Content uploaded by Catherine L Ward
Author content
All content in this area was uploaded by Catherine L Ward on May 05, 2023
Content may be subject to copyright.
Original article
Pre-post Mixed Methods Study of a Parent and Teen Support
Intervention to Prevent Violence Against Adolescents in the
Philippines
Rosanne M. Jocson, Ph.D.
a
,
*
, Liane Peña Alampay, Ph.D.
b
, Jamie M. Lachman, D.Phil.
c
,
d
,
e
,
Denise Hazelyn A. Maramba, M.Psy.
b
, Marika E. Melgar, M.A.
b
, Catherine L. Ward, Ph.D.
f
,
Bernadette J. Madrid, M.D.
g
, and Frances Gardner, D.Phil.
c
a
National Institute of Education, Nanyang Technological University, Singapore, Singapore
b
Department of Psychology, Ateneo de Manila University, Quezon City, Philippines
c
Department of Social Policy and Intervention, University of Oxford, Oxford, United Kingdom
d
MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, United Kingdom
e
Centre for Social Science Research, University of Cape Town, Cape Town, South Africa
f
Department of Psychology and Safety and Violence Initiative, University of Cape Town, Rondebosch, South Africa
g
Child Protection Unit, Philippine General Hospital, University of the Philippines, Manila, Philippines
Article history: Received July 30, 2022; Accepted February 17, 2023
Keywords: Child abuse; Prevention; Parenting; Adolescents; Philippines
ABSTRACT
Purpose: This study examines the feasibility of a culturally adapted parenting intervention (MaPa
Teens) within the national cash transfer system to reduce violence against adolescents, the first
such program in the Philippines.
Methods: Thirty caregiver-adolescent dyads who were beneficiaries of a government conditional
cash transfer program participated in a pilot of a locally adapted version of the Parenting for
Lifelong Health for Parents and Teens program. Primary outcomes of reducing child maltreatment
and associated risk factors were evaluated using a single-group, pre-post design. Focus group
discussions explored the perceptions of participants and facilitators regarding program accept-
ability and feasibility.
Results: Significant and moderate reductions were reported in overall child maltreatment and
physical abuse (caregiver and adolescent reports) and in emotional abuse (adolescent report).
There were significant reductions in neglect, attitudes supporting punishment, parenting stress,
parental and adolescent depressive symptoms, parent-child relationship problems, and significant
improvement in parental efficacy in managing child behavior. Adolescents reported reduced
behavior problems, risk behavior, and witnessing of family violence. Participants valued learning
skills using a collaborative approach, sustained their engagement between sessions through text
messages and phone calls, and appreciated the close interaction with caring and skilled facilitators.
Program areas of improvement included addressing barriers to attendance, increasing adolescent
engagement, and revising the sexual health module.
IMPLICATIONS AND
CONTRIBUTION
MaPa Teens is the first
known locally adapted
evidence-based parenting
program to prevent
violence against adoles-
cents in the Philippines.
The results of this pilot
evaluation show prom-
ising indications of the
program’s effectiveness in
reducing violence against
adolescents and the feasi-
bility of its integration
within an existing cash
transfer delivery system.
Conflicts of interest: JML is the CEO of Parenting for Lifelong Health (PLH), a
charitable organization based in the United Kingdom that developed the
Parenting for Lifelong Health for Parents and Teens program, which is licensed
under a Creative Commons Attribution 4.0 International license. JML also receives
occasional fees for providing training and supervision for PLH programs. LPA,
RMJ, JML, CLW, and FG have participated (and are participating) in several
research studies involving the program as investigators, and the Universities of
Ateneo de Manila, Oxford, Glasgow, and Cape Town receive research funding for
these. Conflict is avoided by declaring these potential conflicts of interest and by
conducting and disseminating rigorous, transparent, and impartial evaluation
research on both this and other similar parenting programs.
Trial registration: ClinicalTrials.gov (NCT03903445).
*Address correspondence to: Rosanne M. Jocson, Ph.D., National Institute of
Education, Nanyang Technological University, 1 Nanyang Walk, Singapore 637616.
E-mail address: rosanne.jocson@nie.edu.sg (R.M. Jocson).
www.jahonline.org
1054-139X/Ó2023 Society for Adolescent Health and Medicine. All rights reserved.
https://doi.org/10.1016/j.jadohealth.2023.02.027
Journal of Adolescent Health xxx (2023) 1e8
Discussion: The study provides preliminary support for the effectiveness and feasibility of the
program in reducing violence against Filipino adolescents. Findings suggest potential adaptations
of the program, and that investment in more rigorous testing using a randomized controlled trial
would be worthwhile.
Ó2023 Society for Adolescent Health and Medicine. All rights reserved.
Globally, almost one billion children and adolescents annually
experience physical and psychological violence in the home [1].
Physical violence includes corporal punishment behaviors,
whereas psychological or emotional violence includes verbal
forms of abuse such as shouting at a child [2,3]. Prevalence rates
of mild to severe forms of violence are higher in low- and
middle-income countries (LMICs) than in higher-income coun-
tries [2], where the impact is compounded by higher levels of
poverty and limited access to support services. In the Philippines,
a national study on violence against children found that 66% of
the respondents aged 13 to 24 reported experiencing physical
violence prior to age 18, with 60% of these incidents occurring in
the home and most commonly perpetrated by mothers, fathers,
and siblings [4].
High rates of abuse and violence against adolescents are
concerning given documented evidence of negative effects on
developmental and health outcomes. Studies show that adoles-
cents’exposure to violence prospectively predicts risk behaviors
[5], substance use [6], chronic physical health conditions [7],
internalizing and externalizing problems [8,9], and academic
difficulties [9]. The negative effects of abuse and harsh parenting
may be aggravated in conditions of socioeconomic disadvantage:
several studies link pathways from economic stress to parent
psychological distress, harsh and abusive parenting, and
adolescent health risks and maladjustment [10e12].
There is strong empirical evidence for the effectiveness of
parenting support interventions in reducing child maltreatment
and associated parenting risk factors [13], including in LMICs
[14]. Recognizing the important role of parents in reducing child
maltreatment, international agencies identify parent and care-
giver support as a key evidence-based strategy to end violence
against children [15], in line with the 2030 sustainable devel-
opment goals [16]. A systematic review and meta-analysis of
parenting interventions conducted in LMICs in East and South-
east Asia found that evidence-based parenting programs may be
effective in reducing harsh and abusive parenting and improving
parent-child relationships in these contexts [17]. These programs
strengthen parenting skills by enhancing parental knowledge
and competence in parenting, teaching stress reduction strate-
gies, and facilitating discussions on child development and
behavior management [18e20]. Parenting interventions during
the middle childhood years are as effective as those targeting the
early childhood years, suggesting that it is never too late to invest
in parenting programs for families with older children [21].
However, the existing evidence on parenting interventions to
reduce violence is largely based on programs for caregivers of
young children, rather than the adolescent period, when
demands on parents change, parenting may be more difficult as
children start to become more independent, and violence against
children increases [22].
Parenting for Lifelong Health (PLH) is an initiative in
collaboration with UNICEF and WHO to support evidence-based
parenting programs to reduce violence against children and
adolescents in low- and middle-income contexts. PLH
Philippines has been developing and testing locally adapted
parent support interventions, called Masayang Pamilya (Happy
Family) or MaPa since 2016 [23,24]. A randomized controlled
trial (RCT) of the program for families with children ages two to
6 (MaPa Kids) implemented with beneficiaries of the national
conditional cash transfer program Pantawid Pamilyang Pilipino
Program (4Ps) demonstrated effectiveness in reducing child
maltreatment at posttest and one-year follow-up [25]. Given the
needs of families with adolescents, PLH Philippines developed
the MaPa Teens program in collaboration with government and
community officials and stakeholders, to expand the suite of
violence prevention parenting programs to families with ado-
lescents ages 10 to 17. The program was adapted from the PLH
for Teens program, originally developed and tested in South
Africa [26]. Based on the theory of change, the program used the
Hanf two-stage model by focusing on cultivating positive
parent-adolescent relationships and providing parents with
nonviolent tools to promote prosocial behavior [27,28].
The current mixed-methods study describes results from a
pre-post pilot test of MaPa Teens conducted with families with
adolescent children in Metro Manila. Following the success of
the program for parents of younger children, MaPa Teens was
also implemented with 4Ps beneficiaries to support the most
vulnerable Filipino families. This study aims to (1) examine the
effectiveness of MaPa in reducing adolescent maltreatment,
improving positive parenting, and reducing other risk factors
for child maltreatment and (2) examine the relevance, accept-
ability, and feasibility of the program in an urban Filipino
context.
Methods
Participants
The sample (N¼60) included 30 primary caregivers (M
age
¼
41.66, SD ¼11.53, 90% female) and a target adolescent child aged
10 to 17 (M
age
¼13.40, SD ¼1.99; 43% female) recruited from an
urban community. All families were 4Ps beneficiaries and were
referred by community social welfare officers. The 4Ps condi-
tional cash transfer provides cash grants to eligible low-income
families with children ages 0e18 if they comply with the
following conditions: regular health checks and vaccination,
enrollment of the child in school with at least 85% attendance
rate per month, and attendance in monthly family development
sessions (FDS). Participation in MaPa Teens counted as FDS
attendance in fulfillment of the conditions of receiving cash
grants. Inclusion criteria for caregivers included being 18 or
older, being the primary caregiver of the target adolescent,
spending at least four nights a week in the same household as the
target adolescent in the previous month, and being a beneficiary
R.M. Jocson et al. / Journal of Adolescent Health xxx (2023) 1e82
of the 4Ps program. Exclusion criteria included prior participa-
tion in parenting or family development programs for adult
participants (i.e., belonged to the earlier cohorts of 4Ps benefi-
ciaries), having severe mental health problems for adult and
child participants, and previous referral of the adult or child to
child protection services due to child abuse. 30 of 33 families
(91%) who were recruited were eligible and provided consent to
participate; the families who did not participate continued to
attend FDS as part of the 4Ps program.
Procedure
All procedures were conducted in coordination with gov-
ernment and community officers and staff. Prior to study
enrolment, the program was introduced at a community orien-
tation for 4Ps beneficiaries. Eligible and consenting caregivers
and adolescents completed standardized questionnaires in a
community center prior to the start of the program in April 2019
and within a month after the program ended in July 2019.
Bilingual researchers translated English questionnaires to
Filipino, and translations were checked by back-translation to
ensure linguistic and conceptual equivalence. Trained re-
searchers orally administered the questionnaires in Filipino via
structured one-on-one interviews using e-tablets. Computer-
assisted self-interviewing methods were used for sections on
child maltreatment and family violence to facilitate disclosure of
experiences [29]. After the program, 17 caregivers, 13 adoles-
cents, and three program facilitators participated in focus groups
discussions (FGDs) to explore their experiences and perceptions
regarding program acceptability. Five FGDs were conductedd
two for caregivers, two for adolescents, and one for facilitators.
Each FGD lasted one to two hours and was moderated by a
trained researcher fluent in Filipino. The study received ethics
approvals from Ateneo de Manila University (AdMUR-
EC_18_092PA) and the University of Oxford (SPIC2_18_005).
MaPa Teens program
The community-based program was delivered by trained
professional and graduate student facilitators over nine weekly
group sessions with caregivers and a target adolescent child.
Training was provided over five days (30 hours) by PLH trainers
from Clowns Without Borders South Africa, an NGO that has
supported the dissemination of PLH programs in 29 countries.
4Ps staff and community coordinators assisted with the imple-
mentation of the weekly sessions. The sessions, outlined in
Table 1, focused on developing skills in engaging in positive in-
teractions, forming guidelines and consequences for behaviors,
family budgeting, problem solving, and keeping safe in the
community. Sessions lasted 2e3 hours and were conducted face-
to-face in a community center to which families could easily
walk. Consistent with core principles of evidence-based
parenting interventions, the sessions were delivered with an
emphasis on collaborative discussion and problem-solving,
modeling of positive behaviors, and practice of skills during
group sessions and at home. Each session included the use of
illustrated stories or comics and physical and mindfulness-based
exercises to reduce stress. In between sessions, facilitators sent
four standardized text messages and conducted one phone call to
parents that lasted up to 15 minutes to reinforce skills learned in
previous sessions. Participants were provided with refreshments
during program sessions. Based on facilitator self-report check-
lists, 95% of the program session components were faithfully
delivered. The manual is available at https://www.who.
int/teams/social-determinants-of-health/parenting-for-lifelong-
health.
Measures
Primary outcomes. Overall child maltreatment, physical abuse, and
emotional abuse were assessed using the International Society for
Prevention of Child Abuse and Neglect Child Abuse screening
tool trial version (ICAST-T) [30], an adaptation of the ICAST
parent version (ICAST-P) [31]. The parent version (ICAST-TP, 27
items) and the child version (ICAST-TC, 25 items) measures
incidence of abuse perpetrated against the child in the past
month using a frequency score of 0e8 or more times. Reliabilities
in this study were
a
¼0.87 for parents and
a
¼0.79 for adoles-
cents. The measure has subscales for physical abuse (ICAST-TP, 14
Table 1
MaPa Teens program sessions
Session Format Goals
1. Family goals and one-on-one
time
Joint
a
Identify specific, positive, and realistic goals;
Understand the importance of one-on-one time.
2. Keeping it positive: praise and
instructions
Joint Learn how to praise and appreciate one another; Become more effective at giving specific, positive,
and realistic instructions.
3. Keeping it cool: managing anger
and stress
Joint and Separate
b
Learn how to become more aware of their own emotions, how to respond effectively to other
people’s emotions, and how to communicate about their own emotions.
4. Establishing guidelines to keep
healthy and safe
Joint Learn how make guidelines together and how to create guidelines to keep them healthy and safe.
5. Family budgeting and ways to
save
Joint Learn ways to manage money, reduce stress about money, and establish plans on how to save
together as a family.
6. Accepting responsibility for our
actions
Joint and Separate Learn how to share responsibilities and identify realistic, appropriate, and reasonable consequences
for noncompliance.
7. Solving problems together as a
family
Joint Learn collaborative methods of problem solving.
8. Keeping safe in the community
and responding to crisis
Joint Learn how to effectively respond to conflicts when they arise.
9. Widening circles of support Joint Reflect on experience during the program and discuss how to continue supporting each other after
the program.
a
The session included activities in which caregivers and adolescents participated together.
b
The session included activities in which caregivers and adolescents worked in separate groups.
R.M. Jocson et al. / Journal of Adolescent Health xxx (2023) 1e83
items; ICAST TC, 10 items) and emotional abuse (10 items). Scores
on each subscale and the overall scale were summed.
Secondary outcomes. Secondary outcomes include caregiver and
adolescent report on neglect, positive parenting, attitudes to-
ward corporal punishment, parental monitoring, parent and
child depressive symptoms, and parent-child relationship prob-
lems; caregiver report on parenting efficacy, parent emotional
self-regulation efficacy, parenting stress, and intimate partner
violence and coercion; and adolescent report on behavior prob-
lems, prosocial behavior, risk behavior, and witnessing of family
violence. Caregivers and adolescents reported on community
violence exposure, family functioning, educational aspirations
and expectations, and parental support for education (see
Supplementary Material for a description of secondary outcome
measures).
Implementation outcomes. Implementation outcomes included
recruitment, enrollment, and participation rates. The focus group
discussion guide contained a set of open-ended questions on
participants’experiences during the program, relevance and
acceptability of parenting topics, and program delivery issues.
Analyses
All statistical analyses were conducted using SPSS 26.0.
Intervention effects were examined by conducting paired t-tests
comparing pre-post scores and Wilcoxon signed-rank tests for
comparisons of pre-post outcomes with skewed distributions
(i.e., z skew scores larger than 1.96). Caregiver report and
adolescent report analyses were conducted separately. An
intention-to-treat approach was used in which all outcome data
from participants with pretest data were included in the analyses
regardless of extent of program attendance or completion. All
participants with pretest data were interviewed at posttest, and
there were no missing data.
Bilingual researchers transcribed the FGD recordings
verbatim. The fourth author, fluent in Filipino and English,
analyzed the transcripts using thematic analysis procedures [32].
To enhance trustworthiness in the analytic process, the tran-
scripts were coded in the original language to preserve the
meaning of the responses. Three other researchers who are
skilled in qualitative methods and fluent in Filipino reviewed the
codes and themes to corroborate or suggest alternative in-
terpretations to the analyses. All analysis steps, consultation
notes, and draft reports were documented to improve reliability
of the process.
Results
Table 2 presents socio-demographic characteristics and child
maltreatment risk factors among the sample at pretest. Most
parent participants were the biological mother of the teen.
Economic stress on the household is evident in that the majority
was either unemployed or working in the informal sector, and
nearly a quarter reported acute household hunger. More than
two-thirds of caregivers had experienced corporal punishment
or other forms of abuse as a child.
Primary outcomes
Tables 3 and 4present descriptive and comparative data for
all outcome variables for caregivers and adolescents at pretest
and posttest. Overall child maltreatment and physical abuse
significantly decreased at posttest for caregivers and adolescents.
The decrease in emotional abuse was statistically significant for
adolescent reports only.
Secondary outcomes
Caregiver and adolescent reports of neglect decreased, with
statistically significant decreases found for adolescents only
(Tables 3 and 4). Positive parenting did not significantly change
from pre to posttest. There was a significant improvement in
parental efficacy in managing child misbehavior, and no significant
change was seen in general parental efficacy and emotional self-
regulation efficacy.Parenting stress and parental depressive
symptoms significantly decreased at posttest. There was a sig-
nificant decrease in attitudes supporting punishment and parent-
adolescent relationship problems reported by caregivers and ad-
olescents at posttest. Parental monitoring (solicitation of infor-
mation and rule-setting) did not significantly change from pre to
posttest.
For adolescent outcomes, adolescent depressive symptoms and
adolescent behavior problems (irritability and externalizing
behavior) significantly decreased based on caregiver and
adolescent reports. Adolescents reported a significant decrease
in risk behavior and a nonsignificant change in prosocial behavior.
Table 2
Socio-demographic and child maltreatment risk characteristics of caregivers at
pretest (N ¼30)
Variable n(%)
Female 27 (90%)
Mean age (SD) 43.83 (8.42)
Target adolescent child female 13 (43%)
Mean target adolescent child age (SD) 13.40 (1.99)
Target adolescent child enrolled in school 23 (43%)
Biological parents 27 (90%)
Marital status
Married 16 (53%)
Living with a partner 5 (17%)
Single 3 (10%)
Separated 3 (10%)
Widowed 3 (10%)
Filipino spoken at home 30 (100%)
Education
No high school education 5 (17%)
Some high school education 8 (27%)
Completed high school 17 (57%)
Employment
Employed 6 (20%)
Unemployed 12 (40%)
Informally employed 12 (40%)
Other adult working in household 20 (67%)
Mean household size (SD) 6.63 (2.62)
Mean number of children (SD) 3.50 (1.57)
Presence of other caregiver 24 (80%)
Acute household hunger (more than five times
in the previous 30 days)
7 (23%)
4 or more necessities not met 5 (17%)
Experienced corporal punishment as a child 20 (67%)
Experienced abuse as a child 23 (77%)
Means with SDs are presented when indicated.
R.M. Jocson et al. / Journal of Adolescent Health xxx (2023) 1e84
For family violence and functioning, adolescent witnessing of
family violence significantly decreased at posttest. There was no
significant change in caregivers’reports of intimate partner
violence and intimate partner coercion and in caregiver and
adolescent reports of community violence exposure and family
functioning.
For educational outcomes, there were no significant changes
in caregiver and adolescent reports on educational aspirations,
educational expectations, and parental support for education.
Implementation outcomes
All 30 caregiver-adolescent dyads attended at least one ses-
sion of the program. The overall attendance rate was 73% for
caregivers and 66% for adolescents. Twenty-five caregivers (83%)
and 21 adolescents (70%) attended at least five sessions. Twenty-
one caregivers (70%) and 17 adolescents (57%) attended at least
seven sessions. All participants, including those who attended
fewer sessions, completed post assessments within a month
after the program ended.
Focus group discussions revealed themes on the relevance,
acceptability, and challenges in implementing the program
(Table 5). Caregivers, adolescents, and facilitators shared helpful
learnings and changes in parent-adolescent relationships. Care-
givers and adolescents mentioned that they learned better
awareness and regulation of their own emotions, became more
attuned to each other’s feelings and behaviors, improved their
communication with each other, became more effective and
collaborative in problem-solving and in delegation of household
tasks, engaged in joint efforts to enhance safety in the neigh-
borhood, and learned strategies to budget and save money. Fa-
cilitators regarded one-on-one time, taking a pause, and praise as
topics that were most appreciated by parent and adolescent
participants. Adolescents liked being “thanked and praised”by
their parents and shared that “it feels good.”
Regarding delivery, caregivers appreciated the effective pro-
gram facilitation. They valued the warm attitude and genuine
concern displayed by facilitators about their lives and relation-
ships with their children. One caregiver shared that she “felt safe
sharing [our lives] with them”and that “a relationship was
formed.”Caregivers considered weekly text message reminders
and phone calls from facilitators to be beneficial: “[Receiving
messages and phone calls] feels good because we feel that we are
important.”
Caregivers, adolescents, and facilitators noted some barriers
to participation. Some caregivers mentioned feeling anxious
during their first individual meeting with the program facilita-
tors because they did not know what to expect or how the pro-
gram fit within the larger context of services. Facilitators
encountered challenges in conducting phone consultations
because of weak reception and parents’lack of access to working
mobile phones. Caregivers noted barriers to attendance, such as
sickness, family emergencies, and schedule conflicts with work
and school. On the issue of sexual health, caregivers and facili-
tators noted the discomfort around the topic (“It is embarrassing
to talk about,”- parent said). One facilitator explained, “there are
Table 3
Caregiver-report outcomes at pre and posttest (N ¼30)
Outcome
a
Possible Pretest Posttest Test Statistic
b
pd
Range M (SD) M (SD) t z
Primary
Overall child maltreatment 0e192 14.53 (15.27) 10.17 (12.79) L2.29 .022 L0.46
Physical abuse 0e112 6.13 (7.75) 3.80 (6.82) L2.43 .015 L0.39
Emotional abuse 0e80 8.40 (9.98) 6.37 (7.11) 1.91 .057 0.36
Secondary
Neglect 0e24 0.77 (1.36) 0.67 (1.63) 0.42 .677 0.11
Positive and involved parenting 0e42 36.60 (6.86) 37.90 (7.88) 1.48 .138 0.20
Attitudes toward punishment MICS
c
1e5 2.13 (1.04) 1.73 (0.91) 1.61 .108 0.32
Attitude toward punishment ICAST-I
d
4e20 9.40 (2.19) 8.57 (1.63) 2.12 .042 L0.35
Parent solicitation of information 0e18 13.27 (3.62) 13.93 (3.29) 1.10 .270 0.21
Parent rule-setting 0e21 14.73 (3.45) 14.53 (3.51) 0.34 .738 0.06
Parental efficacy 8e40 34.53 (4.04) 34.50 (3.95) 0.04 .968 0.01
Parental efficacy in managing child behavior 0e16 7.57 (4.22) 5.13 (3.82) 2.87 .008 L0.50
Parent emotional self-regulation efficacy 1e20 11.33 (2.25) 12.27 (2.69) 1.61 .119 0.33
Parenting stress 18e90 49.27 (5.74) 46.93 (6.37) 2.20 .036 L0.43
Parent depressive symptoms 0e26 8.60 (4.75) 6.57 (4.00) 3.55 .001 L0.62
Parent-adolescent relationship problems 1e10 6.48 (2.51) 3.34 (2.71) L4.15 <.001 L1.15
Adolescent depressive symptoms 0e26 7.13 (4.04) 5.73 (3.94) 2.46 .020 L0.45
Adolescent behavior problems 0e28 9.47 (4.97) 7.10 (3.49) 3.80 <.001 L0.65
Intimate partner violence
e
0e64 1.55 (2.70) 1.72 (2.93) 0.26 .798 0.12
Intimate partner coercion
e
0e80 9.70 (12.31) 8.67 (13.38) 1.30 .195 0.17
Community violence exposure 0e96 6.20 (8.93) 4.83 (7.25) 1.39 .165 0.26
Family functioning 23e92 71.90 (9.42) 73.33 (12.40) 1.05 .303 0.24
Educational aspirations 1e7 5.83 (0.70) 5.87 (0.68) 1.66 .097 0.06
Educational expectations 1e7 4.93 (0.98) 5.23 (0.97) 0.28 .783 0.31
Parental support for education
f
6e30 24.79 (3.37) 25.21 (3.34) 0.74 .465 0.15
a
Statistically significant differences (p<.05) between pre and posttest are in bold.
b
Paired t value for normally distributed outcomes and Wilcoxon signed-rank tests z score for skewed outcomes.
c
MICS ¼Multiple Indicator Cluster Survey measures agreement that child needs to be physically punished.
d
ICAST-I ¼ISPCAN Child Abuse Screening Tool-Intervention measures perceived effectiveness of physical punishment.
e
Intimate partner violence and coercion scales answered only by participants living with a partner in the past month (n¼18).
f
Parental support for education scale answered only by participants with school-enrolled child (n¼23).
R.M. Jocson et al. / Journal of Adolescent Health xxx (2023) 1e85
older teens that may benefit from [discussing sexual health], and
they are really open [to discussion], but they see their parents are
not, so the teens do not talk about it either.”Some caregivers
believed that their child was “too young”to think about sexual
topics, while adolescents made no mention of sexual health
issues during focus groups. Lastly, facilitators observed the ten-
dency of some adolescent participants to be disengaged and
distracted during sessions and mentioned the need to find ways
to increase their engagement.
Discussion
This study examined the feasibility of a parenting program
delivered within the national cash transfer system and aimed at
reducing violence against Filipino adolescents. The statistically
significant decrease in pre-post scores on overall child
maltreatment and physical abuse reported by caregivers and
adolescents provides cross-reporter validation of the potential
effectiveness of the program in reducing violence against ado-
lescents. For the secondary outcomes, caregivers reported a
greater sense of efficacy in managing child misbehavior and
lower levels of parenting stress and depressive symptoms. Based
on adolescent reports, there was a significant decrease in neglect,
witnessing of family violence, and notable reduction in risk
behavior. Overall, the changes were small to moderate in
magnitude, with average pre-post decreases of two to three in-
stances of physical abuse, and the largest positive effect was on
parent-adolescent relationship problems. There were no nega-
tive effects on any of the outcomes.
There was no significant difference between pre and posttest
in caregivers’reports of emotional abuse and neglect, positive
parenting, and other secondary outcomes. It should be noted that
caregivers reported an average decrease of two instances of
emotional abuse at posttest, and this decrease was trending
Table 5
Key themes from focus group discussions with caregivers, adolescents, and program facilitators
Helpful learnings and changes in parent-
adolescent relationship
Effective program facilitation Barriers to participation
- Better awareness and regulation of emotions - Good interactions with facilitators - Anxiety at the start of the program
- Attunement to each other’s feelings and
behaviors
- Sustained engagement through weekly phone calls
and text reminders
- Logistical challenges with receiving phone calls
and text messages
- Improved parent-adolescent communication - Helpful and effective program facilitators - Program schedule conflicts with personal and
family affairs
- More effective problem solving and delegation
of tasks at home
- Discomfort with sexual health topics
- Joint efforts to promote safety - Lack of teen engagement
- Learned strategies to budget and save money
Table 4
Adolescent report outcomes at pre and posttest (N ¼30)
Outcome
a
Possible range Pretest
M (SD)
Posttest
M (SD)
Test Statistic
b
pd
tz
Primary
Overall child maltreatment 0e160 12.40 (12.74) 6.07 (7.31) L2.86 .004 L0.45
Physical abuse 0e80 5.17 (7.17) 2.03 (2.95) L2.64 .008 L0.48
Emotional abuse 0e80 7.23 (7.53) 4.03 (5.30) L2.44 .015 L0.38
Secondary
Neglect 0e40 4.73 (6.14) 2.60 (4.97) L2.35 .019 L0.28
Positive and involved parenting 0e42 31.30 (9.15) 31.47 (9.42) 0.10 .923 0.02
Attitudes toward punishment MICS
c
1e5 3.20 (1.32) 2.53 (1.28) L2.29 .022 L0.41
Attitude toward punishment ICAST-I
d
4e20 10.10 (2.52) 10.50 (2.03) 0.67 .512 0.11
Parent solicitation of information 0e18 10.83 (3.68) 11.07 (3.85) 0.45 .657 0.09
Parent rule-setting 0e21 13.17 (4.15) 13.10 (4.27) 0.09 .931 0.02
Parent-adolescent relationship problems 1e10 4.77 (2.13) 3.07 (1.47) 4.34 <.001 L0.69
Adolescent depressive symptoms 0e26 10.37 (3.90) 7.33 (3.60) 3.87 .001 L0.68
Adolescent behavior problems 0e28 8.17 (3.55) 5.37 (3.36) 3.36 .002 L0.60
Adolescent prosocial behavior 1e80 53.20 (10.04) 54.50 (10.07) 0.69 .497 0.12
Adolescent risk behavior 0e64 3.83 (6.29) 1.77 (2.42) L2.38 .017 L0.32
Adolescent witnessing of family violence 0e16 5.27 (4.23) 2.90 (2.99) L3.05 .002 L0.50
Community violence exposure 0e96 5.83 (4.80) 4.77 (4.44) 0.99 .325 0.17
Family functioning 23e92 67.47 (6.96) 68.40 (6.99) 0.80 .432 0.15
Educational aspirations 1e7 6.23 (0.90) 6.07 (0.94) 0.74 .458 0.15
Educational expectations 1e7 5.70 (0.99) 5.43 (1.14) 1.20 .229 0.22
Parental support for education
e
6e30 23.04 (4.03) 23.22 (3.86) 0.21 .834 0.04
a
Statistically significant differences (p<.05) between pre and posttest are in bold.
b
Paired t value for normally distributed outcomes and Wilcoxon signed-rank tests z score for skewed outcomes.
c
MICS ¼Multiple Indicator Cluster Survey measures agreement that child needs to be physically punished.
d
ICAST-I ¼ISPCAN Child Abuse Screening Tool-Intervention measures perceived effectiveness of physical punishment.
e
Parental support for education scale answered only by school-enrolled child (n¼23).
R.M. Jocson et al. / Journal of Adolescent Health xxx (2023) 1e86
toward significance. The nonsignificant change in caregivers’
reports of neglect at posttest could be because of very low re-
ports of neglect at baseline. There was also no significant change
in positive parenting, contrary to the results reported in previous
trials of the PLH program for adolescents in South Africa [26,33],
probably because of the high levels of positive parenting re-
ported by both caregivers and adolescents at pre and posttest.
Caregivers did not report a significant difference in intimate
partner violence and coercion, although adolescents reported
lower frequency of witnessing family violence, suggesting that
other forms of violence may have been indirectly affected.
Results for reduction of child maltreatment are consistent with
those from previous studies on the PLH program for adolescents
[26,33], thereby adding to the evidence on the positive effects of
the program on adolescent children in LMICs. Consistent with the
theory of change [27,28], program components such as positive
instruction-giving, setting realistic consequences, and group
problem solving may equip caregivers with the necessary
knowledge, skills, and resources that promote change in parent-
child relationships; these changes, in turn, may contribute to the
reduction of risk of child maltreatment [23,24,34]. Our findings
imply that these processes of change that involve the strength-
ening of the caregiver-child relationship, such as decreasing
parent-adolescent relationship problems, may remain crucial in
preventing violence during adolescence. This is particularly rele-
vant in the Philippines, where the family serves as an important
source of instrumental and emotional support for adolescents
despite their increasing needs for autonomy [35,36].
The findings suggest the relevance, acceptability, and feasi-
bility of the program in an urban poor context in the
Philippines. Apart from reporting reduced levels of violent
parenting strategies, participants mentioned learning strategies
to improve the caregiver-adolescent relationship, such as
awareness and regulation of emotions, effective communication
skills, collaborative problem-solving, efficient delegation of
tasks at home, budgeting of finances, and promoting safety in
the neighborhood. Caregivers and adolescents found the
collaborative approach helpful and appreciated interacting with
caring facilitators and receiving messages and calls from them
in between sessions. These results imply that nurturing and
collaborative strategies may be effective in the Filipino context,
despite a reported cultural emphasis on authoritarian values
[24]. The findings also highlight the important role of facilitators
in building a collaborative and caring environment and in
sustaining participants’engagement.
The study suggests potential adaptations to improve the
program’s implementation in future trials. First, participants
mentioned family, work, and school schedule conflicts as the
primary barriers to attendance. Facilitators also noted logistical
difficulties in contacting caregivers by phone in between ses-
sions. To address these concerns, facilitators may consider doing
home visits for participants who missed sessions and who do not
have access to working devices. Conducting regular home visits
may be feasible if the facilitators are members of the community
or if they are embedded within existing community services.
Further, program implementation will require close coordination
with local government units, school officials, and community
staff such that the sessions do not conflict with participants’
other commitments at home, work, and school. Second, to
address caregivers’anxieties about participating in the program,
future implementation may benefit from enhanced community
orientation sessions before meeting with program facilitators.
Although it was not yet feasible to engage 4Ps staff and com-
munity leaders as facilitators in this pilot, it would be helpful to
train them as program facilitators in future programs as they
already have a relationship with potential participants [25].
Third, modules on adolescent development, such as sexual
health, can be revised. For instance, caregivers and adolescents
can be allowed their own safe spaces to discuss the topic and
access helpful resources prior to a joint session. Facilitators may
discuss with caregivers their concerns that their children are too
young and not yet ready to learn about adolescent sexual
development. Considering the sensitivity of the topic in the local
culture, facilitators can prepare parents and teens to discuss
sexual health by modeling strategies and using relatable sce-
narios that can ease parents’and teens’discomfort. Fourth,
redesigning program sessions to include strategies that promote
active involvement, such as physical activities and games, may
increase the engagement of teen participants.
The study’sfindings and recommendations should be inter-
preted in light of its limitations. The study used a pre-post design
without a control group; therefore, causal attributions about
program effects cannot be made. Study outcomes were assessed
immediately after the program ended; thus, longer-term effects
on reduction of violence and associated risk factors cannot be
determined. The sample is small, limiting generalizability of the
findings outside the study context of an urban poor community
and delivery within the conditional cash transfer system.
Although the program is designed for both universal and indi-
cated prevention, we did not target families with specific risk
factors for child maltreatment and tested the program with
families characterized by more general risk, namely poverty.
Future studies with larger samples should examine family risk
level and other process factors (e.g., dosage) as moderators of
program effects. Further, the primary caregivers who partici-
pated were mostly mothers, and future trials are needed to
include more fathers and alternate caregivers. Integrating the
program within existing networks and services that include
fathers and considering having a father-only group for some
sessions may increase the involvement of fathers in the program
[37,38]. Lastly, the program was delivered by trained pro-
fessionals and graduate students and needs to be further tested
with government and community staff as facilitators to examine
scalability and applicability in real-world conditions.
Despite these limitations, this study has several contributions.
MaPa Teens is the first known locally adapted evidence-based
parenting program to prevent violence against adolescents in
the Philippines. The results of this study provide evidence for the
feasibility and potential effectiveness of a parenting program to
reduce violence against adolescents in an urban poor context and
present an example of how a parent and adolescent support
program can be integrated within existing government systems.
The compatibility with the Philippines’s conditional cash transfer
system enhances the likelihood that this program can be taken to
scale. The findings add to the increasing evidence base for
parenting and child abuse prevention programs in LMICs
[17,26,39]. These findings can be used to inform further adapta-
tion of the program and more rigorous testing using an RCT or
strong quasiexperimental design with follow-up assessments to
determine sustainability of program effects.
R.M. Jocson et al. / Journal of Adolescent Health xxx (2023) 1e87
Acknowledgments
The program and study were supported by a Programme
Cooperation Agreement between UNICEF Philippines and Ateneo
de Manila University. We thank all the participants of the study
and the research assistants who helped collect the data.
Supplementary Data
Supplementary data related to this article can be found at
https://doi.org/10.1016/j.jadohealth.2023.02.027.
References
[1] United Nations Children’s Fund. Hidden in plain sight: A statistical analysis
of violence against children. New York, NY: UNICEF; 2014.
[2] Hillis S, Mercy J, Amobi A, et al. Global prevalence of past-year violence
against children: A systematic review and minimum estimates. Pediatrics
2016;137:e20154079.
[3] United Nations Children’s Fund. Preventing and responding to violence
against children and adolescents: Theory of Change. New York, NY: UNI-
CEF; 2017.
[4] Council for the Welfare of Children and UNICEF Philippines. National
baseline study on violence against children. 2016. Manila, Philippines.
[5] Begle AM, Hanson RF, Danielson CK, et al. Longitudinal pathways of
victimization, substance use, and delinquency: Findings from the National
Survey of Adolescents. Addict Behav 2011;36:682e9.
[6] Wright EM, Fagan AA, Pinchevsky GM. The effects of exposure to violence
and victimization across life domains on adolescent substance use. Child
Abuse Negl 2013;37:899e909.
[7] McLaughlin KA, Basu A, Walsh K, et al. Childhood exposure to violence and
chronic physical conditions in a national sample of US adolescents. Psy-
chosom Med 2016;78:1072e83.
[8] Mrug S, Windle M. Prospective effects of violence exposure across multiple
contexts on early adolescents’internalizing and externalizing problems.
J Child Psychol Psychiatry 2010;51:953e61.
[9] Margolin G, Vickerman KA, Oliver PH, et al. Violence exposure in multiple
interpersonal domains: Cumulative and differential effects. J Adolesc
Health 2010;47:198e205.
[10] White RMB, Liu Y, Nair RL, et al. Longitudinal and integrative tests of family
stress model effects on Mexican origin adolescents. Dev Psychol 2015;51:
649e62.
[11] Benner AD, Kim SY. Understanding Chinese American adolescents’devel-
opmental outcomes: Insights from the family stress model. J Res Adolesc
2010;20:1e12.
[12] Meinck F, Cluver LD, Orkin FM, et al. Pathways from family disadvantage
via abusive parenting and caregiver mental health to adolescent health
risks in South Africa. J Adolesc Health 2017;60:57e64.
[13] Desai CC, Reece J-A, Shakespeare-Pellington S. The prevention of violence
in childhood through parenting programmes: A global review. Psychol
Health Med 2017;8506:1e21.
[14] Knerr W, Gardner F, Cluver L. Improving positive parenting skills and
reducing harsh and abusive parenting in low- and middle-income coun-
tries: A systematic review. Prev Sci 2013;14:352e63.
[15] World Health Organization. INSPIRE seven strategies for ending violence
against children. Luxembourg: World Health Organization; 2016.
[16] United Nations. Transforming our world: The 2030 agenda for sustainable
development. New York, NY: United Nations; 2015.
[17] McCoy A, Melendez-Torres GJ, Gardner F. Parenting interventions to pre-
vent violence against children in low- and middle-income countries in East
and Southeast Asia: A systematic review and multi-level meta-analysis.
Child Abuse Negl 2020;103:104444.
[18] Puffer ES, Annan J, Sim AL, et al. The impact of a family skills training
intervention among Burmese migrant families in Thailand: A randomized
controlled trial. PLoS One 2017;12:1e19.
[19] Sumargi A, Sofronoff K, Morawska A. A randomized-controlled trial of the
Triple P-positive parenting program seminar series with Indonesian par-
ents. Child Psychiatry Hum Dev 2015;46:749e61.
[20] Sawasdipanich N, Srisuphan W, Yenbut J, et al. Effects of a cognitive
adjustment program for Thai parents. Nurs Health Sci 2010;12:306e13.
[21] Gardner F, Leijten P, Melendez-Torres GJ, et al. The earlier the better? In-
dividual participant data and traditional meta-analysis of age effects of
parenting interventions. Child Dev 2019;90:7e19.
[22] Finkelhor D, Turner HA, Shattuck A, et al. Violence, crime, and abuse
exposure in a national sample of children and youth an update. JAMA
Pediatr 2013;167:614e21.
[23] Alampay LP, Lachman JM, Landoy BV, et al. Preventing child maltreatment
in low- and middle-income countries: Parenting for Lifelong Health in the
Philippines. In: Verma S, Petersen AC, eds. Developmental Science and
Sustainable Development Goals for Children and Youth. Social Indicators
Research Series. Cham, Switzerland: Springer; 2018:277e93.
[24] Mamauag BL, Alampay LP, Lachman JM, et al. A south-to-south cultural
adaptation of an evidence-based parenting program for families in the
Philippines. Fam Process 2021;60:1202e16.
[25] Lachman J, Alampay LP, Jocson RM, et al. Effectiveness of a parenting
programme to reduce violence in a cash transfer system in the
Philippines: RCT with follow-up. Lancet Reg Health West Pac 2021;17:
100279.
[26] Cluver LD, Meinck F, Steinert JI, et al. Parenting for lifelong health: A
pragmatic cluster randomised controlled trial of a non-commercialised
parenting programme for adolescents and their families in South Africa.
BMJ Glob Health 2018;3:1e15.
[27] Forehand RL, McMahon RJ. Helping the noncompliant child: Family-based
treatment for oppositional behavior. 2nd ed. New York: The Guilford Press;
2003.
[28] Hanf C. A two-stage program for modifying maternal controlling
during mother- child (M-C) interaction . In: Paper Presented at the
Meeting of the Wes tern Psychological Assoc iation, Vancouver, BC,
Canada. 1969.
[29] Ward CL, Artz L, Leoschut L, et al. Sexual violence against children in South
Africa: A nationally representative cross-sectional study of prevalence and
correlates. Lancet Glob Health 2018;6:e460e8.
[30] Meinck F, Boyes ME, Cluver L, et al. Adaptation and psychometric prop-
erties of the ISPCAN Child Abuse Screening Tool for use in trials (ICAST-
Trial) among South African adolescents and their primary caregivers. Child
Abuse Negl 2018;82:45e58.
[31] Runyan DK, Dunne MP, Zolotor AJ, et al. The development and piloting of
the ISPCAN child abuse screening Tool-parent version (ICAST-P). Child
Abuse Negl 2009;33:826e32.
[32] Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol
2006;3:77e101.
[33] Cluver LD, Meinck F, Yakubovich A, et al. Reducing child abuse amongst
adolescents in low- and middle-income countries: A pre-post trial in South
Africa. BMC Public Health 2016;16:1e11.
[34] Lachman JM, Cluver L, Ward CL, et al. Randomized controlled trial of a
parenting program to reduce the risk of child maltreatment in South Africa.
Child Abuse Negl 2017;72:338e51.
[35] Alampay LP. Parenting in the Philippines. In: Selin H, ed. Parent. across
Cult. Childrear. Mother. Father. non-Western Cult, Vol. 7. Dordrecht, the
Netherlands: Springer; 2014:105e21.
[36] Fernandez KG. Support means direct help: Filipino adolescents’multidi-
mensional conceptualization of social support. Psychol Stud (Mysore)
2012;57:251e9.
[37] Lachman J, Wamoyi J, Spreckelsen T, et al. Combining parenting and eco-
nomic strengthening programmes to reduce violence against children: A
cluster randomised controlled trial with predominantly male caregivers in
rural Tanzania. BMJ Glob Health 2020;5:1e14.
[38] Siu GE, Wight D, Seeley J, et al. Men’s involvement in a parenting pro-
gramme to reduce child maltreatment and gender-based violence:
Formative evaluation in Uganda. Eur J Dev Res 2017;29:1017e37.
[39] Ward CL, Wessels IM, Lachman JM, et al. Parenting for lifelong health for
young children: A randomized controlled trial of a parenting program in
South Africa to prevent harsh parenting and child conduct problems.
J Child Psychol Psychiatry 2020;61:503e12.
R.M. Jocson et al. / Journal of Adolescent Health xxx (2023) 1e88
