Implementation Science and Impact Evaluation of PfR Programme: A Hybrid cRCT Design
Condition: Parenting; Gender-based Violence; Child Maltreatment; IPV
Study type: Interventional

Summary: 
      The Implementation science and impact evaluation of PfR programme: A hybrid cRCT design study
      will use an effectiveness-implementation hybrid type 2 design to a) determine the
      effectiveness and cost-effectiveness of PfR, and b) determine the feasibility and impact of
      three different implementation strategies in terms of programme delivery. A cluster
      randomised controlled trial (cRCT) will examine the effectiveness, cost-effectiveness, and
      implementation of the Parenting for Respectability (PfR) programme on the reduction of
      violence against children and gender based violence in comparison to those receiving an hour
      lecture on parenting in the Wakiso and Amuru districts of Uganda (N = 54 clusters, 2,160
      parents, 1,080 children, 1:1 allocation ratio).
    

Detailed description: 
      Intimate partner violence (IPV) and violence against children (VAC) are interlinked and are
      major social, development and public health concerns. Globally it is estimated that
      approximately 30% ever-partnered women worldwide have experienced physical and/or sexual
      violence by an intimate partner at some point in their lives. IPV prevalence among women in
      Uganda is very high. The Uganda Demographic and Health Survey 2018 found that 36% of women
      had ever experienced partner physical violence, while 22% had ever experienced partner sexual
      violence. Violence against children is extremely widespread globally, with approximately half
      of all children - one billion aged 2-17 years - reporting having experienced violence in the
      past year. Furthermore, one in five women and up to one in ten men have been victims of
      sexual violence in childhood. The Uganda national VAC survey 2015 found that 59% girls and
      68% boys had experienced physical violence in their childhood, and 35% girls and 17% boys had
      experienced sexual violence in their childhood. Such violence in Uganda and most Sub-Saharan
      African countries is usually perpetrated by people known to children in their homes and
      community. IPV and VAC are major causes of morbidity and mortality, they undermine the social
      functioning of the victims and their families, and have lifetime consequences for physical,
      sexual, reproductive and mental health. The prevention of both forms of violence would
      contribute to many Sustainable Development Goals since they strain health systems, lower
      educational achievement and economic productivity, and undermine economic and social
      development, and elimination of IPV is essential to Goal Five.

      Many studies confirm the link between VAC and IPV, suggesting the need for an integrated
      approach to their prevention. A recent narrative review identified six ways in which they are
      interrelated: they have many shared risk factors, starting in the family; social norms
      legitimise both and discourage children and women from seeking help; both often occur within
      the same household both can be transmitted across generations; they can have similar
      consequences across the lifespan, and finally, both intersect in adolescence, a time of
      heightened vulnerability to violence.

      Factors perpetuating IPV and VAC exist at multiple socio-ecological levels. For IPV, familial
      level factors include having been abused as a child, having an absent or rejecting father,
      inter-partner conflict, and male control of wealth and decision-making. Community level
      factors include women's isolation and male peer groups that legitimize men's violence. At the
      macro level IPV is associated with cultural norms that condone violence within the family,
      schools and community, establish rigid gender roles and link masculinity to toughness, male
      honour, dominance and ownership of women, and it thrives where policy, legislation and
      implementation of laws is weak. VAC is more likely in families that have difficulties
      developing stable, warm and positive relationships, where parents are unresponsive to their
      children, have harsh or inconsistent parenting styles, believe that corporal punishment is an
      acceptable form of discipline or have a poor understanding of child development, and
      therefore unrealistic expectations about the child's behaviour.

      Recognizing that IPV is perpetuated at multiple levels, preventative interventions often
      focus on other psychosocial problems, e.g. poverty or alcohol abuse, as well as on
      inter-partner violence, although they are more effective if their main aim is to reduce IPV.
      The shared familial risk factors for IPV and VAC, and the increasing policy interest in
      optimizing parenting influence, provides a great opportunity for early intervention. An
      increasing number of parenting programs are being implemented and tested in LMICs to reduce
      VAC, and evidence is emerging that, if delivered by trained lay workers, they can be
      effective in improving child outcomes. However, interventions directly addressing early
      prevention of both IPV and VAC in LMICS remain limited.

      Furthermore, very few parenting programs in LMICs harness cultural drivers and pre-existing
      motivations to change behaviour. In sub-Saharan Africa little attention has been paid to one
      of the most important dimensions of parenthood for both mothers and fathers: the need to
      maintain the family's respectability, in large part achieved through the appropriate
      behaviour of the children and their parents. This core motivation might be harnessed in the
      design of interventions to reduce spousal violence, modify negative parenting and encourage
      sensitive parenting, in order to reduce children's future risk of sexual, physical and/or
      emotional violence. In Uganda, the investigators are not aware of any parenting programs that
      deliberately recruit parental couples to complete both single and mixed sex sessions. The
      Investigators therefore designed a community-based parenting program, - Parenting for
      Respectability (PfR), - to address this gap in Uganda, and contribute evidence on how a
      parenting program can address both IPV and VAC. Following careful formative evaluation, the
      investigators conducted a pre-post study to establish whether there was sufficient evidence
      of effectiveness to warrant progression to a randomized controlled trial.

      The programme has undergone formative evaluation (2014-16), 'Proof of Concept' pre-post
      outcome evaluation (2016-2019), and with support from Evaluation Fund, is currently being
      evaluated to assess implementation and scale-up modalities (April 2020-October 2021) in
      central Uganda. The investment in developing PfR so far has provided important lessons about
      the acceptability of PfR and how to refine it. Preliminary outcome evidence suggests that a
      rigorous evaluation of PfR is warranted. The pre-post study has found significant change
      across primary outcomes for both parent- and child-reports, including large effects for
      reduced harsh parenting (Cohen's f2 = 0.42, p < .001) and dysfunctional spousal relationships
      (Cohen's f2 = 0.28, p < .001), as well as increased positive parenting (Cohen's f2 = 0.48, p
      < .001). The programme has been disseminated widely in Uganda (www.parenting.ug.org), and
      both government and NGOs have expressed interest to scale it. However, two key uncertainties
      remain: (i) the optimal way to scale up the intervention in a 'real-world setting', and (ii)
      whether the evidence of effectiveness would be confirmed through a more rigorous,
      experimental, evaluation. As a result, this study will combine a rigorous cluster randomised
      control trial (cRCT) evaluation of PfR with an implementation study using a hybrid type 2
      design to examine its effectiveness and cost-effectiveness as well as answer critical
      contextually relevant implementation science questions. This is essential to ensure that
      precious resources are not wasted and that there are no harmful unintended consequences from
      the programme.
    

Intervention name(s): Parenting for Respectability
Intervention type(s): Behavioral
Intervention description(s): The programme addresses main challenges of Parenting and builds skills in 4 main areas
Poor parental bonding and child attachment;
Harsh parenting
Inequitable socialisation by gender
Parental conflict.
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Cluster Randomized Controlled Trial Hybrid Type 2 Evaluation
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Prevention