Parenting Programmes in low-and middle-income countries
Why low-and middle-income countries?
Ninety percent of the world’s child and adolescent population live in low- and middle-income countries (LMIC) and mental health difficulties affect 10-20% of these children and adolescents. Further, millions live in poverty placing them at even greater risk of poor mental health and limited long-term prospects.
Previous research has demonstrated that behavioural difficulties increase the risk of mental health disorders, maltreatment, poor social functioning and educational attainment in childhood and when children are older antisocial behaviour (including violence and involvement in crime) and poor adult mental health and productivity (Institute of Medicine, 2009).
International agencies, researchers and policy makers have highlighted the urgent need to improve child and adolescent mental health in LMIC through the provision of better access to mental health care and have placed this challenge high on the global public health agenda.
There is growing evidence that positive parenting is at the foundation for healthy child development. Children who grow up in warm and supportive parenting environments are less likely to develop behavioural difficulties even when faced with poverty and deprivation. Parenting interventions have been identified as effective interventions for promoting wellbeing and preventing difficulties and chosen by international agencies such as the World Health Organisation and United Nations Office on Drugs and Crime as the intervention of choice to prevent child behavioural difficulties and their associated problems. However, two recent systematic reviews highlighted significant gaps in knowledge regarding their efficacy for preventing child difficulties in LMIC (Knerr et al., 2013; Mejia et al., 2012).
The project was funded by the National Secretariat of Science, Technology and Innovation in Panama and The University of Manchester.
What have we been doing?
In order to help reduce this research gap, from 2010 to 2014 we completed a feasibility project, comprising a series of studies, in Panama, a middle-income country in Central America, to find out whether a brief, evidence-based intervention (Triple P-Positive Parenting Program Discussion Groups) developed in Australia was culturally acceptable and efficacious in this setting.
Violence is the second cause of mortality in Panama and there are pockets of extreme poverty and high economic inequality, but with the rapid economic changes occurring in Panama, it has the opportunity to invest in public health and services and is committed to rolling out effective parenting support in all state-owned schools for violence prevention.
Surveys were carried out with parents in Panama, both online and face-to-face, to hear their views on the best ways of making the parenting intervention accessible to them, how useful they thought it might be and whether they would take it up if it was offered to them.
Regardless of socio-economic status, gender and level of child behavioural difficulties, parents found the program materials highly interesting and relevant, and the large majority reported being willing to participate in a parenting program if one was offered in their community. Many expressed a preference for self-directed formats such as books, articles and brochures.
We carried out a pilot randomised controlled trial of a single Triple P Discussion Group on dealing with disobedience, lasting two hours and in groups of 10, with 108 parents from high-risk neighbourhoods in Panama City.
Results indicated that the single Discussion Group was effective in reducing parent-reported child behavioural difficulties. Effect sizes were large, d=0.51, d=0.42 and d=1.09 two weeks, three and six months post-intervention. Parents also reported increased positive parenting practices (d=0.19-0.58) and improved maternal mental health (d=0.32-0.61).
25 parents who took part in Discussion Group were interviewed about their views about the programme in order to explore the acceptability and cultural fit of the intervention after it had been offered and completed. The cultural context in which parents live, their parenting needs and the relevance of the intervention to address those needs were described by participants.
In relation to the cultural context in which parents live, parents reported that economic constraints (e.g., wanting to give their children more than they could afford) and housing difficulties made parenting more stressful in addition to the competing demands of having to hold down more than one job to provide for their families and worries about the safety of their children because of the dangerous environments they lived in. The use of physical and verbal aggression toward their children were casually reported by parents indicating that these strategies were normal in this context.
With regard to parenting needs, behavioural difficulties at school, especially poor concentration aggression, and at home, particularly not following instructions, sibling rivalry including high levels of aggression, and tantrums were mentioned as making parenting difficult and for which help was needed. Conflict with their partner was attributed to making parenting harder and being the victim of abuse contributed to abusing their own children.
In relation to the appropriateness of the intervention, parents noted the similarities between parenting needs in different cultures worldwide and considered the intervention materials (e.g., videos and workbooks) culturally appropriate, but that more role play on reducing harsh parenting practices (e.g., abusive communication) was needed. Parents talked about increasing the reach of the intervention to more members of the community and wanting more than one session.
Most parents described the intervention as a positive experience which enabled them to share their own and learn from other parent's problems which gave them skills in independent and collective problem-solving. Parents said the intervention opened up the opportunity to develop strong social ties in their communities with those who had participated in the intervention, but also to share knowledge and skills and form friendships with those who had not participated in the program.
Using data from the interviews described above, we also undertook an exploration of mechanisms behind the changes reported after taking part in the intervention. Strategies for emotion regulation in parents as well as the ability for self-regulation and problem-solving were identified as potential mechanisms underlying the changes. Parents reported changes in their own behaviour such as using more praise and spending quality time with their children, who in turn seemed to be more responsible and better at following instructions.
This research has strengthened our understanding of cultural fit and efficacy of a preventive brief and established interventions (developed in high-income countries) in LMIC, has boosted capacity in UK and Panamanian research communities and has promoted the development of international links to promote implementation and further evaluation.
Outputs to-date from the research
- Mejia, A., Calam, R., & Sanders, M. R. (2015). A pilot randomized controlled trial of a brief parenting intervention in low-resource settings in Panama. Prevention Science. doi:10.1007/s11121-015-0551-1
- Mejia, A., Filus, A., Calam, R., Morawska, A., & Sanders, M.R. (2014). Measuring parenting practices and family functioning with brief and simple instruments: Validation of the Spanish version of the PAFAS. Child Psychiatry & Human Development. doi: 10.1007/s10578-014-0483-1
- Mejia, A., Calam, R., & Sanders, M. R. (2014). Examining the fit of evidence-based parenting programs in low-resource settings: A survey of practitioners in Panama. Journal of Child and Family Studies. doi:10.1007/s10826-014-0028-z
- Mejia, A., Calam, R., & Sanders, M. R. (2014). Examining delivery preferences and cultural relevance of an evidence-based parenting program in a low-resource setting of Central America: Approaching parents as consumers. eScholarID:226394 | DOI:10.1007/s10826-014-9911-x
- Mejia, A, Calam, R & Sanders, M. R. (2012). A review of parenting programs in developing countries: Opportunities and challenges for preventing emotional and behavioral difficulties in children. Clinical Child and Family Psychology Review, 15(2)(http://www.springerlink.com/content/p4732210816x6733/), 163-175. eScholarID:159420 | DOI:10.1007/s10567-012-0116-9
Want to find out more?
- For more information and details on this project email: firstname.lastname@example.org