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BackgroundEncouraging positive parenting practices through evidence-based interventions is vital for the achievement of SDG target 16.2, which aims to eradicate all forms of violence against children while promoting their safety and mental wellbeing. As low- and middle- income countries increasingly adopt parenting programs, policymakers and implementers face the challenge of efficiently transporting, adapting, and implementing them across multiple settings.PurposeThis study seeks to evaluate the real-world experiences, challenges, and best practices in implementing parent support programs in Botswana.MethodA series of interviews with program implementers and stakeholders from governmental and non-governmental organizations were conducted. Key informants from governmental and non-governmental institutions were recruited through purposive and snowball sampling and 17 practitioners participated in the study. Data collection was carried out through online Zoom video conferencing at a convenient time and location for participants.FindingsThe findings indicate several factors that contribute to the successful implementation of parenting programs in Botswana, including (a) enabling factors such as supportive policies, regulations and guidelines, (b) innovative factors such as capacity building, program adaptation and mixed method program delivery, (c) bridging factors through collaborations with skilled organizations, and (d) intra-organizational factors such as organizational resources, program sustainability, and support for program staff.ConclusionNo single organization or strategy can sustainably foster positive parenting support in Botswana. Instead, a collective and collaborative learning approach is necessary to develop lasting and scalable solutions.

Abstract Introduction Adolescent pregnancy is defined as pregnancy at the age of 19 or below. Pregnancy and childbirth complications are the most significant cause of death among 15–19-year-old girls. Several studies have indicated that inequitable gender norms can increase the vulnerability of adolescent girls, including violence exposure, early marriage, and adolescent pregnancy. To address these disparities, gender transformative approaches aim to challenge and transform restrictive gender norms, roles, and relations through targeted interventions, promoting progressive changes. This realist review aims to synthesise existing evidence from a broad range of data sources to understand how, why, for whom, and in what contexts gender transformative approaches succeed in reducing adolescent pregnancy in low- and middle-income countries. Method and analysis We employ a five-step realist synthesis approach: (1) clarify the scope of review and assessment of published literature, (2) development of initial programme theories, (3) systematic search for evidence, (4) development of refined programme theories, and (5) expert feedback and dissemination of results. This protocol presents the results of the first three steps and provides details of the next steps. We extracted data from 18 studies and outlined eight initial programme theories on how gender transformative approaches targeting adolescent pregnancy work in the first three steps. These steps were guided by experts in the field of sexual and reproductive health, implementation science, and realist methodology. As a next step, we will systematically search evidence from electronic databases and grey literature to identify additional studies eligible to refine the initial programme theories. Finally, we will propose refined programme theories that explain how gender transformative approaches work, why, for whom, and under which circumstances. Ethics and dissemination Ethics approval is not required because the included studies are published articles and other policy and intervention reports. Key results will be shared with the broader audience via academic papers in open-access journals, conferences, and policy recommendations. The protocol for this realist review is registered in PROSPERO (CRD42023398293).

Abstract Background Structural interventions are endorsed to enhance biomedical and behavioural HIV prevention programmes for adolescents. Aiming to inform future interventions, we evaluated longitudinal associations between six protective factors that link closely to existing structural HIV prevention interventions, and five sexual risk behaviours for HIV transmission in a cohort of adolescents in South Africa. Methods We used three rounds of data between 2014–2018 on 1046 adolescents living with HIV and 473 age-matched community peers in South Africa’s Eastern Cape (Observations = 4402). We estimated sex-specific associations between six time-varying protective factors − number of social grants, education enrolment, days with enough food, caregiver supervision, positive caregiving, and adolescent-caregiver communication; and five HIV risk behaviours − multiple sexual partners, transactional sex, age-disparate sex, condomless sex, and sex on substances. HIV risk behaviours were analysed separately in multivariable random effects within-between logistic regression models that accounted for correlation of repeated observations on the same individual. We calculated prevalence ratios (PR), contrasting adjusted probabilities of HIV risk behaviours at ‘No’ and ‘Yes’ for education enrolment, and average and maximum values for the other five protective factors. Results The sample mean age was 15.29 (SD: 3.23) years and 58% were girls. Among girls, within-individuals, increases from mean to maximum scores in positive caregiving were associated with lower probability of transactional sex (PR = 0.79; 95%CI = 0.67–0.91); in caregiver supervision were associated with lower probability of transactional sex (PR = 0.75; 95%CI = 0.66–0.84), and age-disparate sex (PR = 0.84; 95%CI = 0.73–0.95); in adolescent-caregiver communication were associated with higher probability of transactional sex (PR = 1.70; 95%CI = 1.08–2.32); and in days with enough food at home were associated with lower probability of multiple sexual partners (PR = 0.89; 95%CI = 0.81–0.97), and transactional sex (PR = 0.82; 95%CI = 0.72–0.92). Change from non-enrolment in education to enrolment was associated with lower probability of age-disparate sex (PR = 0.49; 95%CI = 0.26–0.73). Between-individuals, relative to mean caregiver supervision scores, maximum scores were associated with lower probability of multiple sexual partners (PR = 0.59; 95%CI = 0.46–0.72), condomless sex (PR = 0.80; 95%CI = 0.69–0.91), and sex on substances (PR = 0.42; 95%CI = 0.26–0.59); and relative to non-enrolment, education enrolment was associated with lower probability of condomless sex (PR = 0.59; 95%CI = 0.39–0.78). Among boys, within-individuals, increases from mean to maximum scores in positive caregiving were associated with lower probability of transactional sex (PR = 0.77; 95%CI = 0.59–0.96), and higher probability of condomless sex (PR = 1.26; 95%CI = 1.08–1.43); in caregiver supervision were associated with lower probability of multiple sexual partners (PR = 0.73; 95%CI = 0.64–0.82), transactional sex (PR = 0.63; 95%CI = 0.50–0.76), age-disparate sex (PR = 0.67; 95%CI = 0.49–0.85), and sex on substances (PR = 0.61; 95%CI = 0.45–0.78), and in days with enough food at home were associated with lower probability of transactional sex (PR = 0.91; 95%CI = 0.84–0.98). Conclusion Effective structural interventions to improve food security and education enrolment among adolescent girls, and positive and supervisory caregiving among adolescent girls and boys are likely to translate into crucial reductions in sexual risk behaviours linked to HIV transmission in this population.

Abstract Background Violence against adolescents is a universal reality, with severe individual and societal costs. There is a critical need for scalable and effective violence prevention strategies such as parenting programmes, particularly in low- and middle-income countries where rates of maltreatment are highest. Digital interventions may be a scalable and cost-effective alternative to in-person delivery, yet maximising caregiver engagement is a substantial challenge. This trial employs a cluster randomised factorial experiment and a novel mixed-methods analytic approach to assess the effectiveness, cost-effectiveness, and feasibility of intervention components designed to optimise engagement in an open-source parenting app, ParentApp for Teens. The app is based on the evidence-based Parenting for Lifelong Health for Teens programme, developed collaboratively by academic institutions in the Global South and North, the WHO, and UNICEF. Methods/design Sixteen neighbourhoods, i.e., clusters, will be randomised to one of eight experimental conditions which consist of any combination of three components (Support: self-guided/moderated WhatsApp groups; App Design: sequential workshops/non-sequential modules; Digital Literacy Training: on/off). The study will be conducted in low-income communities in Tanzania, targeting socioeconomically vulnerable caregivers of adolescents aged 10 to 17 years (16 clusters, 8 conditions, 640 caregivers, 80 per condition). The primary objective of this trial is to estimate the main effects of the three components on engagement. Secondary objectives are to explore the interactions between components, the effects of the components on caregiver behavioural outcomes, moderators and mediators of programme engagement and impact, and the cost-effectiveness of components. The study will also assess enablers and barriers to engagement qualitatively via interviews with a subset of low, medium, and high engaging participants. We will combine quantitative and qualitative data to develop an optimised ParentApp for Teens delivery package. Discussion This is the first known cluster randomised factorial trial for the optimisation of engagement in a digital parenting intervention in a low- and middle-income country. Findings will be used to inform the evaluation of the optimised app in a subsequent randomised controlled trial. Trial registration Pan African Clinical Trial Registry, PACTR202210657553944. Registered 11 October 2022, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=24051 .

Introduction Family-Focused Adolescent & Lifelong Health Promotion (FLOURISH) project will adapt, implement and evaluate a programme to support adolescent mental health and well-being through strategies, such as strengthening parenting practices, adolescent-caregiver relationships, adolescent and parent socioemotional skills, and social support.Methods and analysis The project will focus on adolescents aged 10–14 years and their caregivers in North Macedonia and Moldova. The countries were selected based on implementation readiness of two organisations and a need for accessible evidence-informed services to help mitigate health risks due to economic, social and political challenges. Parenting for Lifelong Health (PLH) for Parents and Teens is a family-based programme developed for low-resource settings. PLH has been adapted with input from advisory groups. The programme includes additional components to strengthen impacts on adolescents: adolescent mental health tools, based on UNICEF’s Helping Adolescents Thrive, adolescent peer support and participation booster. This pilot is first of three study phases. The pilot will be a feasibility testing of the adapted intervention and the assessment and implementation procedures to determine further refinements. The pilot will examine if the adapted programme is acceptable for adolescents, their families and providers, explore contextual factors relevant to embedding this programme into longer-term scale-up and investigate whether the programme can be delivered with fidelity and participation; whether the participants report changes in adolescent emotional and behavioural problems, well-being and other outcomes; and whether the study tools are feasible and appropriate. Pre-post adolescent and caregiver questionnaires will provide outcome data. Process evaluation will include attendance and fidelity data, and focus groups. We will examine delivery cost and resource requirements.Ethics and dissemination The study was approved at the University of Klagenfurt (Austria), Medical Faculty at St. Cyril and Methodius University (North Macedonia) and National Committee of Ethical Expertise for Clinical Trials (Moldova). Through stakeholder engagement and dissemination, FLOURISH will advance scale-up of open-source family interventions.Trial registration number Trial registration: ID101095528; project page: https://www.flourish-study.org/about.html; https://www.linkedin.com/company/flourish-study/

AbstractReducing the adolescent birth rate is paramount in achieving the health-related Sustainable Development Goals, given that pregnancy and childbirth are the leading cause of mortality among young women aged 15–19. This study aimed to explore predictors of adolescent pregnancy among girls aged 13–18 years in Maharashtra, India, during the COVID-19 pandemic. Using a mixed-methods approach, primary data were gathered from two regions in Maharashtra between February and April 2022. Quantitative data from face-to-face interviews with 3049 adolescent girls assessed various household, social, and behavioural factors, as well as the socioeconomic and health impacts of COVID-19. Qualitative data from seven in-depth interviews were analysed thematically. The findings reveal that girls from low socioeconomic backgrounds face a higher likelihood of adolescent pregnancy. Multivariable analysis identified several factors associated with increased risk, including older age, being married, having more sexual partners, and experiencing COVID-19-related economic vulnerability. On the other hand, rural residence, secondary and higher secondary education of the participants, and higher maternal education were associated with a decreased likelihood of adolescent pregnancy. In the sub-sample of 565 partnered girls, partner's emotional abuse also correlated with higher rates of adolescent pregnancy. Thematic analysis of qualitative data identified four potential pathways leading to adolescent pregnancy: economic hardships and early marriage; personal safety, social norms, and early marriage; social expectations; and lack of knowledge on contraceptives. The findings underscore the significance of social position and behavioural factors and the impact of external shocks like the COVID-19 pandemic in predicting adolescent pregnancy in Maharashtra, India.Plain Language Summary: Adolescent pregnancy is an important health issue for young girls. In South Asia, one out of every five adolescent girls becomes a mother before turning 18, and in India, around 9% of girls aged 15–19 get pregnant yearly. This study focused on understanding the factors associated with adolescent pregnancy in Maharashtra, India, especially after the COVID-19 pandemic. We collected information from both urban and rural areas in Maharashtra. A total of 3049 adolescent girls participated in a survey, and seven girls participated in detailed interviews. Our analysis showed that factors like older age, being married, having multiple sexual partners, and experiencing economic difficulties due to COVID-19 increased the chances of adolescent pregnancy. On the other hand, living in rural areas, higher education for both the girls and their mothers reduced the likelihood of adolescent pregnancy. Qualitative analysis revealed that economic challenges, concerns about safety and societal norms, early marriage, societal expectations, and lack of knowledge about contraceptives could contribute to adolescent pregnancy in Maharashtra.

Abstract Background In many countries, including in the United Kingdom (UK), COVID-19 social distancing measures placed substantial restrictions on children’s lives in 2020 and 2021, including closure of schools and limitations on play. Many children faced milestones such as transition to secondary school having missed several months of face-to-face schooling in the previous academic years. Methods This paper examines change in mental health difficulties, life satisfaction, school connectedness, and feelings about transition to secondary school among 10–11-year-olds in Wales, UK, using data from repeat cross-sectional surveys before and after the onset of the COVID-19 pandemic. Participants were 4032 10–11-year-old schoolchildren. The first cohort completed a school-based survey in 2019 (prior to introduction of social distancing measures), and the second in 2021 (following full return to school after two rounds of school closure). Results The percentage of children reporting elevated emotional difficulties rose from 17% in 2019 to 27% in 2021 (Odds Ratio = 1.65; 95%CI = 1.23 to 2.20). There was no evidence of increased behavioural difficulties (OR = 1.04; 95%CI = 0.73 to 1.46). There was a tendency toward declines in life satisfaction in all analyses, but this intersected the null (OR = 0.86; 95%CI = 0.70 to 1.07). Children reported a high degree of school connectedness before and after the pandemic, with no evidence of change in ratings of teacher relationships, pupil relationships or pupil involvement in school life. There was no evidence of impacts of the pandemic on children’s feelings about the transition to secondary school, with feelings becoming more positive as transition neared. Most findings were robust to a range of sensitivity analyses. Conclusions Supporting children’s emotional recovery from the COVID-19 pandemic is a public health priority requiring urgent and effective action at multiple levels of society. Maintaining connectedness to school through the pandemic may have played a role in preventing a steeper increase in child mental health difficulties.

ABSTRACTWe explore how organisations working on parenting programmes and other types of family support and violence prevention in low-resource settings experienced the pandemic. In August 2020–May 2021, we interviewed (1) staff from three community-based organisations delivering evidence-informed parenting interventions and other psychosocial services for families in Cape Town, South Africa, (2) staff from a parenting programme training organisation and (3) staff from two international organisations supporting psychosocial services in South Africa. Interviews (22) were thematically analysed, with findings in three areas. First, respondents noted changes in the context, including the job losses, food insecurity, and stress experienced by local communities, and reductions in organisational funding. Second, we found that in response to these context changes, the organisations shifted their focus to food provision and COVID prevention. Parenting and psychosocial programmes were adapted – e.g. by changing the physical delivery settings, reducing group sizes, and taking up digital and phone implementation. Participants reported improved perceptions of remote delivery as a feasible approach for working with families – but internet and phone access remained challenging. Third, the pandemic brought new responsibilities for staff, and both the challenges of working from home and the health risks of in-person work.

Abstract 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

Abstract 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.

Abstract Background Mental health problems may impact adherence to anti-retroviral treatment, retention in care, and consequently the survival of adolescents living with HIV. The adolescent-caregiver relationship is an important potential source of resilience. However, there is a lack of longitudinal research in sub-Saharan Africa on which aspects of adolescent-caregiver relationships can promote mental health among adolescents living with HIV. We draw on a prospective longitudinal cohort study undertaken in South Africa to address this question. Methods The study traced adolescents aged 10–19 initiated on antiretroviral treatment in government health facilities (n = 53) within a health district of the Eastern Cape province. The adolescents completed standardised questionnaires during three data collection waves between 2014 and 2018. We used within-between multilevel regressions to examine the links between three aspects of adolescent-caregiver relationships (caregiver supervision, positive caregiving, and adolescent-caregiver communication) and adolescent mental health (depression symptoms and anxiety symptoms), controlling for potential confounders (age, sex, rural/urban residence, mode of infection, household resources), n=926 adolescents. Results Improvements in caregiver supervision were associated with reductions in anxiety (0.98, 95% CI 0.97–0.99, p=0.0002) but not depression symptoms (0.99, 95% CI 0.98–1.00, p=.151), while changes in positive caregiving were not associated with changes in mental health symptoms reported by adolescents. Improvements in adolescent-caregiver communication over time were associated with reductions in both depression (IRR=0.94, 95% CI 0.92–0.97, p

Abstract 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.

Ending all violence against children by 2030 is a core part of Sustainable Development Goals 5 and 16. A number of promising violence reduction strategies have been identified in research studies. However, we lack an understanding of the implementation and impact of these programs in respect to their delivery at a large scale or within existing service systems, particularly in low- and middle-income countries (LMICs). We advocate for greater collaboration between researchers, policymakers, donors, governments, non-governmental organizations, and program managers and staff to study how violence prevention programs operate on a large scale. We describe a new initiative aiming to foster such collaborations in the field of family strengthening programs.

BackgroundThe INSPIRE framework was developed by 10 global agencies as the first global package for preventing and responding to violence against children. The framework includes seven complementary strategies. Delivering all seven strategies is a challenge in resource-limited contexts. Consequently, governments are requesting additional evidence to inform which 'accelerator' provisions can simultaneously reduce multiple types of violence against children.Methods and findingsWe pooled data from two prospective South African adolescent cohorts including Young Carers (2010-2012) and Mzantsi Wakho (2014-2017). The combined sample size was 5,034 adolescents. Each cohort measured six self-reported violence outcomes (sexual abuse, transactional sexual exploitation, physical abuse, emotional abuse, community violence victimisation, and youth lawbreaking) and seven self-reported INSPIRE-aligned protective factors (positive parenting, parental monitoring and supervision, food security at home, basic economic security at home, free schooling, free school meals, and abuse response services). Associations between hypothesised protective factors and violence outcomes were estimated jointly in a sex-stratified multivariate path model, controlling for baseline outcomes and socio-demographics and correcting for multiple-hypothesis testing using the Benjamini-Hochberg procedure. We calculated adjusted probability estimates conditional on the presence of no, one, or all protective factors significantly associated with reduced odds of at least three forms of violence in the path model. Adjusted risk differences (ARDs) and adjusted risk ratios (ARRs) with 95% confidence intervals (CIs) were also calculated. The sample mean age was 13.54 years, and 56.62% were female. There was 4% loss to follow-up. Positive parenting, parental monitoring and supervision, and food security at home were each associated with lower odds of three or more violence outcomes (p < 0.05). For girls, the adjusted probability of violence outcomes was estimated to be lower if all three of these factors were present, as compared to none of them: sexual abuse, 5.38% and 1.64% (ARD: -3.74% points, 95% CI -5.31 to -2.16, p < 0.001); transactional sexual exploitation, 10.07% and 4.84% (ARD: -5.23% points, 95% CI -7.26 to -3.20, p < 0.001); physical abuse, 38.58% and 23.85% (ARD: -14.72% points, 95% CI -19.11 to -10.33, p < 0.001); emotional abuse, 25.39% and 12.98% (ARD: -12.41% points, 95% CI -16.00 to -8.83, p < 0.001); community violence victimisation, 36.25% and 28.37% (ARD: -7.87% points, 95% CI -11.98 to -3.76, p < 0.001); and youth lawbreaking, 18.90% and 11.61% (ARD: -7.30% points, 95% CI -10.50 to -4.09, p < 0.001). For boys, the adjusted probability of violence outcomes was also estimated to be lower if all three factors were present, as compared to none of them: sexual abuse, 2.39% to 1.80% (ARD: -0.59% points, 95% CI -2.24 to 1.05, p = 0.482); transactional sexual exploitation, 6.97% to 4.55% (ARD: -2.42% points, 95% CI -4.77 to -0.08, p = 0.043); physical abuse from 37.19% to 25.44% (ARD: -11.74% points, 95% CI -16.91 to -6.58, p < 0.001); emotional abuse from 23.72% to 10.72% (ARD: -13.00% points, 95% CI -17.04 to -8.95, p < 0.001); community violence victimisation from 41.28% to 35.41% (ARD: -5.87% points, 95% CI -10.98 to -0.75, p = 0.025); and youth lawbreaking from 22.44% to 14.98% (ARD -7.46% points, 95% CI -11.57 to -3.35, p < 0.001). Key limitations were risk of residual confounding and not having information on protective factors related to all seven INSPIRE strategies.ConclusionIn this cohort study, we found that positive and supervisory caregiving and food security at home are associated with reduced risk of multiple forms of violence against children. The presence of all three of these factors may be linked to greater risk reduction as compared to the presence of one or none of these factors. Policies promoting action on positive and supervisory caregiving and food security at home are likely to support further efficiencies in the delivery of INSPIRE.

Introduction Violence against children is a health, human rights and social problem affecting approximately half of the world’s children. Its effects begin at prenatal stages with long-lasting impacts on later health and well-being. The Evidence for Better Lives Study (EBLS) aims to produce high-quality longitudinal data from cities in eight low- and middle-income countries—Ghana, Jamaica, Pakistan, the Philippines, Romania, South Africa, Sri Lanka and Vietnam—to support effective intervention to reduce violence against children. EBLS-Foundational Research (EBLS-FR) tests critical aspects of the planned EBLS, including participant recruitment and retention, data collection and analysis. Alongside epidemiological estimates of levels and predictors of exposure to violence and adversity during pregnancy, we plan to explore mechanisms that may link exposure to violence to mothers’ biological stress markers and subjective well-being.Methods and analyses EBLS-FR is a short longitudinal study with a sample of 1200 pregnant women. Data are collected during the last trimester of pregnancy and 2 to 6 months after birth. The questionnaire for participating women has been translated into nine languages. Measures obtained from mothers will include, among others, mental and physical health, attitudes to corporal punishment, adverse childhood experiences, prenatal intimate partner violence, substance use and social/community support. Hair and dry blood spot samples are collected from the pregnant women to measure stress markers. To explore research participation among fathers, EBLS-FR is recruiting 300 fathers in the Philippines and Sri Lanka.Ethics and dissemination The study received ethical approvals at all recruiting sites and universities in the project. Results will be disseminated through journal publications, conferences and seminar presentations involving local communities, health services and other stakeholders. Findings from this work will help to adjust the subsequent stages of the EBLS project.

This Campbell systematic review examines the predictors of youth gang membership in low‐ and middle‐income countries. The review summarises findings from eight reports from five countries and the Caribbean region. The lack of available evidence limits the extent to which clear conclusions can be drawn about the factors associated with youth gang membership. The review is based on a very small number of studies, and has significant limitations in coverage. The limited evidence of the correlates of youth gang membership suggests factors that may drive gang membership and suggests areas where interventions may prove promising in the family, school, and community domains, as well as provide a starting point for future studies. Plain language summary Evidence shows which factors predict gang membership in low‐ and middle‐income countries, but more studies needed Youth gang membership is associated with delinquency, violent crime and trafficking. A range of individual, peer, family, school and community factors can predict the likelihood of youths getting involved with gangs. Knowledge of these factors can be helpful for reducing gang membership. What is this review about? Youth gang membership is associated with delinquency, violent crime and trafficking – and gang members are themselves frequently the victims of these offences. Yet youth gangs can also provide a form of social capital, a sense of belonging and purpose to disenfranchised youth. This review identifies the factors associated with young people joining gangs, and the differences between gang‐involved and non‐gang‐involved youth. Understanding these associations is essential to reduce the levels of gang membership and the incidence of related violence. What is the aim of this review? This Campbell systematic review examines the predictors of youth gang membership in low‐ and middle‐income countries. The review summarises findings from eight reports from five countries and the Caribbean region. What studies are included? Studies of youth gangs in in low‐ and middle‐income countries were included, with participants aged 10‐29 years. The studies had to assess an individual predictor or correlate of youth gang membership, where the predictor or correlate is a single characteristic, not a conglomeration of multiple constructs. Included studies had designs including data on both gang‐involved and non‐gang‐involved youth, recruited with strategies that were eligible. Nine studies met the eligibility criteria and were included in the review. One of these studies did not report all the required data and so was not included in the analyses. The studies were conducted in Turkey, Trinidad and Tobago, the Caribbean, El Salvador, China and Brazil. Factors associated with gang membership Domain Significantly associated with gang membership No significant association with gang membership Individual Delinquency Alcohol and soft drug use Male gender Risky sexual behaviours Employment Psychological risk factors (low self‐control, impulsivity) and lack of psychological protective factors (empathy, future orientation, belief in moral order) Victimisation Age Minority ethnicity Protective behaviours surrounding sexual behaviour or alcohol and soft drug use. Peer Socialising with delinquent peers Socialising with pro‐social peers Family Negative family environments Lack of parental monitoring Middle‐income families had greater odds of reporting youth gang membership than those from either high or low‐income families (finding from one study) Parental education Parental attitudes to antisocial behaviour School Low school attachment Exposure to violence at school Educational difficulties Opportunities for prosocial involvement Level of education School type School performance Community Exposed to neighbourhood violence Neighbourhood environment risk or protective factors, or geography What are the main results in this review? The eight studies analysed in the review address the associations between life events and circumstances, and the likelihood of being a youth gang member across five domains: individual, peers, family, school and community. Significant associations were found with factors in each domain. What do the findings of this review mean? The lack of available evidence limits the extent to which clear conclusions can be drawn about the factors associated with youth gang membership. The review is based on a very small number of studies, and has significant limitations in coverage. The limited evidence of the correlates of youth gang membership suggests factors that may drive gang membership and suggests areas where interventions may prove promising in the family, school, and community domains, as well as provide a starting point for future studies. How up‐to‐date is this review? The review authors searched for studies published up to September 2013. This Campbell systematic review was published in December 2018. Summary Background Youth gang membership is well documented throughout low‐ and middle‐income countries, and youth gang members are increasingly associated with delinquency, violent crime and trafficking. They are also frequently the victims of these offences, often in disproportionate numbers compared to non‐gang youth. Yet youth gangs can also provide a form of social capital, a sense of belonging and purpose to disenfranchised youth. Extensive research, primarily from high‐income countries, has categorized five domains of risk and protective factors for youth gang involvement, drawn from the realm of developmental psychology. These domains are: Individual, Peer, Family, School, and Community. Youth gang membership is seen as the culmination of interrelated structural and process factors, which in combination with negative life events may increase the attractiveness of gang membership. This review aimed to identify the factors associated with young people joining gangs, and to identify and quantify the differences between gang‐involved and non‐gang‐involved youth. Understanding these associations is essential to reduce the levels of gang membership and the incidence of related violence. Objectives This review addresses two key objectives: (1) to synthesize the published and unpublished empirical evidence on the factors associated with membership of youth gangs in low‐ and middle‐income countries;(2) to assess the relative strength of the different factors across the domains of individual, family, school, peer group and community. Search methods The search was conducted in English, French, Chinese, Arabic, Russian, Spanish and Portuguese. We searched 55 locations including academic databases, journals, and grey literature locations, and located over 54,000 documents to screen. Selection criteria We included studies meeting the following criteria: Reports on youth gangs All participants aged 10‐29 years Located in low‐ or middle‐income country Assesses an individual predictor or correlate of youth gang membership Predictor or correlate is a single characteristic Predictor or correlate is not a conglomeration of multiple constructs Eligible recruitment strategy for respondents Study design included data on both gang involved and non‐gang involved youth. Data collection and analysis We conducted a broad abstract screening of over 54,000 titles and abstracts, followed by a close abstract screening of 1509 abstracts. We screened the full‐text of 98 documents. Nine studies met the eligibility criteria and were included in the review. One of these studies did not report sufficient data to allow the calculation of a standardized effect size, and so was not included in the analyses. A total of 85 independent effect sizes were extracted from the eight studies with sufficient data to create a standardized effect size. We calculated Cohen's d from continuous data and the Log Odds Ratio from dichotomous data. All effects were categorized into the five predictor domains, and further classified into conceptually similar group and risk or protective factors. We synthesized the data using multiple random effects meta‐analyses with inverse variance weighting. Results The eight studies analysed in the review address the associations between life events and circumstances, and the likelihood of being a youth gang member. All studies were based on cross‐sectional survey data, using different statistical methods to identify correlations between youth characteristics and the likelihood of being a member of a youth gang. No longitudinal, prospective or retrospective studies were located. The studies were conducted in Turkey, Trinidad and Tobago, the Caribbean, El Salvador, China and Brazil. We organized the analyses according to five domains of factors that may be associated with youth gang involvement and summarize the main findings below: Individual factors Delinquency, alcohol and soft drug use, male gender, risky sexual behaviours, employment, psychological risk factors (low self‐control, impulsivity), and victimisation were each associated with significantly higher odds of youth gang membership. Psychological protective factors (empathy, future orientation, belief in moral order) were associated with lower odds. No association between youth gang membership and age, minority ethnicity, or protective behaviours surrounding sexual behaviour or alcohol and soft drug use. Peer factors There is a small amount of evidence that socialising with delinquent peers is associated with increased odds of youth gang membership, but there is no significant relationship demonstrated between socialising with pro‐social peers and youth gang membership. Family factors Negative family environments are associated with more youth gang membership, while both a positive family environment and parental monitoring were associated with lower odds. One study showed that youth from middle‐income families had greater odds of reporting youth gang membership than those from either high or low‐income families. No significant relationship was seen between youth gang membership and parental education or parental attitudes to antisocial behaviour. School factors Low school attachment, exposure to violence at school, educational difficulties and opportunities for prosocial involvement all show significant association with more youth gang membership. No significant relationship was seen between youth gang membership and level of education, school type, or school performance. Community factors There were significantly higher odds of youth gang membership amongst those who reported that they were exposed to violence in their neighbourhood. No demonstrated association between youth gang membership and neighbourhood environment risk or protective factors, or geography. Gang membership is typically viewed as a culmination of interrelated structural and process factors. Understanding the factors associated with youth gang membership can help inform prevention strategies to reduce the levels of youth gang membership and the incidence of youth gang violence. Unfortunately the small number of studies contributing to any analysis limits the conclusions that can be drawn from this study. Moreover, many of the individual and peer associations identified in this review (such as delinquency, drug use, and sexual risk factors) may be as a result of gang membership rather than its cause. However, our results suggest certain family, school, and community level factors associated with gang membership that could be addressed through targeted preventive interventions, particularly family environment, parental monitoring, school attachment, educational difficulties, and exposure to violence in the home, at school, or in the community. Authors’ conclusions The lack of available evidence limits the extent to which we can draw any clear conclusions about the factors associated with youth gang membership. This current review is based on a very small number of studies, and has significant limitations in coverage; however it provides some limited evidence of the correlates of youth gang membership. Specifically, this review suggests factors that may drive gang membership and suggests areas where interventions may prove promising in the family, school, and community domains, as well as provide a starting point for future studies.

BackgroundPoor parenting that leads to child maltreatment during adolescence presents a major public health burden. Research from high-income countries indicates that evidence-based parenting program interventions can reduce child maltreatment. Much less is known, however, about how beneficiaries of these programs experience this process of change. Understanding the process that brings about change in child maltreatment practices is essential to understanding intervention mechanisms of change. This is particularly important given the current scale-up of parenting programs across low- and middle-income countries.ObjectivesThis study aimed to provide insight into how caregivers and adolescents attending a parenting program in South Africa perceived changes associated with abuse reduction.MethodsSemi-structured interviews were conducted with caregivers and adolescents (n = 42) after the intervention, as well as observations of sessions (n = 9) and focus group discussions (n = 240 people). Participants were adolescents between the ages of 10-18 and their primary caregiver residing in peri-urban and rural program clusters in the Eastern Cape Province of South Africa. Data were coded in Atlas.ti, and thematic content analysis was conducted.FindingsBased on participant perceptions, the Sinovuyo Teen parenting program workshops catalyzed change into practice by creating an environment that was conducive to learning alternatives. It did so through prioritizing a process of mutual respect, openness, and being valued by others, giving legitimacy to a respectful reciprocity and new ways of spending time together that enabled caregivers and teenagers to shift and normalize more positive behaviors. This in turn led to reductions in physical and verbal abuse.ConclusionsThis study's findings may be of use to policymakers and practitioners who need to understand how parenting programs support parents and teenagers in increasing positive parenting approaches and changing potentially harmful practices. It additionally highlights the importance of assessing the experiences of both parents and teenagers attending such programs.

Abstract Background No known studies have tested the effectiveness of child abuse prevention programmes for adolescents in low- or middle-income countries. ‘Parenting for Lifelong Health’ ( http://tiny.cc/whoPLH ) is a collaborative project to develop and rigorously test abuse-prevention parenting programmes for free use in low-resource contexts. Research aims of this first pre-post trial in South Africa were: i) to identify indicative effects of the programme on child abuse and related outcomes; ii) to investigate programme safety for testing in a future randomised trial, and iii) to identify potential adaptations. Methods Two hundred thirty participants (adolescents and their primary caregivers) were recruited from schools, welfare services and community-sampling in rural, high-poverty South Africa (no exclusion criteria). All participated in a 12-week parenting programme, implemented by local NGO childcare workers to ensure real-world external validity. Standardised pre-post measures with adolescents and caregivers were used, and paired t-tests were conducted for primary outcomes: abuse (physical, emotional abuse and neglect), adolescent behaviour problems and parenting (positive and involved parenting, poor monitoring and inconsistent discipline), and secondary outcomes: mental health, social support and substance use. Results Participants reported high levels of socio-economic deprivation, e.g. 60 % of adolescents had either an HIV-positive caregiver or were orphaned by AIDS, and 50 % of caregivers experienced intimate partner violence. i) indicative effects: Primary outcomes comparing pre-test and post-test assessments showed reductions reported by adolescents and caregivers in child abuse (adolescent report 63.0 % pre-test to 29.5 % post-test, caregiver report 75.5 % pre-test to 36.5 % post-test, both p

Abstract Background Rates of youth violence are disproportionately high in many low- and middle-income countries [LMICs] but existing reviews of risk factors focus almost exclusively on high-income countries. Different search strategies, including non-English language searches, might be required to identify relevant evidence in LMICs. This paper discusses methodological issues in systematic reviews aiming to include evidence from LMICs, using the example of a recent review of risk factors for child conduct problems and youth violence in LMICs. Methods We searched the main international databases, such as PsycINFO, Medline and EMBASE in English, as well as 12 regional databases in Arabic, Chinese, English, French, Spanish, Portuguese and Russian. In addition, we used internet search engines and Google Scholar, and contacted over 200 researchers and organizations to identify potentially eligible studies in LMICs. Results The majority of relevant studies were identified in the mainstream databases, but additional studies were also found through regional databases, such as CNKI, Wangfang, LILACS and SciELO. Overall, 85 % of eligible studies were in English, and 15 % were reported in Chinese, Spanish, Portuguese, Russian or French. Among eligible studies in languages other than English, two-thirds were identified only by regional databases and one-third was also indexed in the main international databases. Conclusions There are many studies on child conduct problems and youth violence in LMICs which have not been included in prior reviews. Most research on these subjects in LMICs has been produced in the last two-three decades and mostly in middle-income countries, such as China, Brazil, Turkey, South Africa and Russia. Based on our findings, it appears that many studies of child conduct problems and youth violence in LMICs are reported in English, Chinese, Spanish and Portuguese, but few such studies are published in French, Arabic or Russian. If non-English language searches and screening had not been conducted in the current review, 15 % of eligible studies would have been missed. Although there are benefits to non-English language searches and the inclusion of non-English studies in meta-analyses, systematic reviewers also need to consider the resources required to incorporate multi-lingual research.

This Campbell systematic review examines why the implementation of preventive interventions to reduce youth involvement in gangs and gang crime may fail or succeed low and middle‐income countries. The review summarises findings from four studies conducted in Latin America and the Caribbean. These include findings from field observations and interviews with 63 former gang members in Guatemala, Honduras and El Salvador, 940 respondents in three Jamaican communities, 24 participants in Nicaragua and 25 participants in Peru. It is not possible to make any conclusions regarding the effectiveness of preventive interventions. Four factors may be important for intervention design and implementation: Having a range of programme components that appeal to youth such as arts and sports. Active engagement of youths and gang leaders in forming and implementing the programme. Ensuring continuity of social ties outside the gang which are fragile and may not be preserved after short‐term interventions. Ongoing violence and gang involvement limits successful implementation so needs to be addressed. Plain Language Summary Background Youth gang membership and the crime that it generates is a serious problem in low‐and middle‐income countries, involving many thousands of young people and resulting in billions of dollars of crime, loss of life, and social disruption. This review assessed the evidence on preventive interventions that focus on increasing social capacity to reduce gang membership or rehabilitate gang members outside of the criminal justice system. Approach We conducted an extensive search of the published and unpublished academic literature, as well as government and non‐government organization reports to identify studies assessing the effects of preventive youth gang interventions in low‐and middle‐income countries. We also included studies assessing the reasons for success or failure of such interventions and conducted a thematic synthesis of overarching themes identified across the studies. Results We did not identify any studies assessing the effect of preventive gang interventions in LMICs using an experimental or quasi‐experimental design. Four studies evaluating the reasons for implementation success or failure were included. The limited number of studies included in the review suggests that the findings identified here should provide a direction for future research, rather than any substantive or generalizable claim to best practice. Specifically, the synthesis of reasons for implementation success or failure identified five factors that may be important for intervention design and implementation. Preventive gang interventions may be more likely to be successfully implemented when they include: a range of program components that appeal to youth, active engagement of youth, where their agency is embraced and leadership is offered, programs that offer continuity of social ties outside of the gang, and a focus on demobilization and reconciliation. Implications The lack of evidence prevents us from making any conclusions about which interventions are most effective in reducing youth involvement in gangs. To identify programs that work and those that do not researchers, practitioners and commissioners should begin to rigorously evaluate the effectiveness of preventive gang programs in the field. Executive Summary BACKGROUND Youth gangs are frequently associated with high levels of crime and violence in low‐and middle‐income countries ‐‐ creating fear, reducing social cohesion, costing billions of dollars in harm and many thousands of lives diverted to criminality. However, youth gangs are also seen to fill a void, as a means of overcoming extreme disadvantage and marginalization. Preventive interventions focus on capacity building and social prevention, and are designed to work proactively to stop crime before it occurs, either by preventing youth from joining gangs or by reducing recidivism by rehabilitating gang members outside of the criminal justice system. By addressing the causes of youth gang membership, these interventions seek to reduce or prevent gang violence. OBJECTIVES There were two key objectives to this review. To review the evidence on the effectiveness of interventions designed to prevent youth involvement in gangs and gang crime in low‐ and middle‐income countries. This objective has two parts: to summarize the overall effectiveness of interventions, and to examine variability in effectiveness across different interventions and populations. To identify the reasons why the implementation of preventive interventions to reduce youth involvement in gangs and gang crime may fail or succeed in low‐and middle‐income countries. SEARCH METHODS The search for eligible studies was conducted in August and September 2013, as part of a broader project that systematically reviewed literature on conduct problems and crime in low‐ and middle‐income countries (LMIC). The search strategy included published and unpublished literature with no date constraints. The search was conducted across 17 academic databases, 8 individual journals, and 10 grey literature repositories. There were no language restrictions on the eligibility of documents, and the search was conducted in seven languages: English, French, Chinese, Arabic, Russian, Spanish and Portuguese. The geographic location of studies was limited to low‐ and middle‐income countries, defined as such by the World Bank at least 50 per cent of the time since 1987, when the recordings start. SELECTION CRITERIA Studies were eligible for the review of effectiveness if they: (1) reported on youth gangs; (2) included participants between 10 and 29 years old; (3) were located in a LMIC; (3) assessed a preventive intervention; and (4) used an eligible quantitative study design. Studies were eligible for the review of reasons for implementation success or failure if they: (1) reported on youth gangs; (2) included participants between 10 and 29 years old; (3) were located in a LMIC; (4) assessed a preventive intervention; (5) evaluated the reasons for success or failure; (6) reported on the sampling strategy; (7) reported on data collection; and (8) reported on the type of analysis. DATA COLLECTION AND ANALYSIS A team of reviewers assessed each title and abstract for preliminary eligibility, which was confirmed during full‐text screening. No studies were eligible for the review of effectiveness. For the review of reasons for implementation success or failure, we recorded any evidence of barriers or facilitators of implementation that were identified by the study authors. None of the four studies that were eligible for the thematic synthesis were graded as having low study quality. The review contains a description of each intervention, a summary of the authors' findings and conclusions about barriers and facilitators of implementation success, and a thematic synthesis of overarching themes identified across the studies. RESULTS No studies were identified for the review of effectiveness. Four studies were eligible for the review of reasons for implementation success or failure. The synthesis of reasons for implementation success or failure in the four studies identified five factors that may be important for intervention design and implementation. The limited evidence from the thematic synthesis indicates that preventive gang interventions may be more likely to be successfully implemented when they include: a range of program components that appeal to youth, programs that offer continuity of social ties outside of the gang, a recognition that ongoing violence and gang involvement can severely limit successful implementation, and active engagement of youth, where their agency is embraced and leadership is offered. AUTHORS' CONCLUSIONS There is a serious lack of rigorous evaluations of preventive gang interventions in low‐ and middle‐income countries from which to draw conclusions about best‐practice. Yet there are a large number of preventive gang programs currently in the field, and many studies that assert their effectiveness. We urge the research and practitioner communities to develop a program of rigorous evaluation, both quantitative and qualitative, in order to establish a benchmark for best practice and to systematically capture important learnings from a range of low‐ and middle‐income country contexts.