account both the host country's perspective and the health patterns of the population of origin.

Predictors of changing patterns of adherence to containment measures during the early stage of COVID-19 pandemic: an international longitudinal study.

BACKGROUND: Identifying common factors that affect public adherence to COVID-19 containment measures can directly inform the development of official public health communication strategies. The present international longitudinal study aimed to examine whether prosociality, together with other theoretically derived motivating factors (self-efficacy, perceived susceptibility and severity of COVID-19, perceived social support) predict the change in adherence to COVID-19 containment strategies. METHOD: In wave 1 of data collection, adults from eight geographical regions completed online surveys beginning in April 2020, and wave 2 began in June and ended in September 2020. Hypothesized predictors included prosociality, self-efficacy in following COVID-19 containment measures, perceived susceptibility to COVID-19, perceived severity of COVID-19 and perceived social support. Baseline covariates included age, sex, history of COVID-19 infection and geographical regions. Participants who reported adhering to specific containment measures, including physical distancing, avoidance of non-essential travel and hand hygiene, were classified as adherence. The dependent variable was the category of adherence, which was constructed based on changes in adherence across the survey period and included four categories: non-adherence, less adherence, greater adherence and sustained adherence (which was designated as the reference category). RESULTS: In total, 2189 adult participants (82% female, 57.2% aged 31-59 years) from East Asia (217 [9.7%]), West Asia (246 [11.2%]), North and South America (131 [6.0%]), Northern Europe (600 [27.4%]), Western Europe (322 [14.7%]), Southern Europe (433 [19.8%]), Eastern Europe (148 [6.8%]) and other regions (96 [4.4%]) were analyzed. Adjusted multinomial logistic regression analyses showed that prosociality, self-efficacy, perceived susceptibility and severity of COVID-19 were significant factors affecting adherence. Participants with greater self-efficacy at wave 1 were less likely to become non-adherence at wave 2 by 26% (adjusted odds ratio [aOR], 0.74; 95% CI, 0.71 to 0.77; P < .001), while those with greater prosociality at wave 1 were less likely to become less adherence at wave 2 by 23% (aOR, 0.77; 95% CI, 0.75 to 0.79; P = .04). CONCLUSIONS: This study provides evidence that in addition to emphasizing the potential severity of COVID-19 and the potential susceptibility to contact with the virus, fostering self-efficacy in following containment strategies and prosociality appears to be a viable public health education or communication strategy to combat COVID-19.

Handwashing adherence during the COVID-19 pandemic: A longitudinal study based on protection motivation theory.

RATIONALE: The associations between the number of COVID-19 cases/deaths and subsequent uptake of protective behaviors may reflect cognitive and behavioral responses to threat-relevant information. OBJECTIVE: Applying protection motivation theory (PMT), this study explored whether the number of total COVID-19 cases/deaths and general anxiety were associated with cross-situational handwashing adherence and whether these associations were mediated by PMT-specific self-regulatory cognitions (threat appraisal: perceived vulnerability, perceived illness severity; coping appraisal: self-efficacy, response efficacy, response costs). METHOD: The study (#NCT04367337) was conducted in March-September 2020 among 1256 adults residing in 14 countries. Self-reports on baseline general anxiety levels, handwashing adherence across 12 situations, and PMT-related constructs were collected using an online survey at two points in time, four weeks apart. Values of COVID-19 cases and deaths were retrieved twice for each country (one week prior to the individual data collection). RESULTS: Across countries and time, levels of adherence to handwashing guidelines were high. Path analysis indicated that smaller numbers of COVID-19 cases/deaths (Time 0; T0) were related to stronger self-efficacy (T1), which in turn was associated with higher handwashing adherence (T3). Lower general anxiety (T1) was related to better adherence (T3), with this effect mediated by higher response efficacy (T1, T3) and lower response cost (T3). However, higher general anxiety (T1) was related to better adherence via higher illness severity (T1, T3). General anxiety was unrelated to COVID-19 indicators. CONCLUSIONS: We found a complex pattern of associations between the numbers of COVID-19 cases/deaths, general anxiety, PMT variables, and handwashing adherence at the early stages of the pandemic. Higher general anxiety may enable threat appraisal (perceived illness severity), but it may hinder coping appraisal (response efficacy and response costs). The indicators of the trajectory of the pandemic (i.e., the smaller number of COVID-19 cases) may be indirectly associated with higher handwashing adherence via stronger self-efficacy.

Employee silence in health care: Charting new avenues for leadership and management.

ISSUE: Health care management is faced with a basic conundrum about organizational behavior; why do professionals who are highly dedicated to their work choose to remain silent on critical issues that they recognize as being professionally and organizationally significant? Speaking-up interventions in health care achieve disappointing outcomes because of a professional and organizational culture that is not supportive. CRITICAL THEORETICAL ANALYSIS: Our understanding of the different types of employee silence is in its infancy, and more ethnographic and qualitative work is needed to reveal the complex nature of silence in health care. We use the sensemaking theory to elucidate how the difficulties to overcoming silence in health care are interwoven in health care culture. INSIGHT/ADVANCE: The relationship between withholding information and patient safety is complex, highlighting the need for differentiated conceptualizations of silence in health care. We present three Critical Challenge points to advance our understanding of silence and its roots by (1) challenging the predominance of psychological safety, (2) explaining how we operationalize sensemaking, and (3) transforming the role of clinical leaders as sensemakers who can recognize and reshape employee silence. These challenges also point to how employee silence can also result in a form of dysfunctional professionalism that supports maladaptive health care structures in practice. PRACTICE IMPLICATIONS: Delineating the contextual factors that prompt employee silence and encourage speaking up among health care workers is crucial to addressing this issue in health care organizations. For clinical leaders, the challenge is to valorize behaviors that enhance adaptive and deep psychological safety among teams and within professions while modeling the sharing of information that leads to improvements in patient safety and quality of care.

Measuring antenatal depressive symptoms across the world: A validation and cross-country invariance analysis of the Patient Health Questionnaire-9 (PHQ-9) in eight diverse low-resource settings.

Measures that produce valid and reliable antenatal depressive symptom scores in low-resource country contexts are important for efforts to illuminate risk factors, outcomes, and effective interventions in these contexts. Establishing the psychometric comparability of scores across countries also facilitates analyses of similarities and differences across contexts. To date, however, few studies have evaluated the psychometric properties and comparability of the most widely used antenatal depressive symptom measures across diverse cultural, political, and social contexts. To address this gap, we used data from the Evidence for Better Lives Study-Foundational Research (EBLS-FR) project to examine the internal consistency reliability, nomological network validity, and cross-country measurement invariance of the nine-item version of the Patient Health Questionnaire (PHQ-9) in antenatal samples across eight low-resource contexts. We found that the PHQ-9 scores had good internal consistency across all eight countries. Correlations between PHQ-9 scores and constructs conceptually associated with depression were generally consistent, with a few exceptions. In measurement invariance analyses, only partial metric invariance held and only across four of the countries. Our results suggest that the PHQ-9 yields internally consistent scores when administered in culturally diverse antenatal populations; however, the meaning of the scores may vary. Thus, interpretation of PHQ-9 scores should consider local meanings of symptoms of depression to ensure that context-specific conceptualizations and manifestations of antenatal depressive symptoms are adequately reflected. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

"What does that mean?": The content validity of the ISPCAN Child Abuse Screening Tool - Child version (ICAST-C) in Romania, South Africa, and the Philippines.

BACKGROUND: The International Society for Prevention of Child Abuse and Neglect (ISPCAN) Child Abuse Screening Tool (Children's Version), known as the ICAST-C Version 3, is used widely to assess violence against children, but there is limited psychometric evidence, especially on content validity. OBJECTIVE: This study aimed to assess the content validity of the ICAST-C with adolescents in Romania, South Africa, and the Philippines. METHODS: A purposive sample of adolescents (N = 53, 51 % female) were recruited from urban areas in Romania, the Eastern Cape Province of South Africa, and Metro Manila, Philippines. Semi-structured one-on-one in-depth cognitive interviews sought adolescent perspectives on the relevance, comprehensibility, and comprehensiveness of the ICAST-C. Data were analysed using template analysis. RESULTS: The ICAST-C was broadly perceived to be relevant and comprehensive in measuring violence against children in all study locations. However, there were issues with the comprehensibility of the measure, described at three levels: interpreting items, undertaking coherent elaborations of relevant behaviors and places, and generating a coherent response to the questions. CONCLUSIONS: Suggestions to revise the ICAST-C include, among others, adding a practice or how-to section on answering the survey, clarifying the intent of questions, especially on neglect and sexual abuse, emphasizing that questions cover all locations, and asking more positive questions. Pilot studies testing the content validity and cultural appropriateness are needed as a matter of practice in large self-report surveys.

Associations Between ADHD Symptoms and Maternal and Birth Outcomes: An Exploratory Analysis in a Multi-Country Cohort of Expectant Mothers.

OBJECTIVE: ADHD symptoms can adversely impact functioning in a range of domains relevant for maternal well-being and fetal development; however, there has been almost no research examining their impact during pregnancy. We aimed to address this gap. METHOD: We used data (n = 1,204) from a longitudinal birth cohort study spanning eight countries to address this gap. RESULTS: ADHD symptoms in the third trimester of pregnancy were associated with lower social support from family (b = -0.16, p = .031), friends (b = -0.16, p = .024), and significant others (b = -0.09, p = .001); higher stress (b = 0.34, p < .001) and depressive symptoms (b = 0.31, p < .001), and increased likelihood of an unwanted pregnancy (b = 0.30, p = .009). Significant associations with tobacco use (b = 0.36, p = .023) and premature birth (b = 0.35, p = .007) did not survive correction for multiple comparisons and there were no significant associations with alcohol use, low birth weight, or unplanned pregnancy. CONCLUSION: Results suggest that women with ADHD symptoms could benefit from earlier, more regular screening for mental health difficulties and greater mental health support during pregnancy.

Patterns of adverse childhood experiences and associations with prenatal substance use and poor infant outcomes in a multi-country cohort of mothers: a latent class analysis.

BACKGROUND: This paper enumerates and characterizes latent classes of adverse childhood experiences and investigates how they relate to prenatal substance use (i.e., smoking, alcohol, and other drugs) and poor infant outcomes (i.e., infant prematurity and low birthweight) across eight low- and middle-income countries (LMICs). METHODS: A total of 1189 mother-infant dyads from the Evidence for Better Lives Study cohort were recruited. Latent class analysis using the Bolck, Croon, and Hagenaars (BCH) 3-step method with auxiliary multilevel logistic regressions was performed. RESULTS: Three high-risk classes and one low-risk class emerged: (1) highly maltreated (7%, n = 89), (2) emotionally and physically abused with intra-familial violence exposure (13%, n = 152), (3), emotionally abused (40%, n = 474), and (4) low household dysfunction and abuse (40%, n = 474). Pairwise comparisons between classes indicate higher probabilities of prenatal drug use in the highly maltreated and emotionally abused classes compared with the low household dysfunction and abuse class. Additionally, the emotionally and physically abused with intra-familial violence exposure class had higher probability of low birthweight than the three remaining classes. CONCLUSION: Our results highlight the multifaceted nature of ACEs and underline the potential importance of exposure to childhood adversities on behaviors and outcomes in the perinatal period. This can inform the design of antenatal support to better address these challenges.

Working as a Healthcare Professional and Wellbeing During the COVID-19 Pandemic: Work Recovery Experiences and Need for Recovery as Mediators.

Considering the high impact strain that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has put on medical personnel worldwide, identifying means to alleviate stress on healthcare professionals and to boost their subjective and psychological wellbeing is more relevant than ever. This study investigates the extent to which the relationships between the status of working in healthcare and the subjective and psychological wellbeing are serially mediated by work recovery experiences and the need for recovery. Data were collected from 217 Romanian employees (44 health professionals and 173 employees from other domains) using a cross-sectional design with self-report instruments, during the first stage of the nationwide lockdown. The results of the serial mediation analyses revealed that working in the medical field is indirectly related to subjective and psychological wellbeing through the following: (i) mastery experiences and (ii) mastery experiences as an antecedent of the need for recovery. As such, our findings indicate that (i) working in the medical field is, in fact, linked to healthcare professionals' subjective and psychological wellbeing, and they provide some input on (ii) how recovery experiences and the need for recovery intervene in these relationships. Based on these findings, theoretical, methodological, and practical implications were suggested, and future research directions were proposed to maximize healthcare professionals' wellbeing.

Socioeconomic inequalities in adolescent health complaints: A multilevel latent class analysis in 45 countries.

Our study evaluated the relationship between adolescent health complaints and socioeconomic position in 45 countries. Data are from the 2017/2018 international Health Behaviour in School-aged Children survey which used proportionate sampling among adolescents aged 11 to 15 years old (n=228,979). Multilevel, multinomial regression analysis assessed the association between the multilevel latent classes with socioeconomic status (SES; at the household and country level). Three distinct latent classes were identified: No Complaints, Psychological Complaints, and a Physical and Psychological Complaints class; where, low household SES was highest for the physical and psychological complaints class. The findings suggest that health promotion policies and interventions among adolescents should consider the specific needs of adolescents living with low household SES as they report more subjective health complaints.

Perceived stress during the prenatal period: assessing measurement invariance of the Perceived Stress Scale (PSS-10) across cultures and birth parity.

Maternal prenatal stress places a substantial burden on mother's mental health. Expectant mothers in low- and middle-income countries (LMICs) have thus far received less attention than mothers in high-income settings. This is particularly problematic, as a range of triggers, such as exposure to traumatic events (e.g. natural disasters, previous pregnancy losses) and adverse life circumstances (e.g. poverty, community violence), put mothers at increased risk of experiencing prenatal stress. The ten-item Perceived Stress Scale (PSS-10) is a widely recognised index of subjective experience of stress that is increasingly used in LMICs. However, evidence for its measurement equivalence across settings is lacking. This study aims to assess measurement invariance of the PSS-10 across eight LMICs and across birth parity. This research was carried out as part of the Evidence for Better Lives Study (EBLS, vrc.crim.cam.ac.uk/vrcresearch/EBLS). The PSS-10 was administered to N = 1,208 expectant mothers from Ghana, Jamaica, Pakistan, the Philippines, Romania, South Africa, Sri Lanka and Vietnam during the third trimester of pregnancy. Confirmatory factor analysis suggested a good model fit of a two-factor model across all sites, with items on experiences of stress loading onto a negative factor and items on perceived coping onto a positive factor. Configural and metric, but not full or partial scalar invariance, were established across all sites. Configural, metric and full scalar invariance could be established across birth parity. On average, first-time mothers reported less stress than mothers who already had children. Our findings indicate that the PSS-10 holds utility in assessing stress across a broad range of culturally diverse settings; however, caution should be taken when comparing mean stress levels across sites.

The impact of psychiatric disorders on caregivers: An integrative predictive model of burden, stigma, and well-being.

PURPOSE: The study investigates the predictors of caregivers' experienced burden, stigma, and well-being, when looking after family members diagnosed with a psychiatric disorder. DESIGN AND METHODS: This cross-sectional study included 168 caregivers; perceived burden, stigma, well-being, knowledge, illness perception, and medical variables were assessed. FINDINGS: A number of correlates of burden, stigma, and well-being have been identified and are being discussed. The integrative predictive model showed that the caregiver's emotional representation of illness best predicts burden (ß = 0.38, p < 0.001), stigma (ß = 0.53, p < 0.001) and well-being (ß = -0.36, p < 0.001). PRACTICE IMPLICATIONS: Our results can enable health professionals to tailor psychosocial interventions addressed to family members of individuals living with a psychiatric condition.

Families with complex needs: an inside perspective from young people, their carers, and healthcare providers.

Complex health needs are demanding and often require additional medical, psychological and social support. All those involved (e.g., patients, carers, professionals) face a unique set of challenges and needs, especially in families where the patient is a child or a young person with a lifelong condition. The aim of the study was to explore carers' and young people's needs when living with long term conditions, as well as the views of the healthcare professionals supporting them. Semi-structured interviews with 30 participants (11 professionals, 10 parents, and 9 young people) were conducted. Interviews focused on 3 main areas-(1) medical needs, (2) psychological needs, and (3) communication needs-and were analyzed using thematic analysis. Four main themes emerged: (1) Acceptance takes time refers to the often long and challenging process of adapting to the diagnosis and living with the condition; (2) Close guidance captures the importance of specialised and long term guidance in accessing and managing the complexities of the medical system; (3) Open communication shows the families' need to be collaboratively connected to healthcare providers and other families facing similar difficulties; and (4) Long-term support underlines the importance of long term formal and informal support strategies. The participants' experiences and views have provided us with insight and guidance for developing and implementing personalized and integrated services. This inside perspective is key for future research aimed at better understanding the impact of complex conditions and meaningful ways to support families throughout their journeys.

Mapping psychosocial interventions in familial colorectal cancer: a rapid systematic review.

BACKGROUND: Approximately 5% of colorectal cancer (CRC) cases are part of a well-defined inherited genetic syndrome and up to approximately 30% of these cases have a clinically defined familial basis. Psychosocial interventions in familial colorectal cancer address aspects mainly focused on affective, cognitive and behavioural outcomes. The present review aims to systematically map out the available psychosocial interventions for individuals with a family history of CRC and describe the current state of the research. METHODS: An extensive electronic search was conducted to investigate the literature published until June 2020. Inclusion criteria consisted of quantitative studies published in English that explored the impact of psychosocial interventions for familial CRC, clearly defined the psychosocial intervention offered and included participants with a family history of CRC. RESULTS: The analysis included 52 articles. Genetic counselling, educational interventions, psychological interventions and multimodal interventions were identified across the studies. In terms of diagnoses, Lynch Syndrome, Familial Adenomatous Polyposis, Familial Colorectal Cancer were the main conditions included in the studies. Affective, cognitive, behavioural aspects and quality of life emerged as the most frequently explored outcomes. The studies included individuals with both personal and familial history of CRC or family history alone. CONCLUSIONS: Our rapid review provides an overview of the literature exploring the impact of psychosocial interventions for familial CRC. The psychosocial interventions identified had an overwhelmingly positive impact across all types of outcomes measured. Genetic counselling appeared to be most beneficial, and this is expected as it is purposively designed to address genetic conditions. Further quantitative analysis of primary empirical research is needed to determine the efficacy and effectiveness of psychosocial interventions as well as the mechanisms through which they exert their effect.

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.

The Interplay Between Strictness of Policies and Individuals' Self-Regulatory Efforts: Associations with Handwashing During the COVID-19 Pandemic.

BACKGROUND: Patterns of protective health behaviors, such as handwashing and sanitizing during the COVID-19 pandemic, may be predicted by macro-level variables, such as regulations specified by public health policies. Health behavior patterns may also be predicted by micro-level variables, such as self-regulatory cognitions specified by health behavior models, including the Health Action Process Approach (HAPA). PURPOSE: This study explored whether strictness of containment and health policies was related to handwashing adherence and whether such associations were mediated by HAPA-specified self-regulatory cognitions. METHODS: The study (NCT04367337) was conducted among 1,256 adults from Australia, Canada, China, France, Gambia, Germany, Israel, Italy, Malaysia, Poland, Portugal, Romania, Singapore, and Switzerland. Self-report data on cross-situational handwashing adherence were collected using an online survey at two time points, 4 weeks apart. Values of the index of strictness of containment and health policies, obtained from the Oxford COVID-19 Government Response Tracker database, were retrieved twice for each country (1 week prior to individual data collection). RESULTS: Across countries and time, levels of handwashing adherence and strictness of policies were high. Path analysis indicated that stricter containment and health policies were indirectly related to lower handwashing adherence via lower self-efficacy and self-monitoring. Less strict policies were indirectly related to higher handwashing adherence via higher self-efficacy and self-monitoring. CONCLUSIONS: When policies are less strict, exposure to the SARS-CoV-2 virus might be higher, triggering more self-regulation and, consequently, more handwashing adherence. Very strict policies may need to be accompanied by enhanced information dissemination or psychosocial interventions to ensure appropriate levels of self-regulation.