Transporting evidence-based interventions across cultures: using focus groups with teachers and parents of pre-school children to inform the implementation of the Incredible Years Teacher Training Programme in Jamaica

A qualitative evaluation of the mechanisms of action in an early childhood parenting programme to prevent violence against children in Jamaica

BACKGROUND

Violence against children (VAC) is a global public health problem, and parenting programmes are a key strategy to reduce VAC at home. We developed and evaluated a preschool-based, early childhood, violence prevention, parenting programme (the Irie Homes Toolbox) in Jamaica and reported significant reductions in parents' use of VAC [Effect size (ES) = -0.29] and increases in parents' positive practices (ES = 0.30). This study presents qualitative findings on the mechanisms of action of the programme.

METHODS

As part of a cluster randomized trial, 115 parents from nine preschools participated in the Irie Homes Toolbox parenting programme. The programme consisted of eight 90-min sessions with groups of six parents and focussed on strengthening parent-child relationships, understanding children's behaviour, using appropriate discipline strategies and understanding and managing emotions. We conducted in-depth, semi-structured interviews with a stratified random sample of 28 parents (two to four parents per school) and with nine preschool teachers (one teacher per preschool). Topic guides were developed to explore participants' perspectives of the mechanisms of action of the programme. All interviews were audio-recorded and transcribed, and data were analysed using the framework approach.

RESULTS

The most salient direct pathways to reduced VAC by both parent and teacher reports were through parents' use of alternative strategies to manage child misbehaviour and through improved parent well-being, especially parents' self-management skills. Other factors leading to reduced VAC by parents, reported by both parents and teachers, included self-identification as an 'Irie parent', use of proactive parenting strategies and improved child behaviour. Parents reported that the main factors leading to continued use of VAC were their inconsistency in using positive discipline strategies and poor emotional self-regulation.

CONCLUSION

Reports from participating parents and preschool teachers indicate that contents related to parental self-management and how to use positive discipline strategies to manage child misbehaviour were important factors on the pathway to reduced VAC.

The Irie Classroom Toolbox, a universal violence-prevention teacher-training programme, in Jamaican preschools: a single-blind, cluster-randomised controlled trial

BACKGROUND

Violence is a leading global public health problem, and interventions in early childhood are important in the primary prevention of violence. We tested whether the Irie Classroom Toolbox, a violence-prevention teacher-training programme reduced violence against children by teachers and reduced class-wide child aggression in Jamaican preschools (catering to children aged 3-6 years).

METHODS

We did a single-blind, cluster-randomised controlled trial in 76 preschools in Kingston and St Andrew, randomly selected, using simple randomisation, from 120 eligible preschools. Inclusion criteria were two to four classes of children; at least ten children per class; and located in an urban area. We randomly assigned preschools (1:1) to either the Irie Classroom Toolbox intervention or waiting-list control that received no intervention, using a computer-generated randomisation sequence by an independent statistician masked to school identity. The Toolbox involved training teachers in classroom behaviour management and promoting child social-emotional competence. All assessors were masked to group assignment. All teachers and classrooms in the selected schools participated in the study. Within each school, we used simple randomisation to randomly select up to 12 children aged 4 years for evaluation of child outcomes. The Toolbox intervention was implemented from August to April the following year. Teacher and classroom measures were done at baseline (the summer school term; ie, May to June), post-intervention (after 8 months of intervention; ie, May to June of the following year), and 1-year follow-up (ie, May to June 2 years later). The primary outcomes were observations of violence against children (including physical violence and psychological aggression) by teachers occurring across one full school day, and class-wide child aggression occurring over five 20-min intervals on another school day, all measured at post-intervention and 1-year follow-up and analysed by intention to treat. This trial is registered with ISRCTN, number ISRCTN11968472.

FINDINGS

Between June 22, 2015, and April 29, 2016, (after baseline measurements were completed), we assigned 38 preschools (with 119 teachers) to the Toolbox intervention and 38 preschools (with 110 teachers) to control. 441 children in the intervention schools and 424 in the control schools were included in the evaluation. All schools were included in the post-intervention and follow-up analyses. There were fewer counts of violence against children by teachers in the intervention schools compared with control schools at post-intervention (median counts 3 [IQR 0-11] vs 15 [3-35]; effect size -67·12%, 95% CI -80·71 to -53·52, p<0·0001) and 1-year follow-up (median counts 3 [IQR 0-9] vs 6 [1-16]; effect size -53·86, 95% CI -71·08 to -36·65, p<0·0001). No differences between groups were found for class-wide child aggression at post-intervention (effect size 0·07, 95% CI -0·16 to 0·29, p=0·72) or 1-year follow-up (-0·14, -0·42 to 0·16, p=0·72).

INTERPRETATION

In Jamaican preschools, the Irie Classroom Toolbox effectively reduced violence against children by teachers. The Toolbox was designed for use with undertrained teachers working in low-resource settings and should be effective with early childhood practitioners in other LMICs. Additional research is needed to further develop the Toolbox to reduce class-wide child aggression.

FUNDING

Medical Research Council, Wellcome Trust, UK Aid, and the National Institute of Health Research.

Design and Implementation of the Irie Homes Toolbox: A Violence Prevention, Early Childhood, Parenting Program

This paper describes the development of the Irie Homes Toolbox, a violence prevention program targeting parents of children aged two to six years. The intervention was designed to complement an existing, teacher-training, violence prevention program, the Irie Classroom Toolbox, thus promoting an integrated approach across home and school settings. The Irie Homes Toolbox was developed through a four-stage process by integrating data from theory, formative research, and practice to ensure the intervention is acceptable, feasible, relevant, and effective in the context. The perspectives of Jamaican preschool teachers and parents of preschool children, who are the end users, were integrated into the design of the intervention throughout the development process. Stage one involved integrating theory and formative research to inform the initial intervention design. Stages two and three involved iterative cycles of design, implementation and evaluation of the intervention content, process of delivery, structure and materials. Stage four involved a further cycle of learning through a process evaluation conducted as part of a cluster-randomized controlled trial. Data from each of these four stages was used to inform the design and ongoing revisions of the toolbox with the aim of developing a low-cost, scalable and sustainable intervention for the Jamaican context. The resulting program is theory-informed and uses empirically derived content and behavior change principles operationalized for the context in which it will be delivered. The Irie Homes Toolbox is suitable for integration into the existing preschool provision in Jamaica, thus utilizing an existing service and existing staff and increasing the likelihood for wide-scale dissemination.

Effect of transporting an evidence-based, violence prevention intervention to Jamaican preschools on teacher and class-wide child behaviour: a cluster randomised trial

INTRODUCTION

Based on extensive piloting work, we adapted the Incredible Years (IY) teacher-training programme to the Jamaican preschool setting and evaluated this adapted version through a cluster-randomised trial.

METHODS

Twenty-four community preschools in Kingston, Jamaica were randomly assigned to intervention (12 schools, 37 teachers) or control (12 schools, 36 teachers). The intervention involved training teachers in classroom management through eight full-day training workshops and four individual 1-h in-class support sessions. Outcome measurements included direct observation of teachers' positive and negative behaviours to the whole class and to high-risk children and four observer ratings: two measures of class-wide child behaviour and two measures of classroom atmosphere. Measures were repeated at a six-month follow-up.

RESULTS

Significant benefits of intervention were found for teachers' positive [effect size (ES) = 3.35] and negative (ES = 1.29) behaviours to the whole class and to high-risk children (positive: ES = 0.83; negative: ES = 0.50) and for observer ratings of class-wide child behaviour (ES = 0.73), child interest and enthusiasm (ES = 0.98), teacher warmth (ES = 2.03) and opportunities provided to share and help (ES = 5.72). At 6-month follow-up, significant benefits of intervention were sustained: positive behaviours (ES = 2.70), negative behaviours (ES = 0.98), child behaviour (ES = 0.50), child interest and enthusiasm (ES = 0.78), teacher warmth (ES = 0.91), opportunities to share and help (ES = 1.42).

CONCLUSIONS

The adapted IY teacher-training programme produced large benefits to teacher's behaviour and to class-wide measures of children's behaviour, which were sustained at 6-month follow-up. Benefits were of a similar magnitude to those found in a pilot study of the minimally adapted version that required significantly more in-class support for teachers.

Irie Classroom Toolbox: a study protocol for a cluster-randomised trial of a universal violence prevention programme in Jamaican preschools

INTRODUCTION

We aim to determine the effectiveness of a school-based violence prevention programme implemented in Jamaican preschools, on reducing the levels of aggression among children at school, and violence against children by teachers.

METHODS AND ANALYSIS

This is a 2-arm, single-blind, cluster-randomised controlled trial with parallel assignment. Clusters are 76 preschools in Kingston, and all teachers and classrooms in the selected schools are included in the study. In addition, a random sample of up to 12 children in the 4-year-old classes have been selected for evaluation of child-level outcomes. The intervention involves training teachers in classroom behaviour management and in strategies to promote children's social-emotional competence. Training is delivered through five full-day workshops, monthly in-class coaching over 2 school terms, and weekly text messages. The primary outcome measures are: (1) observed levels of child aggression and (2) observed violence against children by teachers. Secondary outcomes include observations of the levels of children's prosocial behaviour and the quality of the classroom environment, teachers' reports of their mental health, teacher-reported child mental health, direct tests of children's self-regulation and child attendance.

ETHICS AND DISSEMINATION

If this intervention were effective at improving the caregiving environment of young children in school, this would have significant implications for the prevention of child mental health problems, and prevention of violence against children in low and middle-income countries where services are often limited. The intervention is integrated into the school system and involves training existing staff, and thus, represents an appropriate strategy for large-scale implementation and benefits at the population level. Ethical consent for the study was given by the School of Psychology Ethics and Research Committee, Bangor University (ref: 2014-14167), and by the University of the West Indies Ethics Committee (ref: ECP 50,14/15).

TRIAL REGISTRATION NUMBER

ISRCTN11968472; Pre-results.

State of the Nigerian child - neglect of child and adolescent mental health: a review

BACKGROUND

As most child health initiatives in Nigeria lack a child and adolescent mental health (CAMH) strategy, CAMH issues have remained obscure to the country's policy-makers. The lack of current and representative epidemiological data on the mental health of Nigerian children continues to be a barrier to advocacy for CAMH policy initiatives. In view of the importance of CAMH to national development, there must be a continued search for ways of bringing the state of CAMH in Nigeria to the attention of policy-makers.

OBJECTIVES

To use information from UNICEF's State of the World's Children as proxy data to speculate on the state of child mental health in Nigeria.

METHODS

With a view to discussing its CAMH implications, social and health indicators in the Nigerian child were extracted from UNICEF's 2012 edition.

RESULTS

Most of the social and health indicators assessed reflect significant mental health risks. Up to 65% of households live on less than US$1·25 per day, child malnutrition is evident in up to 40% of children, and the primary and secondary school net enrolment ratios are only 63% and 25%, respectively. In addition, the rate of attendance for antenatal care was 45%, and only 39% of deliveries were supervised by skilled birth attendants. Child labour and under-age marriage is very common. A literature review demonstrates that children living in these circumstances are at significant risk of mental health problems.

CONCLUSION

Current data on the state of Nigerian children contain indices that can serve as proxy information for the state of CAMH in the country. Policy-makers need to invest more in pre-emptive child health initiatives as a way of preserving the physical and mental health of children.

Where lies the risk? An ecological approach to understanding child mental health risk and vulnerabilities in sub-saharan Africa

Efforts at improving child-health and development initiatives in sub-Saharan Africa had focused on the physical health of children due to the neglect of child and adolescent mental health (CAMH) policy initiatives. A thorough and broad-based understanding of the prevalent child mental-health risk and vulnerability factors is needed to successfully articulate CAMH policies. In this discourse, we present a narrative on the child mental-health risk and vulnerability factors in sub-Saharan Africa. Through an ecological point of view, we identified widespread family poverty, poor availability and uptake of childcare resources, inadequate community and institutional childcare systems, and inadequate framework for social protection for vulnerable children as among the risk and vulnerability factors for CAMH in the region. Others are poor workplace policy/practice that does not support work-family life balance, poor legislative framework for child protection, and some harmful traditional practices. We conclude that an ecological approach shows that child mental-health risks are diverse and cut across different layers of the care environment. The approach also provides a broad and holistic template from which appropriate CAMH policy direction in sub-Saharan Africa can be understood.

Reducing child conduct problems and promoting social skills in a middle-income country: cluster randomised controlled trial

BACKGROUND

There is an urgent need for effective, affordable interventions to prevent child mental health problems in low- and middle-income countries.

AIMS

To determine the effects of a universal pre-school-based intervention on child conduct problems and social skills at school and at home.

METHOD

In a cluster randomised design, 24 community pre-schools in inner-city areas of Kingston, Jamaica, were randomly assigned to receive the Incredible Years Teacher Training intervention (n = 12) or to a control group (n = 12). Three children from each class with the highest levels of teacher-reported conduct problems were selected for evaluation, giving 225 children aged 3-6 years. The primary outcome was observed child behaviour at school. Secondary outcomes were child behaviour by parent and teacher report, child attendance and parents' attitude to school. The study is registered as ISRCTN35476268.

RESULTS

Children in intervention schools showed significantly reduced conduct problems (effect size (ES) = 0.42) and increased friendship skills (ES = 0.74) through observation, significant reductions to teacher-reported (ES = 0.47) and parent-reported (ES = 0.22) behaviour difficulties and increases in teacher-reported social skills (ES = 0.59) and child attendance (ES = 0.30). Benefits to parents' attitude to school were not significant.

CONCLUSIONS

A low-cost, school-based intervention in a middle-income country substantially reduces child conduct problems and increases child social skills at home and at school.

Workshops with teachers: health education for management with adolescents

OBJECTIVE: To describe the experience during the execution of an extension project, which used a municipal school setting in Uberaba-MG. METHODS: Experience report using health education strategies, focused on workshops with teachers ofElementary School. RESULTS: We conducted seven meetings with 30 teachers from the three school shifts, initially seeking connection and situational diagnosis. In five other sessions we worked with the themes teachers considered to be the necessities, and in the last encounter we presented a case study that allowed verification of learning. CONCLUSION: Despite technical, structural and human difficulties, the richness of the discussions raised and the reports from teachers, confirmed the success of the project, reaching the value of a social and interventionist character.

Child and adolescent mental health worldwide: evidence for action

Mental health problems affect 10-20% of children and adolescents worldwide. Despite their relevance as a leading cause of health-related disability in this age group and their longlasting effects throughout life, the mental health needs of children and adolescents are neglected, especially in low-income and middle-income countries. In this report we review the evidence and the gaps in the published work in terms of prevalence, risk and protective factors, and interventions to prevent and treat childhood and adolescent mental health problems. We also discuss barriers to, and approaches for, the implementation of such strategies in low-resource settings. Action is imperative to reduce the burden of mental health problems in future generations and to allow for the full development of vulnerable children and adolescents worldwide.