Parenting for Lifelong Health (PLH) Philippines Evaluation Study: Multisite randomised controlled trial to compare the efficacy of a culturally-adapted parenting programme, Masayang Pamilya, versus services as usual in the reduction of child maltreatment and improvement of child wellbeing in low-income Filipino families with children aged two to six years in Metro Manila (N = 120). A previous study focused on adaptation and feasibility testing was conducted from January 2016 to February 2017. Community-based participatory approaches were used to culturally adapt the Sinovuyo programme to a Filipino context. A formative evaluation using qualitative in-depth interviews and focus group discussions with parents, as well as consultative workshops with service providers and other stakeholders, examined issues regarding the needs and concerns of Filipino parents, appropriateness of intervention components and delivery, and other specific cultural issues in order to balance "fidelity" to evidence-based practices with "fit" to the local context \[11\]. The Sinovuyo programme was then adapted into the MaPa programme with local materials and approaches developed to fit the Philippine cultural context based on findings from the formative evaluation.
Over the past decade there have been increasing calls for the scale-up of evidence-based interventions in order to reduce the risk of violence against children in low- and middle-income countries (LMICs) \[1\]. In particular, parenting programmes for families with young children have been shown to be effective in reducing the risk of child maltreatment and improving child wellbeing with promising evidence emerging from low- and middle-income countries \[2-4\]. These group-based programmes typically aim to strengthen caregiver-child relationships through positive parenting and to help parents to manage child behaviour problems through effective, age-appropriate, nonviolent discipline strategies. Despite the emerging evidence of the effectiveness of parenting interventions in reducing violence against children, many local governments and service providers in LMICs face multiple challenges implementing evidence-based parenting programs in resource poor contexts \[5\]. Parenting programmes are often too expensive to deliver effectively at scale in low-resource settings due to their complexity, intensity, and length \[3\]. Parenting programmes developed and evaluated in other contexts also may not fit the local service delivery context and may require adaptation to be relevant to the local culture of families. Additional programme content may also be necessary to address stress related to economic deprivation, high community violence, and parental distress. The process of delivery may also need to be simplified to improve participant engagement and the quality of delivery. As a result, it is essential that programmes implemented in LMICs are 1) effective at reducing violence against children, 2) integrated within the existing service delivery system, 3) feasible and culturally acceptable to service providers and families, and 4) scalable in terms of their affordability, replicability, and sustainability while reaching a maximum number of beneficiaries. However, there are currently very few parenting programmes that meet these criteria in LMICs, such as the Philippines, where the need is the greatest \[3\]. The PLH Philippines Evaluation Study aims to fill this gap by examining the efficacy of a locally-adapted, evidence-based parenting programme, the Masayang Pamilya Para Sa Batang Pilipino Parenting Programme (MaPa), for families with children ages two to six years living in Metro Manila who are enrolled in the Philippine Department of Social Welfare and Development (DSWD) conditional cash transfer system. Our overall objective is to use a randomised controlled trial design to test the efficacy of the MaPa programme in reducing the risk of child maltreatment while improving child socio-emotional development, child behaviour, and parental mental health in comparison to treatment as usual controls in Metro Manila. Our primary objective is to examine the impact of the MaPa programme on the primary outcome of child maltreatment in comparison to treatment-as-usual controls at immediate post-intervention and at 1-year follow-up. Our secondary objective is to examine the impact of the MaPa programme on proximal outcomes associated with increased risks of child maltreatment, namely, positive parenting, intrusive parenting, and harsh parenting in comparison to treatment-as-usual controls at immediate post-intervention and at 1-year follow-up. Another secondary objective is to examine the impact of the MaPa programme at immediate post-intervention and at 1-year follow-up on child behaviour problems, child development outcomes (i.e., communication skills and socio-emotional development), parenting efficacy, parental wellbeing, parenting stress, parental depression, marital satisfaction, and intimate partner violence, in comparison to treatment as usual controls. Our tertiary objective is to examine the implementation of the MaPa programme when delivered within the DSWD conditional cash transfer system in terms of programme adherence by parents (i.e., recruitment, enrolment, attendance, engagement, dropout, and completion) and delivery by service providers (i.e., competency and fidelity). Our final objective is to examine predictors of programme adherence and associations between programme adherence and primary and secondary outcomes at immediate post-test and at 1-year follow-up.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
PREVENTION
Masking
DOUBLE
Enrollment
120
The MaPa programme includes the following content: 1) spending one-on-one time with children; 2) describing actions and feelings for cognitive development and socio-emotional awareness; 3) using praise and rewards to encourage positive behaviour; 4) establishing limits through effective instruction giving and consistent household rules; 5) nonviolent discipline such as ignoring negative attention seeking behaviour, and consequences for noncompliance, rule-breaking, and aggressive behaviour; 6) problem solving with children; and 7) mindfulness based stress reduction for caregivers.
Content uses a thematic manual that includes sessions on Filipino family dynamics, early childhood development, child behaviour management, marital relationships, prevention of child maltreatment, health care, nutrition, and government anti-poverty initiatives, as well as disaster preparedness. \[12\].
Barangay Western Bicutan
City of Taguig, National Capital Region, Philippines
Change in frequency of child maltreatment
Child maltreatment will be measured using parent report of the ISPCAN Child Abuse Screening Tool-Intervention scale (19 items, ICAST-I), an adaptation of a multi-national and consensus-based survey instrument measuring parent-report the incidence and prevalence of child abuse and neglect (ICAST-P). It was validated in 6 LMIC and 7 languages (α = 0.77-0.88) and measures four types of abuse: physical, emotional and sexual abuse, as well as neglect. Response code for the ICAST-I was adapted to a scale from 0 to more than 8 times to assess the frequency of a certain behaviour in the past month. This study will assess incidence of child maltreatment by creating dichotomous variables for physical abuse, verbal abuse, and neglect, as well as an overall indication of previous child abuse (0 = no abuse; 1 = previous abuse). We will also assess frequency of overall abuse by summing all of the subscales as well as for each individual subscale.
Time frame: Change from baseline at 7 months and at 19 months
Change in frequency of positive parenting
Positive parenting behavior will be assessed using the Parenting of Young Children Scale (PARYC, 21 items) \[5\]. The PARYC measures the frequency of parent behavior over the previous month. Items are summed to create total frequency scores for positive parenting (7 items, e.g., "how often do you play with your child"), setting limits (7 items, e.g., "how often do you stick to your rules and not change your mind") and proactive parenting (7 items, e.g., "how often do you explain what you want your child to do in clear and simple ways"). It has been used with strong reliability in previous studies on the program adapted in this study \[20\].
Time frame: Change from baseline at 7 months and at 19 months
Change in frequency of dysfunctional parenting
Dysfunctional parenting behavior will be assessed using the Parenting Scale (PS, 30 items) \[6\]. This scale examines parent attitudes and beliefs regarding discipline practice. Responses are based on a 7-point Likert scale in which parents are presented with a situation and then are asked to choose between two alternative responses to a situation (1 = most effective; 7 = most ineffective; i.e., situation: "When I say my child can't do something;" response, score = 1: "I stick to what I said;" or response score = 7: "I let my child do it anyway"). Items are summed to create an overall score as well as for three subscales: Laxness, Over-reactivity, and Verbosity. The PS has been used widely to assess the effectiveness of parenting programs, including in low-resource settings such as Panama \[21\].
Time frame: Change from baseline at 7 months and at 19 months
Change in levels of endorsement of physical punishment
This study will ask one question from the UNICEF Multiple Indicator Cluster Survey \[1\] regarding parental attitudes to physical discipline based on a 5-point Likert scale of 0 to 4: "In order to bring up, raise up, or educate a child properly, the child needs to be physically punished." Caregivers will report whether they disagree or agree with the statement (0 = disagree strongly; 4 = agree strongly).
Time frame: Change from baseline at 7 months and at 19 months
Change in number of daily child behavior problems and parenting behaviors
An adapted version of Parent Daily Report Checklist (PDR, 44 items) will be used to assess day-to-day occurrences of child behavior problems and parenting behavior \[12\]. It was designed to avoid potential challenges parents may have in recalling events in retrospective scales, and has been used widely in multiple contexts as an assessment of child and parent behavior change during program delivery \[46-49\]. The PDR does not assess frequency of behavior but rather the occurrence (i.e., "Yes" or "No"). Parents indicate whether a child behavior occurred within the previous 24 hours (35 items, e.g., complaining, lying). In order to assess parenting behavior, this study will also ask parents about their own behavior (6 items, e.g., used physical discipline, or praised child) and self-efficacy (3 items, e.g., had a feeling that I could not cope with parenting).
Time frame: Change from baseline at 7 months and at 19 months
Change in number of child behavior problems
The Eyberg Child Behavior Inventory assesses child behavior problems \[30\]. This 36-item survey examines externalizing behavior problems in children ages 2 to 16 using both an Intensity Scale and Problem Scale. Parents are asked how often a specific behavior occurs and whether the behavior is considered a problem. Items based on the most typical child behavior problems. The Intensity Scale rates frequency of occurrence based on a 7-point Likert-like scale (1 = never occurs; 7 = always occurs). The Problem Scale measures whether the parent identifies a specific behavior as a problem (0 = no; 1 = yes). Both scales are summed up to create a total Intensity Score and Problem Score. The ECBI has been used extensively throughout the world as a diagnostic tool as well as to evaluate parenting programs in RCTs \[31-34\]. Clinical cut-off scores suggested for psychopathological problem behavior are 131 for the Intensity Score and 15 for the Problem Score \[35\].
Time frame: Change from baseline at 7 months and at 19 months
Change in levels of child development - communication skills
Child development will be assessed using the communication subscale of the parent-report version of the Ages and Stages Questionnaires, Version 3 (ASQ-3) \[13\]. This 6-item screening tool measures infant and toddler development of communication skills from 2 months to 6 years of age. Distinct items are administered according to the child's age in 2-month intervals rounded to the nearest interval. The ASQ-3 is administered via caregiver self-report based on "Yes," "Sometime," or "Not Yet" for each developmental milestone. In addition, if the caregiver is not sure of a specific item, s/he is given the opportunity to perform the task with his/her infant or toddler during the assessment. Items for each subscale are summed to create total scores as well as an overall indication of child development. Cut-off scores will be used based on international ASQ cut-offs according to the manual for normal development, borderline delay, and developmental delay \[13\].
Time frame: Change from baseline at 7 months and at 19 months
Change in levels of child socio-emotional development
Child socio-emotional development will be assessed using the parent-report version of the Ages and Stages Questionnaires: Social-Emotional, Version 2 (ASQ-SE2) \[14, 36\]. This screening tool was designed to specifically assess socio-emotional development for children from 1 month to 6 years of age. Questionnaires are administered to the parent depending on the age of the child (i.e., 24, 30, and 36 month intervals). Items examine seven domains of socio-emotional development: self-regulation, compliance, adaptive functioning, autonomy, affect, social-communication, and interaction with others. Parents report on whether the specific child behavior occurs "often or always," "sometimes," or "rarely or never," as well as whether the behavior is a concern for the parent (yes/no). The ASQ:SE has been used extensively as a global screening tool, including multiple low- and middle-income countries \[37-41\].
Time frame: Change from baseline at 7 months and at 19 months
Change in levels of parent efficacy
Parenting efficacy will be assessed using the Efficacy Subscale of the Parenting Sense of Competence Scale (8 items; PSOC-ES) \[37\]. The PSOC has been widely used in studies to evaluate parenting self-esteem, efficacy, or competence \[37\]. The PSOC Efficacy Subscale measures parental perception of competence, problem-solving ability, and capability in the parenting role (e.g., ""I honestly believe I have all the skills necessary to be a good mother/father to my child"). Each item is rated on a 6-point scale that ranges from 1 (strongly disagree) to 6 (strongly agree). Items are summed to create a total score of parental self-efficacy.
Time frame: Change from baseline at 7 months and at 19 months
Change in levels of parenting stress
Parenting stress will be measured using the Parenting Stress Index (PSI) (36 items) \[8\]. This scale has been used widely throughout the world \[22-25\], including prior use in low- and middle-income countries \[26, 27\]. Items include subscales for parental distress (e.g., "I often have the feeling that I cannot handle things very well"), parent-child dysfunction (e.g., "Sometimes I feel my child doesn't like me and doesn't want to be close to me"), and difficult child (e.g., "I feel that my child is very moody and easily upset"). Items are summed to create a total score for parenting stress as well as for each subscale.
Time frame: Change from baseline at 7 months and at 19 months
Change in levels of parental depression
The Depression, Anxiety, and Stress Scale (DASS) will assess caregiver depression. The DASS is a 21-item scale used as a screening tool to measure depression, anxiety, and stress in adults. Caregivers report on the frequency of depressive symptoms in the previous week using a Likert scale (0 = Never, 1 = Sometimes, 2 = Often, 3 = Always; e.g., "I felt that I had nothing to look forward to"). Total DASS scores range from 0 to 63 with subscales from 0 to 21. Recommended cut-offs indicating severity of depression are 5-6 for mild, 7-10 for moderate, 11-13 for severe, and 14 and up for extremely severe. Cut-offs for anxiety are 4-5 for mild, 6-7 for moderate, 8-9 for severe, and 10 and up for extremely severe. Cut-offs for stress are 8-9 for mild, 10-12 for moderate, 13-16 for severe, and 17 and up for extremely severe.
Time frame: Change from baseline at 7 months and at 19 months
Change in levels of parental wellbeing
The WHO-5 Well-Being Scale (WHO-5) will measure parental psychological well-being \[10\]. This 5-item scale was derived using psychometric analyses from the longer 28-item WHO Well-Being Scale. The validation study of the WHO-5 showed 93% sensitivity and 64% specificity when compared with the General Health Questionnaire and the Patient Health Questionnaire \[28\]. Parents indicate the frequency that they experience well-being in the past month (e.g., "My daily life has been filled with things that interest me") based on a Likert scale from 0 to 5 ("At no time" to "All of the time"). Items are added up with scores ranging from 0 to 25.
Time frame: Change from baseline at 7 months and at 19 months
Change in levels of parent dependency on alcohol
Parental dependency on alcohol will be assessed by asking parents to report on alcohol consumption during the past month (1 item). Dependency is based on 3 or more drinks per day for female participants and 5 or more per day for male participants \[48\]. Due to the sensitive nature of these items, additional items dealing with other activities to reduce stress have been included in this section to encourage accuracy (3 items; e.g., "In the past month, have you been for a walk or done some other exercise to help you relax?").
Time frame: Change from baseline at 7 months and at 19 months
Change in frequency of intimate partner violence
Adult self-report of the victimhood of intimate partner violence will be assessed using an adapted version of the Revised Conflict Tactics Scale Short Form (CTS2S; 8 items) \[42\]. Items include the frequency of negotiation (e.g., "partner suggested compromise to an argument"), physical assault (e.g., "partner hit me with something"), and psychological aggression (e.g., "partner insulted or swore at me"). Answers are coded on a 5-point Likert scale of 0 to 4 (0 = never happened; 4 = more than 3 times in the past month). The CTS2S will determine an overall indication of IPV on a level of severity (sum of items) and prevalence (dichotomous variable indicating experience of conflict or not) as well as for each subscale.
Time frame: Change from baseline at 7 months and at 19 months
Change in levels of marital satisfaction
Adult report of marital satisfaction will be assessed using the Kansas Marital Satisfaction Scale (KMSS; 3 items) {Schumm, 1986 #3905}. The KMSS was developed as a validated but brief measurement of marital relations. Items include satisfaction with marriage, spouse or partner, and quality of the relationship with a spouse/partner. Responses options are coded on a 7-point Likert scale of 1 to 7 (1 = extremely dissatisfied; 7 = extremely satisfied). Total scores are created by summing the items. The KMSS has been found to correlate strongly with other measures relationship adjustment and quality of marriage, and showed strong internal reliability in the feasibility pilot of the MaPa programme (α = .89).
Time frame: Change from baseline at 7 months and at 19 months
Change in levels of parent/child sleep
Parent/child sleep will be assessed by asking parents to report average daily number of hours the parent and child slept in the previous five days. In order to increase the accuracy of self-report data, research assistants will ask the parent to report on the hours of sleep for each day including hours that the child sleeps during the day. Mean score for hours slept for both parent and child will be calculated summing each day and then dividing by the number of days (i.e., 5 days).
Time frame: Change from baseline at 7 months and at 19 months
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