Promoting positive parenting and mental wellbeing in Hong Kong Chinese parents: A pilot cluster randomised controlled trial.

OBJECTIVE: Effective and brief positive parenting interventions could be adopted widely, but evidence is limited. We aimed to evaluate the effectiveness of a positive parenting programme in Hong Kong Chinese parents.
METHODS: We conducted a pilot cluster randomised controlled trial in 2017 in 144 Hong Kong Chinese parents (84.7% women, mean age 42.5 [SD 5.87] years) of school-age children (mean age 10.9 [2.8] years) in 4 family service centres (clusters). The intervention included two 2-hour interactive talks (4 hours in total). The contents covered skills of giving praise, showing appreciation and playing enjoyable family games. The control group was offered the intervention after all the data were collected. Praise, appreciation and enjoyment related behaviours were measured as primary outcomes at baseline, 1 month and 3 months. The secondary outcomes were subjective happiness, wellbeing, personal health and happiness, family health, family happiness and harmony, and family relationship. After the completion of all assessments, five focus group discussions with the parents and four individual in-depth interviews with community service providers were conducted to explore their experiences.
RESULTS: Compared with the control group (n = 69), the intervention group (n = 75) showed greater positive changes in appreciation and enjoyment at 3 months with small effect sizes (d = 0.42 and 0.32, respectively), and greater improvements in the secondary outcomes at 3 months with small effect sizes (d: 0.29-0.48). In the focus groups, the parents reported more praise to their children, better temper control, more focus on their children's strengths and better family relationships. According to the service providers, most of the parents enjoyed the activities.
CONCLUSIONS: The brief intervention in community settings with the engagement of community service providers has shown preliminary effectiveness in promoting positive parenting and mental wellbeing of Hong Kong Chinese parents. TRIAL REGISTRATION: The authors confirm that all ongoing and related trials for this intervention are registered. The study reported in this manuscript is registered as clinical trial at clinicaltrials.gov: NCT03282071. https://clinicaltrials.gov/ct2/show/NCT03282071.

Introduction

“Guan” (training, control or governance) possesses a very positive connotation in Chinese culture, meaning governing and training but also showing care and love [1]. Chinese parents value governance and obedience, which is rooted in culture under the influence of Confucianism [2]. Western parents tend to use praise in abundance in order to boost their children’s confidence, whereas Chinese parents are apt to apply praise sparingly to prevent their children becoming complacent [3, 4]. A lower degree of acceptance and warmth were reported in Chinese parents, and also more hostile and neglecting compared with parents from other cultures [5]. Although training and controlling are considered positive in China [1], the high prevalence of child maltreatment is worrying. A 2006 report on Chinese parents with children aged 18 years or below found more than half of Hong Kong parents had used corporal punishment and nearly 5% of parents had maltreated their children physically, resulting in injuries [6]. Another report in 2019 on Hong Kong children attending Grade 1 to 3 (aged 6–10 years) showed that the past year prevalence of minor physical abuse, severe abuse, psychological abuse, and neglect were 64%, 23%, 84%, and 23%, respectively [7]. A meta-analysis of 22 studies in Chinese families showed that physical abuse was associated with adverse mental health outcomes [8]. In contrast, appreciation, warmth, affection and positive engagement predict children’s social competence and school achievement [9, 10].

To reduce the risk of child maltreatment in the community, parental competence and parenting practices are to be enhanced. Parents may not be competent to praise children appropriately. Person praise (e.g., “You’re smart!”) and inflated praise (e.g., “That’s incredibly beautiful!”) may weaken children’s motivation and feelings of self-worth [4]. Process praise, on the other hand, focuses on the efforts paid or the process (e.g., “Great job! You must have worked very hard.”), which can enhance the recipients’ intrinsic motivation when experiencing subsequent failure, and strengthen their resilience in facing difficulties [11]. Parents may benefit from training on positive parenting since they experience various child-rearing challenges. Low household income and education [12], low family functioning [13], children’s behavioural problems [12] and high expectation towards children [14] were all the sources of parental stress. Parents who held stronger traditional Chinese values were found to have more feelings of shame towards child behaviour problems, and lower intentions to seek help [15]. The limited resources of services and potential stigma may be barriers to access to consultation. Population-based approach is recommended to extend the impact of evidence-based interventions at the population level [16, 17]. A successful example is the multi-level Triple P model, using preventive parenting and family support strategy to enhance family protective factors and reduce risk factors associated with maltreatment [18, 19].

Brief and inexpensive interventions, if effective, can be adopted widely and sustainably [20]. Given the typical busy urban lifestyle in Hong Kong, brief interventions may encourage attendance and result in high adherence, especially for the general population who are self-perceived healthy. Only a few studies using less intensive positive parenting interventions were conducted among Chinese parents [20-23]. All of these studies adopted at least four group sessions of intervention [20-23]. Triple P model was implemented in Hong Kong by the Department of Health as part of its child health service. The programme was delivered by nurses who were supervised by a clinical psychologist, which involves substantial cost to the government and time to the parents [24]. Therefore, shorter community-based public health interventions are worth exploring, but relevant evidence is limited.

In January 2016, the Centre for Health Protection of the Department of Health of the Hong Kong Government launched a 3-year territory-wide “Joyful@HK” campaign to promote mental wellbeing under three themes: Sharing, Mind, and Enjoyment (SME) [25]. SME was used as the slogan of the Joyful@HK campaign. ‘Sharing’ connects family and friends, and supports those in need. ‘Mind’ entails keeping an open mind and being positive and optimistic. ‘Enjoyment’ is about engaging in enjoyable activities to maximise one’s potential and achieve satisfaction [25]. Target populations of this campaign included adolescents, adults and elderly people. The projects in adults aimed to improve the public awareness of Mixed Anxiety and Depressive Disorder (MADD), which was the most common mental disorder in Hong Kong adults (6.9%) [26]. The present trial, Joyful Parenting Pilot Project, was one of the projects in adults under the campaign. With the participation of the community service providers, the objective of this pilot trial was to evaluate the effectiveness of simple interventions with only two sessions in promoting positive parenting behaviours and parents’ wellbeing. We aimed to use enjoyable and simple family games to engage the parents and promote their practice of giving praise and showing appreciation. We hypothesised that participants in the intervention group would report more positive changes in giving praise and showing appreciation, as well as a higher level of happiness and wellbeing. Qualitative data were also collected through focus groups in parents and in-depth interviews in community service providers to understand the experiences of parents.

Materials and methods

This pilot cluster randomised controlled trial used both quantitative and qualitative evaluation methods. The trial (NCT03282071) was conducted in 2017–18 by the University of Hong Kong and the Hong Kong Family Welfare Society (HKFWS). The organization supports holistic approach that encompasses the physical, mental and spiritual needs of different family members. For each integrated family service centre of the HKFWS, some clients use the services frequently and many of them may know each other well. Therefore, cluster design (assigning the participants recruited by the same centre to the same group) was adopted to avoid the potential contamination between the intervention and control groups.

Participants

Four integrated family service centres of the HKFWS participated in the trial. Parents aged 18 to 59 years were recruited by the four service centres through leaflets and a public poster in the centres. Parents who were able to speak Chinese and complete questionnaires were eligible. Those who could not read Chinese or had severe mental illness were excluded. Grandparents or other types of caregivers were not included. Family members (including children) of the participating parent were also invited to join a family gathering activity after completion of the interventions. Ethical approval was obtained from the Institutional Review Board of the University of Hong Kong / Hospital Authority Hong Kong West Cluster (reference number: UW17-240, dated 5 July 2017). Written informed consent was obtained in adult participants and parents provided written consent for children under the age of 18. The study was registered (NCT03282071, S1 Protocol). We reported the results following CONSORT guideline (S1 Checklist).

Procedures

Four random numbers were generated by a computer. One person not involved in the randomisation process prepared sequentially numbered, opaque, and sealed envelopes, each containing a group allocation card. Two centres were randomised into the intervention group and two into the control group. The randomisation process was concealed from the researchers and cluster representatives. However, the recruitment staff and the enrolled parents were not blind to the allocation status as the intervention was obvious. We measured all the outcomes at baseline (before the first session of intervention), conducted the second assessment at 1 month (before the second session of intervention) and the third assessment at 3 months. A family gathering activity was provided to the participants after the final outcome assessment, which was used to encourage the participation and thank the participants for their completion of questionnaires. The waitlist control group received related services after data collection had been completed.

Joyful parenting intervention

The design of the study was based on the concept of SME, Seligman’s PERMA (Positive Emotion, Engagement, Relationships, Meaning and Accomplishment) model [27], and the findings from our previous project about increasing appreciation and reducing criticism in parents [28]. The interventions were designed by academic researchers together with community service providers, including two 2-hour interactive talks (4 hours in total) (S1 File). The contents included skills of giving praise, showing appreciation, and playing enjoyable and interactive family games. The instructors in each centre were two experienced social workers in the field of family counselling, with a senior social worker monitoring and providing guidance in the whole period.

In the first interactive talk, the instructors briefly introduced the symptoms of MADD and the ways to seek help for emotional disturbances. Then the instructors brought the importance of positive mind and discipline to build a positive environment and promote parent-child relationship. Also, SME and the benefit of praise and appreciation were introduced. Three simple and interactive family games were led by the social workers, enabling the parents to observe and experience how to give praise or show appreciation. The parents tried to praise each other through playing the games cooperatively. The principles of praise were emphasised: provide detailed and specific praise by using more adjective words (specific praise), praise for improvements rather than focusing on the achievements (give outcome praise in the right way: e.g. The parents had a high expectation on children’s academic performance, but children’s improvement from grade C to B was still worth praising), praise for their efforts made in the process even if they fail (process praise), have a consistent and reasonable standard, and be sincere. Parents were encouraged to write down eight strengths of their children and share with the other parents in the group. Simple worksheets were assigned to the parents to record their practice of three types of praise (specific praise, process praise and outcome praise) and family games they arranged in the following four weeks. Times of praise (each type of praise done in one day was counted as 1 time) and family games in each week were documented.

After one month, we conducted the second interactive talk to reinforce the effect. The one-month gap between the two talks was to let the parents have time to practice the learned skills. They discussed about their experience in the past month and shared with the other participants. If the parents could not think of any words to praise, they could show their care and encouragement by simple actions such as a pat on the back. Lego games and role-playing games were organised in group format. Same as the ones in the first talk, these games were designed to remind the parents of the person and the behaviours that were worth praising. The parents were provided with the materials of the Lego and were encouraged to play together with their children at home and show appreciation during the games.

Outcome measurements

Primary outcomes: Praise, appreciation and enjoyment related behaviours

We developed the outcome and impact-oriented questionnaires to assess the changes in the participants. Praise, appreciation and enjoyment were consistent with our delivered content of the intervention. Praise included 3 items (congeneric reliability was 0.88, range 0–21), “In the past seven days, how many days did you praise for children’s efforts in words or actions / praise for children’s strengths in words or actions / encourage children in words or actions”. Each item of praise also included one sub-question about the frequency of praise each day (once, twice, three times, four times or more). The total times of praise in the past 7 days were calculated by multiplying the number of days and the times per day (range 0–84). Appreciation and Enjoyment in the past 7 days both included 2 items (range 0–14): “In the past seven days, how many days did you observe children’s strengths carefully / understand children in a positive way”, and “In the past seven days, how many days did you enjoy the time with children / hold outdoor activities with children”. The congeneric reliability was 0.89 and 0.62, respectively. A higher score indicated higher level of positive parenting behaviour. Significant correlations were found between praise, appreciation, enjoyment and subjective happiness, wellbeing (r = 0.19–0.43, all p < 0.05), indicating that these measurements have acceptable validity in estimating better wellbeing and higher level of subjective happiness.

Secondary outcomes

Subjective happiness

The 4-item Subjective Happiness Scale was used to assess individual participant’s overall happiness [29]. The response of each item was a 7-point Likert scale. The score was the average of 4 items after reverse coding of the 4th item (range: 1 to 7). Higher scores indicated higher levels of happiness. The reliability and validity of the Chinese version have been established in the general population [30]. The Cronbach’s alpha was 0.82, and the test-retest reliability was 0.70.

Wellbeing

The 7-item Short Warwick-Edinburgh Mental Well-being Scale with the 5-point Likert scale (1 = none of the time, 5 = all the time) was used. The score was calculated by summing all seven items with a range of 7 to 35 [31]. A higher score indicated higher level of wellbeing. The Chinese version indicated good validity and reliability in our previous paper [32]. The congeneric reliability was 0.85 and the test-retest reliability was 0.70.

Personal health and happiness

Personal health and happiness were measured by asking the respondents “How healthy / happy do you think you are”. Respondents rated each item from 0 (not at all) to 10 (very healthy / happy). Higher scores indicate more healthy and happy [33].

Family health, happiness and harmony

Family health, happiness, and harmony were measured by asking the respondents “How healthy / happy / harmonious do you think your family is”, which was reported in our previous papers [34, 35]. Respondents rated each item from 0 (not at all) to 10 (very healthy / happy / harmonious). Higher scores indicate higher level of family health, happiness, and harmony.

Family relationship

Family relationship included three items “the level of understanding / intimacy / communication with family members”. Respondents rated each item from 0 (none) to 10 (full understanding / intimacy / communication with family members), resulting in a total score of 0–30. Higher scores indicate better family relationship. The congeneric reliability was 0.91.

Intention to change

The intention to praise children’s effort in words or actions, observe children’s strength carefully, and enjoy the time with children were measured after the first talk. The questions were rated on a 5-point Likert scale, with “1” indicating “no intention at all” and “5” indicating “with strong intention”.

Subjective changes and process evaluation

The subjective changes in praise, appreciation and enjoyment were measured at 1 month and 3 months. The questions were rated on a 5-point Likert scale, with “1” indicating “much less” and “5” indicating “much more”. Process evaluation was conducted after each talk. Some questions were rated on a 0–10 scale (“0” indicating “unsatisfied”, “10” indicating “satisfied”), such as the satisfaction of the activity, whether they can learn SME from the activity, and whether they can gain mental health knowledge from the activity. The participants were also asked whether they would like to share the activity with others (yes / no).

Evaluation of children

At 3 months, the children were invited to complete a short questionnaire by themselves or with the help of their parents. Their self-perceived praise, appreciation and enjoyment were asked: “how many days did your parents praise for your efforts in words or actions / praise for your strengths in words or actions / encourage you in words or actions / observe your strengths carefully / understand you in a positive way / enjoy the time with you / hold outdoor activities with you?”. Questions about personal health and happiness, family health, happiness and harmony were also asked, which were the same as the parent’s version.

Focus groups and in-depth interviews

After completing all the quantitative outcome assessments, focus group discussion of the parents and individual in-depth interviews of the service providers were conducted. The focus group discussion was mainly to explore parents’ satisfaction with the contents, subjective changes and suggestions for future programmes. The in-depth interviews aimed to explore community partners’ perceptions on the usefulness, difficulties in implementation and suggestions. All discussions and interviews were conducted by one moderator (project coordinators who were familiar with the trial and had observed all the activities) and one note-taker. All the parents in the intervention group were invited to join the focus groups. Parents who were interested and available could join the discussions. Five focus group discussions of parents were conducted, with an average of 9 parents in each group (7–12 parents per group, 34 women and 11 men). Four social workers (1 man and 3 women) who have participated into the project were invited to complete the individual in-depth interviews.

Fidelity

To evaluate whether the interventions had been delivered following the protocol, the researchers (project staff, government research officers, and senior officers from HKFWS) completed the fidelity checklist for each session of the activities, checking the extent that the actual activity aligned to the proposed rundown and the extent that the instructors conveyed the core messages.

Data analysis

Quantitative data were analysed using STATA 13.0. Baseline characteristics were compared using Chi-square tests. Multilevel mixed-effects linear regression model (command XTMIXED) was used to calculate between-group mean differences (intervention vs. control) in the outcome changes, adjusting for clustering effect, significantly different demographics and baseline outcome variables. The model was fitted via restricted maximum likelihood method. The principle of intention-to-treat (ITT) analysis was adopted by including all the randomised subjects. The missing observations from lost to follow-up or not completing follow-up questionnaires were dealt with chained equations imputation [36]. Five imputed datasets were generated and pooled using Rubin’s rules [36]. An effect size (Cohen’s d) of 0.2 was considered as a small effect, 0.5 a medium effect, and 0.8 a large effect [37]. All significance tests were two-sided with a 5% level of significance. A supplementary analysis was conducted by only adjusting for clustering effect and baseline outcome variables, which was unspecified in the protocol. Qualitative data were analysed using thematic analysis [38]. All the interviews were transcribed verbatim, and the transcripts were read throughout. The relevant or interesting keywords were highlighted as initial codes. The codes were collated into potential themes and the relevant data were gathered together. The entire data set was reviewed, and the themes were checked again to figure out a thematic map. The themes were checked and refined until clear definitions and names were created. Some compelling contents were extracted and reported as examples [38].

Results

Four family centres (144 parents, mean age 42.5 (SD 5.87) years) were recruited with two centres randomised into the intervention group (75 parents, mean age 41.8 (5.51) years) and two into the control group (69 parents, mean age 43.3 (6.19) years) in September 2017. Fig 1 shows the CONSORT flow chart. The retention rates of the intervention group and control group were 96% at 1 month and 87% at 3 months. Table 1 shows the majority of the participants (77.3% in the intervention group and 92.8% in the control group, p = 0.010) were women. The intervention group had higher education level (p = 0.001), higher proportion in full-time employment (p = 0.017), and higher household income (p = 0.03) than the control group. Sex, education level, working status, household income and baseline of the corresponding outcome variable were included as covariates in subsequent outcome analyses.

Fig 1

CONSORT flow chart.

Table 1

Demographic characteristics.

Demographics	Categories	Total (n = 144) n (%)	Intervention (n = 75) n (%)	Control (n = 69) n (%)
Sex	Man	22 (15.3)	17 (22.7)	5 (7.2)
	Woman	122 (84.7)	58 (77.3)	64 (92.8)
Birthplace	Hong Kong	55 (38.2)	28 (37.3)	27 (39.1)
	Guangdong Province	56 (38.9)	29 (38.7)	27 (39.1)
	Other places	33 (22.9)	18 (24.0)	15 (21.7)
Marital status	Married	122 (84.7)	66 (88.0)	56 (82.4)
	Unmarried	22 (15.3)	9 (12.0)	13 (18.8)
Education level	Primary or below	7 (16.7)	1 (1.3)	6 (8.7)
	Secondary or diploma	133 (78.5)	55 (73.3)	58 (84.1)
	Degree or higher	24 (16.7)	19 (25.3)	5 (7.2)
Working status	Full-time work	40 (27.8)	27 (36.0)	13 (18.8)
	Part-time work	21 (14.6)	11 (14.7)	10 (14.5)
	Housekeeper	75 (52.1)	34 (45.3)	41 (59.4)
	Others	8 (5.6)	3 (4.0)	5 (7.2)
Household monthly income, HK$	< 20,000	74 (51.7)	31 (41.3)	43 (63.2)
	20,000 to 40,000	41 (28.7)	27 (36.0)	14 (20.6)
	> 40,000	28 (19.6)	17 (22.7)	11 (16.2)
Number of children	1	43 (29.9)	25 (33.3)	18 (26.1)
	2	79 (54.9)	41 (54.7)	38 (55.1)
	3 or more	22 (15.3)	9 (12.0)	13 (18.8)

Primary outcomes

The parents in the intervention group showed greater positive changes in appreciation (between-group mean difference, BMD = 1.19, 95% CI: 0.27 to 2.12, Cohen’s d = 0.42, p = 0.011) and enjoyment (BMD = 0.98, 0.01 to 1.94, d = 0.32, p = 0.047) than the control group at 3 months (Table 2). Praise did not show significant changes at 3 months (Table 2). S1 Table shows the outcomes without adjusting for baseline characteristics, which were similar to the adjusted outcomes.

Table 2

The comparison between intervention group (n = 75) and control group (n = 69).

Items	Phase	Mean (SD)		BMD (95%CI) a	Cohen’s d (95% CI)	P-value b
		Intervention (n = 75)	Control (n = 69)	Intervention vs Control	Intervention vs Control
Praise (days)	Baseline	11.49 (5.15)	11.34 (4.79)
	1 month	12.23 (4.91)	11.05 (4.81)	0.99 (-0.35, 2.34)	0.20 (-0.07, 0.48)	0.148
	3 months	13.09 (4.12)	12.34 (4.22)	0.10 (-1.37, 1.57)	0.02 (-0.33, 0.38)	0.896
Praise (times)	Baseline	28.35 (22.92)	25.56 (18.54)
	1 month	28.87 (22.34)	22.35 (16.88)	5.24 (-0.01, 10.49)	0.26 (-0.001, 0.53)	0.050
	3 months	28.61 (18.33)	25.40 (16.72)	1.46 (-2.88, 5.80)	0.08 (-0.16, 0.33)	0.510
Appreciation	Baseline	7.03 (3.72)	7.86 (3.56)
	1 month	8.37 (3.66)	8.44 (3.36)	0.06 (-1.04, 1.16)	0.02 (-0.30, 0.33)	0.918
	3 months	8.86 (2.81)	7.83 (2.91)	1.19 (0.27, 2.12)	0.42 (0.09, 0.74)	0.011
Enjoyment	Baseline	7.78 (3.78)	7.42 (3.29)
	1 month	7.82 (3.22)	7.58 (3.09)	0.41 (-0.61, 1.43)	0.13 (-0.19, 0.45)	0.435
	3 months	8.92 (3.31)	7.75 (2.77)	0.98 (0.01, 1.94)	0.32 (0.003, 0.63)	0.047
Subjective happiness	Baseline	4.47 (1.19)	4.52 (1.10)
	1 month	5.03 (1.10)	4.54 (1.08)	0.36 (0.10, 0.62)	0.33 (0.09, 0.57)	0.006
	3 months	5.12 (0.93)	4.64 (1.05)	0.39 (0.14, 0.64)	0.39 (0.14, 0.65)	0.002
Well-being	Baseline	24.82 (3.80)	23.82 (4.62)
	1 month	25.81 (3.94)	24.67 (3.74)	0.31 (-0.69, 1.31)	0.08 (-0.18, 0.34)	0.538
	3 months	27.32 (3.83)	24.81 (4.55)	1.20 (0.17, 2.24)	0.29 (0.04, 0.53)	0.023
Personal health	Baseline	6.15 (2.05)	6.10 (2.27)
	1 month	6.99 (2.04)	6.18 (2.23)	0.40 (-0.09, 0.89)	0.19 (-0.04, 0.42)	0.109
	3 months	7.29 (1.84)	6.32 (2.15)	0.81 (0.26, 1.35)	0.41 (0.13, 0.68)	0.004
Personal happiness	Baseline	6.15 (2.31)	6.15 (2.19)
	1 month	6.97 (1.99)	6.45 (2.11)	0.25 (-0.21, 0.72)	0.12 (-0.10, 0.35)	0.281
	3 months	7.25 (1.79)	6.37 (2.07)	0.72 (0.21, 1.23)	0.37 (0.11, 0.64)	0.006
Family health	Baseline	6.25 (2.32)	6.25 (2.22)
	1 month	7.23 (1.87)	6.48 (1.94)	0.39 (-0.09, 0.86)	0.20 (-0.05, 0.45)	0.110
	3 months	7.33 (1.66)	6.50 (1.95)	0.65 (0.12, 1.17)	0.36 (0.07, 0.65)	0.016
Family happiness	Baseline	6.40 (2.54)	6.37 (2.13)
	1 month	7.38 (1.99)	6.55 (1.92)	0.46 (-0.04, 0.95)	0.24 (-0.02, 0.49)	0.070
	3 months	7.45 (1.67)	6.46 (1.98)	0.74 (0.22, 1.25)	0.41 (0.12, 0.68)	0.005
Family harmony	Baseline	6.23 (2.59)	6.49 (2.09)
	1 month	7.20 (2.09)	6.80 (1.96)	0.27 (-0.23, 0.77)	0.13 (-0.11, 0.38)	0.294
	3 months	7.39 (1.89)	6.63 (1.96)	0.72 (0.22, 1.22)	0.37 (0.11, 0.63)	0.005
Family relationship	Baseline	20.71 (6.80)	20.85 (5.05)
	1 month	22.36 (5.03)	20.73 (4.76)	1.11 (-0.16, 2.39)	0.23 (-0.03, 0.49)	0.087
	3 months	23.06 (4.69)	20.34 (5.23)	2.36 (0.96, 3.76)	0.48 (0.19, 0.76)	0.001

BMD, between-group mean difference; CI, confidence interval.

a The differences between two groups at 1 month or 3 months were adjusted for the baseline of the corresponding variables, sex, education level, working status and family income, and cluster effect.

b p values were calculated using multilevel mixed-effects linear regression model.

According to the collected worksheets of home practice from 52 parents, praise was given 7.13 (SD 5.21), 6.69 (5.79), 6.63 (5.83) and 4.48 (5.84) times from the first to the fourth week, respectively. There was a statistically significant difference between groups (F (3, 204) = 4.101, p = 0.007). The post hoc test revealed that the home practice of praise was lower in the fourth week compared with the first (p = 0.018) and second week (p = 0.048). Parents arranged 2.87 (2.20), 2.73 (2.18), 2.46 (2.00) and 1.56 (1.99) times of family games from the first to the fourth weeks. The fourth week practice of family games reduced significantly compared with the first three weeks (p = 0.002, p = 0.005 and p = 0.029, respectively).

The parents in the intervention group showed greater increases in subjective happiness at 1 month (BMD = 0.36, 0.10 to 0.62, d = 0.33, p = 0.006) and 3 months (BMD = 0.39, 0.14 to 0.64, d = 0.39, p = 0.002) than the control group (Table 2). We also found greater and significant improvements in the other outcomes at 3 months, including wellbeing (BMD = 1.20, 0.17 to 2.24, d = 0.29, p = 0.023), personal health (BMD = 0.81, 0.26 to 1.35, d = 0.41, p = 0.004), personal happiness (BMD = 0.72, 0.21 to 1.23, d = 0.37, p = 0.006), family health (BMD = 0.65, 0.12 to 1.17, d = 0.36, p = 0.016), family happiness (BMD = 0.74, 0.22 to 1.25, d = 0.41, p = 0.005), family harmony (BMD = 0.72, 0.22 to 1.22, d = 0.37, p = 0.005) and family relationship (BMD = 2.36, 0.96 to 3.76, d = 0.48, p = 0.001) (Table 2).

After the first talk, all the parents reported intention or strong intention to praise children’s effort in words or actions, observe children’s strengths carefully, and enjoy the time with children. Fifty-two percent to 61% parents reported strong intention to have more positive parenting behaviours.

At 1 month and 3 months, more than 95% parents perceived a little or much more positive changes of parenting behaviours. Most of the parents in the intervention group reported improvement of health (78.9%) and happiness (90.1%). The scores of the process evaluation at different time-points were all above 8 out of 10 (ranged from 8.2 to 8.8) except one item “can learn from MADD” (score 7.9). All the parents reported the willingness to share the programme with others.

The adherence to the proposed rundown of the first and the second interactive talk was 87.8% (SD 15.0) and 96.3% (7.4), according to the evaluation of 11 observers and 9 observers, respectively. The adherence to the core messages of the first and the second talk was 85.6% (7.3) and 90.0% (9.3), respectively.

Evaluation of the children

A total of 141 children completed the questionnaires before the family gathering activity. The average age was 10.9 (2.8) years (range 4 to 18 years; 5.6% aged 4–7 years, 61.5% aged 8–11 years, 23.1% aged 12–15 years, 9.8% aged 16–18 years). Around half the children were boys (51.8%). Most of the children were in primary school (62.4%) or secondary school (32.6%). No significant difference in the outcomes of the children was found between the intervention group (n = 70) and the control group (n = 71).

The major themes included the overall impression, the impact of the interventions and subjective changes, difficulties met during practice, and suggestions for future improvement. Parents thought that the programme was helpful. Most of the parents enjoyed the simple family games, which made them understand the praise skills soon after engaging into the activities. Through playing games, the interaction with other parents or families brought fun, joy and relaxation. Some parents liked the cohesion of learning and playing.

“I like the games. The atmosphere was quite nice. During the process, the instructors taught many positive words to praise. Everyone enjoyed and felt happy.” (Male, 46 years old)

Helpful programme in general

Positive changes

Parents reported positive changes after the intervention, such as more praise to their children and paying more attention to observe their children’s strength. Their family relationship improved, and children performed better after they were given praise. Some parents reported better control of temper when their children did not perform well.

“My child become more proactive and more willing to help me with the housework.” (Female, 42 years old)

“I know more about praise and appreciation (after the talks). Our relationship has improved.” (Female, 45 years old)

“We used to focus on success and winning all the time. Now I try to observe my child’s strengths more carefully.” (Female, 47 years old)

“When I get really angry and want to criticize my child, I try to control my temper.” (Female, 37 years old)

Difficulties met

It was hard for the parents to control temper sometimes. They met some difficulties when praising their children in daily life, particularly for the older children. It was common that the parents got angry when their children did not perform well in school work.

“My child did not focus on study even before the examination. I talked to him, but he would not listen. Then I got angry.” (Female, 40 years old)

“It is quite hard to praise children as you must observe carefully all the time. Perhaps I’m not good at it. I could only use a few common words.” (Female, 42 years old)

“My older child is a student in middle school, and he complained that my praise was a little bit annoying.” (Female, 41 years old)

Suggestions

Some parents suggested that more similar workshops and talks should be arranged in the future. The programme could be delivered to the grandparents who were also the common caregivers of children.

“It would be nice to have more similar classes, or we would forget all the contents after a while.” (Female, 41 years old)

Community service providers’ view

Community service providers said most of the parents enjoyed the activities. The social workers themselves also learned from the project. However, they felt some difficulties in delivering the heavy contents in two talks. They suggested that the intervention sessions should last longer.

“The parents were very cooperative in the games. Most of them were involved and very happy.” (Male)

“We often focus on changing parent’s mindset to be positive. This activity made me realize that sometimes they could act first, even though they need some time to convert the way of thinking afterwards.” (Female)

“I think the time is too rush, the activity was only two hours but included playing, teaching, and filling questionnaires.” (Female)

Discussion

We evaluated the effectiveness of two simple interactive talks in improving the positive parenting behaviours in Hong Kong Chinese parents. The implementation had followed the protocol with high fidelity. The compliance to intervention was high at the follow-ups. The quantitative results showed the effectiveness of our intervention in improving parents’ appreciation and enjoyment, with small effect sizes at 3 months (d: 0.42 and 0.32, respectively), which was our primary goal. Moreover, the subjective happiness, wellbeing, personal health and happiness, family health, happiness and harmony, and family relationship (d: 0.29–0.48) all improved with small effect sizes at 3 months. Primary prevention mental health programmes usually have small effect on positive parenting behaviours [39]. Our findings are consistent with the universal approach for parenting practices (d: 0.39) [19].

We did not observe significant changes in praise, according to the quantitative data. However, more than 95% parents reported that they expressed more praise and appreciation to their children. The qualitative data have also shown more praise in some parents. The small sample size of the pilot study might have led to the non-significant increase of parents’ praise behaviour. Another possible explanation is that the practice of praise and family games has just decreased at the one-month evaluation point. According to the collected worksheets of home practice, the 4th week practice of praise and family games reduced significantly, just within the period of our one-month outcome evaluation. Process praise required detailed description and information, which might be difficult for parents to practise. Some parents also reported difficulties in temper control, especially when they were not satisfied with their children’s performance in schools. The mindset of fixing problems and belief in the usefulness of criticism may be difficult to change in short-term. We did not measure criticism or abuse in the present study, but it would be useful to include the measurements in future study, to evaluate whether such programs could prevent or reduce children maltreatment.

Although parents did not increase the frequency of praise, it is possible that the intervention has changed the mindset of the parents as evidenced by the higher level of appreciation and enjoyment at 3 months. The improvement in appreciation and enjoyment might lead to positive changes in subjective happiness, wellbeing, personal health and happiness, family health, happiness and harmony, and family relationship. The quality of appreciation and communication may be more important than the quantity of praise. To get a sustainable effect, regular booster interventions and activities are needed to further improve the quality of praise and appreciation. Our simple interventions and family games were to involve parents into the activities quickly. We emphasised the importance of practice and used simple messages to make them act immediately. The core components are clear to the participants but the skills to deal with different situations in daily life are to be strengthened.

Our study had several limitations. First, because validated questionnaires were not available and many existing ones were too long, we developed the outcome and impact-oriented questionnaires to assess the changes in the participants. The measurements showed acceptable to good congeneric reliability. Future studies should test the validity of the praise measurements. Second, we did not measure the outcomes of children at baseline, thus the comparison between the intervention and control group might be affected by the imbalanced baseline. However, the interventions and outcome evaluation mainly targeted on parents. Future studies could include more measurements on the children. Third, because the target population was healthy and the ‘usual care’ was no care, a waitlist control was adopted. To control for any effect due to attention or interaction, alternative psychological placebos could be used in future studies. Fourth, as a pilot trial, only four family centres were involved, and there might be some other unmeasured confounders. Although pilot studies would not aim at statistical significance, we did record some significant changes. The intervention can thus be scaled up and larger trials with improvements are warranted. Given the difficulties in recruiting fathers, and mothers may have a stronger influence on the children rearing in Hong Kong, targeting mothers seems to be an effective strategy.

Population-based interventions and primary prevention are scarce but necessary in the healthcare system. Our pilot trial of population-based positive parenting in Hong Kong Chinese parents, with the engagement of community service providers, can be a useful reference by future larger trials or adopted as a routine community practice. The skills of praise, appreciation and enjoyment are part of positive parenting and a set of parenting skills such as temper control and positive discipline might also be included in future programmes. The programmes for building parental competence not only help parents increase their own self-efficacy in positive parenting, but also benefit the children and prevent the children maltreatment.

(PDF)

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CONSORT 2010 checklist of information to include when reporting a randomised trial*.

(DOC)

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Programme rundown.

(DOCX)

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(DOCX)

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25 Jun 2021

PONE-D-20-37785

Promoting positive parenting and mental wellbeing in Hong Kong Chinese parents: a cluster randomised controlled trial

PLOS ONE

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Reviewer #1: Partly

Reviewer #2: Partly

Reviewer #3: Partly

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Reviewer #1: I Don't Know

Reviewer #2: I Don't Know

Reviewer #3: Yes

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Reviewer #1: Important note: This review pertains only to ‘statistical aspects’ of the study and so ‘clinical aspects’ [like medical importance, relevance of the study, ‘clinical significance and implication(s)’ of the whole study, etc.] are to be evaluated [should be assessed] separately/independently. Further please note that any ‘statistical review’ is generally done under the assumption that (such) study specific methodological [as well as execution] issues are perfectly taken care of by the investigator(s). This review is not an exception to that and so does not cover clinical aspects {however, seldom comments are made only if those issues are intimately / scientifically related & intermingle with ‘statistical aspects’ of the study}. Agreed that ‘statistical methods’ are used as just tools here, however, they are vital part of methodology [and so should be given due importance].

COMMENTS: In my opinion, sample size used is small because as per lines 36-38 [Results: Compared with the control group (n = 69), the intervention group (n = 75) showed greater positive changes in appreciation and enjoyment at 3-month with small effect sizes (d = 0.42 and 0.32, respectively)] the effect size is ‘small’ and small effect size study needs a larger sample size {refer to table-2, page-158 of: “A power primer” by J. Cohen in Psychological Bulletin, 1992, vol.:112, pp 155-159]. Considering that it is a ‘pilot’ (line 25), of course, sample size is not a big issue. [However, I very strongly feel that a word ‘pilot’ study should also appear in title.]

Since this is a [though pilot] cluster randomised controlled trial, statistical comparison of baseline characteristics [last ‘p-value’ column in Table 1] is not desirable. Please note

To provide a description of baseline characteristics is entirely reasonable (since it is clearly important in assessing to whom the results of the trial can be applied), however, it does not require the division of baseline characteristics by treatment groups (however, if done – alright). Statistical comparison of baseline characteristics is not desirable at all [because even if P-value turns out to be significant (while comparing baseline characteristics despite random allocation), it is, by definition, a false positive] as you then are supposed to be testing ‘randomization’ then, which in any single trial may not balance all baseline characteristics because ‘randomization’ is a sort of ‘insurance’ and not a guarantee scheme.

References:

1. Stuart J. Pocock, et al., ‘Subgroup analysis, covariate adjustment and baseline comparisons in clinical trial reporting: current practice and problems’, Statistics in medicine, 2002; 21:2917–2930 [Particularly page 2927]

2. Harrington D, et al., ‘New guidelines for statistical reporting in the journal’, N Engl J Med 2019;381:285-6

[Important message (indirectly/ultimately indicated) from these articles: Never do any comparison with respect to ‘baseline’ characteristics {by applying statistical significance test(s)}, when allocation is done randomly].

’P-values’ {last column} reported in Table 2 [The comparison between intervention group (n=75) and control group (n=69)] are supposed to have yielded by “Multilevel mixed-effects linear regression model” [as nothing has been given in the footnote]. It could have been simple to do it by non-parametric equivalent to unpaired ‘t’ test namely Mann-Whitney ‘U’ test on ‘change scores’ as though the measures/tools used are appropriate, most of them yield data that are in [at the most] ‘ordinal’ level of measurement [and not in ratio level of measurement for sure {as the score two times higher does not indicate presence of that parameter/phenomenon as double (for example, a Visual Analogue Scales VAS score or say ‘depression’ score)}]. Then application of suitable non-parametric test(s) is/are indicated/advisable [even if distribution may be ‘Gaussian’ (i.e. normal)]. Agreed that there is/are no non-parametric test(s)/technique(s) available to be used as alternative in all situation(s) [suitable / most desired/applicable], but should be used whenever/wherever they are available

Further, in my opinion, account given in ‘Focus groups and in-depth interviews’ section (lines 307-358) could be [and should be, I guess] reduced. Referring to lines 395-405 [Our study had several limitations…….] studies ‘quality’ becomes highly questionable. Even as a pilot study, in my considered opinion, this study does not contribute any new information.

Reviewer #2: Overall

This paper investigated the efficacy of a brief positive parenting programme on or positive parenting (praise, appreciation, enjoyment) in a sample of 144 Hong Kong parents. The study had a mixed-method design, combining a randomized controlled trial (RCT) with group discussions. Quantitative measures were taken at baseline and again 1 month and 3 months post intervention. Group discussions with parents and individual discussions with providers were held post-intervention. Intervention effects were found for positive parenting and mental wellbeing.

The promotion of positive parenting is of great importance, especially in a Hong Kong context, given the prevalence of “tiger parenting” within Hong Kong (and Chinese) communities. I commend the authors for undertaking this study and for drawing attention to the effects of positive parenting. Well done for recruiting 144 parents, for conducting implementation fidelity checks, and for controlling for confounders in the analysis.

Introduction

The authors provide a rationale for the study, although the rationale for the actual intervention is not convincing to me. The introduction needs revision as there is some unclarity and a lack of nuance. For example:

52: In Chinese culture, it is commonly thought that praising children breeds complacency and hinders learning

54: “more than half of Hong Kong parents has used corporal punishment and 4.5% has maltreated their child physically”

- I am confused by this sentence as, to me, corporal punishment is physical maltreatment. In my view, this sentence needs to be rephrased, looking carefully what the cited authors meant

- 56: The paper (5) that the authors cite is not focused on Chinese/ Hong Kong parents and is perhaps not the best reflection of Hong Kong parenting and child outcomes. Cultural differences exist in child outcomes following physical punishment. Some studies reported that African-American parents living in low SES areas use physical punishment as a strategy to keep their children safe, whereas European parents use physical punishment in anger. The child outcomes differ greatly between these cultures. The same may be the case for Chinese families.

59: positive parenting protects against child behaviour problems. Indeed, studies have reported this, but the ones cited here (Shek et al, 2003 and Chronis et al 2007) are not the right ones to cite. It would be better to look for studies that have a longitudinal design, specifically looking at the effect of positive parenting and not in an ADHD sample (Chronis), as the authors’ study is not about ADHD.

68: “typical problem and treatment oriented parenting programmes have limited impact at the population level.” I don’t think this is true and the cited paper doesn’t claim this.

75: I don’t understand the proposed need for shorter positive parenting programmes. Shorter than Triple P? Triple P has many different intervention levels, including very brief ones. Incredible Years is rather long, but the authors don’t refer to this programme

80: I assume to Joyful Parenting Pilot Project aimed to promote positive parenting behaviours amongst parents (not just any adult). Did this project involve several interventions?

I would like to learn a bit more about the actual intervention. How do fun family games lead to increased praise?

87: This sentence implies that only qualitative data were collected.

Methods

How were demographics obtained? Why were participants randomised by cluster? What were the inclusion and exclusion criteria? How were parents within the centres recruited?

99: “Family members (could be children or adolescents) of the participating parent were also invited to join a family gathering activity after completion of the interventions” What does this mean? Is this essential to understanding the procedure (i.e. replicating the study)?

102: “The study protocol (dated 1 June 2017) was fixed before the ethical approval and enrollment of participants.” What does this mean? Again, is this essential for the study to be replicated?

Ethical approval:

Was assent obtained from underaged children over 7 years? Clinical trial registry data is mixed up with ethical approval data. Please separate these.

Procedure:

The authors state that randomization happened via numbers generated by a computer, but continue by stating how group allocation occurred using envelopes.

The intervention procedure doesn’t make sense to me. Baseline levels were taken, measures were repeated after the first talk and again after the second talk, after which family activities took place. A more common method would be to measure baseline levels, provide the intervention to the intervention group, repeat the measures post-intervention and again at follow-up. After all assessments are done, the control group receives the intervention.

Intervention:

Describe what “Sharing, Mind and Enjoyment” and “knowledge of Mixed Anxiety and Depressive Disorder (MADD)” mean instead of just using names. Also, I would suggest rewriting this section to separate the measures (such as MADD) from the actual intervention. Be really precise in describing the intervention as this is a new intervention and readers will not have heard of it. What does interactive talk entail? It sounds like a lecture provided to parents.

Did control group parent take part in the family gathering activity? Was this event used as incentive?

Outcome measures:

It is generally better to include measures that have been validated and that are reliable, especially for primary outcome measures. With self-developed measures, you don’t know if you are measuring what you want to measure. I have strong doubts about the validity and reliability of the primary outcome measures. For the next study, I would suggesting looking at existing literature to review what kind of measures can be used to measure your outcomes of interest. This also enables comparison between studies.

In the abstract it is unclear what the purpose was of the focus group discussions and the interviews. The methods explains the purpose of the group discussions, but not of the interviews.

Also (re information in the abstract), it is more informative to know how many parents took part in a focus group discussion. It is less informative to report on the number of group discussions, as two parents can be considered a group, as well as 10. A group of 10 people will likely provide more information than a group pf two people.

Analysis of the qualitative data should not be included in the statistical analysis section.

Results

I appreciate the distinction the authors made between primary and secondary outcomes. Table one needs revision to include outcomes of the t-tests/ chi-square tests (please check APA guidelines for required content). How was the effect size calculated? Why is the effect size not included in Table 2? SD is also not reported.

I am not convinced of the results, mainly due to the self-developed primary outcome measures and the timing of the second set of assessments (during the intervention). Presentation of the results is sometimes unclear, e.g.,

263: “parents gave praise in 7.13 (SD 5.21), 6.69 (5.79), 6.63 (5.83) and 4.48 (5.84) days from the first to the fourth week” According to the methods section, the maximum score is 84. The scores presented in the results appear rather low. Also, the results should present the intervention effects, not mean scores.

I feel as if the thematic analysis could have yielded more in-depth results. If more in-depth data is available it may be interesting to present the group discussions and individual interviews in a separate paper.

Discussion

With the summary of the essential findings, it is unclear if the findings refer to the 1-month or the 3-month assessments. The authors state they expected small effect sizes, however, this was not stated in the previous sections. Why did the authors expect small effect sizes? The qualitative findings are not discussed (or I may have missed this part).

The potential theoretical and practical implications have not been identified. Apart from the suggestion to have a larger sample size, the authors do not provide suggestions for future research.

Additional comments:

As an English as second language speaker myself, I appreciate how difficult and illogical the English language can be. I would suggest to seek editorial assistance from a native English speaker. There are quite a few improvements to be made throughout the paper, e.g.

28: Two talks were delivered, including praise and appreciation skills, and enjoyable family games �  this implies that “praise”, “appreciation skills”, and “enjoyable family games” are talks, while in effect these are skills taught or discussed during the talks.

30: at baseline, 1 month, and 3 months. Note: singular (and hyphen) is used in other cases, e.g. 3-month follow-up, at 3 months

31: when expressing comparisons (e.g. greater), you need to include what it is compared to, e.g. we expected greater improvement reported by intervention group parents as compared to those in the control group

39: small effect sizes (plural)

83: Praise is always singular, as is content (127)

84: easy-to-catch family games? What are those? Simple games that are easy to learn?

95 “under the Hong Kong Family Welfare Society”

99: “Family members (including children)”

Some of the references are a bit old. Some more Chinese/Hong Kong studies (Triple P):

Chan S, Leung C, Sanders M (2016) A randomized controlled trial comparing the effects of directive and non-directive parenting programs as a universal prevention program. J Child Serv 11: 38-53

Guo M, Morawska A, Sanders MR (2016) A randomized controlled trial of Group Triple P with Chinese parents in mainland China. Behav Modif 40: 825-851.

Reviewer #3: Abstract: The abstract would benefit from being more concise, particularly under methods. The hypotheses shouldn’t be stated under the methods. The authors should include information on the sample (e.g., parents of children of what age? Were this parents with concerns for their children or general public?) When did the study take place and duration? Were the focus groups conducted after or before the interventions and what were the focus groups for? The concluding statement seems to be exaggerated given the small effect size and short follow up duration. What is the impact for such a trial?

Introduction: The introduction presents Chinese parenting style. It is not clear to the reader what age group of children the authors are referring to. The introduction currently is weak and does not present a good rationale for why brief parenting programmes are needed in Hong Kong. More context should be given. The objective is to promote positive parenting practices and mental wellbeing in parents, yet no discussion is given on why parent mental wellbeing is important and how this link to children wellbeing. Line 52: Is this a belief or is there evidence to support such claim? Line 54 the author cited that more than half of Hong Kong parents has used corporal punishment. This statement requires further elaboration otherwise is out of context. The authors should state whether this data was from a survey and the sample size of the survey. Line 60: what does the author mean by children’s social achievement? Line 61-63: Not sure what the author mean in this sentence. What does the author mean by reward? Reward does not always necessarily lead to positive behaviour but can increase undesired behaviours in children. Line 68-75: Does the author mean targeted/selected parenting program? The authors should explain the public health model and why universal approaches are needed for prevention. Existing literatures should be drawn and expand on. The authors should also expand on the few studies that were conducted on Chinese parents. A stronger rationale for brief parenting programmes is needed. Line 80: What do the authors mean by pilot engagement trial?

Method: Family service centres were engaged to recruit. Were these parents already clients from the service centre? The authors stated that the family centres provide comprehensive and extensive professional support, does this mean that their service clients were those at risk or a high risk? A definition should be given re parents. Did the authors only recruited parents? What about caregivers? The inclusion and exclusion criteria should be clearly stated. Given the brief nature of the intervention, did the research team exclude families that were at risk? If so, what were used to screen families? Line 108: What about child assent? If the children did not want to participate, does that mean the family is excluded? Consort diagram should be included. More information on recruitment should also be given. Line 119: why were the assessment completed before the intervention were completed? If the 3 month assessment was conducted before the family gathering activities, how did the authors measure the effect of the family activities? The authors can consider using a diagram to show the intervention and schedule of assessments. A table can also be used to explain the content of the intervention. What was the reason for the one month gap between the two talks? Why lego? Line 149: What was the validity of the scale for measuring praise. How confident are the authors in regard to recall bias? The reliability of the enjoyment scale appear just acceptable.

Results: Line 299 There were no mention that children were required to complete assessments, this should be stated clearly in the methods section. Was specific questionnaires used to collect response from children? How reliable are data collected from a 4 year old?

Discussion: The authors state that the primary outcome is positive parenting practices, however the self-developed scales does not seem to measure parenting practices. For example, a measure on enjoyment. Can the author justify why these scales were chosen or used? It was unclear in the methods section that there were worksheet available for parents. This should be stated in the methods. The authors didn’t find significant changes in praise, and suggested that parents beliefs in the usefulness of criticism may be difficult to change in short-term. What are the implications of such findings? Perhaps modification to the content of how praise are taught? And how can the authors reduce the use of criticism in parents? Line 384: How does appreciation and enjoyment link to quality of communication? There are very few male participants, any thoughts on how this can be improved?

There are grammatical errors and typos throughout the manuscript, the manuscript would benefit from careful proof reading.

The author stated that data can not be shared due to consent reasons. Data that are deidentified should be made available upon request for example for inclusion into meta-analyses. Given journal policy for data sharing and availability, the authors should consider the inclusion of such statement in consent forms and PIS in future studies.

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Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: (No Response)

Reviewer #2: No

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: (No Response)

Reviewer #2: No

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: COMMENTS: I noted that, ABSTRACT is well drafted but assay type. Please note that it is preferable to divide the ABSTRACT with small sections like ‘Objective(s)’, ‘Methods’, ‘Results’, ‘Conclusions’, etc. which is an accepted practice of most of the good/standard journals [including this one]. If I remember correctly, it was divided in small sections earlier. May please consider (again).

Thank you very much for adding a word “pilot” in title and removing ‘p-value’ column in Table 1 [i.e. statistical comparison of baseline Characteristics] as suggested {both actions highly appreciated}. I completely agree that “the cluster effect should be adjusted for and thus the Mann-Whitney ‘U’ test on ‘change scores’ may not be usable”, but wanted to indicate that direct / head-to-head comparison between groups is desirable [that does not mean that use of “Multilevel mixed-effects linear regression model” which definitely adjust for clustering effect is wrong but note that this technique is not originally developed for comparison of between-group mean differences. In this context [authors may already know the reference], here is a good reference: Donner Allen and Klar Neil. `Design and Analysis of Cluster Randomization Trial in Health Research’, Oxford University Press Inc., New York, 2000.

The fact that ‘though the measures/tools used here are appropriate, most of them yield data that are in ‘ordinal’ level of measurement [and not in ratio level of measurement for sure {as the score two times higher does not indicate presence of that parameter/phenomenon as double (for example, a Visual Analogue Scales VAS score or say ‘depression’ score)}].

I certainly know the vital importance of ‘Focus groups and in-depth interviews’ in research but I only suggested to reduce account given in section.

Ultimately, in my considered opinion now, ‘let the respected editor decide the future course’. I do not have any specific recommendation.

Reviewer #2: The authors put in a lot of effort to take on board reviewers’ suggestions. However, there are still outstanding issues that need to be addressed, plus some new ones due to the changes in the introduction. There are still quite a few English grammar mistakes. E.g.,

line 74: “meaning to govern and train but also to show care and love”, line 78 “reported themselves as low acceptance”,

line 83 “a latest report”. Please make use of a proficient English speaker for the next version.

Line 111: “Chinese parents showing warmth and reward to children is more of getting children’s”

Line 173: “Those who cannot read Chinese or were suffering from “

My comments relate to the revision with the track and changes.

Abstract:

The abstract could benefit from some reorganising. It is helpful to stick to the common “intro, methods, results, discussion, conclusion”. Be succinct and only state the essential.

Line 35: Please add children’s mean age.

Line 38: I am unclear what the difference may be between praise and appreciation skills.

Line 39: remove the comment on the control group not receiving an intervention during the study. This is how control groups work. Instead, you could state, “the control group participants were offered the intervention after all data were collected”

I would advise to make a distinction between primary outcomes and secondary outcomes in the results reported in the abstract as well.

Introduction:

The authors made the introduction more relevant. There is still some restructuring and fine tuning needed. E.g.,

Line 79: The authors state “despite cultural differences in training and controlling”. However, these differences have not been discussed, it was only stated that training and control is considered positive in China.

Line 77: Sentence structure is incorrect. Western parents use praise to boost children’s confidence, whereas Chinese parents use praise to ..” or “Western parents tend to use praise in abundance in order to boost their children’s confidence, whereas Chinese parents tend to use praise sparingly to prevent their children becoming arrogant (NB arrogant is just an example).

Line 82: Unclear what is meant, please clarify. Is this what the authors meant: “.. more than half of HK parents had used corporal punishment, with 4.5% of these cases resulting in injuries”

The authors sometimes jump from one topic to the next and the research that is cited does not always apply to the arguments being made. E.g., after talking about physical abuse (until line 89), the authors suddenly start discussing social support.

Line 92: why do the authors talk about students? What is students’ life satisfaction? Children’s satisfaction with their life at school? This can have so many other causes other than parenting. How old were these children?

Again, the use of ‘students being satisfied’ in line 107. Maybe students were not satisfied because of the amount of homework. This needs to be better specified. The following suggestion regarding family support (line 108) implies that the students in line 107 had received family support.

Line 110: “yet parents may not know how to praise children appropriately”. Earlier in the introduction the authors talked about praise and parents preferring to be strict. This needs to be combined and some additional literature needs to be reviewed. Perhaps this can be combined with the parenting challenges that Chinese parents experience.

Lines 113-117: Good addition of praise types. Please add an example of process praise.

Line 127-128: references are needed to back up these statements

Lines 129-133: the authors discuss Triple P as a good example of a universal parenting intervention. This makes the reader wonder why the authors did not use that programme instead, which is well known, effective, and translated into Mandarin. What is the rationale for using the authors’ intervention? With 4 group sessions, Triple P is already pretty brief. Is it too costly (i.e., you do need a qualified triple P facilitator)? Are there too many points of contact with triple P (i.e., 4 group sessions vs only 2 interactive talks)?

For attachment-based interventions research suggests that shorter is better. No such evidence exists for behavioural-based interventions. So why is shorter better? It seems to me that the authors’ intervention is time consuming too, with all the family games to be played over the course of one (or two?) months.

Line 145: to what extent were parents involved in the study design? I see no evidence of CBPR in the current study except for service providers being interviewed. This is not participatory research.

Methods

Thanks for providing a rationale for using a clustered design.

Line 196: leave out: “The intervention group received the interventions first.” It is sufficient to say that the control group received access to the intervention after data collection was complete.

Line 197: the term follow-up is not appropriate here as there is no actual follow-up assessment (i.e., assessment after the post-intervention assessment). Common description of assessment points are: baseline (Time 1), post-intervention (Time 2), ..-month follow-up (Time 3). Not sure how to describe the authors’ research design, as Time 2 is only after the first part of the intervention.

Line 203: leave out: “.. no interventions during the assessment period” see my previous point re line 196.

Joyful parenting intervention/ SME intervention lines 205-248 - I find the use of both these names confusing

- What is the name of the actual intervention?

- Who developed this and how?

- Based on what?

- What is the interactive aspect of the talks? They still sound like lectures to me.

- Is there information available to the public so this study can be replicated?

- Line 210: praise (positive sharing). The definition of ‘praise’ is not ‘positive sharing’. I think most readers will know what praise is (the expression of approval), so perhaps not necessary to supply a definition here.

- Regarding ‘Appreciation skills’, I have only ever heard of literary appreciation skills, so not sure what this refers to.

- Line 236: family games during 4 or 3 weeks? The authors talk about 4 weeks, but then state 21 days.

- How much paly and practice happened? One or two months?

Line 217, what does MADD stand for (this has been deleted) – acronyms should be explained at first mentioning.

Lines 219-220 (reference 29) belongs in the introduction.

Lines 226-232: this belongs in the introduction, not in the methods. Please integrate with what is already in the introduction.

The goal of the methods section is to allow for a study to be replicated by someone else. This is currently not possible and more information needs to be provided.

No evidence of any interaction in the ‘interactive talks’. These talks sound like lectures and should not be described as being interactive. The subsequent games do seem interactive as do the practice with focussing on positive traits

There is insufficient evidence of the validity and reliability of the primary outcome measures. How do the authors know their measures assess what they were designed to assess? Any changes found between the control and intervention group could be something else entirely. Retrospective behaviour-related questions (e.g., to quantify the amount of praise) are not necessarily reliable. Plus, as there was no placebo intervention, any changes measured may be due to the effect of attention. These are all aspects that need to be discussed in the limitation section of the study.

The high level of correlation between the different primary outcomes is not necessarily positive as it may be indicative of the different measures assessing the same construct rather than separate constructs. Evidence on some of the secondary outcomes is much stronger as some were based on existing questionnaires.

Measuring children’s perception of the level of parental praise is a great way to make the parent measure of praise stronger. This should be emphasised more, but only if the child questions were very similar to the parent questions.

Fidelity only checked by the researchers, not by an independent other. How was the quality of the qualitative component ensured?

Discussion

Line 503: “.. two simple interactive talks”. What about all the family games that took place over the course of one (or two?) months? It’s not such a brief intervention after all. There are only two points of contact.

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Reviewer #1: No

Reviewer #2: No

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3 Jun 2022

Promoting positive parenting and mental wellbeing in Hong Kong Chinese parents: a pilot cluster randomised controlled trial

PONE-D-20-37785R3

Dear Dr. Man Ping Wang,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: (No Response)

Reviewer #2: Yes

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Reviewer #1: (No Response)

Reviewer #2: Yes

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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: (No Response)

Reviewer #2: No

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: (No Response)

Reviewer #2: Yes

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: COMMENTS: Since all of the comments made on earlier draft by me (and hopefully by other respected reviewers also) were/are attended positively, I recommend the acceptance because the manuscript now has achieved acceptable level, in my opinion.

Reviewer #2: (No Response)

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Reviewer #1: Yes: Dr. Sanjeev Sarmukaddam

Reviewer #2: Yes: Nike Franke

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11 Jul 2022

PONE-D-20-37785R3

Promoting positive parenting and mental wellbeing in Hong Kong Chinese parents: a pilot cluster randomised controlled trial

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