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An Assessment of Trends in Parenting and Child Outcomes in a Rural South African Community and Consequent Intervention Design

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The high prevalence of child maltreatment requires innovative, scaleable solutions. Three community-wide surveys (2012, 2013, and 2016) in Touwsranten, South Africa, assessed parents’ positive parenting and corporal punishment; their mental health, substance misuse, parenting stress and intimate partner violence; children’s mental health; and interest in parenting support, in preparation for an intervention to support positive parenting. The first two surveys followed parents longitudinally. Focus group discussions were also held in 2017. Across surveys one and two, corporal punishment and positive parenting were reported as frequent. Child and parent mental health problems, parenting stress, intimate partner violence, and risky alcohol use increased across surveys 1 and 2 and remained steady at the third survey. Survey 3 revealed no change in corporal punishment, parent or child mental health, or intimate partner violence; reports of risky alcohol use and parenting stress increased; and there was a small increase in use of positive parenting strategies. Qualitative data suggested that corporal punishment, alcohol use, and intimate partner violence may have been under-reported. Parents indicated a desire for parenting support. The consequent intervention design included the delivery of four parenting programs alongside a social activation process intended to amplify the message of parenting programs, with the intention of increasing positive parenting and reducing corporal punishment community-wide.
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Int. Journal on Child Malt. (2024) 7:105–126
https://doi.org/10.1007/s42448-023-00179-4
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RESEARCH ARTICLE
An Assessment ofTrends inParenting andChild Outcomes
inaRural South African Community andConsequent
Intervention Design
CatherineL.Ward1,2 · ChandréGould3· MarilynT.Lake4·
DiketsoMufamadi‑Mathebula1,3· LisaM.Kleyn1· WarrenParker5·
WilmiDippenaar6
Accepted: 1 September 2023 / Published online: 21 September 2023
© The Author(s) 2023
Abstract
The high prevalence of child maltreatment requires innovative, scaleable solutions.
Three community-wide surveys (2012, 2013, and 2016) in Touwsranten, South
Africa, assessed parents’ positive parenting and corporal punishment; their mental
health, substance misuse, parenting stress and intimate partner violence; children’s
mental health; and interest in parenting support, in preparation for an intervention
to support positive parenting. The first two surveys followed parents longitudinally.
Focus group discussions were also held in 2017. Across surveys one and two, cor-
poral punishment and positive parenting were reported as frequent. Child and par-
ent mental health problems, parenting stress, intimate partner violence, and risky
alcohol use increased across surveys 1 and 2 and remained steady at the third sur-
vey. Survey 3 revealed no change in corporal punishment, parent or child mental
health, or intimate partner violence; reports of risky alcohol use and parenting stress
increased; and there was a small increase in use of positive parenting strategies.
Qualitative data suggested that corporal punishment, alcohol use, and intimate part-
ner violence may have been under-reported. Parents indicated a desire for parenting
support. The consequent intervention design included the delivery of four parenting
programs alongside a social activation process intended to amplify the message of
parenting programs, with the intention of increasing positive parenting and reducing
corporal punishment community-wide.
Keywords Child maltreatment· Needs assessment· Parenting· Social activation·
Community-wide
Extended author information available on the last page of the article
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106
C.L.Ward et al.
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Introduction
Child maltreatment, including corporal punishment, occurs at high rates around
the globe and especially in low- and middle-income contexts (Hillis etal., 2016).
This is also true of South Africa (Adam etal., 2016; Meinck etal., 2015; Ward
etal., 2018). Both corporal punishment and harsher forms of child maltreatment
are associated with a range of adverse outcomes for children, including inter-
nalising and externalising disorders (Afifi etal., 2017; Cuartas, 2021; Gershoff
etal., 2018; Zielinski & Bradshaw, 2006). The importance of eradicating vio-
lence against children is recognized in the 2030 UN Sustainable Development
Goals, most notably in Target 16.2, which calls for an end to ‘all forms of vio-
lence against…children’. This is a key issue in South Africa, which is recognized
as one of the most unequal and violent countries in the world, creating situations
of multiple disadvantage for children, especially amongst those in historically
disadvantaged communities (Das-Munshi etal., 2016).
Parents tend to be amongst the chief perpetrators of violence against children
(Meinck etal., 2015). Key family-level risk factors for parents to use corporal
punishment or to perpetrate more severe forms of child maltreatment include
not knowing alternatives (Cluver etal., 2018), the stress of parenting (Chiocca,
2017; Clément & Chamberland, 2008; Stith etal., 2008), intimate partner vio-
lence (Chiesa etal., 2018), poor parental mental health (Berlin etal., 2011; Stith
etal., 2008), substance misuse (Staton-Tindall etal., 2013), and parents’ social
isolation (Stith etal., 2008). Furthermore, abusive parenting and caregiver mental
health have been shown to mediate between family disadvantage and adolescent
outcomes (Meinck etal., 2015), suggesting that parenting interventions may help
buffer the effects of family disadvantage. Caregiver praise and monitoring have
also been identified as ‘development accelerators’, i.e., caregiver attributes that
improve children’s lives across a number of Sustainable Development Goal tar-
gets simultaneously, including in contexts of deep adversity (Haag etal., 2022).
Fortunately, programs based on social learning theory and offering parents
positive, non-violent alternatives to harsh discipline have been shown to be effec-
tive in reducing such violence (Barlow etal., 2006; Chen & Chan, 2016; Knerr
etal., 2013; Vlahovicova etal., 2017). In particular, social learning theory-based
programs have been shown to increase parent–child attachment (O’Connor etal.,
2013) to reduce re-traumatising harsh parenting and increase positive parenting
(which can buffer against adversity), improve self-regulation of both caregiver
and child (Sanders & Mazzucchelli, 2013), and reduce parenting stress (Bennett
etal., 2013), all of which are key aspects of trauma-informed work with chil-
dren’s caregivers (Johnson etal., 2018). The importance of parenting programs
as a key strategy, both to prevent violence against children and to support healthy
relationships between caregivers and children, is recognized both by the World
Health Organization (WHO; WHO, 2016; WHO, 2022) and the South African
government (for instance, see the South African Children’s Act, No. 38 of 2005).
Few organisations, however, examine either trends in corporal punishment and
positive parenting before implementing prevention programs, or whether parents
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An Assessment ofTrends inParenting andChild Outcomes ina…
are interested in the kind of support that programs offer. As a needs assessment,
preparatory to beginning work in a small community in the rural Western Cape
province of South Africa, we carried out three surveys to assess trends in par-
enting, risk factors for harsh parenting, and related child outcomes, and to ask
parents if they would like to be involved in a parenting program. Ideally, to
study community-wide interventions, one would recruit multiple communities
and carry out a cluster randomized trial, but the intention with this work was to
design and pilot test the intervention before carrying out a bigger study. In such
situations, carrying out multiple pretests can allow for identification of trends and
potential biases in estimating the effects of treatment (Shadish etal., 2002). The
triple pretest was thus intended not only to explore family-level risk and protec-
tive factors playing a role in children’s mental health, and thus to drive the design
of an appropriate intervention if indicated, but also to assess trends for the pur-
poses of post-intervention causal inference. This paper thus reports on trends in
children’s mental health and family-level risk factors in a particular community
and the related intervention design.
Method
Study Design andSetting
The study took place in in Touwsranten, a small, historically disadvantaged, town-
ship1 in the rural Western Cape province, South Africa. A door-to-door survey
(June/July 2012) identified the number of households with children and was fol-
lowed by three waves of a community-wide survey of caregivers (August 2012,
March 2013, and January 2016), as well as focus group discussions in 2017. These
three waves of data aimed to assess trends in parenting, child behaviour, and factors
impacting parenting and child behaviour, in Touwsranten, with a view to developing
an intervention to support parents and improve children’s mental health, if needed.
The choice of Touwsranten as a location for this study was determined by
several factors. Firstly, Touwsranten was a small, stable community, with
defined geographic boundaries and was isolated from other communities. This
meant that there were low rates of in- and out-migration, particularly amongst
the majority Afrikaans-speaking population, which would make it possible to
track caregiving and child behaviour over time without large changes in the
sample. Secondly, the 2011 Statistics South Africa census data put the popula-
tion of Touwsranten at 2,245 (personal communication, Statistics South Africa,
28 May 2021), thus providing a sufficiently large sample for effects to emerge.
Thirdly, Touwsranten was home to a stable community-based organisation, the
Seven Passes Initiative that had been providing afterschool care and educational
1 In South Africa, the word ‘township’ refers specifically to areas set aside under Apartheid for people of
colour to live and thus identifies a marginalized area.
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C.L.Ward et al.
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support to children of the community since 2008. This provided a base for the
research and likewise for any future parenting intervention.
Participants
A 2012 door-to-door survey identified 304 households with children between the
ages of six and 18. In wave 1, one caregiver from each household where there
were children of these ages was invited to participate in the study, and 223 car-
egivers agreed. The participant was asked to answer questions about one child,
preferably the youngest child in the household. In wave 2, the same participants
were invited to be re-interviewed 6 months later, along with other caregivers
who were newly identified using the same inclusion criteria (n = 33). Fourteen
of the wave 1 participants declined to be re-interviewed (a refusal rate of 6.3%),
resulting in a sample size of 242 for wave 2.
These two waves were followed by a third in 2016. Waves 1 and 2 had indi-
cated that parenting support would be valued and potentially helpful to parents
and children. And in 2016, a grant from the World Childhood Foundation made
it possible to begin planning the intervention. Given the gap between wave 2
and the award of the grant, a third wave of data collection was planned to estab-
lish whether there had been significant changes in the community. In preparation
for wave 3, a second door-to-door survey was conducted, which identified 762
households, of which 481 households included children aged 0–18. The wider
age range was included because if this wave identified that an intervention was
still needed, we intended to offer it to parents of the full age range of children. In
wave 3, the number of children per household in Touwsranten ranged from one
to six (M = 1.74; SD = 1.12), and 838 children in total were identified in Tou-
wsranten: 22 aged 4–7 months, 159 aged 12–30 months, 325 aged 31 months–9
years, and 332 aged 10 and older. In these 481 households, 506 caregivers met
the criteria for an interview in wave 3 (i.e., they were residents of Touwsranten
and the primary caregiver of a child under the age of 18), and 462 consented to
be interviewed: 411 mothers and 62 fathers, a response rate of 91.3%. Thirty-
three caregivers refused to be interviewed, a low refusal rate of 6.9%.
Each caregiver was asked to choose his/her youngest child under 18 years old
as their ‘focus child’ and completed questionnaire responses about that child.
The sample included 365 Afrikaans- and 108 isiXhosa-speaking caregivers.
Measures
Demographics
Caregivers were asked to report on their own and their child’s sex and ages, and
their relation to the focus child, as well as their food security.
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An Assessment ofTrends inParenting andChild Outcomes ina…
Caregivers’ Self‑Report Measures ofTheir Parenting
The Alabama Parenting Questionnaire (APQ) Global Parent Report was used to
assess the parenting behaviour of parents of children 6–18 years old in this study.
The APQ is a 42-item questionnaire for parents (Essau etal., 2006) and has five
different subscales, namely, (a) poor supervision and monitoring, (b) parental
involvement, (c) positive parenting, (d) inconsistent discipline, and (e) corporal
punishment (Shelton etal., 1996). The items are answered on a 5-point Likert
scale ranging from 1 (never) to 5 (always), but wave 1 data revealed that par-
ents struggled to differentiate between ‘never’ and ‘very little of the time’, and
‘often’ and ‘always’ (Ward etal., 2015). Answer categories were thus collapsed
to ‘never/very little of the time,’ ‘sometimes,’ and ‘often/always.’
The APQ has shown adequate reliability in studies conducted in the US (Shel-
ton et al., 1996), Australia, and Canada (Elgar etal., 2007), with Cronbach’s
alphas greater than α = 0.70 for all subscales except poor monitoring and super-
vision (α = 0.67) and corporal punishment 0 (α = 0.55) in an Australian study
(Dadds etal., 2003). In this study, the inconsistent discipline subscale had poor
internal consistency (Cronbach’s alpha was 0.58), and it was therefore excluded;
for the same reason, corporal punishment items were treated individually.
Two subscales of 7 items each (‘setting limits’ and ‘supporting positive behav-
iour’) from the Parenting Young Children Scale (PARYC; McEachern et al.,
2012) assessed the parenting behaviours of parents of children 18 months to 5
years (e.g., ‘how many times in the past month did you teach your child new
skills?’; ‘how many times in the last month did you stick to your rules and not
change your mind?’). These subscales had response options of 1 (never) through
7 (almost daily in the past month). The original validation study demonstrated
validity of the PARYC scale amongst high-risk caregivers from rural communi-
ties in Charlottesville and Pittsburgh (McEachern etal., 2012).
Caregiver Report Measures ofTheir Children’s Outcomes
The Child Behaviour Checklist (CBCL) for children aged 6–18 and the pre-
school CBCL (for children aged 1½—5) were used to assess children’s emotional
and behavioural problems (Achenbach & Rescorla, 2000, 2001; Ebesutani etal.,
2010). The CBCL for children aged 6 to 18 is a 118-item self-completion scale
for caregivers about the behaviour of their child (e.g. ‘drinks alcohol without
parents’ approval,’ ‘argues a lot,’ and ‘overeating’). The preschool Child Behav-
iour Checklist is a 99-item self-completion scale that assesses child outcomes for
children 18 months to 5 years (e.g., ‘can’t concentrate’, ‘can’t pay attention for
long’). Item responses are on a 3-point Likert scale (not true, sometimes, often/
very true). The CBCL is robust in a variety of cultural contexts, including South
Africa (Achenbach & Rescorla, 2001; Calkins & Dedmon, 2000; Gross etal.,
2006; Mesman, Bongers, & Koot, 2003; Nöthling, Martin, Laughton, Cotton, &
Seedat, 2013).
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110
C.L.Ward et al.
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Correlates ofParenting Behaviour andChild Outcomes
Parenting Stress The Parenting Stress Index Short Form (PSI-SF; Abidin,
1990) was used to assess parenting stress. This is a 36-item self-completion
scale that quickly screens for stress in the parent-child relationship (e.g., ‘my
child is not able to do as much as I expected’). The PSI-SF has been used
extensively in a variety of contexts and samples in the US (Haskett et al.,
2006; Reitman etal., 2002; Smith etal., 2001), with good test-retest reliabil-
ity (average score of 0.76) and high internal consistency (0.85) in the original
validation study in rural and urban areas of Virginia (Abidin, 1990). Moreover,
the PSI-SF has been found to have high test–retest reliability and validity in
a sample of parents of South Africa children (Potterton etal., 2007) and sen-
sitivity to change after parenting programs (Cowen & Reed, 2002; Wolfe &
Hirsch, 2003).
Caregiver Mental Health The General Health Questionnaire (GHQ; Goldberg, 1979)
was used to assess caregiver mental health. The questionnaire consists of 28 items
(e.g., ‘have you been getting scared or panicky for no good reason?’; ‘have you been
getting edgy and bad tempered?’), with four possible responses scored using binary
options, i.e., 0 (‘better than usual’ or ‘same as usual’) and 1 (‘worse than usual’ or
‘much worse than usual’). Using this scoring method, any total score greater than 3
indicated ‘psychiatric caseness’ (Goldberg, 1979). The instrument has been shown
to be a reliable and valid measure of psychological well-being in over 38 different
contexts (Jackson, 2007).
Caregiver Experience of Intimate Partner Violence Sixteen items from the Con-
flict Tactics Scale—Revised (CTS-2; Straus et al., 1996) were used to assess
levels of intimate partner violence (IPV). These items explored psychological
and physical aggression. These ranged from mild (e.g. ‘my partner insulted or
swore at me’) to severe (e.g. ‘my partner used a gun or a knife on me’) forms
of violence. The CTS-2 is the most widely used measure of intimate partner
violence (IPV) (Newton etal., 2001; Straus etal., 1996) and has been found to
have good internal consistency and factor validity in diverse samples (Calvete
etal., 2007; Lucente etal., 2001; Newton etal., 2001) including in South Africa
(Swart etal., 2002).
Caregivers’ Self‑Report Measures of Their Alcohol Use The alcohol subscale
from the ASSIST was used to assess the risk level of the respondents’ alcohol
intake (Group, 2002; Humeniuk etal., 2008). The ASSIST has been validated
in a number of diverse settings, including the USA, Spain, India, Zimbabwe,
and South Africa (Humeniuk etal., 2008; Rubio Valladolid etal., 2014; van der
Westhuizen etal., 2016). The ASSIST was found to have high internal consist-
ency (α = 0.81–0.95 across different substances), as well as convergent and
discriminant validity in a sample (n = 200) of South African emergency centre
patients (van der Westhuizen etal., 2016).
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An Assessment ofTrends inParenting andChild Outcomes ina…
Procedure
Fieldworkers for quantitative data collection were recruited by the Seven Passes Ini-
tiative and trained by two authors (CLW and CG) in ethics and interviewing skills.
In waves 1 and 2 fieldworkers administered paper questionnaires. In wave three,
questionnaires were administered using the Mobenzi (www. Moben zi. com) digital
platform. This made it possible to link each fieldworker to a specific phone and to
manage the daily survey submissions and analytics on the Mobenzi web console,
thereby facilitating cleaning and data analysis in real-time. While efforts were made
in wave 3 to interview the same caregivers who had been interviewed in wave 2, this
was not always possible, both because many of the children who were the focus of
the interview in waves 1 and 2 were now older than 18, or because the children’s
primary caregivers had changed.
Interviews took about 2 hours and were conducted in private. Refreshments were
offered to each caregiver interviewed. Fieldworkers provided respondents with a list
of local organisations that provide support for parenting, intimate partner violence,
and substance misuse.
In addition to the quantitative data, five focus group discussions were held with
twenty community members. Community members were recruited to participate in
these through an announcement at a public meeting and flyers distributed throughout
the community, inviting anyone who had been interviewed to attend. Only women
volunteered to participate. To thank participants, they were given an R50 voucher
for a local clothing store. Three themes were explored in these discussions: what
it had been like to complete the questionnaires; what methods of discipline were
primarily used in the community; and what stressors affected parenting in the town-
ship. Participants gave separate informed consent to participate in the focus group
discussions.
Ethical clearance for the study was obtained from the Research Ethics Com-
mittee of the Faculty of Humanities at the University of Cape Town (reference no.
PSY2015-049).
Data Analysis
Analyses of the quantitative data were conducted using R (R Core Team, 2022),
with the aim of investigating the stability (or otherwise) in child and parental social
risk factors within the Touwsranten cohort over 3 baseline waves. Both raw and
standardised estimates (median and inter-quartile range) are reported for descrip-
tive data. Since the majority of participants surveyed at wave 1 were followed up at
wave 2 (89%), Wilcoxon signed-rank and McNemar’s tests were conducted to assess
change across waves 1 and 2 for participants who were assessed at both waves.
Given that the majority of participants in wave 3 were independent from those who
were assessed at waves 1 and 2, Wilcoxon’s rank-sum and chi-squared tests were
used to assess how participants at wave 3 differed from participants at wave 2. Qual-
itative data were analysed using thematic analysis (Braun & Clarke, 2006).
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112
C.L.Ward et al.
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Results
The cohort was made up of a total of 462 unique caregivers, where all children
were 6 years or older. Only 63 caregivers were interviewed across all 3 base-
line waves: 155 caregivers completed any two of the three waves, while 244 only
completed one wave. Most participants interviewed at wave 1 were followed up
at wave 2 (216 participants, 89%), in comparison to 63 participants who com-
pleted all 3 baseline waves (13.6%), suggesting a heterogeneous sample at wave 3
relative to waves 1 and 2. Cronbach’s alphas for all scales ranged between 0.714
(total APQ score, excluding corporal punishment) and 0.961 (PSI-SF). The extent
of poverty in Touwsranten was indicated by the finding that, in wave 1,183 fami-
lies (60.4%) had run out of money to buy food more than four times in the pre-
ceding month.
Parenting andChild Outcomes Across theThree Waves
The three samples are described in Table1. The median age of children across
the three waves was 11, and child gender distributions were similar across waves.
Most parents (92% wave 1, 94% wave 2, and 89% wave 3) were the biological par-
ents of the children who were the focus of the survey. On the Alabama Parenting
Questionnaire, median parenting scores suggested that parents often used posi-
tive parenting strategies, had slightly lower levels of parental involvement, and
demonstrated poor monitoring of their children less than ‘sometimes’. Median
scores suggested that spanking was prevalent, but that slapping and beating with
an object were infrequent. Over the three waves, increasing numbers of parents
reported poor mental health: 0 (0%) in the first wave, 0 (0%) in the second, and
43 (15%) in the third wave. Reports of alcohol use showed a similar pattern: in
the first wave, 33 parents (14.6%) reported risky drinking patterns; in the second,
51 (21.8%) reported risky drinking; and in the third wave, 60 (22.5%) reported
risky drinking. Reports of intimate partner violence amongst those parents who
had a current partner were similar at the second (71; 29%) and third (73; 26%)
waves but lower at the first wave (52; 23%). The qualitative data suggested that
these apparent fluctuations may represent increasing trust in the confidentiality of
the surveys. A majority of parents in the first (120; 54%) and second (159; 66%)
waves reported being in the high range for parenting stress, but this fell consider-
ably by the time of the third wave to 14 (5%).
Children’s outcomes seemed to deteriorate slightly from the first to second
waves and then hold steady (which may again represent greater trust in study
confidentiality). Overall, in wave 1, 39 children (18%) were in either the clini-
cal or borderline ranges for either internalising or externalising disorders; while
at wave 2, this was 57 (28%); and at wave 3, it was 66 (26%). At the first wave,
32 children (14.4%) were in the borderline or clinical ranges on the internalising
subscale of the Child Behaviour Checklist. This increased slightly to 36 (17.9%)
at the second wave and 44 (17.8%) at the third wave. Fewer children appeared to
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An Assessment ofTrends inParenting andChild Outcomes ina…
Table 1 Longitudinal sample characteristics across baseline waves (1–3)
Raw estimates Standardised estimates
Wave 1 (n = 223) Wave 2 (n = 242) Wave 3 (n = 278) Wave 1 (n = 223) Wave 2 (n = 242) Wave 3 (n = 278)
Child gender
Male (n, %) 111 (50%) 109 (49%) 130 (47%)
Female (n, %) 111 (50%) 113 (51%) 146 (53%)
Child age 11.00 (8.10, 13.50) 11.10 (8.50, 13.60) 11.40 (9.20, 14.50)
Parent relationship to
child
Biological (n, %) 68 (92%) 77 (94%) 247 (89%)
Grandparent (n, %) 5 (6.8%) 4 (4.9%) 20 (7.2%)
Other (n, %) 1 (1.4%) 1 (1.2%) 9 (3.3%)
Positive parenting (children aged 6–17)
Total 3.85 (3.46, 4.23) 3.85 (3.38, 4.15) 4.15 (3.69, 4.62) − 0.35 (− 0.97, 0.25) − 0.35 (− 1.10, 0.13) 0.13 (− 0.60, 0.87)
Positive parenting 4.33 (3.67, 5.00) 4.67 (3.67, 5.00) 4.67 (4.00, 5.00) − 0.08 (− 0.99, 0.84) 0.38 (− 0.99, 0.84) 0.38 (− 0.53, 0.84)
Poor monitoring 2.20 (1.80, 2.80) 2.40 (2.00, 2.80) 1.80 (1.40, 2.40) 0.34 (−0.20, 1.15) 0.61 (0.07, 1.15) −0.20 (−0.74, 0.61)
Involvement 3.80 (3.20, 4.30) 3.60 (3.00, 4.40) 4.00 (4.20, 4.60) − 0.11 (−0.83, 0.49) − 0.35 (−1.07, 0.61) 0.13 (− 0.83, 0.86)
Positive parenting (children aged 1.5–5 yrs, n = 132)
Total 4.21 (2.93, 5.09) − 0.21 (− 1.01, 0.71)
Setting limits 3.86 (2.71, 5.18) − 0.08 (− 0.80, 0.74)
Supporting positive
behaviour
4.43 (3.10, 5.57) 0.06 (− 0.78, 0.78)
Corporal punishment, children aged 6–17
Spank 3.00 (1.00, 3.00) 3.00 (1.00, 5.00) 3.00 (1.00, 5.00) 0.14 (− 1.11, 0.14) 0.14 (− 1.11, 1.38) 0.14 (− 1.11, 1.38)
Slap 1.00 (1.00, 1.00) 1.00 (1.00, 1.00) 1.00 (1.00, 1.00) − 0.38 (− 0.38, −
0.38)
− 0.38 (− 0.38, −
0.38)
− 0.38 (− 0.38, − 0.38)
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114
C.L.Ward et al.
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Table 1 (continued)
Raw estimates Standardised estimates
Wave 1 (n = 223) Wave 2 (n = 242) Wave 3 (n = 278) Wave 1 (n = 223) Wave 2 (n = 242) Wave 3 (n = 278)
Hit with an object 1.00 (1.00, 1.00) 1.00 (1.00, 1.00) 1.00 (1.00, 3.00) − 0.54 (− 0.54, −
0.54)
− 0.54 (− 0.54, −
0.54)
− 0.54 (− 0.54, 0.98)
Children’s internalis-
ing (T score)
45.00 (39.00, 52.00) 48.00 (39.00, 58.00) 48.00 (43.00, 57.00) − 0.41 (− 0.97, 0.25) −0.13 (−0.97, 0.79) −0.13 (−0.60, 0.72)
Clinical (n, %) 18 (8.1%) 26 (13%) 32 (13%)
Borderline clinical
(n, %)
14 (6.3%) 10 (4.9%) 12 (4.8%)
Children’s externalis-
ing (T score)
46.00 (40.00, 53.00) 50.00 (41.00, 58.00) 49.00 (41.00, 57.00) − 0.32 (− 0.86, 0.31) 0.04 (− 0.77, 0.72) − 0.05 (− 0.77, 0.69)
Clinical (n, %) 12 (5.4%) 24 (12%) 30 (12%)
Borderline clinical
(n, %)
7 (3.2%) 15 (7.3%) 21 (8.3%)
Parent poor mental
health
0.00 (0.00, 0.00) 0.00 (0.00, 0.00) 0.00 (0.00, 2.00) − 0.48 (− 0.48,
−0.48)
− 0.48 (− 0.48,
−0.48)
− 0.48 (− 0.48, 0.00)
Poor mental health 0 (0%) 0 (0%) 43 (15%)
Risk of alcohol use
disorder
0.00 (0.00, 2.00) 0.00 (0.00, 3.00) 0.00 (0.00, 8.00) − 0.64 (− 0.64, −
0.39)
− 0.64 (− 0.64,
−0.29)
− 0.64 (− 0.64, 0.37)
High/moderate risk 33 (14.6%) 51 (21.8%) 60 (22.5%)
Parental stress total 129.00 (118.00,
134.00)
133.00 (123.00,
140.00)
83.00 (73.00, 96.00) 1.98 (1.48, 2.20) 2.16 (1.70, 2.48) − 0.11 (− 0.57, 0.47)
High 120 (54%) 159 (66%) 14 (5%)
Intimate partner
violence
0.00 (0.00, 0.00) 0.00 (0.00, 5.00) 0.00 (0.00, 4.00) − 0.46 (− 0.46, −
0.46)
− 0.46 (−0.46, 0.06) − 0.46 (− 0.46, − 0.04)
IPV in last 6 months 52 (23%) 71 (29%) 73 (26%)
Unless otherwise specified, median and IQR are reported
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An Assessment ofTrends inParenting andChild Outcomes ina…
demonstrate externalising behaviour problems: at the first wave, 19 (8.6%) were
in the clinical or borderline range for externalising behaviour, whereas at the
second (39; 19.3%) and third (51; 20.3%), a similar proportion of children were
reported to have conduct problems.
Trends inParent andChild Outcomes Over Time
Trends over time were examined by comparing results across waves one and two
from those parents who completed both waves (dependent observations, Table2)
and then comparing the results from all parents who completed wave 2 with all
who completed wave 3, excluding those who completed both waves 2 and3 surveys
(independent observations, Table2).
The comparison between reports of the same parents at waves 1 and 2 revealed
that there were statistically significant but, in practical terms, very slight deteriora-
tions in parenting behaviours, except for slapping children and hitting with the hand,
which appeared to reduce slightly in frequency. There were marked increases in the
proportion of parents reporting risky alcohol use (14.2 to 20.3%) and intimate part-
ner violence (21 to 27%), and an increase in the proportion of parents reporting high
levels of parenting stress (54 to 63%).
In terms of children’s outcomes reported by parents who participated in both wave
1 and wave 2, there were slight increases in the mean T-scores for children’s internalis-
ing and externalising, but with marked increases in the proportion of children reported
to be in the clinical and borderline clinical ranges at wave 2: an increase in the propor-
tion of children who might benefit from an intervention from 13.1 (n = 28) to 17.8%
(n =38) for internalising and 7.5 (n = 16) to 19.1% (n = 41) for externalising.
When the changes from the independent samples at waves 2 and 3 were exam-
ined, there were no changes in parents’ use of spanking or slapping, or reports of
intimate partner violence. There was a statistically significant increase in reports of
risky alcohol use and a decrease in the proportion of parents reporting parenting
stress. There was too little variation in reports of mental health symptoms to permit
analysis. There was a small but statistically significant change in overall use of posi-
tive parenting strategies, apparently driven by a decrease in poor monitoring and a
slight increase in involvement. There was no change in rates of children’s internalis-
ing or externalising disorders from wave 2 to wave 3.
Qualitative Data
Focus group discussions showed that respondents found some questions difficult to
understand and others difficult to answer, especially if they were not the fulltime
caregiver of the child in question (e.g. they were caring for a relative’s child). Most
experienced the interview positively. A small number of participants were worried
about what would happen to their data and were concerned that it might lead to a
visit from a social worker investigating claims of child maltreatment. We had indi-
cated in the consent form that if a child (or a caregiver) was in danger, we would
have to report this to the mandated agency; however, this was not necessary during
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116
C.L.Ward et al.
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Table 2 Dependent and independent observations (Wave 1 v Wave 2; and Wave 2 v Wave 3)
Variables Longitudinal sample, waves 1 and 2 Independent samples, waves 2 and 3
Wave 1 (n = 216) Wave 2 (n = 216) p-value Wave 2 (n = 166) Wave 3 (n = 204) p-value
Child gender
Male (n, %) 109 (51%) 110 (51%) 0.785 71 (49%) 92 (46%) 0.645
Female (n, %) 105 (49%) 104 (49%) 75 (51%) 110 (54%)
Child age 10.9 (3.5) 11.4 (3.5) < 0.001 12.1 (3.8) 11.3 (3.5) 0.090
Positive parenting 3.83 (0.51) 3.76 (0.59) < 0.001 3.70 (0.63) 4.05 (0.62) < 0.001
Positive parenting 4.22 (0.77) 4.33 (0.84) < 0.001 4.22 (0.93) 4.39 (0.73) 0.295
Poor monitoring 2.32 (0.62) 2.41 (0.58) < 0.001 2.43 (0.59) 1.97 (0.72) < 0.001
Involvement 3.75 (0.74) 3.59 (0.93) < 0.001 3.51 (0.99) 3.86 (0.81) 0.002
Corporal punishment children 6–18
Spank 2.58 (1.37) 2.81 (1.56) < 0.001 2.87 (1.59) 2.71 (1.62) 0.318
Slap 1.31 (0.78) 1.24 (0.78) < 0.001 1.31 (0.88) 1.33 (0.89) 0.772
Hit with an object 1.36 (0.85) 1.19 (0.68) < 0.001 1.22 (0.70) 1.74 (1.36) < 0.001
Children’s internalising (T score) 46 (11) 48 (12) < 0.001 48 (12) 50 (11) 0.144
Clinical (n, %) 16 (7.5%) 28 (13%) 19 (13%) 24 (13%)
Borderline clinical (n, %) 12 (5.6%) 10 (4.8%) 10 (7.1%) 10 (5.6%)
Children’s externalising (T score) 46 (10) 50 (11) < 0.001 49 (12) 49 (11) 0.899
Clinical (n, %) 10 (4.7%) 24 (11%) 16 (11%) 18 (10%)
Borderline clinical (n, %) 6 (2.8%) 17 (8.1%) 10 (7.0%) 15 (8.4%)
Parent poor mental health 0.00 (0) 0.00 (0.00) NA 0 (0) 2 (4) < 0.001
Poor mental health (n, %) 0 (0%) 0 (0%) 0 (0%) 31 (15%)
Risk of alcohol use disorder 3 (8) 4 (8) 0.005 4 (8) 5 (8) 0.029
High/moderate risk 30 (14.2%) 44 (20.3%) 31 (18.4%) 40 (19.5%)
Parental stress 124 (17) 131 (16) < 0.001 132 (15) 88 (23) < 0.001
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Table 2 (continued)
Variables Longitudinal sample, waves 1 and 2 Independent samples, waves 2 and 3
Wave 1 (n = 216) Wave 2 (n = 216) p-value Wave 2 (n = 166) Wave 3 (n = 204) p-value
High 116 (54%) 134 (63%) 111 (67%) 13 (6.4%)
Intimate partner violence 2 (8) 3 (6) < 0.001 3 (6) 4 (9) 0.702
IPV in last 6 months 46 (21%) 59 (27%) 50 (30%) 53 (26%)
Unless otherwise specified, mean and standard deviation are reported
Figures in bold are p-values that indicate statistical significance
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118
C.L.Ward et al.
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the surveys. Participants reported high levels of corporal punishment in the com-
munity, and some were uncomfortable answering questions about corporal punish-
ment, suggesting that corporal punishment may have been under reported. Similarly,
alcohol use in the community was reported as prevalent and has having a negative
impact on caregiving. Intimate partner violence was also reported as taking place
in many homes, and discomfort was expressed with answering questions about it.
Finally, participants identified financial stress, partner’s infidelity, and difficult child
behaviour as key sources of parenting stress.
In wave 1, we also asked parents if they would be interested in parenting support,
and if so, how would they like it delivered. The majority said they wanted home vis-
its (53.8%), followed by a course (38.6%), a pamphlet to read (27.1%), or a once-off
workshop (16.2%). Less attractive options were a parenting hotline (11.6%), a cell-
phone app (4.6%), or information on the internet (1.6%).
Discussion
Our earlier work examining relationships between variables at wave 1 reveals that
parenting stress, parental mental health, and corporal punishment were associated
with children’s internalising and externalising behaviour, and that intimate partner
violence was also associated with children’s externalising (Ward etal., 2015). Anal-
yses of these three waves of survey data suggest that although there were changes
that were statistically significant, overall there was little or no substantive change.
Some apparent changes (for instance, in the sample who completed both waves 1
and 2, increased reports of intimate partner violence and risky alcohol use) may
reflect increased trust in the confidentiality of the research team over the repeated
waves of the survey, rather than actual changes in prevalence.
It is also notable that parents were reporting high proportions of children to be in
either the borderline or clinical ranges of the Child Behaviour Checklist; approxi-
mately 1 in 5 children fell into one or both of these ranges for either internalising or
externalising behaviours. This prevalence is similar to CBCL parent-reported rates
of disorders in US military families (Kelley etal., 2003), considerably higher than
those reported in an Iranian sample of children aged 6–12 (Tehrani-Doost etal.,
2011), and similar to those of children in a sample in Sao Paulo, Brazil (Rocha etal.,
2013). Regardless of similarity to other samples, however, this is a very high pro-
portion of children in a community to need care. Furthermore, the clinic in this com-
munity provided no mental health services, and the nearest services were located
in the town of George, a 30-min drive away, making them inaccessible for parents
without cars (i.e. all parents in the community) in an area with very poor and expen-
sive public transport.
Likewise, parent reports of their mental health symptoms and the stress
they experienced in parenting were also high. Reported rates of intimate part-
ner violence and substance misuse were low compared with anecdotal reports in
the community and were no doubt underreported in the survey, at least in the
first wave. Corporal punishment was also revealed as a common parenting strat-
egy. Analyses of the wave 1 data showed that all these problems (mental health
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An Assessment ofTrends inParenting andChild Outcomes ina…
problems, parenting stress, intimate partner violence, and substance misuse) were
related to child behaviour problems (Ward etal., 2015), and these three waves of
data found that they changed little over time.
Given this lack of change over time, it was clear that spontaneous reduction
in harsh parenting and improvements in child mental health were unlikely, and
that an intervention would be necessary, if children’s mental health were to be
improved in the community. The question then arose: how best to protect and
support children in a community with few formal services? Based on these
results, the Seven Passes Initiative decided to offer parent skills training pro-
grams, on the basis that parenting programs have evidence for reducing violence
against children and increasing positive parenting skills (Coore Desai etal., 2017;
Knerr et al., 2013; Mikton & Butchart, 2009) and improving children’s mental
and behavioural health (Medlow etal., 2016; Pedersen etal., 2019). Although
inconclusive, there is some evidence that suggests that parenting interventions
may improve children’s outcomes even in contexts of intimate partner violence
(Coore Desai etal., 2017; Latzman etal., 2019), substance misuse (Bröning etal.,
2012; Reupert etal., 2017), and poor parent mental health (Suarez etal., 2016).
Furthermore, while the evidence is again inconclusive, some studies have found
that parenting interventions improve parent mental health, at least in the short-
term (Barlow & Coren, 2018). Reductions in parenting stress have also been
found in several parenting programs (Barlow & Coren, 2018). In recognition of
the broader context of parenting, the Seven Passes Initiative also undertook to
support parents who needed help with intimate partner violence, substance mis-
use, mental health problems, and food insecurity, and built up a network of pro-
viders to whom they could refer parents with these needs.
However, even when widely offered in a community, it is unlikely that all par-
ents will attend a parenting program (Finan etal., 2018). Furthermore, the effect
of parenting programs may not always sustain overtime (Barlow & Coren, 2018).
For this reason, a social activation process was to be offered alongside the parenting
programs (Parker & Becker-Benton, 2016). The process involved an action research
activity following the Action Media method (Parker & Becker-Benton, 2016) to
identify community perspectives on parenting, identify community-led actions to
support parenting and parent–child engagement, and develop a manifesto, slogans,
songs, and branding to support change processes. A steering committee was estab-
lished to lead the process, and activities over the period of the study included com-
munity mural painting, street clean-ups, playground repair, family-level endorse-
ment of the parenting manifesto, display of support through branded stickers on
front doors, and a series of community-events including fund-raising activities, par-
ent–child games evenings, including parenting activities to national day celebrations
such as Youth and Women’s Day (both national holidays in South Africa), amongst
other opportunities for parents and children to spend time together.
The four Parenting for Lifelong Health programs (see https:// www. who. int/ teams/
social- deter minan ts- of- health/ paren ting- for- lifel ong- health) were chosen as the par-
enting programs, on the basis that they covered ages of children from pregnancy
to 18, had been tested in randomized controlled trials (Cluver etal., 2018; Cooper
etal., 2009; Vally etal., 2015; Ward et al., 2020), and were accessible: costs lie
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120
C.L.Ward et al.
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in training and coaching of facilitators, not materials; and training was available in
South Africa. These programs include:
(i) A home-visiting program for pregnant women until the baby is 6 months old,
with the goal of improving maternal attachment (Cooper etal., 2009), which
has theoretical links to later child mental health (Barlow etal., 2016; Fearon
etal., 2010; Sroufe, 2005);
(ii) A group-based dialogic book-sharing program with evidence for improving
infant vocabulary and theory of mind (Vally etal., 2015), as well as improv-
ing parent-child attachment, all of which have theoretical links to violence
reduction and child mental health (Dodge etal., 2008; Ogilvie etal., 2014);
(iii) A group- and social learning theory-based intervention for parents of children aged
2–9, with evidence for reducing violence against children (Ward etal., 2020);
(iv) A group- and social learning theory-based intervention for parents and children
aged 10–17, with evidence for reducing violence against children and a range
of child conduct problems (Cluver etal., 2018).
The theory of change for this intervention as a whole (see Fig.1) was thus in
summary as follows: that the delivery of parenting programs (which cover the full
age range of children, i.e. zero to 18), combined with a social activation process,
would lead to a community-wide shift towards positive parenting. This would be
achieved through two pathways. The delivery of the parenting programs (three of
which are group-based) would increase the use of positive parenting strategies,
reduce corporal punishment, and increase parent social support, which could lead to
improved parent mental health, reduced parenting stress, and improved communica-
tion and relationships between caregivers and children. In parallel, a social activa-
tion process would identify and amplify existing community values about positive
parenting, undertake activities to support those values, and disseminate messages
of positive parenting and care widely across the community, thus both increasing
uptake of the parenting programs and enabling community-wide change towards
Delivery of four PLH
parenting programs
Social activation
Community meeting to identify shared values about positive parenting
Development of a manifesto and ‘brand’ to support caring relationships
between parents and children
Activities that model care and promote positive parent-child interactions
Bring parents together around issues of parenting
Improved child outcomes
(reduced aggression and violence
and anxiety and depression)
Increase in social cohesion
around values of care and
positive parenting
Parents increase positive parenting
practices and reduce corporal punishment
LONG-TERM
OUTCOME
Community-wide shift towards positive parenting
INTERMEDIATE
OUTCOMES
Problem statement
Harsh and inconsistent parenting and the use of corporal punishment contribute to difficult and strained relationships between caregivers and children.
These factors combined with high levels of parenting stress and caregivers’ poor mental health contribute to children’s externalizing (violence and
aggression) and internalizing behaviour (anxiety and depression). Substance abuse and intimate partner violence increase the risk factors for
children’s internalizing and externalizing and for the use of violence against children.
ACTIVITIES Delivery of four PLH
parenting programs
Social activation
Community meeting to identify shared values about positive parenting
Development of a manifesto and ‘brand’ to support caring relationships
between parents and children
Activities that model care and promote positive parent-child interactions
Bring parents together around issues of parenting
Improved child outcomes
(reduced aggression and violence
and anxiety and depression)
Increase in social cohesion
around values of care and
positive parenting
Parents increase positive parenting
practices and reduce corporal punishment
LONG-TERM
OUTCOME
Community-wide shift towards positive parenting
INTERMEDIATE
OUTCOMES
Problem statement
Harsh and inconsistent parenting and the use of corporal punishment contribute to difficult and strained relationships between caregivers and children.
These factors combined with high levels of parenting stress and caregivers’ poor mental health contribute to children’s externalizing (violence and
aggression) and internalizing behaviour (anxiety and depression). Substance abuse and intimate partner violence increase the risk factors for
children’s internalizing and externalizing and for the use of violence against children.
ACTIVITIES
Fig. 1 Intervention theory of change
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positive parenting. The theory of change was informed by several assumptions: (1)
that the PLH programs could be adapted to be contextually and culturally relevant,
(2) that parents would participate in the parenting programs, and (3) that community
members would take ownership of and lead the social activation process.
Pregnant women were to be enrolled with the assistance of the local clinic nurses,
who would inform them about the home visiting program, and if they agreed, refer
them to the Seven Passes Initiative(SPI). Other parents were to be recruited through
community outreach of the parenting facilitators, for instance by going door-to-door
to hand out fliers, or through the social activation program. Group programs were to
be offered in the SPI offices or a local church, which had rooms of sufficient size to
accommodate groups. Monitoring and evaluation were to be provided by the Univer-
sity of Cape Town and the Institute for Security Studies, who would conduct follow-
up waves of surveys 18 months after the start of the intervention, and again another
18 months later.
This paper reports on a detailed assessment of the need and appetite for parent-
ing interventions in a rural South African community, which was relatively isolated
from services. The data reported here are limited in that it proved impossible to fol-
low the identical group of parents across all three waves of the study, and of course,
the data are also limited to this particular community. However, the study did estab-
lish that a high proportion of children were experiencing mental health symptoms,
that parents were frequently using corporal punishment, and thata number of par-
ents were experiencing mental health problems, substance misuse, intimate partner
violence, and high levels of parenting stress; and that these issues were all related.
Despite small fluctuations, rates of these problems remained fairly stable over time;
suggesting that without intervention, they would continue to do so. Results of this
study led to the design of a community intervention to support parenting, which was
to be tested and, if successful, offered to other communities.
Acknowledgements We are grateful to the community of Touwsranten for graciously participating in this
work: to our fieldworkers who worked hard to collect the data, to the staff of the Seven Passes Initiative;
and to the donors whose financial support made this work possible.
Availability of Data, Code, and Material The quantitative dataset and its metadata are available at Ziva-
Hub (https:// figsh are. com/s/ 2957f 717c5 da02a 8fec6). This will be made publicly open on publication—at
present, it is only open to the reviewers. Qualitative data will not be made open because of the risk of
identifying individual respondents.
Funding Open access funding provided by University of Cape Town. This work was supported by a grant
(Grant Agreement 03064) from the Open Society Foundation for South Africa (OSF-SA) and the World
Childhood Foundation (Grant no. 15368).
Declarations
Ethics Approval This work was approved by the Research Ethics Committee of the Faculty of Humanities,
University of Cape Town (approval no. PSY2012-08-01 and PSY2015-049).
Conflict of Interest CLW is one of the founders of Parenting for Lifelong Health but derives no royalties or
other income for use of the programs, although the University of Cape Town does receive research grants
in this area, and this does benefit her academic career. The other authors declare no competing interests.
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122
C.L.Ward et al.
1 3
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
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as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Com-
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from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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Authors and Aliations
CatherineL.Ward1,2 · ChandréGould3· MarilynT.Lake4·
DiketsoMufamadi‑Mathebula1,3· LisaM.Kleyn1· WarrenParker5·
WilmiDippenaar6
* Catherine L. Ward
Catherine.Ward@uct.ac.za
1 Department ofPsychology, University ofCape Town, Rondebosch, CapeTown7701,
SouthAfrica
2 Safety andViolence Initiative, University ofCape Town, CapeTown, SouthAfrica
3 Institute forSecurity Studies, Pretoria, SouthAfrica
4 Department ofPaediatrics & Child Health, South African Medical Research Council (SAMRC)
Unit onChild andAdolescent Health, Red Cross War Memorial Children’s Hospital, University
ofCape Town, CapeTown, SouthAfrica
5 Centre forCommunication, Media andSociety, University ofKwaZulu-Natal, Durban,
SouthAfrica
6 Seven Passes Initiative, Touwsranten, Hoekwil, SouthAfrica
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
1.
2.
3.
4.
5.
6.
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Background: We aimed to complete a nationally representative study of sexual violence against children in South Africa, and its correlates, since we could identify no other such study. Methods: For this nationally representative, cross-sectional study in South Africa, households were selected by use of a multistage sampling frame, stratified by province, urban or rural setting, and race group, and schools were selected on the basis that they were closest to the area in which households were selected. Interviews and self-administered questionnaires in each location inquired into lifetime and last-year prevalence of sexual abuse, and its correlates among children aged 15-17 years, whose parents gave informed consent and they themselves gave informed assent. Findings: The final household sample was 5631 (94·6% participation rate). 9·99% (95% CI 8·65-11·47) of boys and 14·61% (95% CI 12·83-16·56) of girls reported some lifetime sexual victimisation. Physical abuse, emotional abuse, neglect, family violence, and other victimisations were all strongly associated with sexual victimisation. The following were associated with greater risk of sexual abuse (adjusted odds ratio [OR]); school enrolment (OR 2·12, 95% CI 1·29-3·48); rural dwelling (0·59; 0·43-0·80); having a flush toilet (1·43, 1·04-1·96); parental substance misuse (2·37, 1·67-3·36); being disabled (1·42, 1·10-1·82); female (but not male) caregivers' poor knowledge of the child's whereabouts, friends, and activities (1·07, 0·75-1·53) and poor quality of the relationship with the child (ie, poor acceptance; 1·20, 0·55-2·60). The child's own substance misuse (4·72, 3·73-5·98) and high-risk sexual behaviour (3·71, 2·99-4·61) were the behaviours most frequently associated with sexual abuse, with mental health conditions found to be less prevalent than these factors but still strongly associated with sexual victimisation (post-traumatic stress disorder 2·81, 1·65-4·78; depression 3·43, 2·26-5·19; anxiety 2·48, 1·61-3·81). Interpretation: Sexual violence is widespread among both girls and boys, and is associated with serious health problems. Associated factors require multisectoral responses to prevent sexual violence or mitigate consequences. Funding: UBS Optimus Foundation.
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