Invited Review
Parenting interventions to prevent violence against children in low- and middle-income countries in East and Southeast Asia: A systematic review and multi-level meta-analysis

https://doi.org/10.1016/j.chiabu.2020.104444Get rights and content

Abstract

Background

Currently, the strongest evidence for preventing violence against children lies with social learning theory-based parenting interventions. An increasing number of experimental studies on such interventions have been conducted in low- and middle-income countries (LMICs) in East and Southeast Asia.

Objective

To conduct a systematic review and meta-analysis on the effectiveness of parenting interventions in preventing violence against children.

Participants and setting

Parents and primary caregivers living in LMICs in East and Southeast Asia.

Methods

Eleven studies were retrieved through electronic databases, expert contacts, and the reference sections of previous reviews. Studies were appraised for risk of bias and effect estimates pooled using random effects multilevel meta-analysis.

Results

Forty-four effect estimates were meta-analyzed based on five outcome category models, finding a small effect on abusive, harsh, or negative parenting (n = 3, d = −0.42, 95 % CI [− 0.81, −0.02], p < .01, I2 = 72 %); 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 < .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, 0.53], I2 = 85 %).

Conclusions

The results suggest that parenting interventions can reduce rates of particular forms of violence against children, as well as promote positive parent-child interactions.

Introduction

In many low- and middle- income countries (LMICs), prevalence studies indicate that children experience high rates of violence within the context of a relationship of responsibility to the child (Lansford & Deater-Deckard, 2012), with most children having experienced violent discipline in the form of physical or psychological punishment (United Nations Children’s Fund [UNICEF], 2010). Indeed, minimum rates of past year violence against children aged 2–14 years were estimated as the highest in Asia at 68 %, in comparison to Africa, Europe, Latin America, and North America (Hillis, Mercy, Amobi, & Kress, 2016). In the East Asia and Pacific region, amongst those countries for which Multiple Indicator Cluster Survey (MICS) data were available, parents were the most commonly mentioned perpetrators of child physical abuse, with 63 % of girls having experienced such abuse by their mothers in Cambodia, 28 % by their fathers in the Philippines, and 63 % by their mothers in Timor-Leste (UNICEF East Asia and Pacific Regional Office [EAPRO], 2014). Estimates of child emotional abuse amongst lower-middle income countries in the region are also high, affecting 36 % of girls and 37 % of boys, although these prevalence rates include a range of perpetrators (Fang et al., 2015). Finally, many children in LMICs in the region have been victims of neglect, affecting 27 % of girls and 24 % of boys (UNICEF EAPRO, 2014). These high rates of victimization persist despite all countries in East and Southeast Asia being legally bound to the provisions of the Convention on the Rights of the Child, the world’s most widely ratified human rights treaty. Article 19 of the Convention obligates States Parties to take all appropriate measures to protect the child from all forms of violence, abuse, or maltreatment, including while in the care of parents or legal guardians (United Nations [UN], 1989. In recognition of the widespread nature of this problem and these obligations, the Association of Southeast Asian Nations (ASEAN) recently adopted a multi-sectoral Regional Plan of Action on the Elimination of Violence against Children (ASEAN Secretariat, 2017).

The aetiology of violence against children is best described within an ecological framework (Bronfenbrenner, 1979), taking into account the layered contexts and interactions at the individual (child and parent), relational (between child and parent), family, community (e.g. neighborhood, school) and societal (e.g. social norms, economic disparities, legal frameworks) levels. Research studies and reviews of such risk factors mainly derive from high-income country contexts. At the child level, potential risk factors for child maltreatment include child social competence, child internalizing behavior, and child externalizing behavior (Stith et al., 2009), with the latter predicting corporal punishment in a longitudinal study in nine countries including China, the Philippines, and Thailand (Lansford et al., 2015). At the level of the parent, factors include adverse life experiences and mental health problems (Chaffin, Kelleher, & Hollenberg, 1996), substance abuse (Tyler, Howard, Espinosa, & Simpson Doakes, 1997), a history of abuse as a child (Kaufman & Zigler, 1987), and values about corporal punishment (Brayden, Altemeier, Tucker, Dietrich, & Vietze, 1992; Scannapieco & Connell-Carrick, 2005). At the parent-child relationship level, parental perception of the child as a problem, anger and hyper-reactivity, and the quality of the relationship have been significantly associated with child physical abuse and neglect (Stith et al., 2009). At the family level, high family conflict and low family cohesion were found to have some of the strongest associations with child physical abuse in a meta-analytic review (Stith et al., 2009), while family-related factors specifically associated with child maltreatment recurrence include an increased number of dependents or children and family poverty (White, Hindley, & Jones, 2015). At the community level, perceptions of the normativeness of corporal punishment predicted corporal punishment in the study in nine countries that included China, the Philippines, and Thailand (Lansford et al., 2015), while low social and family support, as well as low ‘child visibility’ within the community, was found to increase the risk of maltreatment recurrence (White et al., 2015). Finally, at the societal level, unemployment, alcohol and drug availability, residential instability, and high childcare burden have been positively associated with child maltreatment rates (Freisthler, Merritt, & LaScala, 2006).

Parents and other primary caregivers, given their proximity to the ecological level of the individual child and their fundamental role in childcare, development and protection, provide the conduit through which children experience their world. Even in families facing chronic adversities, positive parent-child relationships and consistent parenting can help buffer and mediate the effects of risk factors on child development, and to serve a protective and supportive function (Luthar & Bidwell Zelazo, 2003). Systematic reviews indicate that parenting interventions can be effective across a range of outcomes relevant to child maltreatment, such as child behavior problems (Furlong et al., 2012; Piquero, Farrington, Welsh, Tremblay, & Jennings, 2009), emotional difficulties (Cartwright-Hatton et al., 2011), parenting competence and stress (Gross et al., 2003; Nixon, Sweeney, Erickson, & Touyz, 2003), maternal depression (Sanders & McFarland, 2000), and couple interaction quality (Cowan, Cowan, & Barry, 2011). Moreover, there is growing evidence that particular parenting interventions can improve positive parenting, reduce harsh parenting, and diminish actual rates of violence against children (Barlow, Johnston, Kendrick, Polnay, & Stewart-Brown, 2006; Barlow, Simkiss, & Stewart-Brown, 2006; Bilukha et al., 2005; Chen & Chan, 2015; Knerr, Gardner, & Cluver, 2013; Vlahovicova, Melendez-Torres, Leijten, Knerr, & Gardner, 2017).

Effective parenting programs for reducing risks of violence perpetration can be individual-based, delivered in home or clinical settings, group-based in community settings, or a combination of individual- and group-based delivery. Many of these programs draw on common theories of change based on social learning (Bandura, 1977) and attachment theories (Bowlby, 1974). These programs fortify parenting skills and sensitivity by providing practical instruction on positive-parent child interaction, the use of positive encouragement, techniques for non-violent discipline, problem solving, socio-emotional coaching, and developmentally responsive supervision (Dishion & Patterson, 2006; Kaminski, Valle, Filene, & Boyle, 2008). Parents and primary caregivers who participate in evidence-based interventions can experience reductions in stress and maternal ill-health, improvements in parenting competence in managing difficult child behavior, strengthened knowledge of child development, and decreased levels of social isolation when taking part in group sessions (Barlow, Smailagic, Ferriter, Bennett, & Jones, 2010; Hurlburt, Nguyen, Reid, Webster-Stratton, & Zhang, 2013). Parenting interventions can also teach parents how to interrupt coercive cycles of parent-child interactions that arise through child behavior problems and dysfunctional parenting skills (Patterson, Chamberlain, & Reid, 1982). For these reasons, parenting interventions that target reductions in difficult child behaviors are often similar to those known to effectively prevent parent-perpetrated violence against children (Knerr et al., 2013).

This systematic review and multi-level meta-analysis is, to our knowledge, the first attempt to undertake a regional synthesis of parenting interventions for the prevention of violence against children. Importantly, it extends beyond similar, international reviews by expanding included outcome measures to all forms of violence against children, identifying non-English language and grey literature, and incorporating multiple regional and country-specific bibliographic databases. Only one other, comparable systematic review is known to have focused on LMICs (Knerr et al., 2013). However, it only reviewed literature published prior to May 2010, did not identify non-English language papers, only included one study from East and Southeast Asia (Jin et al., 2007), and is in need of updating. The current review has been conducted within a context of growing international and regional demand, especially amongst LMICs, to design, transport, adapt, and implement evidence-based parenting programs for the prevention of violence against children.

Section snippets

Data sources, inclusion criteria, and study screening

First, we included interventions that aimed to reduce child maltreatment, harsh or dysfunctional parenting, teach positive child behavior management strategies, or improve parent-child attachment and relationships through changes in general parenting knowledge, attitudes or skills, either as primary or secondary outcomes (adapted from Knerr et al., 2013). Interventions were excluded if: 1) they comprised multiple components, of which parenting was only a minor component, and 2) if they targeted

Results of the search

The electronic database search retrieved 10,378 records, which were imported into EndNote. Responses from expert contacts resulted in an additional 24 records, while hand searching of reference lists led to identifying one further study. After removing duplicates, 10,305 records remained. Following screening, 10,279 studies were excluded for failure to meet inclusion criteria. The full text of 26 remaining studies was then assessed further for eligibility, leading to the exclusion of 15

Summary of main results

Findings from the review and multi-level meta-analysis – excluding the one non-RCT study – suggest that parenting interventions in LMICs in East and Southeast Asia may be effective in significantly reducing abusive, harsh, and negative parenting, as well as improving positive parent-child interactions. The impact of these interventions on secondary outcomes, such as parental knowledge or attitudes, parental stress, and the family environment, resulted in effects that ranged from small to very

Implications for practice

This review and multi-level meta-analysis suggests that parenting interventions in at least three LMICs in East and Southeast Asia can reduce rates of particular forms of parent or primary caregiver-perpetrated violence against children, such as physical and emotional abuse in the guise of discipline. Such interventions may also promote positive parent-child interactions during both the early childhood and adolescent years, which can strengthen protective factors for child maltreatment within

Funding information

The primary author received financial support for this research through a Centenary Scholarship from the Department of Social Policy and Intervention, University of Oxford. The systematic review portion of this study was funded by UNICEF Thailand (contract #43179447).

Declaration of Competing Interest

We are reporting that the systematic review portion of this study was part-funded by UNICEF Thailand, and that an agreement was signed between the primary author (AM) and UNICEF that requires written approval by a senior UNICEF Thailand official prior to publication. Secondly, this paper mentions the WHO Parenting for Lifelong Health (PLH) partnership (http://www.who.int/violence_injury_prevention/violence/child/plh/), a not-for-profit organization dedicated to adapting and testing low-cost,

Acknowledgements

We would like to acknowledge the valuable advice provided by Wendy Knerr during the development of the protocol for this study, as well as the thoughtful comments provided by Jamie McLaren Lachman on the final draft of this paper. We are also grateful to Ratirose Supaporn for her assistance in searching Thai language databases and translating portions of Thai language papers, as well as to Min Wu for her work in translating the Chinese language papers.

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