Strong families: a new family skills training programme for challenged and humanitarian settings: a single-arm intervention tested in Afghanistan.

BACKGROUND: Children living in challenged humanitarian settings (including those in rural/underserved areas, the displaced, refugees, in conflict/post conflict situations) are at greater risk of mental health difficulties or behavioural problems, with caregivers acting as their main protective factors. While many family skills programmes exist, very few were developed for, or piloted in, low resource settings (settings with limited infrastructure, typical of humanitarian settings). We therefore designed a brief and light programme; the Strong Families (SF) programme, consisting of 5 h contact time over 3 weeks. We conducted a pilot study with the aim to test the feasibility of implementation, and a preliminary look at the effectiveness of SF, in improving child behaviour and family functioning in families living in Afghanistan. METHODS: We recruited female caregivers and children aged 8-12 years through schools and drug treatment centres in Afghanistan and enrolled them in the SF programme. Demographic data, emotional and behavioural difficulties of children and parental skills and family adjustment measures were collected from caregivers before, 2 and 6 weeks after the intervention. Outcome was assessed through the SDQ (Strengths and Difficulties Questionnaire), assessing children's behavioural, emotional, and social issues, and PAFAS (Parenting and Family Adjustment Scales), measuring parenting practices and family functioning. RESULTS: We enrolled 72 families in the programme with a 93.1% retention rate (n = 67) for data collection 6 weeks post intervention. Mean age of caregivers was 36.1 years, they had 3.8 children on average and 91.7% of them had experienced war/armed conflict in their past. The average total difficulty score of the SDQ (ranging from 0 to 40, with scores above 16 being indicative of high problems) of the 72 children reduced significantly, from 17.8 at pre-test to 12.9 at post-test and 10.6 at second follow-up, with no difference in gender and most noticeably amongst those with the highest scores at baseline. Likewise, PAFAS scores decreased significantly after the programme, again with caregivers with the highest scores at baseline improving most. CONCLUSIONS: The implementation of a brief family skills programme was seemingly effective and feasible in a resource-limited setting and positively improved child mental health and parenting practices and family adjustment skills. These results suggest the value of such a programme and call for further validation through other methods of impact assessment and outcome evaluation. TRIAL REGISTRATION: ISRCTN76509384. Retrospectively registered on March 9, 2020.

Establishment of a voluntary electronic Chlamydia trachomatis laboratory surveillance system in Germany, 2008 to 2014.

Chlamydia trachomatis (CT) infections are not reportable in Germany and limited data on prevalence are available. CT screening has been offered free of charge to pregnant women since 1995 and to all women under 25 years since 2008. For symptomatic women and men, diagnostic testing is covered by statutory health insurance. We describe the establishment of a nationwide, laboratory-based, voluntary sentinel that electronically collects information on all performed CT tests with test results, test reason and patient information. The sentinel represents one third of all performed CT tests in Germany. In the period from 2008 to 2014, 3,877,588 CT tests were reported, 93% in women. Women aged 20-24 years and men aged 25-29 years were the most frequently tested age groups. The overall proportion of positive tests (PPT) among women was 3.9% and among men 11.0%. The highest PPT among women was in the age groups 15-19 (6.8%) and 20-24 years (5.9%), and among men in the age groups 20-24 (19.2%), 15-19 (15.4%) and 25-29 years (14.8%). The PPT for CT was high among women and men younger than 25 years. Prevention is urgently needed. Monitoring of CT infection in Germany should be continued.

STI tests and proportion of positive tests in female sex workers attending local public health departments in Germany in 2010/11.

BACKGROUND: In Germany, local public health departments (LPHD) are required to offer low-threshold access to confidential counselling and testing for sexually transmitted infections (STI) for sex workers. We collected data from LPHD in Germany to estimate the number of performed STI tests and the proportion of positive STI tests among attending female sex workers (FSW) in order to formulate recommendations for improving STI testing and care for FSW in Germany. METHODS: We recruited LPHD across Germany to collect aggregated data on attending FSW between January 2010 and March 2011. Baseline characteristics, the number of attending FSW, STI tests (HIV, Chlamydia trachomatis, Neisseria gonorrhoea, syphilis and Trichomonas vaginalis) and the number of positive results were provided by participating LPHD. We described the number of STI tests per FSW visit and the proportion of positive test results, including interquartile range (IQR). We tested whether baseline characteristics of LPHD were associated with the proportion of positive test results. RESULTS: Overall, 28 LPHD from 14 of the 16 federal states reported 9284 FSW visits over the study period, with a median of 188 FSW visits (IQR 45-440) per LPHD. Overall, a median of 77.1% (IQR 60.7-88.0) of visiting FSW received a test for Neisseria gonorrhoea, followed by HIV (66.0%, IQR 47.9-86.8), Chlamydia trachomatis (65.4%, IQR 50.7-83.6) and syphilis (61.6, IQR 48.6-78.6). In total, 22,914 STI tests were performed. The proportion of positive tests was 3.1% (IQR 1.3-4.8), with the highest proportion of positive tests for Chlamydia trachomatis (6.8%, IQR 2.5-10.4), followed by Neisseria gonorrhoea (3.2%, IQR 0.0-5.3), Trichomonas vaginalis (3.0%, IQR 0.0-15.4), syphilis (1.1%, IQR 0.0-1.3) and HIV (0.2%, IQR 0.0-0.4). The proportion of positive tests varied between 0 and 13.9% between LPHD, with a higher variation of proportion of positive tests in LPHD with a smaller number of reported STI tests. CONCLUSIONS: Participating LPHD varied in terms of performed STI tests and FSW visits. The proportion of positive STI tests was low, but varied between LPHD. This variation likely reflects different testing strategies. Existing testing guidelines should be used by all LPHD to ensure high quality care for FSW.

Prevalence of pharyngeal and rectal Chlamydia trachomatis and Neisseria gonorrhoeae infections among men who have sex with men in Germany.

OBJECTIVES: To determine the prevalence of pharyngeal and rectal Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections among men who have sex with men (MSM) in Germany and describe associations between these infections, sexual practices and other factors to provide an evidence base for screening recommendations. METHODS: We conducted a cross-sectional study in 22 sentinel sites of sexually transmitted infections across Germany. Pharyngeal and rectal swabs were collected and tested for CT and NG with a nucleic acid amplification test (NAAT). Information on HIV status, number of sex partners and sexual practices was collected and linked to NAAT results. RESULTS: Overall, 2247 MSM were screened for pharyngeal or rectal CT and NG infections; median age was 34 years (range 16-83). Prevalence of CT was 1.5% in pharyngeal and 8.0% in rectal specimens. Prevalence of NG was 5.5% in pharyngeal and 4.6% in rectal specimens. Local symptoms were reported in 5.1% of pharyngeal and 11.9% of rectal infections. Altogether 90.8% of rectal or pharyngeal infections would remain undetected if only symptomatic cases were tested. Rectal infection was significantly more likely in men reporting multiple partners (2-5 partners, OR=1.85; 6-10 partners, OR=2.10; >11 partners, OR=2.95), men diagnosed with HIV (OR=1.60) and men practising receptive anal intercourse without a condom (OR=1.54). Pharyngeal infection was more likely in men reporting multiple partners (6-10 partners, OR=2.88; >11 partners, OR=4.96), and men diagnosed with HIV (OR=1.78). CONCLUSIONS: Pharyngeal and rectal infections in sexually active MSM can remain undetected and thus transmissible if swabbing is not offered routinely. Screening should be offered particularly to MSM diagnosed with HIV and MSM reporting multiple partners.

Why do we Need to go Digital? Process of Developing an Online Facilitator Training Platform for a Global Family Skills Programme for Drug Use Prevention.

Strong Families is a programme developed for families living in challenged or stressful settings to prevent poor mental health and developmental outcomes, violence, and substance use. Facilitators are conventionally trained in person over two full days, by experienced international trainers. During the COVID-19 pandemic and due to travel restrictions, we developed an online course to deliver the content of the training manual electronically, with videos explaining the most difficult exercises, note taking functions and click and reveal activities to check their understanding. We further blended synchronous and asynchronous course formats to accommodate facilitators' different time zones and work schedules. We tied two educational theories (Malcom Knowles theory of andragogy and Blooms taxonomy) into the Strong Families online course, to ensure learners are easily able to understand content, remember it and implement the gained skills within their communities. The aim of this paper is to discuss the process of the development of the Learning Management System and the Strong Families online course, as well as its benefits, key tools and essential considerations for replication through the UNODC multi-country and inter-disciplinary experience in digitalizing the Strong Family skills prevention tool to support other institutions interested in such a process, including in anticipation of future similar circumstances. To date, our online course has been made available in 10 languages, benefitting facilitators from 11 countries and the respective beneficiary families. Further impact evaluation, fidelity of implementation during national scale up and return on investment of integration of blended-learning concepts still need to be assessed.

Lymphogranuloma venereum in men screened for pharyngeal and rectal infection, Germany.

To determine prevalence of lymphogranuloma venereum among men who have sex with men in Germany, we conducted a multicenter study during 2009-2010 and found high rates of rectal and pharyngeal infection in men positive for the causative agent, Chlamydia trachomatis. Many infections were asymptomatic. An adjusted C. trachomatis screening policy is justified in Germany.

Assessing the Efficacy of a Brief Universal Family Skills Programme on Violence and Substance-Use Indicators in Youth in Trentino and Parma, Italy: Study Protocol for a Multi-Centre, Non-Blinded, Cluster-Randomised Controlled Trial (cRCT) of Family UNited.

Homes in which families are experiencing stressful and challenging circumstances can foster a social space that engenders violent behaviours in parents, inadequate childcare, and the exposure of children to criminal and antisocial behaviours at an early age in addition to many other negative social and health consequences throughout their development. Family Skills Training offers a combination of parenting knowledge, skill building, competency enhancement, and support to strengthen family protective factors, such as communication, trust, problem-solving skills, and conflict resolution. Through over a decade-long experience piloting evidence-based family skills packages globally, we developed a universal open-source family skills package, "Family UNited" (FU), designed for families with children aged 8 to 15 years living in low- and middle-income countries (LMIC). The current study aims to explore the efficacy, fidelity, and acceptability of FU in Trentino and Parma, Italy. We plan to conduct a multi-site, non-blinded, two-armed, cluster-randomised controlled trial to assess efficacy in 160 families: the intervention group receiving FU and the waitlist/control group only receiving FU after the completion of all data collection points. We will prospectively collect outcome data, assessing changes in parenting skills and family adjustment in caregivers, children's behaviour, resilience capacities, and attitudes towards peer violence. To assess programme delivery, fidelity, feasibility, and acceptability we will include an embedded process evaluation. This study aims to evaluate the improvement in parenting skills, child well-being, and family mental health after participation in FU, compared to no intervention. Even though this trial is to be conducted in a high-income country, such results complement the existing piloting experience in LMIC. with impact-related measures encouraging the adoption of such approaches globally and beyond the EU borders.

Family UNited: piloting of a new universal UNODC family skills programme to improve child mental health, resilience and parenting skills in Indonesia and Bangladesh.

BACKGROUND: Family is one of the most influential social institutions and caregivers act as the main protective factors for children's mental health and resilience skills. Family skills programmes support caregivers to be better parents and strengthen positive age-specific and age-appropriate family functioning and interactions. We developed a universal, brief and light programme for implementation in low-resource settings, the Family UNited (FU) programme, and conducted a pilot study to show feasibility of implementation, replicability and effectiveness in improving family functioning, child behaviour and resilience. METHODS: We recruited caregivers with children aged 8-14 years through schools in East Java, Indonesia and Dhaka, Bangladesh to the FU programme. Demographic data, emotional and behavioural difficulties of children, child resilience and parental skills and family adjustment measures were collected from children and caregivers before, 2 and 6 weeks after the intervention. Outcome was assessed through the SDQ (Strengths and Difficulties Questionnaire), PAFAS (Parenting and Family Adjustment Scales) and CYRM-R (Child and Youth Resilience Measure). RESULTS: We enrolled 29 families in Bangladesh and allocated 37 families to the intervention and 33 to the control group in Indonesia. Overall, there was no effect over time in the control group on any of the PAFAS subscales, whereas significant reductions in scores were found on six of the seven subscales in either country in the intervention group, most prominently in caregivers with higher scores at baseline. We found highly significant reductions in total SDQ scores in the intervention group in both countries, whereas there was no effect over time in the control group in Indonesia. Boys in the intervention group in Indonesia and in Bangladesh seemed to have benefitted significantly on the SDQ as well as the total resilience scale. Overall, on the CYRM-R, particularly children below the 33rd percentile at pre-test benefitted substantially from the programme. CONCLUSIONS: The implementation of a brief family skills programme was seemingly effective and feasible in resource-limited settings and positively improved child mental health, resilience and parenting practices and family adjustment skills. These results suggest the value of such a programme and call for further validation through other methods of impact assessment and outcome evaluation. TRIAL REGISTRATION: Clinical Trial Registration: ISRCTN99645405, retrospectively registered, 22 September, 2022.

Bridging the Gap between the Pressing Need for Family Skills Programmes in Humanitarian Settings and Implementation.

A supportive environment with nurturing caregivers is essential for the healthy development of children. For children who have been exposed to extreme stress, such as humanitarian contexts, the need for strong, healthy, nurturing caregiver relationships may assume even greater importance. Much research has been building to position family skills interventions as a key tool in encouraging safe and supporting relationships between caregivers and children, thus preventing many problem behaviours and poor mental health. While there is substantial evidence of the effectiveness of family skills interventions in high-income and stable contexts, evidence of interventions that have been tested in humanitarian and challenging settings, such as contexts of refugee and displacement, are far fewer. Despite the role that family skills interventions can play in protecting children from current and future challenges, there is a significant lack of such interventions being utilised in humanitarian settings. We put forward seven likely reasons for this lack of uptake. Furthermore, the Strong Families programme, a UNODC family skills intervention, is presented as an example of an intervention that aims to bridge this gap of interventions that meet the need for humanitarian and contexts of extreme stress. More research is needed to unpack the content, delivery mechanisms and reach of family skills programmes to further aid programme developers in investing in efforts that might provide significant sustained impact for families in humanitarian contexts.

Caring for Your Child during COVID-19-Utilizing a Light-Touch Parenting Resource during Lockdown in Indonesia.

To tackle the spread of COVID-19 globally, countries around the world have responded by implementing measures such as lockdowns, social distance maintenance, temporary school closures, and remote working and learning. COVID-19 social isolation has been found to increase stress, and potentially have long term harmful effects on both mental and physical health. Stress and compromised parenting often place children at risk of violence and abuse. In parallel, times of hardship might also provide an opportunity to build stronger relationships with our children. The United Nations Office on Drugs and Crime (UNODC) joined many other agencies and international organizations in recognizing the threat the pandemic might have on individual and family wellbeing, and has thus availed a number of light-touch parenting resources. One such tool is the 'Caring for your child in response to the COVID-19 lockdown' booklet, developed to enhance parenting skills, and to build family harmony as challenged by the COVID-19 context. This short communication reflects on a feasibility study that took place in Indonesia during the implementation of this booklet with 30 parents in five cities. Thematic analysis identified challenges in parenting during COVID-19, as well as reported positive experiences of engaging in the parenting resource. The findings are discussed with regard to the usefulness of light-touch parenting information, adding to the context of the feasibility and global scalability of reaching families. The implications pave the way to the engagement and implication of more intensive parenting information interventions in high-stress contexts. Despite the challenge, there is promising news for families globally, as agencies and policy-makers begin to recognize the importance of supporting families with the appropriate skills to navigate extreme stress contexts with effective strategies.

Assessing the Feasibility of Providing a Family Skills Intervention, "Strong Families", for Refugee Families Residing in Reception Centers in Serbia.

War exposure and forced displacement threatens the wellbeing of caregivers and their children, leaving them at risk of negative outcomes, such as elevated rates of anxiety, depression and post-traumatic stress disorder. The importance of engaged, responsive and stable parenting for positive child wellbeing has been documented across diverse cultural and economic backgrounds. Despite the higher need for caregivers to be nurturing in challenging settings, they struggle to provide adequate support for their children due to lack of resources or their inability to deal with their own emotional challenges. A feasibility study was conducted of a new, open-access and light-touch family skills intervention, Strong Families (for families in humanitarian and challenged settings) on refugee families residing in Reception Centers in Serbia. Questionnaires and interviews were completed by participating caregivers and facilitators. Qualitative results indicated that the intervention was feasible to run in this humanitarian context, that caregivers viewed the intervention as culturally acceptable and complemented the quantitative results that showed promise for enhancing child behavior and family functioning tested indicators. Despite being a light intervention, Strong Families indicated improvement on child mental health, parenting practices and parent and family adjustment skills. Prioritizing family mental health and functioning as a primary need that parallels that of accessing physical medical care, sanitation and clean water must be the definitive next step in humanitarian aid.

Impact of a Brief Family Skills Training Programme ("Strong Families") on Parenting Skills, Child Psychosocial Functioning, and Resilience in Iran: A Multisite Controlled Trial.

Caregivers have a key role in protecting children's wellbeing, and, with appropriate skills, can prevent a multitude of negative social outcomes, particularly in challenged or humanitarian settings. Accordingly, the Strong Families programme was designed as a light touch family skills programme, with a focus of supporting caregiving during stressful situations. To evaluate the short-term impact of the Strong Families programme, we performed a time-convenience, randomized, controlled trial in Iran. A total of 292 families (63% from Iranian decent, 39% from Afghan decent, and 1% other), with children aged eight to twelve years, were recruited through ten centers in Iran and allocated to an intervention (n = 199) or waitlist/control group (n = 93). The two groups did not differ demographically at baseline. We assessed families prospectively, through three scales, PAFAS (parenting and family adjustment scales), SDQ (strengths and difficulties questionnaire), and CYRM-R (child and youth resilience measure). Caregivers in the intervention group improved (highly) statistically significantly on all but one PAFAS subscales (parental consistency, coercive parenting, positive encouragement, parental adjustment, family relationships, and parental teamwork), which was not noted in the waitlist group. On the SDQ, there were (highly) significant positive changes in scores in the intervention group on all sub-scales and the "total difficulty scale", whereas the waitlist/control group also improved on three (prosocial, conduct problems, and hyperactivity) of the five SDQ subscales. Children originating from Afghanistan improved significantly on the overall resilience scale of the CYRM-R in the intervention group, but not in the waitlist/control group. Overall, all our stratified results of the different scales reflect an accentuated improvement in families with higher levels of problems at baseline. Our comparative results indicated a strong alignment of the strong families programme with its intended short-term impact, per its logical frame on parenting practices and family management skills, children behaviour, caregivers and children mental health, and capacity to cope with stress. We postulate that the potential nudging or diffusion of knowledge (cross-contamination between intervention and waitlist/control group) at the community level could explain improvements in the waitlist/control group on some indicators, however, further research on this is recommend.

Enhancing Teaching Recovery Techniques (TRT) with Parenting Skills: RCT of TRT + Parenting with Trauma-Affected Syrian Refugees in Lebanon Utilising Remote Training with Implications for Insecure Contexts and COVID-19.

Child psychosocial recovery interventions in humanitarian contexts often overlook the significant effect that caregivers can have on improving children's future trajectory. We enhanced the well-established, evidenced-based child trauma recovery programme Teaching Recovery Techniques (TRT) intervention with parenting sessions, i.e., TRT + Parenting (TRT + P), which aims to improve parent mental health and their ability to support their children's mental health. We describe the findings of a three-arm randomised controlled trial comparing enhanced TRT + P vs. TRT and waitlist. The primary aim was to test if children in the enhanced arm of the programme show improved child and caregiver mental health. We recruited 119 Syrian refugee children and one of their caregivers in Beqaa Valley in Lebanon. They were randomised to the TRT, TRT + P, or waitlist control group. Data were collected at baseline and 2 weeks and 12 weeks post intervention. Training of facilitators was via remote training from the United Kingdom. Results showed a highly consistent pattern, with children in the enhanced TRT + P group showing the greatest levels of improvement in behavioural and emotional difficulties compared to children in the TRT or waitlist control groups. Caregivers in the TRT + P group also reported significant reductions in depression, anxiety, and stress. Findings indicate that the addition of the evidence-based parenting skills components has the potential to enhance the effects of interventions designed to improve children's mental health in contexts of trauma, conflict, and displacement. Implications for COVID-19 remote learning are also discussed.

Scabies community prevalence and mass drug administration in two Fijian villages.

BACKGROUND: Scabies has been estimated to affect approximately 300 million people worldwide each year. Scabies rates are high and pose a significant public health problem in Fiji. Community-based comparison treatment trials have not been undertaken. We estimated scabies prevalence and compared the efficacy and tolerability of mass drug administration (MDA) of benzyl benzoate lotion (BB) or oral ivermectin (IVM) in two villages in Fiji. METHODS: A prospective MDA trial was undertaken in two Fijian villages, comparing three daily applications of BB with single dose IVM or permethrin cream for those aged under two years. The therapies were offered to all community members regardless of the presence of scabies or its symptoms. The difference in prevalence was measured before and after the intervention and absolute risk reduction (ARR) and relative risk (RR) calculated. RESULTS: In the BB group, there were 572 eligible participants, of whom 435 (76%) enrolled and 201 (46%) returned for follow-up. In the IVM group, there were 667 eligible participants, of whom 325 (49%) enrolled and 126 (39%) returned. Scabies prevalence was lower after the intervention in both groups. It fell from 37.9 to 20.0% (ARR 18.0%; RR 0.52) in the BB group and from 23.7 to 9.5% (ARR 14.2%; RR 0.40) in the IVM group. CONCLUSIONS: Our study provides proof of principle that MDA for scabies can reduce scabies prevalence at the community level, and that there was no significant difference in this trial between BB and oral IVM.