Promoting parent-child relationships and preventing violence via home-visiting: a pre-post cluster randomised trial among Rwandan families linked to social protection programmes

The effectiveness of parenting interventions in reducing violence against children in humanitarian settings in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Violence against children is a global phenomenon, yet children living in humanitarian settings are at elevated risk of experiencing violent parenting. Parenting interventions are a recommended prevention strategy.

OBJECTIVE

To conduct a systematic review and meta-analysis on the effectiveness of parenting interventions in preventing violence against children and related parent and child outcomes.

PARTICIPANTS AND SETTING

Primary caregivers in humanitarian settings in low- and middle-income countries (LMICs).

METHODS

A highly sensitive multi-language systematic search in electronic and grey-literature database. Studies were appraised for risk of bias, summary effects by certainty of effect, and effect estimates pooled using robust variance estimation.

RESULTS

Twenty-three randomized trials were meta-analyzed finding a small effect on physical and psychological violence (n = 14, k = 21, d = -0.36, 95 % CI [-0.69, -0.04]), positive parenting (n = 16, k = 43, d = 0.48, 95 % CI [0.29, 0.67]), negative parenting (n = 17, k = 37, d = -0.42, 95 % CI [-0.67, -0.16]), parental poor mental health (n = 9, k = 15, d = -0.34, 95 % CI [-0.66, -0.02]), and internalizing behaviors (n = 11, k = 29, d = -0.38, 95 % CI [-0.70, -0.05]); a non-significant effect on externalizing child behaviors (n = 9, k = 17, d = -0.12, 95 % CI [-0.50, 0.27]). Too few studies reported intimate partner violence, sexual violence, and parenting stress outcomes.

CONCLUSIONS

Our findings suggest that parenting interventions in humanitarian settings in LMICs may be an effective strategy to reduce physical and psychological violence, and numerous related parent and child outcomes. However, findings need to be interpreted in light of the limited number of available studies and imprecise statistical significance for selected outcomes.

Interventions that prevent or respond to intimate partner violence against women and violence against children: a systematic review

Efforts to prevent or respond to intimate partner violence (IPV) and violence against children (VAC) are still disparate worldwide, despite increasing evidence of intersections across these forms of violence. We conducted a systematic review to explore interventions that prevent or respond to IPV and VAC by parents or caregivers, aiming to identify common intervention components and mechanisms that lead to a reduction in IPV and VAC. 30 unique interventions from 16 countries were identified, with 20 targeting both IPV and VAC. Key mechanisms for reducing IPV and VAC in primary prevention interventions included improved communication, conflict resolution, reflection on harmful gender norms, and awareness of the adverse consequences of IPV and VAC on children. Therapeutic programmes for women and children who were exposed to IPV facilitated engagement with IPV-related trauma, increased awareness of the effects of IPV, and promoted avoidance of unhealthy relationships. Evidence gaps in low-income and middle-income countries involved adolescent interventions, post-abuse interventions for women and children, and interventions addressing both prevention and response to IPV and VAC. Our findings strengthen evidence in support of efforts to address IPV and VAC through coordinated prevention and response programmes. However, response interventions for both IPV and VAC are rare and predominantly implemented in high-income countries. Although therapeutic programmes for parents, caregivers, and children in high-income countries are promising, their feasibility in low-income and middle-income countries remains uncertain. Despite this uncertainty, there is potential to improve the use of health services to address IPV and VAC together.

Evaluating caregiver-child interactions in low- and middle-income countries: a systematic review of tools and methods

AIMS/BACKGROUND

The United Nations Sustainable Development Goals (SDGs) has placed emphasis on improving early child development globally. This is supported through the Nurturing Care Framework which includes responsive caregiving. To evaluate responsive caregiving, tools to assess quality of caregiver-child interactions are used, however there is little information on how they are currently employed and/or adapted particularly in low- and middle-income countries (LMICs) where children have a greater risk of adverse outcomes. The aim of this review is to provide a comprehensive guide on methodologies used to evaluate caregiver-child interaction - including their feasibility and cultural adaptation.

DESIGN/METHODS

We conducted a systematic review of studies over 20years in LMICs which assessed caregiver-child interactions. Characteristics of each tool, their validity (assessed with COSMIN Risk of Bias checklist), and the quality of the study (Mixed Methods Appraisal Tool) are reported.

RESULTS

We identified 59 studies using 34 tools across 20 different LMICs. Most tools (86.5%) employed video-recorded observations of caregiver-child interactions at home (e.g. Ainsworth's Sensitivity Scale, OMI) or in the laboratory (e.g. PICCOLO) with a few conducting direct observations in the field (e.g. OMCI, HOME); 13.5% were self-reported. Tools varied in methodology with limited or no mention of validity and reliability. Most tools are developed in Western countries and have not been culturally validated for use in LMIC settings.

CONCLUSION

There are limited caregiver-child interaction measures used in LMIC settings, with only some locally validated locally. Future studies should aim to ensure better validity, applicability and feasibility of caregiver-child interaction tools for global settings.

A meta-analytic review of the implementation characteristics in parenting interventions to promote early child development

This review summarizes the implementation characteristics of parenting interventions to promote early child development (ECD) outcomes from birth to 3 years. We included 134 articles representing 123 parenting trials (PROSPERO record CRD42022285998). Studies were conducted across high-income (62%) and low-and-middle-income (38%) countries. The most frequently used interventions were Reach Up and Learn, Nurse Family Partnership, and Head Start. Half of the interventions were delivered as home visits. The other half used mixed settings and modalities (27%), clinic visits (12%), and community-based group sessions (11%). Due to the lack of data, we were only able to test the moderating role of a few implementation characteristics in intervention impacts on parenting and cognitive outcomes (by country income level) in the meta-analysis. None of the implementation characteristics moderated intervention impacts on cognitive or parenting outcomes in low- and middle-income or high-income countries. There is a significant need in the field of parenting interventions for ECD to consistently collect and report data on key implementation characteristics. These data are needed to advance our understanding of how parenting interventions are implemented and how implementation factors impact outcomes to help inform the scale-up of effective interventions to improve child development.

A cluster randomised controlled trial of an early childhood parenting programme delivered through early childhood education centres in rural Zimbabwe

BACKGROUND

Early childhood is a critical period for child development. Effective approaches to support families in low-resource settings in the use of responsive and stimulating parenting are needed.

AIM

The aim of this study was to examine the effects of the Reach Up early childhood parenting programme on children's development, parenting attitudes and practices, when delivered through early childhood development (ECD) centres in Zimbabwe.

METHODS

A cluster randomised controlled trial was conducted in Sanyati, a rural district in Zimbabwe. Twenty-four of 51 available centres were randomised to intervention (n = 12) or control (n = 12) groups. Sixteen mothers with a child aged 12-30 months were recruited from each centre's catchment area (n = 189 intervention; n = 193 control). The intervention comprised two home visits per month delivered by centre teaching assistants over a period of 27 months. Primary outcomes were child Developmental Quotient (DQ), Language, Eye and Hand coordination, Performance and Practical Reasoning subscale scores assessed at follow-up. Secondary outcomes were mothers' attitudes about child development, parenting practices and maternal depressive symptoms all measured at baseline and follow-up. Intention to treat analyses was conducted using mixed-effects regression models with the standard error adjusted for cluster and inverse proportionality weights to adjust for attrition. Significance was set at P < 0.05.

RESULTS

A total of 285 (74.6%) of 382 children enrolled were tested, with 97 children lost to follow-up. The intervention improved the children's DQ by 3.55 points (95% CI 0.82 to 6.28), Eye and Hand by 3.58 (95% CI 0.59 to 6.56) and Practical Reasoning by 4.19 (95% CI 0.96 to 7.42). No significant improvements to Performance or Language scores, parenting attitudes, parenting practices and depressive symptoms were identified.

CONCLUSIONS

A home visiting intervention delivered by ECD teaching assistants promoted children's development. This suggests that outreach from preschools may be an effective platform for delivery of parenting interventions.

Neurodevelopment of children who are HIV-exposed and uninfected in Kenya

INTRODUCTION

Predictors of neurodevelopment among children who are HIV-exposed uninfected (CHEU) are poorly understood.

METHODS

Mothers with and without HIV and their children were enrolled during 6-week postnatal care visits across seven sites in Kenya between March 2021 and June 2022. Infant neurodevelopment was assessed using the Malawi Developmental Assessment Tool, including social, language, fine motor and gross motor domains. We used multivariate linear mixed effects models to identify associations between 1-year neurodevelopment scores, HIV and antiretroviral therapy (ART) exposures, and household factors, adjusted for potential confounders and clustered by the site.

RESULTS

At 1-year evaluation, CHEU (n = 709) and children who are HIV-unexposed uninfected (CHUU) (n = 715) had comparable median age (52 weeks) and sex distribution (49% vs. 52% female). Mothers living with HIV were older (31 vs. 27 years), had lower education (50% vs. 26% primary) and were more likely to be report moderate-to-severe food insecurity (26% vs. 9%) (p < 0.01 for all). Compared to CHUU, CHEU had higher language scores (adjusted coeff: 0.23, 95% CI: 0.06, 0.39) and comparable social, fine and gross motor scores. Among all children, preterm birth was associated with lower gross motor scores (adjusted coeff: -1.38, 95% CI: -2.05, -0.71), food insecurity was associated with lower social scores (adjusted coeff: -0.37, 95% CI: -0.73, -0.01) and maternal report of intimate partner violence (IPV) was associated with lower fine motor (adjusted coeff: -0.76, 95% CI: -1.40, -0.13) and gross motor scores (adjusted coeff: -1.07, 95% CI: -1.81, -0.33). Among CHEU, in utero efavirenz (EFV) exposure during pregnancy was associated with lower gross motor scores compared to dolutegravir (DTG) exposure (adjusted coeff: -0.51, 95% CI: -1.01, -0.03). Lower fine and gross motor scores were also associated with having a single or widowed mother (adjusted coeff: -0.45, 95% CI: -0.87, -0.03) or a deceased or absent father (adjusted coeff: -0.81, 95% CI: -1.58, -0.05), respectively.

CONCLUSIONS

Biologic and social factors were associated with child neurodevelopment. Despite socio-demographic differences between CHEU and CHUU, 1-year neurodevelopment was similar. Addressing IPV and food insecurity may provide benefits regardless of maternal HIV status. DTG use was associated with higher neurodevelopmental scores in CHEU, compared to EFV regimens, potentially contributing to a lack of neurodevelopmental difference between CHEU and CHUU.

Pathways to scale up early childhood programs: A scoping review of Reach Up and Care for Child Development

Evidence-based early childhood development (ECD) programs that strengthen nurturing parenting skills and promote early stimulation, such as Reach Up (RU) and Care for Child Development (CCD), are critical investments for interrupting cycles of intergenerational poverty; however, the implementation impact of these programs varies greatly globally. Analyzing systematically the evidence on the implementation pathways based on contexts (i.e., external and internal influences on intervention implementation), implementation strategies (i.e., mechanisms used to promote program initiation, design, and delivery with existing systems), and implementation outcomes (i.e., related to the implementation goals) can increase the likelihood of implementation success. Our scoping review aimed to identify implementation pathways of RU and CCD programs in low- and middle-income countries. A search in English, Spanish, and Portuguese of grey literature and five databases of peer reviewed literature; from inception through July 16, 2022, yielded 2,267 publications. Using predetermined eligibility criteria, 75 records yielded implementation details for 33 programs across 23 low- and middle-income countries. Two reviewers independently extracted program data on context, implementation strategies, and implementation outcomes following a program theory. A thematic analysis identified 37 implementation strategies across six "building blocks of implementation": program emergence, intersectoriality, intervention characteristics, workforce, training, and monitoring systems. Implementation pathways across building blocks are highly influenced by contextual factors, such as infrastructure, social norms, and the target population's demand and interest, which may shape different implementation outcomes. Six 'building blocks' shaping implementation pathways of CCD and RU in LMICs were identified. The careful consideration of context and use of intentional evidence-based planning can enable the successful implementation of ECD nurturing care interventions. We recommend the use of the ECD Implementation Checklist for Enabling Program Scale Up to guide decision-making regarding context and implementation strategies to support implementation outcomes and subsequent ECD program success.

Growing up amid conflict: Implications of the Developmental Peacebuilding Model

Worldwide, 420 million children are affected by conflict and over half of all children experience violence every year. Thus, youth are unarguably affected by war and settings of persisting societal violence. Despite often being conceptualized as either powerless victims or violent perpetrators, recent advances in research and international policy recognize young people as key change agents in transforming adverse settings into positive environments. Framed by the Developmental Peacebuilding Model, this paper focuses on predictors, outcomes and intervention points within the family for youth peacebuilding. Recent advances of family-based interventions in diverse, non-WEIRD samples will be highlighted. Rooted in existing knowledge, we conclude with concrete suggestions on how to use secondary data to investigate youth peacebuilding across the globe.

Navigating the Tension between Fatherhood Ideals and Realities of a Post-Conflict Setting: A Phenomenological Study of Former Child Soldiers in Sierra Leone

The concept of "fatherhood" in many African countries has traditionally been understood in terms of instrumental support to one's family, most notably, financial provision. However, in Sierra Leone and elsewhere, this narrow understanding of fatherhood is changing as a result of shifting demographic trends and responses to recent crises such as the Ebola pandemic and the aftermath of a civil war. Very little is understood about how male former children associated with armed forces and armed groups (CAAFAG) are navigating fatherhood and understanding their roles as fathers, particularly as many have grown up without fathers or parents themselves and experienced violence. Our study builds upon previous ethnographic research in Sierra Leone, and uses a phenomenological approach to understand 1) the meaning and importance of fatherhood to former child soldiers in Sierra Leone, 2) what fatherhood looks like normatively and ideally, with attention to norms about nurturing care as well as violence, and 3) how ideals of fatherhood may or may not be in tension with socioeconomic circumstances. We find that CAAFAG fathers in Sierra Leone are committed to providing emotional support, encouragement, and a loving upbringing in addition to striving to provide financially. CAAFAG fathers experienced the greatest tension between their ideals of fatherhood and their socio-economic circumstances in terms of financial support, such as paying school fees. In other words, fathers felt inhibited in becoming the types of fathers they hoped to be due to their experiences in a post-conflict, resource-constrained environment.

"Him Leaving Me - That is My Fear Now": A Mixed Methods Analysis of Relationship Dissolution Between Ugandan Pregnant and Postpartum Women Living with HIV and Their Male Partners

High rates of relationship dissolution among pregnant women living with HIV (PWLHIV) and their male partners might increase mothers' and children's vulnerability to financial hardship and poor health outcomes. This mixed methods analysis identified factors associated with separation between PWLHIV and their male partners. We utilized data from a randomized controlled trial ( www.ClinicalTrials.gov NCT03484533) of 500 PWLHIV attending antenatal care in Uganda and 237 male partners between 2018 and 2020 and followed until 12 months postpartum. Multivariate regression models estimated the impact of relationship factors on the adjusted relative risk of separation during follow up, and we conducted in-depth interviews with 45 women and 45 men enrolled in the trial. Overall, 23% of PWLHIV reported separation during the study period. HIV serodifferent status, financial burdens and gender expectations were sources of relationship conflict. Significant factors associated with separation included unmarried, non-cohabitating, shorter, polygamous relationships, as well as HIV non-disclosure and verbal abuse. Participants discussed potential positive and negative consequences of separation, including impact on their mental health, treatment continuation, financial security, and safety. Addressing relationship dynamics is essential to improve counseling messaging and support PWLHIV who are experiencing relationship conflict.

Effectiveness of father-inclusive interventions on maternal, paternal, couples, and early child outcomes in low- and middle-income countries: A systematic review

Most caregiving interventions for young children are directed to female caregivers. Relatively few have included male caregivers as program participants especially in low- and middle-income countries (LMICs). The range of potential benefits that can be achieved through the engagement of fathers and male caregivers has not been adequately explored from a family systems perspective. We reviewed interventions that engaged male caregivers to support young children in LMICs and summarized impacts on maternal, paternal, couples, and child outcomes. We searched MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and Global Health Library for quantitative evaluation studies of social and behavioral interventions that included fathers or other male caregivers to improve nurturing care for young children under 5 years of age in LMICs. Three authors independently extracted data using a structured form. Forty-four articles, representing 33 intervention evaluations, were included. The most common type of intervention targeted fathers along with their female partners and primarily to address child nutrition and health. Across interventions, maternal outcomes were the most evaluated outcomes (82%), followed by paternal (58%), couple's relationship (48%) and child-level outcomes (45%). Overall, father-inclusive interventions had positive impacts on maternal, paternal and couples' relationship outcomes. Although there was greater variation in the degree of supportive evidence for child outcomes compared to maternal, paternal, and couples outcomes, findings suggested mostly positive effects across all outcomes. Limitations included relatively weak study designs and heterogeneity across interventions, outcome types, and measurement tools. Interventions that include fathers and other male caregivers have potential to improve maternal and paternal caregiving, couple's relationships dynamics, and early child outcomes in LMICs. More evaluation studies, using rigorous methods and robust measurement frameworks, is needed to bolster this evidence-base about the effect of fathers' engagement for young children, caregivers, and families in LMICs.

Family Violence Reduction Within a Parenting Intervention in Rwanda: A Mixed-Methods Study

BACKGROUND AND OBJECTIVES

A mixed-methods study of mechanisms of change through which a home-visiting-based early childhood development intervention, Sugira Muryango ("strong family"), reduced violent discipline and intimate partner violence in Rwanda.

METHODS

The cluster-randomized trial of Sugira Muryango enrolled socioeconomically vulnerable families with children aged 6 to 36 months in rural Rwanda. We interviewed 18 female caregivers early in the intervention, and 21 female caregivers and 11 male intimate partners were interviewed after the intervention. Coded interviews identify risk factors for violence and mechanisms of intervention-related change in violence. Quantitative analyses included 931 caregivers (52.6% female) who lived with an intimate partner to examine risk factors for violence, intervention effects, and mechanisms of violence reduction.

RESULTS

The qualitative data identified daily hardships and alcohol problems as risk factors for violent discipline and intimate partner violence. Through Sugira Muryango, caregivers learned that strong relationships between partners and engagement of male caregivers in child care has positive impacts on children's development. Techniques taught by community lay workers improved communication, promoted positive parent-child interactions, and reduced intimate partner violence and violent discipline. Quantitative analyses also found that daily hardships predict violent discipline and intimate partner violence. Sugira Muryango reduced violent discipline, increased father engagement, and increased female caregiving warmth. Moreover, pre- to postintervention change in caregiving warmth was associated with reduced use of violent discipline among female caregivers and marginally associated with reduced female victimization.

CONCLUSIONS

Violence reduction can be integrated into early child development programs to reduce violent discipline and intimate partner violence.

Implementation characteristics of father-inclusive interventions in low- and middle-income countries: A systematic review

Although prior reviews have documented the effectiveness of engaging male caregivers in early childhood interventions, little is known about how these interventions have been designed and implemented to reach, engage, and support male caregivers in low-resource global settings. We searched five bibliographic databases for intervention studies that engaged male caregivers to improve nurturing care for children under 5 years of age in low- and middle-income countries. Forty-four articles met the inclusion criteria, which represented 33 interventions. Fathers specifically were the most common type of male caregivers targeted in these interventions. The majority of interventions invited fathers to participate alongside their female partners. Community-based peer-groups were the most common delivery model. Most interventions used the same program structure for fathers as applied to mothers, with few considering whether implementation adaptations were needed for men. Intervention curricula were multicomponent and largely targeted child nutrition, health, and couples' relationships. A minority of programs addressed parenting, psychosocial wellbeing, violence prevention, gender attitudes, or economic support. Behavior change techniques were limited to interactive counseling and peer learning. Male caregivers remain missing from caregiving interventions for young children. A greater focus on implementation research can inform better inclusion, engagement, and support for male caregivers in nurturing care interventions.

Implementation of UNICEF and WHO's care for child development package: Lessons from a global review and key informant interviews

Introduction

In the last decade, there has been increased global policy and program momentum to promote early childhood development. The Care for Child Development (CCD) package, developed by UNICEF and the WHO, is a key tool responding to the global demand. The CCD package comprises two age-specific evidence-based recommendations for caregivers to 1) play and communicate and 2) responsively interact with their children (0-5 years) and was designed to be integrated within existing services to strengthen nurturing care for child development. The aim of this report was to provide an up-to-date global review of the implementation and evaluation of the CCD package.

Methods

In addition to a systematic review of 55 reports, we interviewed 23 key informants (including UNICEF and WHO personnel) to better understand the implementation of CCD.

Results

The CCD package has been or is being implemented in 54 low- and middle-income countries and territories, and it has been integrated into government services across the health, social, and education sectors in 26 countries. Across these contexts, CCD has been adapted in three primary ways: 1) translations of CCD materials (mostly counseling cards) into local language(s), 2) adaptations of CCD materials for the local context, vulnerable children, or a humanitarian/emergency setting (e.g., including local play activities, using activities that are better suited to children with visual impairments), and 3) substantive modifications to the content of CCD materials (e.g., expansion of play and communication activities, addition of new themes, creation of a structured curriculum). While there is promising evidence and examples of good implementation practice, there has been mixed experience about implementation of CCD with respect to adaptation, training, supervision, integration into existing services, and monitoring implementation fidelity and quality. For example, many users of CCD found difficulties with training the workforce, garnering buy-in from governments, and ensuring benefits for families, among others.

Discussion

Additional knowledge on how to improve the effectiveness, implementation fidelity and quality, and acceptance of CCD is needed. Based on the findings of the review we make recommendations for future efforts to implement CCD at-scale.

Preventing Co-occurring Intimate Partner Violence and Child Abuse in Eastern Democratic Republic of Congo: The Role of Family Functioning and Programmatic Reflections

Co-occurring intimate partner violence (IPV) and child abuse occur at staggering levels in eastern Democratic Republic of Congo (DRC), yet little is known about the relationship between these forms of violence and a feminst-grounded conceptualization of family functioning nor how best to programmatically address these multiple forms of violence in the home. Analysis of cross-sectional baseline data from 203 adult couple dyads participating in a randomized controlled trial was undertaken to (1) understand the correlation of family functioning and violence in the home in North Kivu, DRC; (2) unpack potential shared correlates of violence in the home and family functioning, such as attitudes and behaviors; and (3) describe programmatic implications for delivering violence prevention programming that seeks to address multiple forms of violence in the home. Findings suggest over half of all families reported experiencing IPV against women or use of child abuse by any caregiver. Moderate levels of family functioning were also reported, although women reported lower levels. In adjusted models, a one-point change in family functioning score was associated with a 0.12 reduction in odds of co-occurring experience of IPV and use of child abuse for women, and a 0.03 reduction in odds of co-occurring perpetration for men. A focus on improving family functioning as a primary outcome, alongside explicit targeting of harmful gender norms and skills-based approaches, may be a promising avenue to integrate approaches from different violence prevention fields while maintaining a strong dedication to intersectional feminist-grounded approaches that allows for separate, but at times combined, approaches to reducing IPV and child abuse in the home.

The Apapacho Violence Prevention Parenting Program: Conceptual Foundations and Pathways to Scale

Violence against children (VAC) is a major global issue with long-lasting negative consequences on individuals and societies. The present study presents a review of the literature on drivers of VAC and the core components of evidence-based violence prevention programs. Moreover, it analyzes the existing services and social infrastructure in Colombia to rigorously inform the design of the Apapacho violence prevention parenting program for families with children younger than five targeted toward Colombia. Findings indicate that (1) VAC in Colombia is a multidimensional issue with roots at the individual, family, community, and society levels, (2) evidence-based violence prevention programs share a common set of content and delivery strategies that could inform the components of the Apapacho program, and (3) there is an urgent need for scalable and flexible violence prevention programs for families with young children in Colombia. Considering existing evidence, the Apapacho violence prevention parenting program will be designed using ecological, developmental, and neuroscience-informed perspectives. This article concludes by presenting the initial components of the theory of change and discussing future directions for the design of the Apapacho program and other violence prevention interventions in LMICs.

The mental health of children and young people living in big cities in a revolving postpandemic world

PURPOSE OF REVIEW

The world's population is increasingly urban, with most children and young people growing up and living in cities. Evidence suggests that urbanicity is linked to an increased risk for the development of mental health disorders. Rather than an accumulation of risk factors, urbanization is a complex process that profoundly structures living conditions. In this sense, it is timely to discuss what are the social and structural determinants of mental health of children and young people in such settings.

RECENT FINDINGS

Three domains of determinants of mental health were selected for discussion: economics and living conditions, crime and violence, and urban layouts. For each, we debated realities faced by urban children and young people, providing an overview of recent evidence on implications for mental disorders and well being. We also discuss the potential impacts of the covid-19 pandemic on each domain, as well as recommendations for future action.

SUMMARY

Structural factors are of major relevance for the mental health of children and young people living in cities. The agenda of mental health promotion and prevention must include whole-of-society interventions aimed at improving living conditions, including economic and social capital, violence prevention and urbanistic planning.

Effectiveness of cash-plus programmes on early childhood outcomes compared to cash transfers alone: A systematic review and meta-analysis in low- and middle-income countries

BACKGROUND

To strengthen the impact of cash transfers, these interventions have begun to be packaged as cash-plus programmes, combining cash with additional transfers, interventions, or services. The intervention's complementary ("plus") components aim to improve cash transfer effectiveness by targeting mediating outcomes or the availability of supplies or services. This study examined whether cash-plus interventions for infants and children <5 are more effective than cash alone in improving health and well-being.

METHODS AND FINDINGS

Forty-two databases, donor agencies, grey literature sources, and trial registries were systematically searched, yielding 5,097 unique articles (as of 06 April 2021). Randomised and quasi-experimental studies were eligible for inclusion if the intervention package aimed to improve outcomes for children <5 in low- and middle-income countries (LMICs) and combined a cash transfer with an intervention targeted to Sustainable Development Goal (SDG) 2 (No Hunger), SDG3 (Good Health and Well-being), SDG4 (Education), or SDG16 (Violence Prevention), had at least one group receiving cash-only, examined outcomes related to child-focused SDGs, and was published in English. Risk of bias was appraised using Cochrane Risk of Bias and ROBINS-I Tools. Random effects meta-analyses were conducted for a cash-plus intervention category when there were at least 3 trials with the same outcome. The review was preregistered with PROSPERO (CRD42018108017). Seventeen studies were included in the review and 11 meta-analysed. Most interventions operated during the first 1,000 days of the child's life and were conducted in communities facing high rates of poverty and often, food insecurity. Evidence was found for 10 LMICs, where most researchers used randomised, longitudinal study designs (n = 14). Five intervention categories were identified, combining cash with nutrition behaviour change communication (BCC, n = 7), food transfers (n = 3), primary healthcare (n = 2), psychosocial stimulation (n = 7), and child protection (n = 4) interventions. Comparing cash-plus to cash alone, meta-analysis results suggest Cash + Food Transfers are more effective in improving height-for-age (d = 0.08 SD (0.03, 0.14), p = 0.02) with significantly reduced odds of stunting (OR = 0.82 (0.74, 0.92), p = 0.01), but had no added impact in improving weight-for-height (d = -0.13 (-0.42, 0.16), p = 0.24) or weight-for-age z-scores (d = -0.06 (-0.28, 0.15), p = 0.43). There was no added impact above cash alone from Cash + Nutrition BCC on anthropometrics; Cash + Psychosocial Stimulation on cognitive development; or Cash + Child Protection on parental use of violent discipline or exclusive positive parenting. Narrative synthesis evidence suggests that compared to cash alone, Cash + Primary Healthcare may have greater impacts in reducing mortality and Cash + Food Transfers in preventing acute malnutrition in crisis contexts. The main limitations of this review are the few numbers of studies that compared cash-plus interventions against cash alone and the potentially high heterogeneity between study findings.

CONCLUSIONS

In this study, we observed that few cash-plus combinations were more effective than cash transfers alone. Cash combined with food transfers and primary healthcare show the greatest signs of added effectiveness. More research is needed on when and how cash-plus combinations are more effective than cash alone, and work in this field must ensure that these interventions improve outcomes among the most vulnerable children.

Intergenerational impacts of trauma and hardship through parenting

BACKGROUND

Millions of people worldwide experience severe trauma in their lifetime. Trauma has immediate and long-term effects on emotional wellbeing. Moreover, the experiences of one generation may influence subsequent generations via social and biological pathways. Poor mental health and emotion dysregulation associated with trauma may affect parenting behaviours, which may have long-lasting effects on children's development.

METHODS

We use longitudinal data from a unique sample of 732 caregivers of children aged 6-36 months living in extremely poor rural households in Rwanda to examine associations of caregiver lifetime trauma, recent daily hardships, mental health, and emotion dysregulation with parenting behaviours reflecting parental acceptance and rejection of their offspring.

RESULTS

Cumulative trauma exposure (β = .234, p < .001) and recent daily hardships (β = .323, p < .001) are associated with higher levels of internalising symptoms. Trauma (β = .257, p < .001) and daily hardships (β = .323, p < 0.001) are also associated with post-traumatic stress disorder (PTSD) symptoms. Internalising symptoms predict more rejection (β = .177, p = .001), but show no association with acceptance. Caregiver PTSD symptoms predict more rejection (β = .277, p < .001) and less acceptance (β = -.190, p = .003). Both internalising symptoms (β = .557, p < .001) and PTSD symptoms (β = .606, p < .001) are strongly associated with poor emotion regulation. Indirect effects suggest that caregiver trauma and hardships affect parenting indirectly via elevated caregiver internalising symptoms and PTSD and that some of these effects are accounted for by emotion dysregulation.

CONCLUSIONS

Caregiver internalising and PTSD symptoms are important mechanisms through which caregiver trauma and hardship affect parenting behaviours. Emotion dysregulation is a shared mechanism linking caregivers' mental health problems with parenting behaviours that reflect acceptance and rejection of the child. Emotion regulation is indicated as a key target for prevention of adverse effects of caregiver trauma on mental health and child wellbeing.

Effect of a home-visiting parenting program to promote early childhood development and prevent violence: a cluster-randomized trial in Rwanda

Introduction

Families living in extreme poverty require interventions to support early-childhood development (ECD) due to broad risks. This longitudinal cluster randomised trial examines the effectiveness of Sugira Muryango (SM), a home-visiting intervention linked to Rwanda’s social protection system to promote ECD and reduce violence compared with usual care (UC).

Methods

Families with children aged 6–36 months were recruited in 284 geographical clusters across three districts. Cluster-level randomisation (allocated 1:1 SM:UC) was used to prevent diffusion. SM was hypothesised to improve child development, reduce violence and increase father engagement. Developmental outcomes were assessed using the Ages and Stages Questionnaire (ASQ-3) and the Malawi Development Assessment Tool (MDAT) and anthropometric assessments of growth. Violence was assessed using questions from UNICEF Multiple Indicators Cluster Survey (MICS) and Rwanda Demographic and Health Surveys (DHS). Father engagement was assessed using the Home Observation for Measurement of the Environment. Blinded enumerators conducted interviews and developmental assessments.

Results

A total of 541 SM families and 508 UC families were enrolled and included in the analyses. Study attrition (2.0% children; 9.6% caregivers) was addressed by hot deck imputation. Children in SM families improved more on gross motor (d=0.162, 95% CI 0.065 to 0.260), communication (d=0.081, 95% CI 0.005 to 0.156), problem solving (d=0.101, 95% CI 0.002 to 0.179) and personal-social development (d=0.096, 95% CI −0.015 to 0.177) on the ASQ-3. SM families showed increased father engagement (OR=1.592, 95% CI 1.069 to 2.368), decreased harsh discipline (incidence rate ratio, IRR=0.741, 95% CI 0.657 to 0.835) and intimate partner violence (IRR=0.616, 95% CI:0.458 to 0.828). There were no intervention-related improvements on MDAT or child growth.

Conclusion

Social protection programmes provide a means to deliver ECD intervention.

Trial registration number

NCT02510313.

Promoting mother-infant relationships and underlying neural correlates: Results from a randomized controlled trial of a home-visiting program for adolescent mothers in Brazil

Poverty and teenage pregnancy are common in low-and-middle-income countries and can impede the development of healthy parent-child relationships. This study aimed to test whether a home-visiting intervention could improve early attachment relationships between adolescent mothers and their infants living in poverty in Brazil. Analyses were conducted on secondary outcomes from a randomized controlled trial (NCT0280718) testing the efficacy of a home-visiting program, Primeiros Laços, on adolescent mothers' health and parenting skills and their infants' development. Pregnant youth were randomized to intervention (n = 40) or care-as-usual (CAU, n = 40) from the first trimester of pregnancy until infants were aged 24 months. Mother-infant attachment was coded during a mother-infant interaction when the infants were aged 12 months. Electrophysiological correlates of social processing (mean amplitude of the Nc component) were measured while infants viewed facial images of the mother and a stranger at age 6 months. Infants in the intervention group were more securely attached and more involved with their mothers than those receiving CAU at 12 months. Smaller Nc amplitudes to the mother's face at 6 months were associated with better social behavior at 12 months. Our findings indicate that the Primeiros Laços Program is effective in enhancing the development of mother-infant attachment.

mHealth-Supported Delivery of an Evidence-Based Family Home-Visiting Intervention in Sierra Leone: Protocol for a Pilot Randomized Controlled Trial

Background

Past trauma and exposure to violence have been related to poor emotion regulation and household violence, which can have persistent mental health effects across generations. The Family Strengthening Intervention for Early Childhood Development (FSI-ECD/called Sugira Muryango in Rwanda) is an evidence-based behavioral home-visiting intervention to promote caregiver mental health, positive parenting practices, and early childhood development among families facing adversity. In Sierra Leone and other lower- and middle-income countries, mobile health (mHealth) technology has the potential to improve health care delivery and health outcomes.

Objective

This study aims to (1) apply a user-centered design to develop and test mHealth tools to improve supervision and fidelity monitoring of community health workers (CHWs) delivering the FSI-ECD and (2) conduct a pilot randomized controlled trial of the FSI-ECD to assess feasibility, acceptability, and preliminary effects on caregiver mental health, emotion regulation, caregiving behaviors, and family violence in high-risk families with children aged 6-36 months in comparison with control families receiving standard care.

Methods

We will recruit and enroll CHWs, supervisors, and families with a child aged 6-36 months from community health clinics in Sierra Leone. CHWs and supervisors will participate in 1 problem analysis focus group and 2 user interface/user experience cycles to provide feedback on mHealth tool prototypes. Families will be randomized to mHealth-supported FSI-ECD or standard maternal and child health services. We will collect quantitative data on caregiver mental health, emotion regulation, caregiving behaviors, and family functioning at baseline, postintervention, and 3-month follow up. We will use a mixed methods approach to explore feasibility and acceptability of mHealth tools and the FSI-ECD. Mixed effects linear modeling will assess FSI-ECD effects on caregiver outcomes. Cost-effectiveness analysis will estimate costs across FSI-ECD versus standard care.

Results

Funding for this study was received from the National Institutes of Mental Health on August 17, 2020. Institutional Review Board approval was received on September 4, 2020. Data collection is projected to begin on December 15, 2020.

Conclusions

This study will provide important data on the feasibility, acceptability, and preliminary efficacy of mHealth-supported delivery of an evidence-based family home-visiting intervention in a postconflict LMIC.

Trial Registration

ClinicalTrials.gov NCT04481399; https://clinicaltrials.gov/ct2/show/NCT04481399.

International Registered Report Identifier (IRRID)

PRR1-10.2196/25443

Exploration of Attendance, Active Participation, and Behavior Change in a Group-Based Responsive Stimulation, Maternal and Child Health, and Nutrition Intervention

Delivery of interventions through group sessions allows for in-depth discussions and creates opportunities for group members to work together to identify and solve common problems. However, low attendance may limit impact. We explored factors affecting attendance, active participation, and behavior change in an integrated group-based child development and maternal and child health intervention in Bangladesh. Community health workers (CHWs) facilitated two sessions a month including material on child stimulation; water, sanitation, and hygiene; nutrition, maternal depression, and lead exposure prevention. Sessions were conducted with 320 pregnant women and mothers with children younger than 24 months, in 16 villages in Kishoreganj district. After 4 and 9 months of intervention, we conducted focus group discussions and in-depth interviews with mothers (n = 55 and n = 48) to identify determinants of attendance and behavior change, and to examine potential for intervention scale-up. Recruiting family members to assist with childcare resulted in improved attention during sessions. Adopting a storytelling format for presentation of session materials resulted in more engaged participation during courtyard sessions. Session attendance and behavior change, especially purchasing decisions, were difficult for participants without the support of male heads of the household. Selecting a rotating leader from among the group members to remind group members to attend sessions and support CHWs in organizing the sessions was not successful. Facilitating self-appraisals and planning for water and sanitation allowed participants to identify areas for improvement and track their progress. Key determinants of a participant’s attendance were identified, and the resulting intervention shows promise for future implementation at scale.