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Implementation fidelity is a critical component of intervention science, which aims to understand how interventions unfold in practice to improve outcomes. A key element of fidelity is facilitator competent adherence-the extent to which a program is delivered as prescribed with the specified level of quality. We conducted a two-part systematic review examining these aspects in parenting programs aiming to reduce child behavior problems and maltreatment. Part One reviews measures of facilitator competent adherence and Part Two examines the psychometric properties of the observational measures found. Searches identified 9153 articles from electronic databases, citation tracking, and expert input. After screening using pre-specified criteria, 156 (Part One) and 41 (Part Two) articles remained. In Part One, measure, facilitator, and intervention characteristics were extracted and synthesized from 65 measures. Most measures were observational, used by facilitators and researchers, and employed Likert-scale ratings. In Part Two, evidence on the reliability (internal consistency, inter-rater, intra-rater, test-retest) and validity (content, construct, convergent/divergent, criterion) of 30 observational measures identified from Part One was synthesized and evaluated. An adapted COSMIN checklist was used to assess study and measure quality. We found most studies to be of reasonably high quality. This is the first review to summarize and critically appraise measures of facilitator competent adherence used in the parenting program literature and establish their psychometric properties. The findings underscore the need to advance research on measures of facilitator competent adherence; reliable, valid, and high-quality implementation measures allow for evidence-based decisions regarding the delivery and scale-up of parenting programs. PROSPERO Registration Number: CRD42020167872., (© 2021. The Author(s).)

Background: Parenting interventions and conditional cash transfer (CCT) programmes are promising strategies to reduce the risk of violence against children, but evidence of the effectiveness of combining such programmes is lacking for families in low- and middle-income countries with children over two years of age. This study examined the effectiveness of a locally adapted parenting programme delivered as part of a government CCT system to low-income families with children aged two to six years in Metro Manila, Philippines., Methods: Participants were randomly assigned (1:1) to either a 12-session group-based parenting programme or treatment-as-usual services ( N  = 120). Participation in either service was required among the conditions for receiving cash grants. Baseline assessments were conducted in July 2017 with one-month post-intervention assessments in January-February 2018 and 12-month follow-up in January-February 2019. All assessments were parent-report (ClinicalTrials.gov: NCT03205449)., Findings: One-month post-intervention assessments indicated moderate intervention effects for primary outcomes of reduced overall child maltreatment ( d  = -0.50 [-0.86, -0.13]), emotional abuse ( d  = -0.59 [-0.95; -0.22]), physical abuse (IRR = 0.51 [0.27; 0.74]), and neglect (IRR = 0.52 [0.18; 0.85]). There were also significant effects for reduced dysfunctional parenting, child behaviour problems, and intimate partner violence, and increased parental efficacy and positive parenting. Reduced overall maltreatment, emotional abuse, and neglect effects were sustained at one-year follow-up., Interpretation: Findings suggest that a culturally adapted parenting intervention delivered as part of a CCT programme may be effective in sustaining reductions in violence against children in low- and middle-income countries., Funding: This research was supported by UBS Optimus Foundation and UNICEF Philippines, and by the Complexity and Relationships in Health Improvement Programmes of the Medical Research Council MRC UK and Chief Scientist Office (Grant: MC_UU_00022/1 and CSO SPHSU16, MC_UU_00022/3 and CSO SPHSU18)., Competing Interests: BM, CA, and MG declare that they have no competing interests. JML, JH, FG and CW are co-developers of PLH for Young Children, which is licensed under a Creative Commons 4.0 Non-commercial No Derivatives license, and, with colleagues, co-founders of the Parenting for Lifelong Health initiative. JH is the Director of the Children's Early Intervention Trust, a non-profit institution responsible for the dissemination of the programme in Europe. JML and JH receive occasional fees for providing training and supervision to facilitators and coaches. JML, JH, FG LPA, RJ, BVLM, and CW have participated (and are participating) in several research studies involving the programme as investigators, and the University of Oxford, University of Cape Town, Bangor University, and Ateneo de Manila University, and receive research funding for these. Conflict is avoided by declaring this potential conflict of interests; and by conducting and disseminating rigorous, transparent, and impartial evaluation research on both this and other similar parenting programmes., (© 2021 The Author(s).)

Background: Substance use is a major public health concern worldwide. Alcohol and drug use have increased during recent decades in many low- and middle-income countries, with South Africa, where this study was conducted, having among the highest rates in the world. Despite existing evidence on the effectiveness of family-based interventions in reducing substance use among parents and caregivers in low- and middle-income countries, little is known about the mechanism of change that contributes to the reduction. This study investigated mediators of change in a parenting programme (Parenting for Lifelong Health [PLH]) on reducing substance use among parents and caregivers of adolescents through three potential mediators: parental depression, parenting stress and family poverty., Methods: The current study used a pragmatic cluster randomized controlled trial design. The total sample comprised 552 parent and caregiver of adolescents M = 49.37(SD = 14.69) who were recruited from 40 communities in South Africa's Eastern Cape. Participants completed a structured confidential self-report questionnaire at baseline and a follow-up test 5 to 9 months after the intervention. Structural equation modeling was conducted to investigate direct and indirect effects., Results: Analyses indicated that the effect of the PLH intervention on reducing parental substance use was mediated in one indirect pathway: improvement in parental mental health (reduction in parental depression levels). No mediation pathways from the PLH intervention on parental substance use could be associated with parenting stress or family poverty., Conclusions: The findings of the study suggest that intervention approaches targeting mental health among parents and caregivers have promise for reducing parental substance use. These findings emphasize the need to create supportive environments and systems for parents who suffer from emotional strain and mental health problems, particularly within families experiencing adversity., Trial Registration: Pan-African Clinical Trials Registry PACTR201507001119966. Registered on 27 April 2015. The trial can be found by searching for the key word 'Sinovuyo' on the Pan-African Clinical Trials Registry website or via the following link: http://www.pactr.org/ATMWeb/appmanager/atm/atmregistry?_nfpb=true&_windowLabel=BasicSearchUpdateController_1&BasicSearchUpdateController_1_actionOverride=%2Fpageflows%2Ftrial%2FbasicSearchUpdate%2FviewTrail&BasicSearchUpdateController_1id=1119., (© 2021. The Author(s).)

Background: Children of street-connected women in Kenya are at risk of child maltreatment. There have been increasing calls for positive parenting programs for parents experiencing homelessness, however never has one been implemented with this population. We therefore adapted the evidence-based Parenting for Lifelong Health for Young Children program using participatory methods, and piloted the adapted program with street-connected mothers in Kenya., Objectives: To (a) determine if the adapted program was feasible and acceptable with street-connected mothers, and (b) assess indicative effects on child maltreatment, positive parenting, and parental stress., Participants and Setting: Two groups of 15 mothers (ages 19+, and 20- ) participated between June-July 2018 in Eldoret, Kenya. Participants were eligible if they (a) were the mother of at least one child and (b) self-identified as street-connected., Methods: Feasibility was measured via enrollment, attendance, drop-out rates, and engagement in take-away activities. Focus groups explored program acceptability and program outcomes. Self-report surveys assessed pre-post changes in child maltreatment, parental stress, parental sense of inefficacy, and positive parenting practices., Results: 70% of participants attended ≥3/4 of sessions, 10% dropped out, and >50% of take-away activities were completed. Participants reported high acceptability and requested its continuation for themselves and other parents. There was an increase in supporting good behaviour (t(21)=8.15, p < .000) and setting limits (t(18) = 10.03, p < .000); a reduction in physical abuse (t(23) = -2.15, p = .042) and parental stress (t(22) = -7.08, p < .000); results for parental inefficacy were not statistically significant (t(22) = 0.15, p = .882)., Conclusions: The adapted program is feasible and acceptable to street-connected mothers, and may reduce child maltreatment and parental stress, and increase positive parenting. Further research should test program effectiveness., Competing Interests: The authors declare no conflicts of interest.

Background: This feasibility pilot of the Parenting for Lifelong Health for Young Children program in Thailand aimed to: 1) explore the feasibility of study evaluation approaches; 2) assess the feasibility of delivering an adapted program; 3) report indicative effects on child maltreatment and related outcomes; and 4) examine intervention content associated with key mechanisms of change perceived by caregivers and facilitators., Method: Sixty primary caregivers of children aged 2-9 years were recruited for an 8-week parenting program embedded within the local health system. Mixed-methods approaches included quantitative caregiver-report and observational data from standardized instruments, and qualitative data from individual and group interviews with caregivers and program facilitators. Analyses involved Wilcoxon signed-rank tests, paired t-tests, Friedman's ANOVA, and thematic analysis., Results: Participants reported that most (65%) were grandparents or great-grandparents. Study retention and response rates were high, and enrolled caregivers attended an average of 93% of sessions. Primary outcomes showed caregiver-reported pre-post reductions in overall child maltreatment (d = - 0.58, p < 0.001), as well as reductions in physical (d = - 0.58, p < 0.001) and emotional abuse (d = - 0.40, p < 0.001). Combined caregiver report and observational assessments using the HOME Inventory showed reductions in abusive and harsh parenting (d = - 0.52, p < 0.001). Secondary outcomes demonstrated decreases in child neglect; dysfunctional parenting; poor child monitoring and supervision; parental sense of inefficacy; child behavior problems; daily report on child problem behavior; parent overall depression, anxiety, and stress; and attitudes supporting physical punishment and harsh discipline. There were increases in overall positive parenting, daily positive parenting behavior, as well as HOME Inventory assessments on parent-child relationships. Thematic analyses from interviews and focus group data identified six key program themes associated with strengthened parent-child relationships, reduced child behavior problems, improved attitudes and strategies toward discipline, and improved management of parental stress., Conclusions: This study represents one of few evaluations to test the feasibility of an evidence-based parenting program embedded within routine public health service delivery in a low- or middle-income country. Findings show preliminary effectiveness in reducing child maltreatment, improvements on 22 of 24 secondary outcomes, and perceived mechanisms of change that support quantitative findings. Prospects are promising for program scalability, pending randomized controlled trial results., Trial Registration: 11/01/2019, ClinicalTrials.gov, ID# NCT03539341 .

Background: Despite the rapid dissemination of parenting programs aiming to reduce and prevent violence against children (VAC) worldwide, there is limited knowledge about and evidence of the implementation of these programs at scale. This study addresses this gap by assessing the quality of delivery and impact of an evidence-based parenting program for parents/caregivers and their adolescent girls aged 9 to 14-Parenting for Lifelong Health Teens (PLH-Teens), known locally as Furaha Teens-on reducing VAC at scale in Tanzania. The study will explore participating family and staff perspectives on program implementation and examine factors associated with implementation and how implementation quality is associated with intervention outcomes when the program is delivered to approximately 50,000 parent-child dyads (N = 100,000) in schools and community centers across eight districts of Tanzania., Methods: This mixed-methods study will answer the following research questions: (1) what is the implementation quality and fidelity of PLH-Teens at scale in Tanzania; (2) what factors are associated with the quality of delivery and implementation fidelity of PLH-Teens; (3) how are implementation quality and fidelity associated with intervention outcomes; (4) what are participant and implementing staff perspectives on the acceptability, appropriateness, feasibility, benefits, and challenges of delivering PLH-Teens in their schools and communities; (5) what is the impact of PLH-Teens on VAC and participant well-being; and (6) how much does it cost to deliver PLH-Teens at scale? Qualitative and quantitative data will be collected directly from implementers, parents/caregivers, and adolescents using pre-post questionnaires, observational assessments, cost surveys, focus groups, and interviews. Qualitative data will be analyzed thematically with the aid of NVIVO software. Quantitative data will be cleaned and analyzed using methods such as correlation, regression, and structural equation models using Stata and R. COREQ and TREND guidelines will be used, where appropriate., Discussion: Findings will provide vital insights into some of the factors related to quality implementation at scale. Lessons learned regarding the implementation of PLH-Teens at scale will be applied in Tanzania, and also in the delivery of PLH parenting programs globally.

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.

Background: Eliminating violence against children is a prominent policy goal, codified in the Sustainable Development Goals, and parenting programs are one approach to preventing and reducing violence. However, we know relatively little about dissemination and scale-up of parenting programs, particularly in low- and middle-income countries (LMICs). The scale-up of two parenting programs, Parenting for Lifelong Health (PLH) for Young Children and PLH for Parents and Teens, developed under Creative Commons licensing and tested in randomized trials, provides a unique opportunity to study their dissemination in 25 LMICs., Methods: The Scale-Up of Parenting Evaluation Research (SUPER) study uses a range of methods to study the dissemination of these two programs. The study will examine (1) process and extent of dissemination and scale-up, (2) how the programs are implemented and factors associated with variation in implementation, (3) violence against children and family outcomes before and after program implementation, (4) barriers and facilitators to sustained program delivery, and (5) costs and resources needed for implementation.Primary data collection, focused on three case study projects, will include interviews and focus groups with program facilitators, coordinators, funders, and other stakeholders, and a summary of key organizational characteristics. Program reports and budgets will be reviewed as part of relevant contextual information. Secondary data analysis of routine data collected within ongoing implementation and existing research studies will explore family enrolment and attendance, as well as family reports of parenting practices, violence against children, child behavior, and child and caregiver wellbeing before and after program participation. We will also examine data on staff sociodemographic and professional background, and their competent adherence to the program, collected as part of staff training and certification., Discussion: This project will be the first study of its kind to draw on multiple data sources and methods to examine the dissemination and scale-up of a parenting program across multiple LMIC contexts. While this study reports on the implementation of two specific parenting programs, we anticipate that our findings will be of relevance across the field of parenting, as well as other violence prevention and social programs., Competing Interests: Competing interestsCluver, Ward, Lachman, Hutchings, and Gardner were involved in the development of the PLH programs. Shenderovich, Lachman, and Wessels worked on the PLH trials in South Africa and based their doctoral work on these. The work of Cluver, Shenderovich, Wessels, Ward, Lachman, Okop, Sacolo-Gwebu, and Gardner is partly funded by the UKRI GCRF Accelerating Achievement for Africa’s Adolescents Hub. The work of Lachman has been supported by a GCRF Centre Hub Grant. The work of Cluver, Shenderovich, Wessels, Ward, Lachman, Gardner, Hutchings, and Janowski has been partly funded by grants under the European Research Council’s Horizon 2020 program. The work of Lachman, Ward, and Gardner has also been partly funded by UNICEF Thailand, the work of Hutchings and Lachman by UNICEF Montenegro, and the work of Hutchings, Lachman, Ward, and Gardner by UNICEF Philippines. Further, Lachman is the former Executive Director of Clowns Without Borders South Africa and receives income as a PLH Trainer. Ngcobo is Co-Director of Clowns Without Borders South Africa. Ward reports grants from the National Research Foundation of South Africa and the World Childhood Foundation. Janowski reports a scholarship from the University of Cape Town. Hutchings receives occasional income as a PLH Trainer., (© The Author(s) 2020.)

Introduction: Parenting programmes may reduce the risk of violence against children and improve child well-being. However, additional economic support may be necessary in highly deprived rural communities in sub-Saharan Africa. Furthermore, delivering programmes within farmer groups may increase male caregiver recruitment and engagement., Methods: A parallel cluster randomised controlled trial examined the combined and separate effects of parenting and economic strengthening programmes on reducing violence against children aged 0-18 years in farming communities in Tanzania (n=248 families; 63% male caregivers). Eight villages were randomly assigned to four conditions (2:2:2:2): (1) 12-session parenting programme (n=60); (2) agribusiness training (n=56); (3) parenting and agribusiness combined (n=72); (4) control (n=60). Parent-report, child-report and early childhood observation assessments were conducted at baseline, mid-treatment and post-treatment. Primary outcomes were child maltreatment and parenting behaviour. Secondary outcomes included corporal punishment endorsement, parenting stress, parent/child depression, child behaviour, economic well-being and child development., Results: At post-treatment, parents and children receiving the combined interventions reported less maltreatment (parents: incidence rate ratio (IRR=0.40, 95% CI 0.24 to 0.65; children: IRR=0.40, 95% CI 0.17 to 0.92). Parents reported reduced endorsement of corporal punishment ( D w =-0.43, 95% CI -0.79 to 0.07) and fewer child behaviour problems ( D w =-0.41, 95% CI -0.77 to 0.05). Parents in parenting-only villages reported less abuse (IRR=0.36, 95% CI 0.21 to 0.63) and fewer child behaviour problems ( D w =-0.47, 95% CI -0.84 to 0.11). Parents in agribusiness-only villages reported fewer child behaviour problems ( D w =-0.43, 95% CI -0.77 to 0.08) and greater household wealth ( D w =0.57, 95% CI 0.08 to 1.06). However, children in agribusiness-only villages reported increased physical abuse (IRR=2.26, 95% CI 1.00 to 5.12) and less positive parenting ( D w =-0.50, 95% CI -0.91 to 0.10). There were no other adverse effects., Conclusion: Parent training may be the active ingredient in reducing maltreatment in farmer groups with majority male caregivers, while agribusiness training programmes may have unintended negative consequences on children when delivered alone. Locating parenting support in existing farmer groups can engage much higher proportions of fathers than stand-alone programmes.ClinicalTrials.gov: NCT02633319., Competing Interests: Competing interests: The authors declare the following competing interests: JL reports grants from UBS Optimus Foundation, grants from Netherlands Ministry of Foreign Affairs, grants from Complexity in Health Improvement Programme of the Medical Research Council MRC UK, during the conduct of the study; grants from UNICEF Thailand, grants from UNICEF Philippines, personal fees from Maestral International, grants from EU Horizon 2020, personal fees from Oxford Policy Management, personal fees from Clowns Without Borders South Africa, grants from Oak Foundation, outside the submitted work; and JL is the codeveloper of a non-profit parenting program with the WHO ‘Parenting for Lifelong Health’, under a creative commons license, and receives fees as a trainer for this. JW reports grants from UBS Optimus foundation during the conduct of the study. TS reports personal fees from International Catholic Relief Services, personal fees from Department of Education, University of Oxford, personal fees and other from Journal of Child and Adolescent Mental Health outside the submitted work. JM reports grants from UBS Optimus Foundation, grants from Netherlands Ministry of Foreign Affairs, from Complexity in Health Improvement Programme of the Medical Research Council MRC UK during the conduct of the study. DW reports grants from UBS Optimus Foundation, grants from Netherlands Ministry of Foreign Affairs, from Complexity in Health Improvement Programme of the Medical Research Council MRC UK, during the conduct of the study; and DW has devoted considerable time to developing a parenting programme in Uganda (Parenting for Respectability) which might be perceived to create a bias towards interpreting parenting interventions as effective. FG reports grants from NIHR, during the conduct of the study; grants from UNICEF, grants from EU Horizon 2020, grants from UBS Optimus Foundation, grants from John Fell Oxford University Press Research Fund, personal fees from Blueprints for Health Youth Development, University of Colorado, Boulder, personal fees from Trygfonden Foundation, Denmark, outside the submitted work. FG is also a codeveloper of a non-profit parenting programme with WHO, ‘Parenting for Lifelong Health’, and receives no fees for this., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Research suggests that parenting programs are effective for preventing behavioral and emotional difficulties in children, but a lot more attention needs to be paid to issues of context and culture during the development, testing and implementation of these interventions. The views and needs of underserved and disenfranchised communities in the US and the Global South are often not taken into account for the development and testing of interventions. The successful implementation of evidence-based interventions for vulnerable children and families in underserved and marginalized communities requires careful consideration of how existing paradigms of prevention, evaluation, and implementation science impact issues of social justice and equity. This paper will describe how a team of parenting program researchers has been collaborating with their partners globally in generating local knowledge by balancing the need for rigorous scientific methods with issues of power. Authors from the U.S., Latin America, Africa and Southeast Asia draw on their experiences regarding challenges and successes with issues regarding study design and measurement, the transferability and adaptation of interventions, and the dissemination and implementation of different parenting interventions while placing communities at the center of their efforts through participatory methods. We describe innovative approaches that span the continuum of intervention development, adaptation, optimization, evaluation, implementation, and scale up of different parenting programs for vulnerable children and families across the world. We conclude by offering specific and pragmatic recommendations to increase access of culturally relevant and effective parenting programs in these communities., Competing Interests: Conflict of Interest: All the authors declare that there is no conflict of interest.

Parenting programs in high-income countries have been shown to reduce the risk of child maltreatment. However, there is limited evidence of their effectiveness in low- and middle-income countries. The objective of this study was to examine the initial effects of a parenting program in reducing the risk of child maltreatment in highly-deprived and vulnerable communities in Cape Town, South Africa. Low-income parents (N=68) with children aged three to eight years were randomly assigned to either a group-based parenting program or a wait-list control group. Observational and parent-report assessments were taken at baseline and at immediate post-test after the intervention was delivered. Primary outcomes were parent-report and observational assessments of harsh parenting, positive parenting, and child behavior problems. Secondary outcomes were parent-report assessments of parental depression, parenting stress, and social support. Results indicated moderate treatment effects for increased frequency of parent-report of positive parenting (d=0.63) and observational assessments of parent-child play (d=0.57). Observational assessments also found moderate negative treatment effects for less frequent positive child behavior (d=-0.56). This study is the first randomized controlled trial design to rigorously test the effectiveness of a parenting program on reducing the risk of child maltreatment in sub-Saharan Africa using both observational and self-report assessments. Results provide preliminary evidence of effectiveness of reducing the risk of child maltreatment by improving positive parenting behavior. Further development is required to strengthen program components regarding child behavior management and nonviolent discipline strategies. Future research would benefit from a larger trial with sufficient power to determine program effectiveness., (Copyright © 2017 Elsevier Ltd. All rights reserved.)