Reducing Child Maltreatment in South Africa: Feasibility of a Locally Developed Parenting Program for At-Risk Low-Income Families - Lachman, J. M.; Ward, C. L.; Cluver, L.; Hutchings, J.; Gardner, F. Department of Social Policy & Intervention, University of Oxford Department of Psychology, University of Cape Town Department of Psychiatry and Mental Health, University of Cape Town Safety and Violence Initiative, University of Cape Town School of Psychology, University of Bangor Wales

Outline Study Objectives Background Methods Results Conclusion and Recommendations

Study Objectives Programme Feasibility Evaluation Feasibility Is a locally developed parenting programme derived from evidence-based parenting principles feasible for families affected by HIV/AIDS, intimate partner violence, and poverty in Cape Town? Evaluation Feasibility What is the feasibility of conducting a randomised controlled trial of a locally developed parenting programme in impoverished communities in Cape Town?

Risk factors for child abuse ONTOGENIC i.e. Inter-generational abuse Parent depression Attribution bias MICROSYSTEM i.e. Intimate Partner Violence Marital conflict HIV/AIDS Poverty Step-parents EXOSYSTEM i.e. Social isolation Unemployment Community violence Lack of Social Services MACROSYSTEM i.e. Cultural values Gender relations (Belsky, 1980, 1993; Cicchetti & Manly, 2001; Stith, 2009)

Parenting as a mediator of risk factors for abuse

Evidence-based parenting programmes Systematic review showed parenting programmes best evidence (Mikton and Butchart 2009) Good effect sizes in developed world trials (Barlow, 2006) Group-based programs tend to be less costly Problem: High costs of established programs No evidence in sub-Saharan Africa for families with children 2-9 (Knerr, Gardner & Cluver, Prevention Science 2013)

Developing free child abuse prevention programs

Project Phases Phase 1: Intervention Development (2012) Phase 2: Feasibility Pilot Randomised Controlled Trial (2013) Phase 3: Larger Randomised Controlled Trial (2014-2015) Phase 4: Dissemination and Scale-Up (2015)

Research, policy and clinical practice working together Collaborative research Universities: Oxford Bangor, & UCT

Sinvouyo Caring Families Programme – Designed to go to scale Derived from evidence-based parenting principles (Kaminski, 2008) Group-based approach to behavioural change 12-weekly group sessions Home visit consultations to support learning Role-plays and group problem solving Programme delivery by paraprofessionals Early Childhood Development Level 4 Training, Mentoring, Supervision Low-cost materials Illustrated stories of parenting SMS reminders and booster messages User-friendly programme manual and parent handbook Creative Commons licensing – FREE access & Low Cost!

Evidence-based parenting principles based on social learning theory (Bandura, 1977) Collaborative approach to problem-solving (Webster- Stratton, 1998) Developmentally appropriate activities (Hutchings et al., 2004) Culturally sensitive forms of communication (Kumpfer et al., 2002) Positive parenting skills (Webster-Stratton et al., 2008) Effective supervision and parent-child communication (Coley and Hoffman, 1996) Nonviolent discipline strategies (Gross et al., 2003) Parental self-management, care, and stress relief (Hutchings, in press) Non didactic experiential approach – Parents are experts Sensitive to children ages 3-8 Storytelling, songs, metaphors, and session structure Child-led play, descriptive commenting, emotional labelling, praise and rewards Clear, positive instructions, household rules, consistent supervision Ignoring, Time-Out, consequences, and problem solving with children MBSR, emotional regulation

Location: Khayelithsa, Cape Town

Participants Primary caregivers of children ages 3 to 8 (n = 68) Reside in same household > 4 nights a week isiXhosa speaking Recruitment Ikamva Labantu’s OVC programme Development study participants Referrals from other local NGOs Available for weekday morning sessions

Data collection Intervention effects - quantitative data Parent-self report using mobile phones Home observation assessments with video recordings Programme feasibility – quantitative data Participant satisfaction surveys Attendance registers Facilitator fidelity checklists Programme feasibility – qualitative data In-depth interviews with randomly selected sample (n=12) Focus group with paraprofessional facilitators Programme notes and feedback forms Video recordings of sessions

Results: Evaluation feasibility High recruitment rate (93 out of 126, 73.8%) 68 participants enrolled (73.1%) Most females (98.5%) Most unemployed (97.0%) High retention rate (66 out of 68, 97.0%) Lost 2 participants in control group Only male dropped out Mobile phone assessment method appropriate Reduced data entry and cleaning costs Assessment procedure acceptable Video observations Acceptable though awkward

Results: Programme feasibility Dosage/Attendance: Mean = 9 sessions (75%) SMS reminders, home visits Childcare, Public transportation Employment = Dropout Participant satisfaction High rates of weekly and overall satisfaction Positive feedback on content and collaborative approach (brainstorms, illustrated stories, role- plays, problem solving, home practices) Sinovuyo partner system

Results: Programme feasibility Programme fidelity Content delivered with high degree of fidelity Substantial training and ongoing supervision required Issue of staff retention Cultural acceptability isiXhosa framework Rondavel of support model Children’s songs, stories, and structure of day Nonviolent approaches acceptable Challenges with Time-Out and emotional labelling “The illustrated stories are good because they are visuals, which works really well with this kind of group. They can describe what they see happening in the blocks, and you can take them slowly, block by block, instead of reading and listening. They are connecting what they see and what they are saying, and then in that it is easy for them to actually grasp what you are trying to give them.”

Building a Rondavel of Support

Conclusion – Recommendations for future practice Weekend sessions for employed parents. Target men’s groups and utilize male facilitators Additional materials and activities increase participation and engagement IsiXhosa specific programme content supports behavioural change model Programme fidelity requires ongoing training, supervision, and logistical support Some evidence-based behavioural principles may require additional sessions and time Parenting programmes require budgeting for transport, meals tea, and childcare SMS reminders, manuals, handbook, Sinovuyo partners, and pre-programme home visits

THANK YOU!!! Ilifa Labantwana The John Fell Fund and the Clarendon Fund National Lottery Trust Distribution Fund World Health Organisation And all the research assistants, volunteers, group facilitators, project managers, and other unsung heroes!

References Bandura, A. (1977). Social Learning Theory. . New York City, NY: General Learning Press. Barlow, J., Johnston, I., Kendrick, D., Polnay, L., & Stewart-Brown, S. (2006). Individual and group-based parenting programmes for the treatment of physical child abuse and neglect. Cochrane Database of Systematic Reviews, 3, 1-20. Belsky, J. (1980). Child Maltreatment: An ecological integration. American Psychologist, 35, 320-335. Belsky, J. (1993). Etiology of child maltreatment: a developmental-ecological analysis. [Review]. Psychological Bulletin, 114(3), 413-434. Cicchetti, D., & Manly, J. T. (2001). Operationalizing child maltreatment: developmental processes and outcomes. Dev Psychopathol, 13(4), 755-757. Coley, R. L., & Hoffman, L. W. (1996). Relations of parental supervision and monitoring to children's functioning in various contexts: Moderating effects of families and neighborhoods. Journal of Applied Developmental Psychology, 17(1), 51-68. Gross, D., Fogg, L., Webster-Stratton, C., Garvey, C., Julion, W., & Grady, J. (2003). Parent training of toddlers in day care in low-income urban communities. Journal of Consulting and Clinical Psychology, 71(2), 261-278. doi: Doi 10.1037/0022-006x.71.2.261 Hutchings, J., Bywater, T., Williams, M.E., Whitaker, C. (in press). Parental Depression and Child Behaviour Problems. Behavioural Cognitive Pyschotherapy. Hutchings, J., Gardner, F., & Lane, E. (2004). Making evidence-based intervention work. In D. Farrington, C. Sutton & D. Utting (Eds.), Support from the Start: Working with Young Children and their Families to Reduce the Risks of Crime and Antisocial Behaviour. London: DFES.

References Kaminski, J. W., Valle, L. A., Filene, J. H., & Boyle, C. L. (2008). A meta-analytic review of components associated with parent training program effectiveness. Journal of Abnormal Child Psychology, 36(4), 567-589. doi: 10.1007/s10802-007-9201-9 Knerr, W., Gardner, F., & Cluver, L. (2013). Improving Positive Parenting Skills and Reducing Harsh and Abusive Parenting in Low- and Middle-Income Countries: A Systematic Review. Prevention Science. Mikton, C., & Butchart, A. (2009). Child maltreatment prevention: a systematic review of reviews. Bulletin of the World Health Organization, 87(5), 353-361. Stith, S. M., Liu, T., Davies, L. C., Boykin, E. L., Alder, M. C., Harris, J. M., . . . Dees, J. E. M. E. G. (2009). Risk factors in child maltreatment: A meta-analytic review of the literature. Aggression and Violent Behavior, 14(1), 13-29. Webster-Stratton, C. (1998). Parent Training with Low-income Families: Promoting parental engagement through a collaborative approach. In J. R. Lutzker (Ed.), Handbook of Child Abuse Research and Treatment. New York: Plenum Press. Webster-Stratton, C., Reid, M. J., & Stoolmiller, M. (2008). Preventing conduct problems and improving school readiness: evaluation of the Incredible Years Teacher and Child Training Programs in high-risk schools. Journal of Child Psychology and Psychiatry, 49(5), 471-488.