Anilena Mejia

A Review of Parenting Programs in Developing Countries: Opportunities and Challenges for Preventing Emotional and Behavioral Difficulties in Children

Many children in developing countries are at risk of emotional and behavioral difficulties, which are likely to be elevated due to the effects of poverty. Parenting programs have shown to be effective preventative strategies in high-income countries, but to date the research on their effectiveness in lower-income countries is limited. International organizations such as the World Health Organization have called for the implementation of programs to prevent behavioral difficulties through the development of stable relationships between children and their parents. The aim of the present paper was to review the literature on parenting programs in developing countries in order to identify challenges, opportunities and directions for further research. First, reports of international organizations were reviewed in order to gain a preliminary overview of the field. In a second stage, a non-systematic review was carried out. Databases were searched in order to identify empirical evaluations of parenting programs in low-income countries. Finally, a systematic review was carried out to specifically identify evaluations of programs targeting emotional or behavioral outcomes. Only one study had a strong methodology among those designed to prevent emotional and behavioral outcomes. Opportunities for further program development and research are identified.

Different Strokes for Different Folks? Contrasting Approaches to Cultural Adaptation of Parenting Interventions

Relevant achievements have been accomplished in prevention science with regard to disseminating efficacious parenting interventions among underserved populations. However, widespread disparities in availability of parenting services continue to negatively impact diverse populations in high-income countries (e.g., the USA) and low- and middle-income countries. As a result, a scholarly debate on cultural adaptation has evolved over the years. Specifically, some scholars have argued that in diverse cultural contexts, existing evidence-based parenting interventions should be delivered with strict fidelity to ensure effectiveness. Others have emphasized the need for cultural adaptations of interventions when disseminated among diverse populations. In this paper, we propose that discussions on cultural adaptation should be conceptualized as a “both-and,” rather than an “either-or” process. To justify this stance, we describe three distinct parenting intervention projects to illustrate how cultural adaptation and efficacy of evidence-based interventions can be achieved using contrasting approaches and frameworks, depending on cultural preferences and available resources of local contexts. Further, we suggest the need to develop guidelines for consistent reporting of cultural adaptation procedures as a critical component of future investigations. This discussion is relevant for the broader public health field and prevention science.

Validation of the Spanish version of the CAPES A brief instrument for assessing child psychological difficulties and parental self-efficacy

In the present study, we explored the factor structure as well as validity and reliability of the Spanish version of the Child Adjustment and Parent Efficacy Scale (CAPES) suitable for assessing child behavioural and emotional difficulties (Intensity Scale) and parental self-efficacy (Self-Efficacy Scale) among Spanish-speaking parents from the US, Latin America and Spain. This instrument was designed to be brief and easy to read in order to reach parents with low-literacy levels and from under-resourced backgrounds. Psychometrics for the English version of the CAPES indicates good internal consistency, as well as satisfactory construct and predictive validity of the measure (Morawska et al., 2014). A sample of 174 parents of children (91 boys and 78 girls) from Panama participated in this study. They completed the instrument alongside the Strengths and Difficulties Questionnaire (SDQ) for measuring child psychological problems and the Parenting Task Checklist (PTC) for measuring parental self-efficacy. In addition, a group of 49 parents completed the CAPES at time 1 (T1) and 2 weeks after (T2). Psychometric evaluation of the Spanish version of the CAPES revealed that it has adequate internal consistency and test–retest reliability, as well as satisfactory convergent and discriminant validity. In conclusion, this instrument shows promise as a brief outcome measure to be used in clinical settings and to assess the effects of parenting interventions among Spanish-speaking parents. More research into psychometric properties of the Spanish version of the CAPES is needed, before it can be widely applied in practice.

An Exploration of Parents’ Perceptions and Beliefs About Changes Following Participation in a Family Skill Training Program: a Qualitative Study in a Developing Country

Family skill training programs have been recognized as effective strategies for preventing substance use. However, they have been evaluated mainly in high-income countries. Families in developing countries also face difficulties; therefore, it is important to explore the fit of existing programs in this context. The present study explores parents’ perceptions and beliefs about changes following participation in the Strengthening Families Program 10–14, which was implemented in Panama by the United Nations Office on Drugs and Crime. Thirty parents who had taken part in the program between 2010 and 2011 were interviewed. Thematic analysis was conducted taking a participant-driven inductive stand. An exploration of parents’ narratives suggested that, after the program, they observed changes in themselves as parents, in their children, in the interaction between the two of them, and in their functioning as a couple. Perceived changes centered on communication, limits, obedience, relationship roles, emotional regulation, and social development. For example, parents reported being able to control their emotions in a healthier manner, reducing the use of shouting and setting limits in a more effective way. All these factors have been recognized in previous research as strategies for preventing substance use. It is important to assess participants’ perceptions of programs brought from elsewhere before dissemination efforts can take place. Parents interviewed for this study appeared to hold positive views about this program. This methodology is discussed as a means of evaluating evidence-based interventions in different cultural settings.

How useful are randomized controlled trials in a rapidly changing world

The term evidence-based to label mental health interventions is increasingly common. Fast developments in mental health and social sciences have prompted policy makers to fund and implement only those interventions that have been evaluated through rigorous experimental studies such as randomized controlled trials (RCTs; e.g. Institute of Medicine, 2009; Centers for Disease Control and Prevention, 2011). While in the last 50 years significant investments have been made in high-income countries to establish the evidence of many intervention packages, very little has been done in lowand middle-income countries (LMICs). As a response, there is now a global mental health movement for increasing evaluations and access to evidence-based interventions in LMICs (Collins et al. 2011; Patel, 2012). The argument for establishing intervention effectiveness through RCTs ensures that users are offered services which (quantitatively) reduce the target outcome, and consequently, avoid detrimental impact or waste of resources if there is no impact at all. The main strength of RCTs is their excellent internal validity due to randomization, which ensures that the only difference between the two treatment arms that are compared is their exposure to the treatment of interest. Evidence from RCTs is considered ‘gold standards’. For example, compilations such as Blueprints for Violence Prevention rank mental health interventions based on the number of RCTs demonstrating their efficacy/effectiveness, thus providing a useful tool for guiding large-scale implementation decisions. In this commentary, we briefly argue that although RCTs have contributed immensely to development of mental health services in the last 50 years, positivistic experimental paradigms have several limitations. Other methods with greater external validity (or greater potential for generalizability) should also be considered for determining impact of interventions. More importantly, we discuss whether RCTs are efficient tools given the fast pace at which the society changes. In this discussion, we are not intending to undermine the value of RCTs, but rather to point out some of its limitations and recognize the benefits of other alternative methodologies for establishing intervention impact. In light of this global mental health movement, the present discussion is both relevant to efforts in high-income countries and LMICs.

Exploration of Mechanisms behind Changes after Participation in a Parenting Intervention: A Qualitative Study in a Low-Resource Setting.

Parenting interventions are effective for preventing psychological difficulties in children. However, their active ingredients have not been comprehensively explored. How do they work? What are the mechanisms operating behind changes? In 2012, a randomized controlled trial of a parenting intervention was conducted in low-resource communities of Panama. Effects on child behavioral difficulties, parental stress, and parenting practices were large in the short and long term. This was an ideal opportunity to explore potential mechanisms operating behind effects found in this low-resource setting. Twenty-five parents were interviewed. Data were analyzed through an inductive semantic thematic analysis. Three themes emerged from the data: (a) psychological mechanisms behind changes, (b) behavioral changes in parent, and (c) changes in the children. Parents described that the intervention triggered changes in emotion regulation, self-efficacy, and problem solving. Parents also reported behavioral changes such as praising their children more often, who in turn seemed more responsible and better at following instructions. The study offers participant-driven insight into potential pathways of change after participation in this parenting intervention, pathways that are often overlooked in quantitative studies. Future studies should further explore these pathways, through mediator and moderator analyses, and determine how much is shared across interventions and across different cultural settings.

Strengthening a Culture of Prevention in Low- and Middle-Income Countries: Balancing Scientific Expectations and Contextual Realities

Relevant initiatives are being implemented in low- and middle-income countries (LMICs) aimed at strengthening a culture of prevention. However, cumulative contextual factors constitute significant barriers for implementing rigorous prevention science in these contexts, as defined by guidelines from high-income countries (HICs). Specifically, disseminating a culture of prevention in LMICs can be impacted by political instability, limited health coverage, insecurity, limited rule of law, and scarcity of specialized professionals. This manuscript offers a contribution focused on strengthening a culture of prevention in LMICs. Specifically, four case studies are presented illustrating the gradual development of contrasting prevention initiatives in northern and central Mexico, Panamá, and Sub-Saharan Africa. The initiatives share the common goal of strengthening a culture of prevention in LMICs through the dissemination of efficacious parenting programs, aimed at reducing child maltreatment and improving parental and child mental health. Together, these initiatives illustrate the following: (a) the relevance of adopting a definition of culture of prevention characterized by national commitments with expected shared contributions by governments and civil society, (b) the need to carefully consider the impact of context when promoting prevention initiatives in LMICs, (c) the iterative, non-linear, and multi-faceted nature of promoting a culture of prevention in LMICs, and (d) the importance of committing to cultural competence and shared leadership with local communities for the advancement of prevention science in LMICs. Implications for expanding a culture of prevention in LMICs are discussed.