A Parent Education Program for Single Fathers’ Parent-Child Relationship in Rural China: A Pretest

Abstract

Purpose: This study evaluates a parent education program (PEP), a 13-session group intervention, for single fathers’ parental self-efficacy and father-child relationship in rural areas in China. Methods: Through convenience sampling, 16 single fathers received a parental education program for their parental self-efficacy and the father-child relationship between May 30 and August 30, 2020. Results: Most single fathers (14 out of 16) completed all intervention sessions and assessments. Statistically significant improvements were observed for pre-, post-, and follow-up scores for parental self-efficacy, father-child relationship, and certain subdomains of family participation. Conclusions: A group-based parental education program for parental self-efficacy and parent-child relationship shows promise for supporting single fathers from rural areas in China and in improving the wellness of their children.

Keywords

Chinese rural areas parent education program parental self-efficacy family participation parent-child relationship single father

Single-parent families or households are an increasingly common phenomenon worldwide, with the latest international data reporting that close to 10% of children live in single-parent households (Pew Research Center, 2019). Notably, in the United States, nearly 19 million children, or 25% of all children in the country, live in single-parent families, a percentage almost three times the level in 1960 (Kramer, 2019). Although data from the four most recent censuses in China revealed a relatively low rate of single-parent households overall (4–6%), China is among the countries that have reported the fastest increase in the rate of single-parent households (Hu & Peng, 2015). Specifically, the 2010 Chinese census data revealed that 5.9% of Chinese families are single-parent households, translating to 23 million single-parent families (Wang, 2014). The rate of single-parent households in rural China (6.3%) is higher than that in urban Chinese cities (5.3%) and, notably, the number of single-father households in China is twice that of single-mother households (Wang, 2014; Zhang, 2020).

While most existing research into single-parent households has focused on single-mother households, studies have reported that Chinese single-father households face greater challenges because the fathers are expected to perform both maternal duties of taking care of the child and paternal responsibilities to work (Panter-Brick et al., 2014). Compared with their paternal peers from partnered-parenting households, single-parent fathers are more likely to have low socioeconomic status, poorer psychological and physical health, less support in caregiving duties, and greater workplace challenges (Dhungel et al., 2021; Iztayeva, 2021). For example, Chiu et al. (2018) found that the mortality rate of single fathers was three times higher than single mothers and partnered fathers. Studies have also found that single fathers face higher levels of discrimination in the workplace when compared to single mothers or partnered-parenting employees, resulting in greater psychological distress and increased mental health challenges (Steffens, Preuß, & Scheifele, 2019).

Overall, social work research has primarily focused on father involvement and father-child relationship regardless of their marital status (Maxwell, Scourfield, Featherstone, Holland, & Tolman, 2012; Shapiro & Krysik, 2010). For example, social work researchers have found father’s mental health is predictive of their children’s mental health and healthy development (Tang et al., 2018). Similarly, health social workers also found that supporting fathers’ psychological wellbeing are beneficial for their children who experience major medical conditions, such as congenital heart disease (Li et al., 2018). However, not a lot of research in social work has focused on single fatherhood and fewer has focused on those in rural China (Zhang, 2020).

A key issue in single fatherhood is the parent-child relationship, which primarily includes a parent’s investment in the parental role and the relationship quality (Coles, 2015). Compared with single mothers, single fathers report less time caring for their children and poorer closeness (Cheung & Park, 2016; Dufur, Howell, Downey, Ainsworth, & Lapray, 2010). The compromised father-child relationship is predictive of mid- and long-term outcomes among children such as mental health, academic achievement, and aggressive behaviors (Coles, 2015; Zhang, Li, Bai, & Chen, 2021). Specifically, for example, Cheung and Park (2016) evaluated single-parent families in Hong Kong and revealed that the father-child interaction was significantly worse than mother-child interaction, leading to poorer academic performance. Similarly, another study evaluating single-parent families discovered that children living with divorced single mothers performed as well as children from partnered-parent households, whereas children living with divorced single fathers were disadvantaged in academic performance and subjective wellbeing (Zhang, 2020). Taken all together, it important for single fathers to promote and maintain a high-quality relationship with their children. One potentially effective way is through parent education programs.

Parent education programs are psychoeducational and supportive services for parents to improve their parenting skills and relationship with their children (Ponzetti, 2015). These programs provide caregivers with specific knowledge, resources, and support to develop their parenting skills to promote child and family wellness. Several systematic review and meta-analysis studies found parent education programs to be efficacious in fostering young children and adolescents’ psychological wellness, academic progress, participation in extracurricular activities, and parent-child relationships (Armstrong, Eggins, Reid, Harnett, & Dawe, 2018; Sanders, Kirby, Tellegen, & Day, 2014; Wilson et al., 2012).

In addition, studies have identified that a core objective of parent education programs is to improve parents’ parental self-efficacy (Albanese, Russo, & Geller, 2019; Evans et al., 2012). Parental self-efficacy is defined as a parent’s belief in their ability to perform the parenting role successfully (Wittkowski, Garrett, Calam, & Weisberg, 2017). Higher levels of parental self-efficacy have been consistently linked with a broad range of parenting and child outcomes. For example, a systematic review of 115 studies found that improved parental self-efficacy is associated with improved parental mental health, parent-child relationship, and child development (Albanese et al., 2019). Similarly, Bloomfield and Kendall (2012) evaluated a parental education program and linked parenting self-efficacy with significantly reduced parental stress and improved child behavior, which further improved parent-child relationships post-intervention. In summary, improved parental self-efficacy as a result of parent education programs has major implications in supporting single parents to improve their parent-child relationships.

Promoting parental self-efficacy is especially significant for single fathers residing in rural China. Studies have reported that parents in rural China have general low parental self-efficacy, which has contributed poor parenting styles and outcomes among children in rural China (Liu, Lu, & Holmes, 2019). Most importantly, single fathers in rural China report among the lowest parental self-efficacy, which consistently leads to their children’s mental health issues, risk behaviors of substance use, and poor quality of life (Gao, Li, Chan, Lau, & Griffiths, 2013; Wang, Zhang, & Chen, 2019).

Despite a strong body of literature supporting parent education programs in strengthening parents’ parental self-efficacy and parent-child relationships, there exists a major gap in the literature evidenced by fewer than 20% of the programs targeting single fathers (Tully et al., 2017). As studies have increasingly documented the significant role of fathers in the development and wellness of children (O’Gara, Zhang, Padilla, Liu, & Wang, 2019), it has become clear that parent education programs for fathers, and especially for single fathers, are urgently needed. More importantly, to our knowledge, there exists no study that has evaluated parent education programs for Chinese single fathers who reside in rural areas, which represents a salient mental health disparity among this already underserved population and their children. Therefore, this study evaluates a group-based parent education pilot program for single fathers from rural areas in China. Specifically, we evaluated the following study hypotheses: 1. Is a parent education program associated with single fathers’ improved parental self-efficacy, 2. Is a parent education program associated with single fathers’ improved family participation, that is, family-school communication, participation at school, and participation at home, and 3. Is a parent education program improved single fathers’ parent-child relationship.

Method

Participants and Recruitment

Participants were recruited from a rural residential area in central China with a registered population of 1200 residents from May 30 to August 30, 2020. With the assistance of local administrators, we used convenient sampling strategies and enrolled study participants on a rolling basis. The study flyer was distributed in local community activity centers as well as distributed virtually through social media platforms, for example, WeChat groups. Interested participants reached out to the study team for an initial screening interview. To be eligible to participate, a parent needed to: 1. be 18 years or older, 2. have a child currently between the age of 6 and 12 years old, 3. be a single father, 4. be able to attend the full intervention, 5. be physically and cognitive intact to participate, and 6. subjectively express (during the initial screening interview) the need for an improved parent-child relationship. The reason we focused on single fathers of children 6–12 years old was that this age group is in the strongest need of father involvement, and their fathers are often too busy working to take care of them. Children who are 13 years of age or older often leave the village for school, and their interactions with fathers are significantly reduced (Lu, Yeung, Liu, & Treiman, 2019).

Design Overview and Study Procedure

The study was approved by the Huazhong University of Science and Technology Institutional Review Board. A single group pretest and posttest design was deployed to compare outcomes over time, specifically at pre-treatment, immediate post-treatment, 1-month post-intervention, and 1-year post-intervention intervals. We chose this design over quasi-experimental or randomized controlled trial primarily because of funding limit and feasibility. We considered assign one group of farther into treatment and one group into control, but such design would not effectively allow us to account for provider/facilitator effect. Therefore, we consider the existing design as the best option considering study feasibility.

Figure 1 illustrates how study participant candidates moved (or did not move) through the process of participating. During an initial appointment, study participants received a baseline assessment, including the parental self-efficacy scale, family involvement questionnaire, and child-parent relationship scale. Interested participants then received a pre-session interview to collect their demographic information, current needs, and parenting priorities.

Figure 1.

Study participant flowchart.

Upon completing the baseline assessment and entering the study, single fathers participated in in-person group sessions of six to eight participants. Upon completing all 13 sessions, participants completed face-to-face assessments both immediately post-intervention and at 1 month post-intervention. Additionally, study participants completed a 1-year follow-up assessment virtually with the study research assistants. Participants received incentives for their time and participation in the form of a gift pack composed of life necessities that was valued at $5. Design overview/assessment is outlined in Figure 2.

Figure 2.

Study design/assessment overview.

Parent Education Program Protocol

The parent education program contained four stages (13 sessions) that are based on the Parent Effectiveness Training developed by Thomas Gordon (2000). Like the Parent Effectiveness Program developed by Gordon, the Parent Education Program (PEP) contains key theoretical components of Bandura’s theory of self-efficacy (Smelser & Baltes, 2001). The four stages include 1. promoting self-perception (sessions 1–4), 2. improving parenting-related skills (sessions 5–7), 3. obtaining positive (parenting) experiences (sessions 8–11), and 4. strengthening social support (sessions 12–13). The primary goal of stage 1 is to challenge single fathers’ inappropriate self-perception and to discover the strengths they and their children possess, as well as the important role of father involvement in child caregiving. The primary goal for stage 2 is to strengthen single fathers’ parenting skills and to promote father-child communication. The primary goal for stage 3 is to create opportunities for single fathers to interact with their children, encourage positive interactions, and troubleshoot father-child conflicts. The primary goal for stage 4 is to support single fathers to build a supportive network so they can be more effective parents to their children. Core principles of the PET program, such as the inconsistency principle, not all behaviors are acceptable, and the importance of sharing feelings, are being integrated throughout the intervention. Additionally, we also integrated specific training components from the Systematic Training for Effective Parenting (STEP) into the program (Dinkmeyer & McKay, 1989). Specific STEP techniques/skills, that is, positive listening training and communication training, have been found culturally appropriate and effective for Chinese parents (Cheung & Yau, 1996; Lai, 1993). Therefore, we intentionally integrated these culturally validated techniques into the existing program to promote its effectiveness for Chinese fathers. On average, each session lasted for about 90 minutes with a group of six to eight single fathers. Figure 3 visually outlines the PEP.

Figure 3.

Parent education program outline.

Training, Supervision, and Fidelity Assessment of the Study Clinician

Both group interventions were facilitated by a master of social work graduate student (during her advanced year of study) who received training from the study principal investigator (PI) who has a doctoral degree in social welfare and a professional psychologist with expertise in parent education programs. After each group session, the study clinician took progress notes to reflect on the session and the study PI reviewed all progress notes to ensure treatment fidelity. Ongoing supervision was provided to the study clinician by the study PI every week throughout the study period to address any urgent clinical matters or concerns. A separately trained graduate level research assistant conducted all assessments.

Outcome Measures

Parental Self-Efficacy

Parental self-efficacy was measured by the parent self-efficacy scale (Chen, 2004). This validated Chinese scale includes 10 items evaluating a parent’s parenting self-efficacy, such as “I think my ways of parenting my child are helpful to their growth,” “I know how to effectively parent my child,” or “I think I am a good parent/father.” Participants responded to a 5-point Likert scale from “1 = not at all” to “5 = very true,” and an average score across 10 items ranged from 1 to 5 with a higher score indicating a higher level of parental self-efficacy. Similar to published studies, our sample reported satisfactory psychometric properties of the scale with Cronbach’s alphas of 0.70–0.79 across timepoints.

Family Participation

Family participation was evaluated using the validated and translated Chinese version of the Family Involvement Questionnaire–Short Form (FIQ-SF; Fantuzzo et al., 2013). FIQ-SF contains 20 items evaluating three dimensions of family/parental participation: family-school communication (7 items), parent participation at school (6 items), and parent participation at home (7 items). Participants responded to questions such as “I talk to the teacher about my kid’s daily life” (family-school communication), “I participate in my kid’s school activities” (participation at school), and “I talk to my kid about his/her/their study at home” (participation at home). Participants evaluated each item on a 5-point Likert scale ranging from “1 = not true at all” to “5 = completely true,” and an average score across 20 items was used to evaluate a father’s participation, with a higher score indicating a greater level of parental participation. Our study reported acceptable psychometric performance with Cronbach’s alphas ranging from 0.67 to 0.71 across assessment timepoints.

Parent-Child Relationship

The parent-child relationship was measured using the validated and translated Chinese version of the Child-Parent Relationship Scale Short Form (CPRS; Pianta, 1992). CPRS contains 15 questions evaluating two dimensions of parent-child relationships, parent-child relationship conflict and parent-child relationship closeness; examples include “my kid gets upset with me easily” (conflict) and “my kid will talk to me when they are upset” (closeness). Participants responded to the questions using a 5-point Likert scale ranging from “1 = not at all” to “5 = very true” with average scores (for conflict and closeness separately) ranging from 1 to 5 and higher scores indicating greater levels of parent-child relationship conflict and parent-child relationship closeness, respectively. Our study reported acceptable psychometric performance with Cronbach’s alphas ranging from 0.70 to 0.81 across assessment timepoints.

Data Analysis

Descriptive statistics were used to characterize participants’ demographic and pre-intervention characteristics, as well as participants’ attendance. We also described the mean differences for different outcomes across timepoints. We also used repeated measures of analysis of variance (ANOVA) to evaluate patterns of difference in outcomes across four timepoints, that is, baseline, immediate post-intervention, 1 month post-intervention, and 1 year post-intervention. Partial eta squared was considered as effect sizes for the repeated measures ANOVA, and we calculated 90% confidence interval for partial eta squared effect size as recommended by methodological studies (Richardson, 2011). We retained 14 out of 16 participants for all assessment timepoints, reflecting an 88% retention rate. Group mean imputation was used to address missing data, and sensitivity analyses using other imputation methods revealed the same findings. We selected ANOVA over multivariate analysis of variance (MANOVA) primarily due to concerns of statistical power.

Results

Sample Characteristics

Sixteen eligible participants provided informed consent, completed the baseline assessment and pre-session interviews, and entered the study to receive PEP. As shown in Table 1, participant fathers’ age averaged 35.25 years old (SD = 3.27) and ranged from 26 to 40 years old. Most fathers completed middle school, and the average period of divorce was 4.86 years (SD = 1.77). Participating fathers’ children were, on average, 8.06 years old (SD = 1.56), and 56% (nine children) were girls. Participating fathers’ pre-intervention parental self-efficacy scores averaged 2.39 (SD = 0.35) out of 5. In terms of family participation, fathers’ pre-intervention scores averaged 1.99 (SD = 0.14), 2.13 (SD = 0.29), and 2.01 (SD = 0.12) for family-school communication, participation at school, and participation at home, respectively. Pre-intervention father-child conflict was relatively high (mean = 3.5 out of 5; SD = 0.25) and father-child relationship closeness was relatively low (mean = 2.02 out of 5; SD = 0.20).

Table 1.

Descriptive Statistics.

	Mean (SD)	Frequency (%)
Child’s age	8.06 (1.56)
Child sex (female)		9 (56.2%)
Father’s age	35.25 (3.27)
Father’s education
Elementary school or below		3 (18.8%)
Middle school		9 (56.2%)
High school or above		4 (25%)
Years of being divorced	4.86 (1.77)

Treatment Adherence

Treatment adherence was very strong, evidence by 14 out of 16 participants (88%) who completed all intervention sessions as well as all follow-up assessments. Importantly, the two fathers who did not complete the intervention left due to work-related or logistic reasons, not for reasons such as the intervention was unhelpful or boring.

Differences from Pretest (T₀) to Posttest (T₁) and to One Year Follow-Up (T₃)

Table 2 presents the differences from pretest (T₀) to immediate posttest (T₁) and from pretest (T₀) to 1 year follow-up posttest (T₃) across outcome domains. Specifically, participating fathers’ parental self-efficacy improved by 1.17 points from before and after intervention and maintained the improvement by 1.08 points at 1 year follow-up. Single fathers’ family-school communication and participation at home improved for more than one point, but the improvements were relatively low in their participation at school, that is, T₀ to T₁ difference = 0.13 and T₀ to T₃ difference = 0.05. Finally, participating fathers’ parent-child relationship conflict reduced by 1.47 points from before and after intervention and maintained the improvement by 1.3 points at 1 year follow-up. Similarly, single fathers’ relationship closeness improved by 0.96 points from T₀ to T₁ and by 1.09 points from T₀ to T₃ (1 year follow-up).

Table 2.

Parent Education Program Effects T0 to T1 and T0 to T3 Changes (N = 16).

	T0 to T1 Difference	T0 to T3 Difference
Parental self-efficacy	1.17	1.08
Family participation
Family-school communication	1.35	0.9
Participation at school	0.13	0.05
Participation at home	1.45	1.54
Parent-child relationship
Relationship conflict	−1.47	−1.3
Relationship closeness	0.96	1.09

Table 3.

Parent Education Program Effects Across Timepoints (N = 16).

	T0 (M/SD)	T1 (M/SD)	T2 (M/SD)	T3 (M/SD)	ANOVA	Partial Eta Squared	90% CI
Parental self-efficacy	2.39/0.35	3.56/0.35	3.50/0.39	3.47/0.34	95.66***	0.864	[0.878, 0.967]
Family participation
Family-school communication	1.99/0.14	3.34/0.34	3.46/0.26	2.89/0.62	66.33***	0.816	[0.829, 0.954]
Participation at school	2.13/0.29	2.26/0.26	2.23/0.28	2.18/0.27	0.736	0.047	[0, 0.300]
Participation at home	2.01/0.12	3.46/0.24	3.70/0.30	3.55/0.19	211.58***	0.934	[0.943, 0.985]
Parent-child relationship
Relationship conflict	3.50/0.25	2.03/0.14	1.88/0.19	2.20/0.27	168.94***	0.918	[0.929, 0.981]
Relationship closeness	2.02/0.20	2.98/0.25	3.07/0.38	3.11/0.29	113.36***	0.883	[0.896, 0.972]

Note.***p < 0.001.

Intervention Effects Overtime

Quantitative results using ANCOVA were presented in Table 3. Our first hypothesis was to evaluate if a parent education program is associated with single fathers’ improved parental self-efficacy. Repeated measures of ANOVA supported this hypothesis and revealed a statistically significant pattern of difference in fathers’ parental self-efficacy over time (T₀ to T₃), F(3) = 95.66, p < 0.001, partial $η^{2}$ = 0.86, 90% CI: 0.878–0.967. The magnitude of the effect size, that is, partial $η^{2}$ , reflected a large treatment effect size, suggesting the intervention explained 86% of the variance before and after the treatment. The first hypothesis was supported.

Our second hypothesis was to evaluate if a parent education program is associated with single fathers’ improved family participation, that is, family-school communication, participation at school, and participation at home. This hypothesis was partially supported. Patterns of difference in fathers’ family-school communication, F(3) = 66.33, p < 0.001, $η^{2}$ = 0.82, 90% CI: 0.829–0.954, and fathers’ participation at home, F(3) = 211.58, p < 0.001, $η^{2}$ = 0.93, 90% CI: 0.943–0.985, were both statistically significant. The treatment effect sizes for both outcomes were both large effect size, suggesting the intervention explained a substantial amount of variances before and after treatment. However, the intervention was not associated with improvement in single fathers’ participation at school, F(3) = 0.736, p > 0.05, $η^{2}$ = 0.047, 90% CI: 0–0.30.

Finally, our final hypothesis was to evaluate if a parent education program is associated with single fathers’ improved parent-child relationship, i.e., relationship conflict and relationship closeness. Statistically significant patterns of difference were observed in the reduction in father-child conflict, F(3) = 168.94, p < 0.001, $η^{2}$ = 0.92, 90% CI: 0.929–0.981, and in the improvement in father-child closeness, F(3) = 113.36, p < 0.001, $η^{2}$ = 0.88, 90% CI: 0.896–0.972. The intervention reported large treatment effects for both outcomes, indicating a substantial amount of variance before and after treatment being explained. Figure 4 presents average scores of each outcome over time.

Figure 4.

Change of average score on six outcomes over time.

Discussion

Single fathers face major challenges in caring for their children, and this is especially true for those residing in rural areas in China. Poor father-child relationships negatively impact the livelihoods of their children, making it important to support single fathers’ parental self-efficacy and father-child relationships. Overall, the results of this pilot study were highly promising in that participating fathers reported significant improvement across all but one outcome. Treatment adherence in this study was very strong; close to 90% of participating fathers completed all 13 sessions of the intervention and stayed in the study 1 year post-intervention. This adherence rate is 15–20% better than many reported retention rates (Gulamani, Uliaszek, Chugani, & Rashid, 2020; Michael, 2018). One possible reason for the strong retention rate may be the intervention’s group format; studies have found fathers are more receptive to support groups than individual therapy sessions (Duhig, Phares, & Birkeland, 2002; Glynn & Dale, 2015), a factor social work practitioners may want to take into consideration.

Findings of this study revealed that a parent education program promoting single fathers’ parental self-efficacy is promising in reducing father-child conflict and in promoting father-child relationship closeness. As conceptualized in this study, parental self-efficacy may be a potential mediator in triggering a set of outcomes that are directly linked with children’s wellness, that is, parent-child conflict and closeness. Although this study was not designed or sufficiently powered to evaluate parental self-efficacy as an intervention mediator, significant improvements in single fathers’ parental self-efficacy and father-child relationships preliminarily supported our study conceptualization. This has clinical implications for social workers supporting single fathers in that parental self-efficacy should be an important part of social work assessment and intervention.

Although the evaluated intervention significantly improved single fathers’ family-school communication and participation at home, it failed to improve the fathers’ participation at school. While most skills taught in the program are transferrable to home and school settings, we were not surprised to see this finding. Participation at home and family-school communication can be done when fathers are at home, but school participation would require additional time that many singles fathers do not have. This highlights the importance of integrating an ecological perspective when supporting single fathers, taking into consideration their busy life schedules.

Overall, we consider the evaluated parent education program based on PET very promising for single fathers residing in rural China. For social workers in China supporting these fathers, it is important to undertake the necessary cultural modification of the standard Western program to better fit the needs of clients in China (Zhang et al., 2018). Similarly, for social worker supporting Chinese American fathers in the United States, it is equally important to consider cultural related factor when delivering supportive services (Kim, Ng, & Ahn, 2009). These culturally targeted modifications are essential in engaging Chinese fathers in psychosocial programs as many are doubtful or resistant to these programs in the first place. Therefore, tailoring the programs with content that have high acceptability among Chinese fathers will facilitate the acceptability and engagement of this population.

It is important to note several limitations of this pilot trial. First, despite the findings of the study being significant, they should be interpreted with caution due to the study’s small sample size. It is important to further evaluate the intervention in a larger sample. Second, this study used a quasi-experimental design, which did not compare the parental education program to a control condition. Therefore, the findings of the study should be considered preliminary, and a randomized controlled trial design should be considered in future studies. Finally, given that fathers were recruited from a small residential area, the findings have low generalizability.

Notwithstanding these limitations, results from this study demonstrate the significant potential of a parent education program in supporting single fathers from rural areas of China. The role of parental self-efficacy was identified as an important intermediate outcome for single fathers. Results from this pilot study extend beyond existing parent education programs by evaluating a well-validated parenting program among single fathers from rural areas in China. Social workers may consider using parent education programs to support Chinese single fathers, especially those from rural areas.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research and/or authorship of this article: This study received funding from National Social Sciences Foundation (Grant ID 21BSH121).

ORCID iDs

Yan Luo

Anao Zhang

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A Parent Education Program for Single Fathers’ Parent-Child Relationship in Rural China: A Pretest–Posttest-Follow-Up Study

Abstract

Keywords

Method

Participants and Recruitment

Design Overview and Study Procedure

Parent Education Program Protocol

Training, Supervision, and Fidelity Assessment of the Study Clinician

Outcome Measures

Parental Self-Efficacy

Family Participation

Parent-Child Relationship

Data Analysis

Results

Sample Characteristics

Treatment Adherence

Differences from Pretest (T0) to Posttest (T1) and to One Year Follow-Up (T3)

Intervention Effects Overtime

Discussion

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iDs

References

Differences from Pretest (T₀) to Posttest (T₁) and to One Year Follow-Up (T₃)