ABSTRACT
BACKGROUND: Parenting interventions in humanitarian settings have prioritized the acquisition of parenting knowledge and skills, while overlooking the adverse effects of stress and distress on parenting-a key mediator of refugee children's mental health. We evaluated the effectiveness of the Caregiver Support Intervention (CSI), which emphasizes caregiver wellbeing together with training in positive parenting. METHODS: We conducted a two-arm randomized controlled trial of the CSI with Syrian refugees in Lebanon, with an intent-to-treat design, from September 2019-December 2020. A total of 480 caregivers from 240 families were randomized to the CSI or a waitlist control group (1:1). Retention from baseline to endline was 93%. Data on parenting and caregiver psychological wellbeing were collected at baseline, endline, and three-month follow-up. Prospective trial registration: ISRCTN22321773. RESULTS: We did not find a significant change on overall parenting skills at endline (primary outcome endpoint) (d = .11, p = .126) or at follow-up (Cohen's d = .15, p = .054). We did find a significant effect on overall parenting skills among participants receiving the full intervention-the sub-sample not interrupted by (COVID-19) (d = 0.25, p < .05). The CSI showed beneficial effects in the full sample at endline and follow-up on harsh parenting (d = -.17, p < .05; d = .19, p < .05), parenting knowledge (d = .63, p < .001; d = .50, p < .001), and caregiver distress (d = -.33, p < .001; d = .23, p < .01). We found no effects on parental warmth and responsiveness, psychosocial wellbeing, stress, or stress management. Changes in caregiver wellbeing partially mediated the impact of the CSI on harsh parenting, accounting for 37% of the reduction in harsh parenting. CONCLUSIONS: The CSI reduced harsh parenting and caregiver distress, and demonstrated the value of addressing caregiver wellbeing as a pathway to strengthening parenting in adversity. These effects were achieved despite a pandemic-related lockdown that impacted implementation, a severe economic crisis, and widespread social unrest. Replication under less extreme conditions may more accurately demonstrate the intervention's full potential.
ABSTRACT
This paper reports on a process evaluation conducted as part of a randomized controlled trial of the Caregiver Support Intervention (CSI), a nine-session preventive group psychosocial intervention, with Syrian refugees in Lebanon (n = 480, 240 families). Fifteen focus group discussions (FGDs) were conducted with 122 CSI participants (51% of participants in the intervention arm of the trial), including 63 female and 59 male caregivers. We analyzed the focus group data to explore the mechanism of impact of the CSI on caregiver wellbeing and parenting. We also examine the impact of multiple adversities on the results of the trial, which was conducted in a context of widespread social unrest, a severe economic crisis, and the COVID-19 pandemic. Despite these adversities, participants described improvements in their psychological wellbeing and parenting as a result of the CSI. Changes in parenting include a reduction in harsh parenting and an increase in warm and responsive parenting. Findings suggest a pathway from the mindfulness practices and anger management techniques taught in the CSI, to improved caregiver wellbeing, to positive changes in parenting. Participants described becoming less angry and more patient, as well as better able to lower their arousal before responding to conflictual situations with their children. Increased knowledge of positive parenting also contributed to changes in parenting. About half of focus group participants reported a marked attenuation of effects following the intervention, which they attributed primarily to the high stress generated by the combination of the economic crisis and the pandemic. We examine specific ways in which the focus group findings diverge from the trial results, and consider the limitations of standalone psychosocial interventions in contexts of extreme adversity.