Parenting for Lifelong Health (PLH) - Masayang Pamilya (MaPa) Evaluation Study

Positive parenting behavior will be assessed using the Parenting of Young Children Scale (PARYC, 21 items) [5]. The PARYC measures the frequency of parent behavior over the previous month. Items are summed to create total frequency scores for positive parenting (7 items, e.g., "how often do you play with your child"), setting limits (7 items, e.g., "how often do you stick to your rules and not change your mind") and proactive parenting (7 items, e.g., "how often do you explain what you want your child to do in clear and simple ways"). It has been used with strong reliability in previous studies on the program adapted in this study [20].

Dysfunctional parenting behavior will be assessed using the Parenting Scale (PS, 30 items) [6]. This scale examines parent attitudes and beliefs regarding discipline practice. Responses are based on a 7-point Likert scale in which parents are presented with a situation and then are asked to choose between two alternative responses to a situation (1 = most effective; 7 = most ineffective; i.e., situation: "When I say my child can't do something;" response, score = 1: "I stick to what I said;" or response score = 7: "I let my child do it anyway"). Items are summed to create an overall score as well as for three subscales: Laxness, Over-reactivity, and Verbosity. The PS has been used widely to assess the effectiveness of parenting programs, including in low-resource settings such as Panama [21].

This study will ask one question from the UNICEF Multiple Indicator Cluster Survey [1] regarding parental attitudes to physical discipline based on a 5-point Likert scale of 0 to 4: "In order to bring up, raise up, or educate a child properly, the child needs to be physically punished." Caregivers will report whether they disagree or agree with the statement (0 = disagree strongly; 4 = agree strongly).

An adapted version of Parent Daily Report Checklist (PDR, 44 items) will be used to assess day-to-day occurrences of child behavior problems and parenting behavior [12]. It was designed to avoid potential challenges parents may have in recalling events in retrospective scales, and has been used widely in multiple contexts as an assessment of child and parent behavior change during program delivery [46-49]. The PDR does not assess frequency of behavior but rather the occurrence (i.e., "Yes" or "No"). Parents indicate whether a child behavior occurred within the previous 24 hours (35 items, e.g., complaining, lying). In order to assess parenting behavior, this study will also ask parents about their own behavior (6 items, e.g., used physical discipline, or praised child) and self-efficacy (3 items, e.g., had a feeling that I could not cope with parenting).

The Eyberg Child Behavior Inventory assesses child behavior problems [30]. This 36-item survey examines externalizing behavior problems in children ages 2 to 16 using both an Intensity Scale and Problem Scale. Parents are asked how often a specific behavior occurs and whether the behavior is considered a problem. Items based on the most typical child behavior problems. The Intensity Scale rates frequency of occurrence based on a 7-point Likert-like scale (1 = never occurs; 7 = always occurs). The Problem Scale measures whether the parent identifies a specific behavior as a problem (0 = no; 1 = yes). Both scales are summed up to create a total Intensity Score and Problem Score. The ECBI has been used extensively throughout the world as a diagnostic tool as well as to evaluate parenting programs in RCTs [31-34]. Clinical cut-off scores suggested for psychopathological problem behavior are 131 for the Intensity Score and 15 for the Problem Score [35].

Child development will be assessed using the communication subscale of the parent-report version of the Ages and Stages Questionnaires, Version 3 (ASQ-3) [13]. This 6-item screening tool measures infant and toddler development of communication skills from 2 months to 6 years of age. Distinct items are administered according to the child's age in 2-month intervals rounded to the nearest interval. The ASQ-3 is administered via caregiver self-report based on "Yes," "Sometime," or "Not Yet" for each developmental milestone. In addition, if the caregiver is not sure of a specific item, s/he is given the opportunity to perform the task with his/her infant or toddler during the assessment. Items for each subscale are summed to create total scores as well as an overall indication of child development. Cut-off scores will be used based on international ASQ cut-offs according to the manual for normal development, borderline delay, and developmental delay [13].

Child socio-emotional development will be assessed using the parent-report version of the Ages and Stages Questionnaires: Social-Emotional, Version 2 (ASQ-SE2) [14, 36]. This screening tool was designed to specifically assess socio-emotional development for children from 1 month to 6 years of age. Questionnaires are administered to the parent depending on the age of the child (i.e., 24, 30, and 36 month intervals). Items examine seven domains of socio-emotional development: self-regulation, compliance, adaptive functioning, autonomy, affect, social-communication, and interaction with others. Parents report on whether the specific child behavior occurs "often or always," "sometimes," or "rarely or never," as well as whether the behavior is a concern for the parent (yes/no). The ASQ:SE has been used extensively as a global screening tool, including multiple low- and middle-income countries [37-41].

Parenting efficacy will be assessed using the Efficacy Subscale of the Parenting Sense of Competence Scale (8 items; PSOC-ES) [37]. The PSOC has been widely used in studies to evaluate parenting self-esteem, efficacy, or competence [37]. The PSOC Efficacy Subscale measures parental perception of competence, problem-solving ability, and capability in the parenting role (e.g., ""I honestly believe I have all the skills necessary to be a good mother/father to my child"). Each item is rated on a 6-point scale that ranges from 1 (strongly disagree) to 6 (strongly agree). Items are summed to create a total score of parental self-efficacy.

Parenting stress will be measured using the Parenting Stress Index (PSI) (36 items) [8]. This scale has been used widely throughout the world [22-25], including prior use in low- and middle-income countries [26, 27]. Items include subscales for parental distress (e.g., "I often have the feeling that I cannot handle things very well"), parent-child dysfunction (e.g., "Sometimes I feel my child doesn't like me and doesn't want to be close to me"), and difficult child (e.g., "I feel that my child is very moody and easily upset"). Items are summed to create a total score for parenting stress as well as for each subscale.

The Depression, Anxiety, and Stress Scale (DASS) will assess caregiver depression. The DASS is a 21-item scale used as a screening tool to measure depression, anxiety, and stress in adults. Caregivers report on the frequency of depressive symptoms in the previous week using a Likert scale (0 = Never, 1 = Sometimes, 2 = Often, 3 = Always; e.g., "I felt that I had nothing to look forward to"). Total DASS scores range from 0 to 63 with subscales from 0 to 21. Recommended cut-offs indicating severity of depression are 5-6 for mild, 7-10 for moderate, 11-13 for severe, and 14 and up for extremely severe. Cut-offs for anxiety are 4-5 for mild, 6-7 for moderate, 8-9 for severe, and 10 and up for extremely severe. Cut-offs for stress are 8-9 for mild, 10-12 for moderate, 13-16 for severe, and 17 and up for extremely severe.

The WHO-5 Well-Being Scale (WHO-5) will measure parental psychological well-being [10]. This 5-item scale was derived using psychometric analyses from the longer 28-item WHO Well-Being Scale. The validation study of the WHO-5 showed 93% sensitivity and 64% specificity when compared with the General Health Questionnaire and the Patient Health Questionnaire [28]. Parents indicate the frequency that they experience well-being in the past month (e.g., "My daily life has been filled with things that interest me") based on a Likert scale from 0 to 5 ("At no time" to "All of the time"). Items are added up with scores ranging from 0 to 25.

Parental dependency on alcohol will be assessed by asking parents to report on alcohol consumption during the past month (1 item). Dependency is based on 3 or more drinks per day for female participants and 5 or more per day for male participants [48]. Due to the sensitive nature of these items, additional items dealing with other activities to reduce stress have been included in this section to encourage accuracy (3 items; e.g., "In the past month, have you been for a walk or done some other exercise to help you relax?").

Adult self-report of the victimhood of intimate partner violence will be assessed using an adapted version of the Revised Conflict Tactics Scale Short Form (CTS2S; 8 items) [42]. Items include the frequency of negotiation (e.g., "partner suggested compromise to an argument"), physical assault (e.g., "partner hit me with something"), and psychological aggression (e.g., "partner insulted or swore at me"). Answers are coded on a 5-point Likert scale of 0 to 4 (0 = never happened; 4 = more than 3 times in the past month). The CTS2S will determine an overall indication of IPV on a level of severity (sum of items) and prevalence (dichotomous variable indicating experience of conflict or not) as well as for each subscale.

Adult report of marital satisfaction will be assessed using the Kansas Marital Satisfaction Scale (KMSS; 3 items) {Schumm, 1986 #3905}. The KMSS was developed as a validated but brief measurement of marital relations. Items include satisfaction with marriage, spouse or partner, and quality of the relationship with a spouse/partner. Responses options are coded on a 7-point Likert scale of 1 to 7 (1 = extremely dissatisfied; 7 = extremely satisfied). Total scores are created by summing the items. The KMSS has been found to correlate strongly with other measures relationship adjustment and quality of marriage, and showed strong internal reliability in the feasibility pilot of the MaPa programme (α = .89).

Parent/child sleep will be assessed by asking parents to report average daily number of hours the parent and child slept in the previous five days. In order to increase the accuracy of self-report data, research assistants will ask the parent to report on the hours of sleep for each day including hours that the child sleeps during the day. Mean score for hours slept for both parent and child will be calculated summing each day and then dividing by the number of days (i.e., 5 days).