Li et al. BMC Public Health 2013, 13:1079http://www.biomedcentral.com/1471-2458/13/1079R E S E A R C H A R T I C L E Open AccessEffectiveness of a parental training programme inenhancing the parent–child relationship andreducing harsh parenting practices and parentalstress in preparing children for their transition toprimary school: a randomised controlled trialHo Cheung William Li1*, Sophia SC Chan1, Yim Wah Mak2 and Tai Hing Lam3AbstractBackground: Entering primary school is an important childhood milestone, marking the beginning of a child’s formaleducation. Yet the change creates a time of vulnerability for the child, the parents and the parent–child relationship.Failure to adjust to the transition may place the family in a psychologically devastating position. The aims of this studywere to test the effectiveness of a parental training programme in enhancing the parent–child relationship anddecreasing parental stress by reducing harsh parenting in preparing children for the transition to primary school.Methods: A randomised controlled trial incorporating a two-group pre-test and repeated post-test was conducted inone of the largest public housing estates in Hong Kong. A total of 142 parents were recruited, with 72 parentsrandomly assigned to the experimental group and 70 to the control group. Harsh parenting practices, parent–childrelationships and parental stress were assessed.Results: In comparison to parents in the control group, those in the experimental group engaged in less harshparenting practices and reported better parent–child relationships. However, parental stress scores did not differsignificantly between the two groups.Conclusion: This study addressed a gap in the literature by examining the effectiveness of the training programme forenhancing parent–child relationship and decreasing parental stress at the time of a child’s transition to primary school.The findings from this study provide empirical evidence of the effectiveness of the parental training programme andhighlight the significance of parenting in promoting a smooth transition for children from kindergarten to primary 1.Trial registration: ClinicalTrials.gov: NCT01845948.Keywords: Children, Harsh parenting practices, Parent–child relationships, Parental stress, TransitionBackgroundMoving from kindergarten to primary 1 is perceived asone of the most important milestones for children, mark-ing the beginning of their formal education. This transi-tion can be both an exciting and an anxiety-provokingexperience for children, having a profound effect on them[1-3]. A recent study showed that the transition creates* Correspondence: william3@hku.hk1School of Nursing, The University of Hong Kong, 4/F, William M. W. MongBlock, 21 Sassoon Road, Pokfulam, Hong KongFull list of author information is available at the end of the article© 2013 Li et al.; licensee BioMed Central Ltd. TCommons Attribution License (http://creativecreproduction in any medium, provided the or stress for children, as evidenced by high levels of worryand low levels of happiness before the start of the aca-demic year in primary school [4]. Furthermore, the transi-tion may not only have an effect on the children but alsocreate stress within the families because parents need toadjust themselves to new roles. In contemporary Chinesesociety in particular, most men and women must work fulltime outside their homes and take up multiple social rolesas paid workers, spouses and parents. Tang [5] reportedthat due to insufficient skills, time and energy to fulfilsuch demanding roles, many Chinese parents experiencehis is an open access article distributed under the terms of the Creativeommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andiginal work is properly cited.

Li et al. BMC Public Health 2013, 13:1079 Page 2 of 12http://www.biomedcentral.com/1471-2458/13/1079considerable stress. When children move from kindergar-ten to primary school, the parents’ concerns shift — fromtheir child’s physical well-being to their child’s futuresuccess. In this circumstance, some parents may adoptcomponents of a harsh parenting style in rearing their chil-dren, which may actually cause some harm to the family.According to Shek [6], harshness in fathers and a demand-ing style in mothers can trigger child–parent conflicts, withthe relationship being bidirectional. Furthermore, parentalcriticism not only increases conflicts in the family but canalso incite emotional and aggressive behaviour in the child[7]. A previous study showed that conflicts within the fam-ily were positively related to children’s emotional problems,whereas positive parent–child relationships were inverselyrelated to such problems [8]. Some parents may believe,however, that offering praise when their children do wellwill cause the children to fail because they will becomeoverly proud of themselves. However, lack of praise may de-crease parental warmth, which is an essential element inpromoting emotional adjustment and social and scholasticachievement in children [9].Hong Kong has witnessed a significant change in familystructure, with extended families gradually being replacedby small nuclear families over the past few decades [10].Children are thus receiving more attention from parentsas a result of there being fewer, if any, siblings in the nu-clear family. In addition, most parents and school childrenin Hong Kong share a belief that a desirable career andbright future are the inevitable results of strong academicachievement. There is a famous Chinese proverb that says,‘In textbooks you will find girls with complexions like jadeand houses made of gold’. Under the influence of suchtraditional Chinese thought, children in Hong Kong areunder sustained and substantial pressure within the familyand at school while growing up [11]. Meanwhile, HongKong Chinese parents are also exposed to considerablestress when their child is promoted from kindergarten toprimary 1 education.The transition creates a time of vulnerability for thechild, the parents and the child–parent relationship.Failure to adjust to the transition, on the part of either theparents or the child, might place the family in a psycho-logically devastating position. There is some evidence thatgood provision for transitions will result in fewer difficul-ties encountered by children in later school life [3]. Theliterature highlights that parental involvement in the prep-aration of children plays a significant role in ensuring asuccessful transition [12]. Indeed, if the transition can behandled in an appropriate manner, it can be regarded as avaluable opportunity for children to learn not only how tosolve problems, but also how to develop confidence in re-sponse to a changing environment. Such experiences willlay a good foundation for their future learning and pro-mote their interest in life-long learning. Therefore, before the admission to primary school, providing interventionsthat can help children and parents adjust to their newroles and developmental tasks during the stressful schooltransition period is crucial.Studies conducted in Western countries have shown thatprogrammes focusing on parenting are beneficial to thepsychological well-being of both children and parents[3,13-16]. One such programme is the Triple P-PositiveParenting Programme (the Triple P system, TPS), whichaims to bring about positive psychological outcomes bypromoting positive parenting. Sanders et al. [3] investigatedthe effectiveness of the TPS in reducing the prevalence ofchildren’s mental health problems, parental adjustmentdifficulties and dysfunctional parenting at the time of tran-sition. They found that this programme was able to reducethe emotional problems and psychosocial difficulties forchildren living in TPS communities. In addition, parentswho followed the programme were less likely to engage incoercive parenting or experience stress and/or depressiveepisodes. Consistent findings were obtained by Beckettet al. [14], who examined the effectiveness of differenttypes of parenting programmes to improve the social be-haviour and reading ability of children at risk. The resultsindicated that compared with parents in the control group,parents who followed a programme that focused on build-ing a better parent–child relationship (Incredible Years)tended to report their children as having fewer behaviouralproblems. In addition, these parents felt more able to man-age their child’s behavioural problems. Thus, there is com-pelling evidence to support the importance of parenting inreducing the psychological and emotional problems ofboth young children and their parents, potentially helpingthem to go through a school transition.The most common primary 1 preparatory programmerun by schools in Hong Kong teaches children how to or-ganise their school bags, observe school rules and regula-tions, familiarise themselves with school timetables anddifferent subjects and record homework in their studenthandbooks [17]. Thus, the programme activities focus onthe physical preparation of children, with the importanceof parental involvement and the psycho-educational needsof parents during the process of transition often over-looked by schools and by the parents themselves. Indeed,there is a need for parental training programmes on thepreparation of children for transition to primary schoolsin Hong Kong.Although the programmes implemented in Westerncountries show promising results in promoting the psy-chological well-being of children and parents at the timeof transition, these programmes may not be applicable toparents in Chinese society because of the different culturalcontext. As a former British colony, Hong Kong peoplehave been subject to the effect of Westernisation. How-ever, many of them are still rooted in Chinese culture

Li et al. BMC Public Health 2013, 13:1079 Page 3 of 12http://www.biomedcentral.com/1471-2458/13/1079because of the influence of Confucianism [18], which em-phasises governance and obedience [19]. Therefore, par-ents in Hong Kong commonly believe in the notion of‘spare the rod and spoil the child', making them unable torecognise the harmful effects of harsh parenting [20]. Inaddition, some of the gestures (like hugging and kissing)that show parental warmth are unlikely to be adopted byparents in Chinese society because these parents are con-siderably more reserved than parents in Western countries[21]. Hence, rather than promoting positive parenting, dis-couraging harsh parenting seems to be a more feasibleand suitable approach for Chinese parents.Given the above issues, there is a great need to developand evaluate appropriate interventions for Chinese parentsso that they can help their children enjoy a smooth pas-sage to a pleasurable learning life in primary school, whichwill come about by building good parent–child relation-ships and decreasing parental stress. The aims of thisstudy were to test the effectiveness of a parental trainingprogramme in improving the parent–child relationshipand decreasing parental stress by reducing harsh parentingat the time of transition.Hypotheses of the interventionThe three hypotheses were:1: Parents who received the parental trainingprogramme would engage in less harsh parentingpractices when compared with parents who receivedassessment only.2: Parents who received the parental trainingprogramme would report better parent–childrelationships when compared with parents whoreceived assessment only.3: Parents who received the parental trainingprogramme would reduce the level of stress duringthe transition when compared with parents whoreceived assessment only.Theoretical frameworkThe importance of the parent–child relationship duringtransition can be accounted for within Lazarus andFolkman’s [22] framework of cognitive appraisal, stressand coping. According to this framework, the emotionalexperience of an individual towards a potentially stressfulevent is determined by that individual’s primary and sec-ondary appraisals. Primary appraisal refers to the individ-ual’s evaluation of the meaning and significance of theevent as it pertains to the individual’s well-being. Thoseevents that are perceived by the individual as being im-portant and relevant are likely to provoke emotional stress.Secondary appraisal refers to the individual’s assessmentof his or her capability to cope with such an event. Thoseindividuals with more available resources are likely to have better control over stressful situations, resulting in min-imal psychological distress. Indeed, social support fromparents has long been recognised as an important re-source in secondary appraisal [23,24]. Specifically, parentscan promote effective coping in their children via coach-ing (listening to children’s voices and providing feedback)and modelling (setting examples of coping behaviour).These strategies can enable children to consider everypossible solution to deal with stressful situations and canlessen the effect of such situations on the children’s psy-chological health [23]. Therefore, it is anticipated that chil-dren who have a positive relationship with their parentsare most likely to receive social support from them, result-ing in a smooth transition to primary school life.Most social cognitive theories assume that intention tochange is the best predictor of actual change. However, in-dividuals often do not behave in accordance with their in-tentions. Examples include habitual smokers and personswho are obese. There is increasing evidence that the HealthAction Process Approach (HAPA) is helpful in explainingthe psychological mechanisms in bridging the gap betweenintention and actual change in health behaviour. This studywas guided by the HAPA, which has been widely used toaddress the gap between intention to change and a person’sactual change in behaviour [25-27]. The HAPA model wasoriginally adopted in changing health-compromising behav-iour by using an inductive approach involving two phases:the pre-intentional motivation process and the volitionprocess. The former process emphasises raising an individ-ual’s intention either to engage in a preventive measure orto modify risky behaviour in favour of a healthy practice.The volition process is self-regulatory and determinedby action plans and action control. These two mediatorshelp the individual to structure a strategy for maintaininghealthy practices and defeating other conflicting ideas[28,29]. Indeed, harsh parenting can be regarded as health-compromising behaviour within a family. It is well docu-mented that most parents comprehend the importance ofpositive parenting, but regrettably find it difficult to refrainfrom harsh parenting [30]. This has important implicationsfor restructuring a new parenting programme. Through in-corporating a HAPA to such a programme, it is expectedthat parents will engage in positive parenting and developstrategies to minimise negative parenting by motivatingthem to put positive parenting into practice.MethodsDesignThis study was carried out in one of the largest publichousing estates in Hong Kong. A randomized controlledtrial, two-group pre-test and repeated post-test, between-subjects design was employed. A simple completerandomization was adopted in this study. We put twosealed opaque envelopes in a box, with one labelled

Li et al. BMC Public Health 2013, 13:1079 Page 4 of 12http://www.biomedcentral.com/1471-2458/13/1079experimental and another labelled control. Each parentwas asked to draw one envelop from the box to determinegroup assignment. Another sealed opaque envelop withthe same group assignment being drawn was then putback in the box again before the next assignment. Asingle-blinded technique was used, in which the personwho was responsible for data collecting, was unaware ofthe intervention allocation of the study participants.ParticipantsChinese parents living in Tung Chung with a child tobe promoted from kindergarten to primary one educa-tion, and meeting the inclusion criteria for the study,were invited to participate in it. The criteria were thefollowing: (1) parent must be able to read and writeChinese, and (2) parent must have had primary schooleducation or above. Parents with identified cognitiveand learning problems were excluded, as were childrenwith such problems. A convenience sampling of 142parents was recruited during the school summer holi-days in 2009.InterventionIn the control group, parents had no intervention exceptthat an information leaflet for parents on helping chil-dren to adapt to the new primary school life publishedby Education Bureau was given to each parent at theend of data collection. The content of the informationleaflet include the following: the aims of primary education; the layout of the school and its facilities; the details of school life, including timetabling,school regulations, homework policies, use oftextbooks/learning packages and exercise books,assessment methods, policies and procedures on sickleave, and school routines; the mode of home−school collaboration.In the experimental group, parents participated in theparental training programme approximately 1 month be-fore the start of the academic year in primary school. Twosocial workers, each with a minimum of 5 years’ experi-ence in providing family counselling, implemented the in-terventions. The parental training programme was set upfor small groups of 8 to 12 parents each and ran for 4 con-secutive weeks. The programme consisted of four groupsessions, each lasting about 2 hours. Overall, the parentalintervention included teaching parents (1) to use more ac-tive listening skills, (2) to engage less in harsh parentingpractices, (3) to use more praise and encouragement and(4) to set reasonable expectations in the rearing of theirchildren. Each session began with a review of the skills orconcepts discussed in the previous sessions, i.e., each session built upon the previous session. The followingthree approaches were used to facilitate the learningprocess: Metaphor: by using the living plant as a symbol ofgrowth and nurturing, the concept of parentingbecomes easy for parents to master. Teaching without a teacher: this means encouragingparents to learn from each other through groupdiscussion. Role playing and planning: parents have theopportunity to act out roles in front of groupmembers. They can then refine their parenting planand skills and gain the self-confidence to actualisethe plan with their children.The parental training programme, which aims to en-hance the parent–child relationship and reduce parentalstress at the time of transition, was developed by the re-search team. The intervention components were selectedon the basis of the theoretical framework of parentingstyles put forth by Baumrind [31]. Under this frame-work, harsh parenting is a child rearing style that com-municates high levels of demandingness but low levelsof responsiveness. It is characterised by the use of cor-poral punishment or verbal hostility to convey high ex-pectations without any explanation [31,32]. In fact,according to the results of a published study, active lis-tening and praising are positively associated with re-sponsiveness, whereas setting reasonable expectations isnegatively correlated with demandingness [32]. There-fore, the research team decided to include these compo-nents in the intervention to reduce harsh parenting.The development of the intervention was based on theHAPA model, according to which risk perception is a distalantecedent for raising the intention to change in the pre-intentional motivation process. In the initial motivationstage, a parent might have already developed an intentionto help his/her child adapt the transition. Within this stage,risk awareness is seen as a distal antecedent (for example,‘My child and I are at risk of family health problems or dis-turbances in the family harmony or family happiness if thetransition does not go well’). Parents in the group weretherefore invited to discuss any potential problems that thefamily or child might encounter during the transition. Thishelped the parents to become aware of the negative conse-quences of a maladaptive transition and subsequently de-velop an intention to help their children through thetransition. Further elaboration of the parents’ thoughtsabout the consequences and positive outcome expectanciesin smoothing the transition was then facilitated.In applying the HAPA to the parenting programme, self-regulation was emphasised in the motivation process,whereby role playing, demonstration and re-demonstration

Li et al. BMC Public Health 2013, 13:1079 Page 5 of 12http://www.biomedcentral.com/1471-2458/13/1079were applied. Parents were invited to demonstrate a quarrelthey might have with their child and the usual ways theywould deal with it. Other parents in the group were invitedto suggest some alternative ways for handling the quarreland techniques the role-players could use to control theirown emotions. These activities helped parents to structurean appropriate strategy to refrain from harsh parentingpractices and maintain a positive attitude.The programme was designed as a cognitive-dissonance-based intervention for use in group therapy to help parentsbuild supportive relationships with their children and thushelp the families smoothen the transition to primary 1 edu-cation. Parents were encouraged to enhance their know-ledge and parenting skills through an inductive learningapproach. Parent–child relationships could then be en-hanced by changing the attending parents’ parenting prac-tices. Several goals may be particularly important inpreventing adjustment problems: Increasing parents’ awareness of what the childrenneed in the transition. Motivating parents to change to and maintainpositive parenting by increasing their risk awarenessand reinforcing the consequences of harshparenting. Enhancing positive parent–child interactions andrelationship-building between the parents and childvia warm parenting, positive parent–child interac-tions and use of praise. Helping parents identify high-risk situations duringthe transition that might create adjustment difficul-ties, such as writing, doing homework and perform-ing other school tasks. Facilitating development, planning, rehearsing andrevising parental strategies to smooth the transition.The protocol, which covers the schedule of activitiesand the session contents, is described in Table 1.To ensure the integrity of the intervention, the same so-cial workers were responsible for the parental training.These social workers were required to complete a 2-hourtraining workshop that was provided by the principal in-vestigator. The workshop covered children’s psychologicalneeds, information regarding positive and negative parent-ing, practical tips and counselling techniques. The socialworkers were also required to record the total time spentin each parental training session.Concerning the quality of the intervention, an inter-vention component checklist was developed by the re-search team. Ten intervention sessions were randomlychosen to be videotaped. The tapes were then audited bythe research team using the checklist. Comments andsuggestions were given to the social workers in the regu-lar weekly evaluation meetings. MeasuresSelf-reported parent–child relationshipThe parent–child relationship of the participants wasmeasured by using a self-reporting method consisting oftwo items, with one asking “How satisfied are you withthe parent–child relationship?” and the other ‘As a parent,how satisfied are you with yourself?’ Each item is rated ona 6-point Likert scale ranging from 1 (total unsatisfactory)to 6 (total satisfactory). A total is calculated by addingthe two items together to obtain a score ranging from 2to 12, with higher scores indicating better parent–childrelationships.Chinese version of perceived parental aggression scalePerceived parental aggression scale is one of the subscalesof Parental Acceptance Rejection Questionnaire [33],which is a parent self-report instrument that measuresharsh parenting, i.e. physical or verbal aggression towardschildren. It contains 15 items and each item is rated on a5-point Likert scale ranging from 1 (never) to 5 (always).A total is calculated by adding all items together to obtaina score ranging from 15 to 75, with higher scores indicat-ing higher levels of hostility and aggression to the child.The psychometric properties of the perceived parentalaggression scale have been empirically tested [33,34],showing adequate reliability and validity.Parental Stress Scale (PSS)The PSS was developed by Berry and Jones [35] to assess aparent’s subjective feelings of strain, difficulty and dissatis-faction in reaction to stressors in the parent–child relation-ship. The PSS consists of 18 items on the perception ofparental stress, using a 5-point Likert scale from 1 to 5 (1 =strongly disagree, 2 = disagree, 3 = somewhat disagree, 4 =agree, 5 = strongly agree). A total is calculated by adding allitems together to obtain a score ranging from 18 to 90, withhigher scores indicating higher levels of parental stress.The psychometric properties of the PSS have been em-pirically tested [35-37], showing good concurrent valid-ity, excellent construct validity and adequate internalconsistency reliability. The Chinese version of the PSShas been translated and used by Cheung [36], the find-ings demonstrating acceptable psychometric propertiesfor researchers to assess stress among Chinese parents.Data collectionRecruitment and data collection were conducted duringthe summer in 2009. Participants were recruited throughreferrals from the Hong Kong Sheung Kung Hui WelfareCouncil in Tung Chung. Prior to the study, ethicalapproval was obtained from the Institutional ReviewBoard of the University of Hong Kong. The centre’s headof Sheng Kung Hui integrated services in Tung Chungwas fully informed of the study’s purpose, nature, design

Table 1 Intervention protocol for parentsSession Objectives ActivitiesOne 1. To understand children need from parents when they move to primary school; • Introduction: Introduce the objectives and general rules of the programme. Parents are encouraged tobe active in participation in group activities, such as role play and discussion.• Sharing: Facilitators invite parents to share how they interact with their child at home.• Role play: Facilitators invite two parents to demonstrate an interaction between parent and child.Scenario: The child reported the difficulties encountered in the school to a parent.• Group discussion: Identify strategies to enhance smooth interaction between parent and child.2. To learn the importance of parent involvement in preparing, and dealingwith the transition; • Round up: Facilitators sum up the content that discussed in this session and encourageparents to practice the skills at home.3. To learn the important skills of active listeningTwo 1. To learn the consequences of harsh parenting • Review: Facilitators review the skills or concepts discussed in previous sessions• Sharing: Facilitators invite parents to share their methods in rearing their children2. To engage in less harsh parenting practices • Role play: Scenario: Parents were invited to demonstrate a quarrel they might havewith their child and the usual ways they dealt with it.• Group discussion: Alternative ways for handling the quarrel and controlling emotions.• Round up: Facilitators sum up the content that discussed in this session and encourageparents to engage in less harsh parenting practices at home.Three 1. To learn positive interaction • Review: Facilitators review the skills or concepts discussed in previous sessions2. To learn and practice parenting skill: expressing love and concern;acknowledge efforts taking the point of view of their children and praise their children • Sharing: Facilitators invite parents to share whether they would often use praise andencouragement in rearing their children.• Role play: Interaction between parent and child. Scenario: When receiving unfavourablereport about the child’s school performance.• Group discussion: The pros and cons of using praise and encouragement in rearing their children.• Round up: Facilitators sum up the content that discussed in this session and encourage parentsto use more praise and encourage.Four To set reasonable expectations of their children • Review: Facilitators review the skills or concepts discussed in previous sessions.To learn positive interaction when dealing with their children’s homework,tests and examination • Sharing: Facilitators invite parents to share their expectations of their children.• Group discussion: What are the consequence of having unreasonable expectations of their children.• Exercise: Facilitators ask parents to think about and write down their own reasonable expectationsof their children.• Round up: Facilitators sum up the content that discussed in this session and encourage parents toset reasonable expectations of their children.Li et al. BMC Public Health 2013, 13:1079 Page 6 of 12http://www.biomedcentral.com/1471-2458/13/1079

Li et al. BMC Public Health 2013, 13:1079 Page 7 of 12http://www.biomedcentral.com/1471-2458/13/1079and duration. Written consent was obtained from par-ents after they were told the purposes of the study andagreed to participate. Parents were told that they wereunder no obligation to participate, could withdraw fromthe study with impunity at any time and were assured ofthe confidentiality of the data to be collected.After they had signed consent forms, a research assistantcollected demographic and baseline data from parents.Data collection was divided into three phases: at the timeof recruitment (pre-intervention), at six weeks and threemonths after the intervention. Parents were asked to re-spond to the Chinese version of the parental acceptance-rejection scale, parental stress scale, and self-report scaleon parent–child relationship in respect of the transitionfrom kindergarten to primary school.Data analysisTo minimize attrition bias, intention-to-treat analysis wasdone with missing data substituted by the last-observation-carried-forward procedure. The Statistical Package forSocial Sciences (SPSS) software, version 18.0 for Windowswas used for data analysis. The homogeneity of the experi-mental and control groups regarding the demographicand baseline data were assessed using inferential statistics(independent t-test and chi-square). Mixed between-withinsubjects ANOVA (split-plot ANOVA) was used to deter-mine which intervention was more effective in enhancingparent–child relationships, helping parents to engage inless harsh parenting practices, and reducing the level ofparental stress during the transition from kindergarten toprimary school.ResultsA total of 215 parents living in Tung Chung wereapproached and assessed for eligibility to participate in thestudy. Of 215 families, 152 met the inclusion criteria. How-ever, 10 parents were unable to participate because theywere not available for the intervention during the sched-uled period. The remaining 142 parents were randomlyassigned to the experimental and control groups, with 72parents in the experimental group and 70 parents in thecontrol group. The response rate was 93.4%. The overallretention rates for the experimental and control groupswere 83.3% and 85.7%, respectively. Nevertheless, the at-tendance rates for the intervention sessions were low, withonly 48.6 per cent of the experimental group attending allintervention sessions, with 15 participants (42.9%) absentfrom one, two or three sessions. A Consolidation Standardsof Reporting Trials (CONSORT) flowchart is shown inFigure 1. Information on the demographic and baselinecharacteristics of the experimental and control groups ispresented in Table 2. The experimental and control groupswere similar with respect to the demographic and baseline characteristics, suggesting a high level of homogeneity ofvariance between these two groups.The results of mixed between-within subjects ANOVAon perceived parental aggression, parent–child relation-ship, and parental stress scores across the three time pe-riods are shown in Table 3. The results indicated thatparents in the experimental group engaged in statisticallysignificant less harsh parenting practices and reported bet-ter parent–child relationships than parents in the controlgroup. Using the commonly used guidelines proposed byCohen [38], the eta squared of 0.01, 0.06, and 0.14 are typ-ically interpreted as small, moderate, and large effect sizesrespectively. The results suggest moderate-to-large inter-vention effect sizes. Post-hoc test, using Tukey procedure,confirmed that the differences between groups were statis-tically significant in both six weeks and three months afterintervention. Nevertheless, the results of mixed between-within subjects ANOVA showed that there was no statisti-cally significant difference in parental stress scores betweenthe experimental and control groups.DiscussionThe overall results provide support for the effectiveness ofimplementing a parental training programme to enhanceparent–child relationship and reduce harsh parentingpractices and parental stress in preparing children for thetransition to primary school.Effect of the parental training programme on harshparenting practices and parent–child relationshipThe results of mixed between-within subjects ANOVA onharsh parenting practices and parent–child relationshipsindicated that there was a statistically significant main ef-fect for time. That is, there was a change in parents’ harshparenting practices and the parent–child relationships inboth groups across the three different time periods. Therewas also a statistically significant interaction between timeand the intervention, indicating that the changes in par-ents’ harsh parenting practices and the parent–child rela-tionships over the different time periods differed betweenthe experimental group and the control group. Greaterchange across different time periods was found in the ex-perimental group than in the control group. In comparisonto parents in the control group, parents in the experimen-tal (intervention) group engaged in significantly less harshparenting practices and reported better parent–child rela-tionships. There are some factors that shed light on thesefindings. It has been well documented that Hong KongChinese parents are influenced by the social-cultural em-phasis on obedience, social conformity and academic per-formance [39]. Consequently, many parents in Hong Kongengage in harsh parenting practices in rearing their chil-dren. Although some parents do realise the importance ofpositive parenting, many of them find it difficult to refrain

Approached (n = 278) Refused to participate (n = 63)Assessed for eligibility (n = 215) Did not meet inclusion criteria (n = 63)Refused to participate (n = 10)Respond rate: 93.4%ReasonsNot available for interventions No longer interested to participateRandomized (n =142) Control GroupT1 (n = 70)T2 (n = 67)Retention = 95.7%T3 (n = 60)Retention = 85.7%Reasons for not turn upUnsatisfied with the grouping (n =2)No longer interested to participate (n =8)Experimental GroupT1 (n = 72)T2 (n = 66)Retention = 91.7%T3 (n = 60)Retention = 83.3%Reason for not turn upClashed with other activities (n = 8)No longer interested to participate (n =4) Analyzed (n = 70)Analyzed (n = 72)Figure 1 The consolidated standards of reporting trial (CONSORT) flowchart to track participants through randomized controlled trial.Li et al. BMC Public Health 2013, 13:1079 Page 8 of 12http://www.biomedcentral.com/1471-2458/13/1079from engaging in harsh parenting practices. One of themajor objectives of the parental training programme wasto increase parents’ awareness of risk and reinforce in theirminds the consequences of harsh parenting. Role playing,demonstration and re-demonstration not only providedopportunities for parents to act out their roles in front ofgroup members, but also helped them structure an appro-priate strategy to refrain from engaging in harsh parentingpractices and to maintain positive parenting. Most import-antly, parents were able to refine the plan and their skillsand enjoy more self-confidence in actualising the plan withtheir children. This may explain why parents in the experi-mental group engaged less harsh parenting practices inrearing their children.Transition creates a time of vulnerability for the parent–child relationship. Previous reports have pointed out thatparents who adopt harsh parenting practices and criticismin rearing their children trigger child–parent conflicts and thus hamper the relationship between themselves and theirchildren [6,7]. Therefore, we reasoned that if parents en-gage in less harsh parenting practices in rearing their chil-dren, the parent–child relationships would be enhanced.Effect of the parental training programme on parental stressThe results of the mixed between-within subjects ANOVAindicated that there was a statistically significant main ef-fect for time. This finding suggests that there was a reduc-tion in the level of parental stress following the transitionto primary 1 (6 weeks and 3 months after the interven-tion), regardless of the type of intervention given. This isunderstandable because the parents and their children hadalready gone through the transition, and some of the prob-lems encountered during the transition had been over-come; thus, the parents’ stress might have decreased. Yet,there was a statistically significant interaction between thetime and intervention, which was revealed by the fact that

Table 2 Demographic and baseline characteristics of the experimental and control groups (N = 142)n (%) χ2 pExperimental (n = 72) Control (n = 70)Gender of parentMale 8 (11.1) 10 (14.3) 0.10 0.75 nsFemale 64 (88.9) 60 (85.7)Age range for parents20-29 7 (9.7) 8 (11.4) 5.44 0.14 ns30-39 46 (63.9) 34 (48.6)40-49 14 (19.5) 25 (35.7)50 or above 5 (6.9) 3 (4.3)Parents’ education attainmentNo formal education 3 (4.2) 2 (2.9) 0.60 0.96 nsPrimary 4 (5.6) 5 (7.1)Lower secondary 26 (36.1) 23 (32.9)Upper secondary 32 (44.4) 34 (48.5)Tertiary 7 (9.7) 6 (8.6)M (SD) t pHarsh parenting 35.61 (7.62) 35.44 (7.40) 0.13 0.89 nsParent–child relationship 8.31 (1.31) 8.31 (1.20) −0.04 0.96 nsParental stress 67.54 (6.34) 66.31 (6.23) 1.17 0.25 nsns = Not significant at p > 0.05.Li et al. BMC Public Health 2013, 13:1079 Page 9 of 12http://www.biomedcentral.com/1471-2458/13/1079the changes in the levels of parental stress over timewere dissimilar between the experimental group andthe control group. Parents in the experimental grouphad lower levels of stress than parents in the controlgroup. Nevertheless, the differences were not statisti-cally significant. The effect size for the interventionwas relatively small (0.03), and the result of the poweranalysis was only 0.40, indicating a high chance of atype II error (60%). Low statistical power resulted in anon-significant difference when, in fact, the interven-tion might have been effective. The results suggest thatthe relationship between the particular interventionand parental stress might have been affected by thesmall sample size. Therefore, it would be interesting tosee whether further studies involving larger sampleswould uncover a significant relationship between theparental training programme and parental stress.There may be several other reasons for this non-significant finding in terms of the effect of parentaltraining programme on parental stress. One possible ex-planation lies in the difficulty of determining whetherwe can even expect parental stress to respond to theparental training programme; the programme did notinvolve teaching parents any stress management skills.The training programme had a more specific effect inhelping parents refrain from harsh parenting practicesand enhancing the parent–child relationship. Parental stress as an outcome measure might be less responsiveto the inter vention.The baseline parental stress and harsh parentingscores were clinically elevated. One possible explan-ation is that the stress levels and behaviour of parentsmight have changed markedly before the transition. Al-though we did not obtain any information about par-ents’ stress levels and behaviour at an earlier time, weexpected that these outcome measures would havereturned to normal with removal of the stressor (i.e.,with the children having already transitioned to pri-mary school). However, this study was designed toexamine the net differences in mean scores betweenthe experimental and control groups. The completerandomisation should have been able to eliminate sucha confounding effect because the extent of decrease inoutcome measures in both groups should have beensimilar. Therefore, the net differences in the stress andthe parenting practices of participants in the experi-mental and control groups should be attributablemainly to the inter vention effect.The overall results provide evidence that the parentaltraining programme was effective in facilitating asmooth transition from kindergarten to primary school.In fact, there was generally positive feedback from par-ents after their participation in the programme. Oneparent commented as follows:

Table 3 The results of mixed between-within subjects ANOVA on harsh parenting scores, parent–child relationship scores and parental stress scores in parentsacross the three time periods (N = 142)Harsh parenting Parent–child relationship Parental stressF-value p-value Eta squared Observed power F-value p-value Eta squared Observed power F-value p-value Eta squared Observed powerTime effect 18.13 0.00* 0.27 1.0 6.35 0.00* 0.08 0.89 29.07 0.00* 0.29 1.0Interaction effect 10.49 0.00* 0.13 0.98 7.51 0.00* 0.10 0.94 3.15 0.04* 0.04 0.65Intervention effect 10.63 0.00* 0.07 0.89 16.35 0.00* 0.11 0.98 2.29 0.08 0.03 0.40Notes: *Significant at p <0.05.Li et al. BMC Public Health 2013, 13:1079 Page 10 of 12http://www.biomedcentral.com/1471-2458/13/1079

Li et al. BMC Public Health 2013, 13:1079 Page 11 of 12http://www.biomedcentral.com/1471-2458/13/1079‘I did not realise the negative effects of harshparenting on children before attending theprogramme. Now, I will use more praise andencouragement instead of harsh parenting practices inrearing my child.’LimitationsThis study was limited in that all data were collected in adistrict in Hong Kong, and a small, convenience samplewas used, which might limit its generalizability. A multi-district, with larger sample size to examine the effective-ness of the parental training programme to helping theirchildren attain a smooth transition is recommended in fu-ture studies. Another limitation of this study was that asimple two-item measure was adopted to assess theparent–child relationships, and the psychometric proper-ties of this measure were not comprehensively examinedbefore use. This limitation may affect the legitimacy of thefindings and result in misleading numbers. A validatedmeasure should be used to assess the parent–child rela-tionship in future studies. Additionally, no observationmeasure was included in the study to assess whether thechildren moved smoothly into primary school. In HongKong, young children attend primary schools based on thegeographical location of their homes. The teachers whowork in primary schools are normally not the sameteachers who work in the kindergartens. Therefore, infor-mation provided by teachers from either the kindergartensor primary schools may reflect whether the children betteradapt to primary school life after the intervention. It isrecommended that researchers consider the possibility ofgaining access to both kindergartens and primary schoolsto obtain more reliable data by introducing observationmeasures in future studies.Practical implicationsThe findings of this study have important implicationsfor future practice. The results showed that many par-ents adopted harsh parenting skills in rearing their chil-dren during the transition period, which created a timeof vulnerability for the parent–child relationship. Themost important implications for practice from this studyrelate to the determination of the effectiveness of theparental training programme to enhance parent–childrelationship and reduce harsh parenting practices in thepreparation of children for transition to primary school.On the other hand, results showed that a child’s transi-tion from kindergarten to primary school may createconsiderable stress for the parents. Apart from worryingabout their children’s academic achievement and schoolperformance, many parents reported that they had diffi-culty in accepting the role of teaching and helping theirchildren deal with the emotional frustrations that mayemerge during the transition period. Teaching parents some stress management skills in the preparatory paren-tal training programme is therefore a matter of crucialimportance. Indeed, problems that arise from a child’stransition to primary school are common around theworld. Thus, health educators and healthcare profes-sionals in other parts of the world may incorporate thefindings from this study when developing and evaluatingan appropriate programme to facilitate a smooth transi-tion for children to primary school life.ConclusionThis study has addressed a gap in the literature by pro-viding empirical evidence that the parental trainingprogramme is effective in helping parents engage in lessharsh parenting practices in rearing their children, andenhancing parent–child relationships towards the tran-sition from kindergarten to primary one. Most import-antly, this study highlights the significance of parentalinvolvement in promoting a smooth passage to a pleas-urable learning life for children in the primary school.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsAll authors contributed to the study design. WHCL and YWM are responsiblefor patient recruitment, data collection and data analysis. WHCL isresponsible for writing manuscript. THL and SSSC are responsible forreviewing, proofreading and editing the manuscript. All authors contributedto and approved the final manuscript.AcknowledgementsThis study was funded by The Hong Kong Jockey Club Charities Trust.Author details1School of Nursing, The University of Hong Kong, 4/F, William M. W. 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Public Health Nurs 2009, 26(2):153–160.doi:10.1186/1471-2458-13-1079Cite this article as: Li et al.: Effectiveness of a parental trainingprogramme in enhancing the parent–child relationship and reducingharsh parenting practices and parental stress in preparing children fortheir transition to primary school: a randomised controlled trial. BMCPublic Health 2013 13:1079.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submit