Adaptation and feasibility pilot of an evidence-based parenting intervention within the Thai public health system to prevent violence against young children
Keywords: violence against children
child maltreatment
parenting
Thailand
positive parenting
child abuse
violence prevention

Background: Social learning theory-based parenting interventions constitute the best evidence for preventing child physical and emotional maltreatment. While such programmes have demonstrated effectiveness in high-income countries, the evidence base in low- and middle-income countries (LMICs) is still nascent. This doctoral thesis focuses on the cultural and contextual adaptation of a parenting programme, Parenting for Lifelong Health for Young Children (PLH-YC), for the purpose of feasibility pilot testing with low-income families with children aged 2-9 years in Udon Thani, Thailand.
Methods: This thesis is comprised of three publishable papers that encompass the development and feasibility/piloting phases of the UK Medical Research Council guidelines on developing and evaluating complex interventions. It utilises an overarching mixed methods evaluation design. The first study, a systematic review and multi-level meta-analysis, aimed to synthesise the evidence base on the effectiveness of parenting interventions to prevent violence against children and associated outcomes in LMICs in East and Southeast Asia. Sources included electronic databases, expert contacts, and reference lists of previous reviews. Inclusion criteria for outcome measures encompassed all forms of violence against children, with studies including non-English language and grey literature. Studies were appraised for risk of bias, while effect size estimates were pooled using random effects multi-level meta-analysis.
The second study used qualitative methods to examine the cultural and contextual relevance of the key programme themes, process, structure, schedule, and logistics of PLH-YC, alongside potential barriers and opportunities for scaling up the programme within the public health system in Thailand. For the purpose of this formative evaluation, individual interviews were conducted with 20 professionals and academics, while three focus group discussions were held with a Parenting Experts Working Group – consisting of six professionals and academics. A hybrid approach to thematic analysis was utilised, combining deductive and inductive approaches.
The third study was a pilot that tested the feasibility of an adapted version of PLH-YC for low-income families in Udon Thani, including suitability of study evaluation approaches, feasibility of delivering the adapted intervention, indicative effects, and perceived key mechanisms of change associated with intervention content. This mixed methods study embedded a qualitative component within a larger, pre-post quantitative evaluation. Parents (N = 60) of children aged 2-9 years were recruited into a weekly, 8-session parenting intervention delivered through the local health system. Quantitative parent-report, observational data, and programme implementation measures were collected using standardised instruments, while qualitative data was drawn from individual interviews with participating parents (n = 11) and programme facilitators (n = 8). Outcomes of interest were rates of physical and emotional maltreatment (primary outcomes) and associated risk factors (secondary outcomes). Analyses utilised Wilcoxon signed-rank tests, paired t-tests, Friedman’s ANOVA, Cronbach’s alpha, and thematic analysis.
Results: In the first study, the review led to the inclusion of 11 studies representing 2,812 parent, caregiver, and child participants. The multi-level meta-analysis comprised 44 effect sizes spanning five outcome categories, finding a small effect on abusive, harsh, or negative parenting (n = 3, d = -0.42, 95% CI [- 0.81, -0.02], p < 0.01, I2 = 72%), the primary outcome of interest. Effects on secondary outcomes included a large, non-significant effect on parental knowledge or attitudes (n = 5, d = 1.40, 95% CI [-0.30, 3.10], I2 = 95%); a small effect on positive parent-child interactions (n = 5, d = 0.25, 95% CI [0.19, 0.32], p < 0.001, I2 = 0); a small, non-significant effect on parental stress (n = 2, d = -0.13, 95% CI [-0.38, 0.11], I2 = 0); and a small, non-significant effect on family environment (n = 3, d = 0.21, 95% CI [-0.12 to 0.53], I2 of 85%).
The second study found that many of the original aspects of PLH-YC were perceived by participants to be relevant, yet tensions were identified between perceived social norms, practices, and needs. Recommendations concerned programme language of delivery; reflection of local family demographics and material culture; emphasis on positive parent-child relationship building; encouragement of child participation; removal of time-out and inclusion of child development and self-discipline content; provision of ‘mini-scripts’ as a programme method; weekend programme delivery; utilisation of health workers as facilitators and recruiters; use of inclusive recruitment approaches and incentives to encourage participation; establishment of local primary care centres as programme venues; and adoption of top-down policy implementation, cross-sectoral partnerships, and model delivery centres as scale-up strategies.
The third study found high rates of study retention (98.3%), programme enrolment (96.7%), enrolee attendance (92.5%), and completion (96.6%). Reliability of outcome instruments using Cronbach’s alpha showed 16 out of 27 values within acceptable ranges. Analyses of primary outcomes showed parent-reported reductions in overall child physical and emotional abuse (d = -0.58, p < 0.001), as well as physical abuse (d = -0.58, p < 0.001) and emotional abuse (d = -0.40, p < 0.001) subscales. The HOME Inventory, which combines parent report and observations, showed reductions in abusive and harsh parenting (d = -0.52, p < 0.001). There were improvements in 22 out of 24 secondary outcomes. In addition, six key programme themes were associated with strengthened parent-child relationships, reduced child behaviour problems, improved attitudes and strategies toward discipline, and improved management of parental stress.
Conclusion: This thesis comprised the first known regional systematic review of parenting interventions for violence prevention, the first known formative evaluation to examine the cultural and contextual relevance of a parenting intervention in Thailand, and the first known feasibility pilot of a parenting intervention aiming to prevent violence against children in Thailand. There is provisional support in the East and Southeast Asian region for the implementation of evidence-based parenting interventions to prevent violence against children; high levels of cultural relevance and suitability of PLH-YC within the Thai implementation context; suitability of pilot study evaluation approaches and intervention delivery, as well as initial effectiveness; and promising prospects for scaling up within the public health system. Further research, through a randomised controlled trial and evaluations after scale-up, will need to assess if such effects are both replicated and sustained over time.