When Everyone Said “Don’t Start”: Implementing a Digital Parenting and Family Wellbeing Program Through Political Uncertainty in Mexico’s National Family Health System

When Everyone Said “Don’t Start”: Implementing a Digital Parenting and Family Wellbeing Program Through Political Uncertainty in Mexico’s National Family Health System | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article When Everyone Said “Don’t Start”: Implementing a Digital Parenting and Family Wellbeing Program Through Political Uncertainty in Mexico’s National Family Health System Maxwell C. Klapow, J. Ruben Parra-Cardona, Nancy B. Amador, Ana Pro Alcantára, and 10 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8805265/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Successful prevention initiatives in low- and middle-income countries depend on strong government–research partnerships, yet these collaborations are often tested by political volatility, limited service capacity, and competing institutional priorities. This paper describes the multisectoral coalition that co-developed and implemented Crianza con Conciencia+ (CC+), a digital parenting and caregiver wellbeing program delivered through Mexico’s national family health system. Multiple research institutions partnered with a UN child welfare agency and Mexican state and federal government to rapidly adapt, implement, and evaluate CC+ across four states during a period marked by election restrictions, natural disasters, and shifting institutional conditions. Guided by the EPIS and RE-AIM frameworks, partners used co-design, shared leadership, and flexible implementation structures to navigate these disruptions. We highlight three key lessons for future prevention partnerships: co-design and collective leadership strengthen ownership and resilience; trusted bridge institutions are crucial for navigating political and bureaucratic barriers; and partnerships and implementation plans must be intentionally designed for disruption rather than stability. Preventive Medicine Psychology Health Policy Other Public Policy partnership LMIC government digital behavioral science Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction The Global Need for Partnerships to Promote Prevention Initiatives In the wake of the COVID-19 pandemic, caregiver mental health and parenting stress have emerged as critical public health challenges with profound implications for child development and wellbeing ( Parental Mental Health & Well-Being | HHS.Gov , 2024; Prime et al., 2020 ). Common mental health disorders (CMDs) such as depression and anxiety are among the leading causes of disability globally, disproportionately affecting caregivers in low- and middle-income countries (LMICs) ( GBD 2019 Mental Disorders Collaborators, 2022 ) . Violence against children is similarly elevated in LMIC settings, strongly associated with cultural norms supporting corporal punishment that are intensified by contextual adversity such as poverty, high illiteracy rates, and community violence. In addition, low-income families in LMICs commonly lack opportunities to access evidence-based parenting interventions — often delivered in-person by trained professionals — that can accommodate their strenuous life and working conditions ( Knerr et al., 2013 ). These factors have a high likelihood of becoming predictors of an array of caregiver and child mental health problems, as well as multi-generational cycles of interpersonal violence ( Patel et al., 2018 ; Toth & Cicchetti, 2013 ) . Within this context, parenting programs focused on primary prevention have been consistently identified by leading global health agencies including the World Health Organization (WHO) and UNICEF as key public health strategies to promote child, adolescent, and caregiver wellbeing. Prevention and implementation science offer powerful tools to address this need, particularly when implementing large-scale prevention initiatives that integrate key stakeholders such as child protection systems, practitioners, and governments. Over the past two decades, expanding evidence has demonstrated that parenting programs and caregiver mental health interventions can improve parenting skills, reduce violence against children, improve child development outcomes, and reduce caregiver distress ( Gardner & Backhaus, 2022 ; Jeong et al., 2021 ). In addition, efforts to develop digital and blended models for delivery and lay-facilitator led programs have further extended the potential reach and reduced the cost of such programs, making the possibility of true population-level interventions more feasible ( Cluver et al., 2018 ; Jäggi et al., 2025 ). Despite this progress, the gap between what is known to be effective and what is available to families exposed to intense adversity in LMICs remains wide. Although several evidenced-based parenting interventions have demonstrated robust effectiveness ( Gardner & Backhaus, 2022 ) , few have achieved meaningful scale nor sustainment within service delivery systems by governments at local and national levels in LMICs. In this paper, we present a multisectoral global partnership designed to adapt and scale a universal, parenting and caregiver mental health support program within Mexico’s existing institutional systems. Specifically, we describe the rapid cultural and contextual adaptation and implementation of the Parenting for Lifelong Health (PLH) blended digital-human programs for parents of both adolescents and young children into Crianza con Conciencia+ (CC+) through a partnership between UNICEF, the National Institute of Psychiatry Ramón de la Fuente Muñiz (INPRFM), Parenting for Lifelong Health, the University of Oxford, the University of Tennessee at Knoxville (UTK), and state-level Sistema Nacional para el Desarrollo Integral de la Familia (DIF) systems. Partnerships as the Foundation of Global Collaboration Addressing Positionality The promise of prevention science to address these interlinked challenges is dependent on the ability of researchers and institutions to work collaboratively with governments and communities. Translating evidence into sustainable policy and practice requires confronting longstanding questions of power, equity and ownership that shape global partnerships ( Baumann et al., 2019 ; Parra-Cardona et al., 2021 ).Thus, prevention researchers committed to global prevention must be keenly aware of the risks of engaging in and perpetuating scientific imperialism, particularly when considering the historical oppression that LMICs have experienced throughout their development as nations. For example, the “America for Americans” Monroe doctrine, represented a guiding foreign policy embraced by the US in the 1800s, emphasizing the need to protect the American continent (South-, Central-, and North-) from European interference. As such, the United States was identified as the primary and exclusive source of influence and dominance for the continent ( Gilderhus, 2006 ) . As global prevention scientists, we consider it essential to begin any initiative by examining the positionality of all participating collaborators in light of historical legacies of imperialism and dominance exerted by high-income countries. Otherwise, dynamics of dominance and oppression—although unintended—can be replicated in subtle but damaging ways. Global prevention scientists therefore have a responsibility to remain accountable for these legacies to ensure that collaborations are guided by the needs and priorities established by LMICs ( Baumann et al., 2019 ). Our team approaches this work from an epistemological stance shaped by conducting prevention research in both Latin American and non-Latin American settings, including extensive experience with prevention trials, rigorous evaluation, and a longstanding bias toward partnering with government systems. We recognize that these experiences and preferences have inevitably influenced how we engaged in this collaboration. Establishing Global Partnerships Global partnerships must be grounded in clear communication aimed at overtly addressing power positionality of involved partners. This process leads to establishing mutual accountability and trust. Whereas we recognize this process is aspirational based on the complexities associated with establishing multisectoral global collaborations, we firmly believe that efforts to achieve these goals must guide all phases of collaboration including co-design, co-implementation, and collaborative evaluation. This foundation is critical to facilitate prevention initiatives to be situated within the structures and systems that will ultimately deliver them in sustainable ways. The challenge, however, is that these structures and systems have multiple actors. Community organizations and frontline providers carry the local credibility and relationships necessary to build trust with families. Academic and technical partners contribute scientific stewardship, mechanisms for evaluation, and theoretical expertise. Technologists carry expertise in user experience design to create products populations want to use. Governments control the policy levers, financing streams, and delivery platforms that determine scale. Thus, while each of these actors bring indispensable assets, none can achieve population-level impact alone. Establishing partnerships that integrate and promote these complementary strengths are thus critical for advancing prevention science. They enable translation of evidence into practice and policy, promote co-ownership of initiatives between stakeholders, and build legitimacy for interventions. Partnerships are, however, inherently fragile, particularly in initial phases of implementation. Even with the best of intentions, no matter how well-aligned, they are vulnerable to shifting political priorities, resource constraints, and fluctuating power dynamics amongst institutions with differing mandates ( Hailemariam et al., 2019 ; Sarkies et al., 2021 ). The field of prevention science has repeatedly observed that the scalability of prevention interventions does not exclusively depend on their effectiveness, but primarily, in the capacity of all parties involved to create partnerships that support them. In our experience, this success lies in mutual trust and the capacity to maintain active and transparent lines of communication in which competing agendas (e.g., research vs service) can be overtly and continuously addressed, as well as negotiated. The following section describes the national context in which these ideas were operationalized. By understanding the scale and nature of child maltreatment and caregiver mental health challenges in Mexico, we clarify why a partnership between researchers and government focused on a national prevention initiative was both necessary and urgent. Child Maltreatment, Punitive Parenting Practices, and Caregiver Mental Health: A Brief Overview of the Mexican Context UNICEF recently reported that across Latin America and the Caribbean, violence continues to be part of everyday life, including high rates of violence against children, with two in three children aged 1–14 in Latin America and the Caribbean experiencing violent discipline at home ( UNICEF, 2022 ) . With only 11 countries in the region having laws that fully prohibit corporal punishment, 73 million children remain without legal protections in the region. Violence against children remains widespread within Mexican households. National estimates indicate that at least 63% of families employ punitive disciplinary practices, with over half of children experiencing psychological aggression, 38% physical punishment, and 6% severe punishment. In practice, many children are disciplined through shouting, yelling, or other forms of verbal hostility. Importantly, these high rates of maltreatment contrast sharply with caregivers’ underlying attitudes: fewer than 10% of Mexican mothers surveyed by UNICEF in 2022 endorsed corporal punishment as a desirable or acceptable form of discipline. In contrast to other contexts (such as the US in which corporal punishment in schools is still legal in 17 states) corporal punishment in schools has been fully prohibited across all Mexican states. Existing legislation has also partially prohibited corporal punishment at home, though has not been approved by all relevant federal entities ( Valencia Corral et al., 2020 ). This discrepancy between the existing legal protections for children and elevated maltreatment rates suggest that punitive parenting practices may persist less from cultural endorsement and more from stress, limited knowledge and skills of alternative discipline strategies, and limited access to programs aimed at promoting nurturing and non-punitive parenting practices. These patterns are closely intertwined with caregiver mental health. Depression, anxiety, and chronic stress are well-established predictors of harsh and inconsistent parenting, and Mexico continues to face substantial gaps in meeting the mental health needs of its adult population. Depression and anxiety remain the most common mood disorders—disproportionately affecting women—yet the country has just 3.71 psychiatrists and 2.23 psychiatric nurses per 100,000 people, with even fewer available in rural and low-resource regions ( GBD 2019 Mental Disorders Collaborators, 2022 ) . An estimated 87.4% of adults with mild to moderate conditions, such as depression or anxiety, do not receive treatment ( Kohn et al., 2018 ). These mental-health service constraints have direct implications for child protection: caregiver distress and emotional dysregulation increase the likelihood of harsh discipline, while reducing caregivers’ capacity to engage in consistent, nurturing practices. Parenting programs represent a promising dual-benefit strategy for both reducing violence against children and strengthening caregiver mental health. Evidence from a recent WHO review found that parenting programs produced larger reductions in parental depression than pharmacological approaches alone ( Gardner & Backhaus, 2022 ). This growing body of evidence signals the potential of scalable parenting interventions, specifically hybrid digital delivery, to simultaneously promote nurturing caregiving and address mental-health gaps as part of broader national prevention systems. The Current Study The objectives of this manuscript are three-fold. First, we document how a deliberately structured, multisectoral coalition adapted, implemented, and sustained our partnership to deliver CC+ during a period of exceptional political, environmental, and institutional volatility. Second, we analyze the formal and informal mechanisms that enabled this partnership to function effectively, including co-design processes, shared leadership, and the pragmatic use of implementation science frameworks. Finally, we extract lessons for prevention scientists and policymakers working in similarly complex environments, including designing for disruption, utilizing trusted bridge institutions, and embedding interventions within systems that are themselves in flux. By detailing both the scientific and relational dimensions of this initiative, we illustrate that successful government-research partnership depends not only on intervention effectiveness, but also on coalition design, ethical partnership, and the capacity to manage disruption. To contextualize the partnership, we begin with a brief overview of the CC+ intervention model and phases, followed by a description of the study’s design and implementation process. We then reflect on the sequential development of the collaboration and highlight the enabling conditions that supported partnership resilience and sustainment. CC+ Program Overview Crianza con Conciencia Positiva is a blended digital, in-person, and remotely delivered parenting and caregiver wellbeing program co-developed by INPRFM, UNICEF Mexico, PLH, DIF, and the University of Oxford. The intervention is built on ParentText , a rule-based parenting chatbot developed by PLH ( Ambrosio et al., 2024 ; Cooper et al., 2024 ; Schafer et al., 2023) . Prior research has demonstrated that blended and digital approaches to delivering parenting support can be feasible, acceptable, and effective ( Jäggi et al., 2025 ; Klapow et al., 2024 ). In addition to content aimed at enhancing parenting practices, CC+ includes a universal caregiver mental health component focused on strengthening protective factors for positive mental health and improving psychological wellbeing to address the high rates of caregiver psychological distress in addition to promoting positive and nonviolent parenting practices. CC + was co-developed with Mexican stakeholders to reach families through existing government channels with minimal infrastructure demands. Caregivers of children aged 2 to 17 years participate in a six-week hybrid program consisting of: An in-person onboarding session led by DIF facilitators, introducing families to the CC+ materials and WhatsApp tools; Six chatbot-led parenting courses delivered via WhatsApp focused on positive discipline, communication, and caregiver and child/adolescent mental health; Facilitator-led WhatsApp group sessions providing asynchronous weekly lessons on building parents’ psychological wellbeing, conducting check-ins on comprehension of parenting content, and facilitating peer support; and Home practice activities designed to help caregivers apply new strategies between sessions. Caregivers selected a primary parenting goal (e.g., improving parent-child communication) and completed daily self-paced modules within the chatbot including short videos, comics, and multiple-choice quiz interactions that allowed for personalization of content based on caregiver responses (e.g., child age, stress level, or parenting challenges). Figure 1 presents a sample interaction from the chatbot interface, while Fig. 2 illustrates the components of the intervention over time from onboarding through group sessions. [FIGURE 1 ] [FIGURE 2 ] Despite a short implementation timeline, partners agreed that contextual and cultural adaptation was critical for the initiative to succeed. INPRFM led this process based on their vast experience implementing large scale prevention and mental health initiatives in Mexico. Thus, the cultural adaptation of CC + for the Mexican context was conducted by following established frameworks for cultural adaptation ( Barrera et al., 2013 ; Baumann et al., 2015 ) and human-centered design principles ( Yardley et al., 2015 ) to ensure that all materials reflected the lived experiences, language, and values of Mexican families. Over six months, PLH, INPRFM, UNICEF, and the University of Oxford teams conducted co-design workshops and rapid user-testing exercises with caregivers, facilitators, and government implementers across four states. The process localized content at multiple levels: Language and tone: All materials were rewritten in Mexican Spanish with attention to regional dialects, humor, and conversational rhythm typical of WhatsApp communication. Content contextual and cultural relevance: Parenting examples were reframed to align with common family structures and stressors including multigenerational households, economic pressures, and community-level stressors such as community violence. Parenting and mental health content also emphasized cultural strengths and values such as the protective effect of social support (i.e., community) and strong commitment to family (i.e., familismo). Media adaptation: Illustrations, emojis, and videos were redesigned by a Mexican illustrator to create three distinct illustrative styles which caregivers gave feedback on and refined. This process helped ensure that the intervention was appropriately adapted for Mexico’s sociocultural and institutional context. It also addressed an ethical imperative to center local expertise, avoiding the extractive tendencies that can arise when global interventions are implemented into new contexts. Finally, INPRFM and Oxford jointly led an evaluation of the intervention, which included a single-group feasibility study in Baja California, Chihuahua, Mexico City, and Michoacan, as well as a pre–post evaluation assessing program acceptability, usability, and potential signals of harm and change. Across the four participating states, 296 caregivers enrolled, primarily mothers of children aged 2–10. Data collection included chatbot usage logs, facilitator fidelity reports, caregiver and facilitator pre/post-intervention surveys, including the Implementation Outcomes Scale for Digital Mental Health Interventions (iOSDMH; Obikane et al., 2022 ) adapted for Spanish, as well as qualitative focus group discussions. In total, 77% of caregivers completed the post-intervention follow-up survey at between two and four weeks post-intervention, depending on the study site, indicating good retention. Full feasibility, acceptability, and signals of change findings are reported in a forthcoming manuscript. The following sections reflect on our partnership, challenges and strategies, and lessons learned for future research-government partnerships for prevention initiatives. Reflecting Back on the Process: From Inception to Implementation and Evaluation A Collaborative Partnership Established in the Midst of a Challenging Context This partnership emerged from years of advocacy and stakeholder engagement led by UNICEF Mexico in collaboration with the Mexican government aimed at reducing the prevalence of violence against children. It also grew out of ongoing collaborations amongst the consortium members, including existing partnerships between UNICEF and PLH, research collaborations between academics at the University of Oxford and UTK, and previous work in Mexico between UTK and INPRFM. Although the available resources had to be used within a short timeframe, these stakeholders agreed that implementing a parenting initiative at scale could make a meaningful contribution to the Mexican government’s ongoing efforts to eradicate child maltreatment and improve caregiver mental health. With the specification of an 18-month timeline for the entire project, the group reached a consensus to submit a concise proposal for a scaling feasibility study focused on four states, representing northern and central regions of Mexico. The multisectoral stakeholders selected the PLH’s ParentText chatbot as the core intervention to be adapted and implemented, recognizing both its non-commercial, open-access model and prior success in other LMIC settings which made CC+ particularly suitable for large-scale delivery in Mexico. The timing of implementing this prevention initiative, however, was characterized by significant contextual challenges. First and most notably, the peak of the implementation phase overlapped with Mexico’s federal “election ban” lasting March through June 2024. In Mexico, this period is characterized by rigorous restrictions for government employees to prevent any type of political influence on the populations they serve. Thus, we foresaw that recruitment and retention efforts were going to be deeply impacted by the context experienced by providers of services affiliated with welfare agencies in Mexico, as these agencies were restricted in the amount and type of interactions service providers could have with families with regards to nonessential services. Within this regulatory framework, participation in the prevention initiative would be considered nonessential and thus subject to these restrictions. Despite these anticipated challenges, the group agreed that the potential lessons learned from conducting the study under such conditions far outweighed the risks. Accordingly, the collaboration was formally established, with UNICEF facilitating both funding and convening authority for the initiative’s implementation. Negotiated Governance Due to the funding restrictions and limited timeline, the group agreed on the need to have a governance agreement in which roles were clearly differentiated. UNICEF Mexico was designated as the leading policy support partner, responsible for facilitating funding for the initiative and serving as a key convener among all stakeholders. In addition, UNICEF Mexico established parameters to ensure the intervention could be effectively transferred to local partners to support long-term sustainability within national systems. PLH and the INPRFM served as joint lead coordinating institutions based on their complementary strengths in research and implementation. PLH was the original developer of ParentText and brought extensive experience implementing large-scale digital parenting solutions in LMICs, including under conditions of fiscal constraint and contextual instability. INPRFM’s longstanding leadership in community-engaged mental health research and its history of rigorous, service-oriented partnerships made its involvement essential within the Mexican context. The University of Oxford team, through the Global Parenting Initiative, brought expertise in the adaptation and evaluation of blended, digital, and in-person parenting interventions in resource-limited settings and led the development of the digital mental health component. Finally, the UTK, represented by the second author, provided expert consulting throughout all the phases of the study based on his understanding of the Mexican welfare system having worked in DIF Chihuahua as the state coordinator for children in vulnerable contexts, as well as his expertise having led NIH-funded cultural adaptation trials of prevention parenting programs for Latine populations across the US, Mexico, and Chile. In Mexico, the National System for Integral Family Development (DIF) was identified as the ideal adopter for the intervention as DIF is the primary service agency in the country charged with offering a variety of direct services to promote wellbeing of disadvantaged families. Thus, represented by state agencies, DIF was identified as a highly strategic co-leader for all the core activities of this project, including recruitment, service delivery, and evaluation. DIF’s deep roots in local communities and longstanding trust its personnel have built with families was instrumental for engaging community leaders and caregivers, ensuring adequate inclusion of local community leaders and caregivers who would give voice to the needs of local implementation sites and populations. Navigating Challenges by Utilizing Implementation Frameworks and Strategies Utilizing comprehensive implementation frameworks with distinct objectives was essential for achieving positive outcomes. This was particularly the case when considering several contextual barriers faced throughout the study. Among the most salient ones, the study was impacted by the political ban period, directives from federal agencies to restrict non-essential services to providers across government agencies, natural disaster recovery in the central and southwest regions of the country, and episodes of increased community violence in one of the participating states, among others. The cumulative impact of these challenges could have easily stalled the implementation of this study across all phases by making it impossible to conduct rigorous research, creating disagreements between partners too difficult to navigate, or exceeding the resources available within the coalition. The precise utilization of two complementary frameworks was essential to the success of this project. First, the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework pictured in Fig. 3 ( Moullin et al., 2020 ) allowed us to identify factors at multiple systems levels, including outer-context (e.g., elections, natural disasters, political ban, security threats), inner-context factors (e.g., DIF limited service capacity during a political ban period, the intervention being delivered during summer holidays when caregivers had less bandwidth to participate, existing government programs in progress, government staff changes across all levels, individual state institutions’ specific processes, facilitator readiness and high motivation to support the project), and bridging factors (e.g., UNICEF and DIF’s respective convening power; INPRFM’s dual service–research role). Table 1 displays a sample of key implementation barriers and facilitators identified using EPIS. This multilevel assessment was essential for us to plan multi-level strategies in response to the multiple inner- and outer-context challenges. [FIGURE 3 ] Additionally, the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, pictured in Fig. 4 ( Glasgow et al., 1999 ) complemented EPIS by guiding how the team designed and adjusted implementation strategies in response to those challenges. Whereas EPIS provided a diagnostic lens to understand what factors were influencing implementation, RE-AIM allowed the team to structure how we could respond pragmatically while preserving core research and program goals. Thus, the framework helped us prioritize and track key dimensions of delivery: Reach , through community-based recruitment led by DIF facilitators and supervisors during the election ban; Effectiveness , by monitoring short-term indicators of intervention impact such as satisfaction with the intervention, improvement of key family interactions, and signals of harm; Adoption , by coordinating facilitator training and government engagement across multiple states; Implementation , by maintaining fidelity monitoring and adaptive supervision; and Maintenance , by embedding CC+ within UNICEF’s national parenting agenda and national policies to strengthen family well-being to support long-term sustainability. Table 2 provides a summary of key strategies grouped by RE-AIM domain used to overcome barriers within the initiative. This lens helped us balance rigor with contextual realities and maintain confidence when making necessary adaptations. [FIGURE 4 ] Together, EPIS and RE-AIM served as guardrails that helped reduce reactive decision-making, fostered a common language between partners, and strengthened trust when navigating difficult decisions. Rather than improvising midway through disruption, the coalition drew on these frameworks to ensure that pivots were both principled and credible. Leaning on Coalition Members to Lead Within Their Respective Areas of Leadership and Influence EPIS and RE-AIM were most effective when Mexican coalition members served as the stewards of leadership, influence, and credibility. For example, when election stop-orders halted federal public-facing work, DIF staff shifted to community-driven strategies, such as organizing small group information sessions and encouraging word-of-mouth referrals between caregivers, which not only sustained recruitment and retention in Mexico City but also exceeded targets by more than 50%. Thus, a central reason for the initiative’s success was the extraordinary dedication of DIF service providers, who, despite already carrying full workloads, routinely extended their hours to ensure the project’s progress. At the policy level, UNICEF-Mexico helped secure access to state-level delivery channels at a time when many agencies were significantly constrained. As the national research partner, INPRFM adapted the evaluation protocol to improve accessibility for families in rural areas with low literacy rates, while balancing ethics committee requirements with government data-collection protocols. These adjustments streamlined recruitment and implementation processes, which proved critical when outer-context factors threatened the project. The University of Oxford led the development and embedding of caregiver mental health content into the parenting intervention and safeguarded research fidelity by adjusting timelines and developing analytic pipelines to allow for quicker turnaround of findings as the project timeline grew more compressed. Furthermore, drawing on prior experience delivering digital parenting interventions in resource-limited settings, PLH coordinated project management across partners and reorganized research workflows into shorter sprint cycles, enabling rapid integration of partner-led adaptations without extending timelines. Managing With the Expectation of Disruption The careful examination of barriers and facilitators achieved with the use of the EPIS framework, led the team to recognize early on that disruptions to implementation would not be occasional obstacles to avoid, but instead predictable features of the implementation environment for this project. The team subsequently recognized that managing CC+ would therefore require planning for pauses, pivots, and restarts. This reframing was critical in two respects. First, technical and research team members were able to establish project management workflows designed to absorb shocks: organizing short cycles with clear deliverables, contingency timelines embedded within evaluation plans, and communication protocols aligned with the EPIS framework helped pre-specify how decisions should be made as challenges emerged. Second, this approach allowed for more productive engagement with the government. Rather than generating friction when delays occurred, the coalition built trust by recognizing that multifaceted constraints would be a core characteristic of this initiative. This led to a shared commitment and acceptance that rigorous science would be pursued without insisting on ideal conditions. Viewing disruption as a predictable feature also shaped how adaptations to the project work plan were made. Instead of treating research and implementation plan changes as threats to the initiatives, the team worked with government partners to identify categories of critical data (e.g., recruitment and attrition rates, chatbot usage, adverse events), ideal data (e.g., acceptability ratings, pre/post surveys, facilitator fidelity scores), and bonus data (e.g., post-intervention focus groups). While difficult to identify prior to implementation, these categories were essential for making adjustments to implementation without jeopardizing core research objectives. For instance, when it became clear that many caregivers would likely not be able to participate in post-intervention qualitative data collection, the team adopted the Implementation Outcomes Scale for Digital Mental Health Interventions measure (iOSDMH; Obikane et al., 2022 ). INPRFM reviewed the psychometric properties and adapted items for Spanish, providing a more feasible way to capture critical data (adverse events) and ideal data (acceptability, user perceptions) than reliance on focus groups alone. A similar adaptive mindset was reflected at the community level. In one rural setting, local leaders and facilitators transformed barriers such as limited internet connectivity, poor road access, and safety concerns into opportunities for collaboration and family engagement. Because most families lacked home internet access, the facilitator partnered with the local school to host onboarding and focus group sessions. They also conducted calls and info sessions for recruitment and joined weekly meetings to provide ongoing support, while families opted in some cases to travel to the nearest town to download intervention materials. This flexibility allowed the program to be tested in an otherwise hard-to-reach context without compromising the integrity of its components, and it underscored the pressing need for scalable interventions designed with remote rural communities in mind. Importantly, anticipating volatility in this way created confidence among government partners that the research team could remain flexible, while reassuring researchers that adaptations would not erode scientific integrity. It also helped the research team to approach implementation challenges as opportunities to generate more data about constraints likely to exist at scale. Thus, managing with the expectation of disruption helped the coalition recognize that flexibility could not rely on ad hoc adjustments; it needed to be embedded from the start. This realization led directly to co-designing not only the intervention content but also the implementation approach and strategies, from recruitment to training to data collection, so that intervention delivery could remain feasible even under volatile conditions. Lessons Learned Co-Design is Essential for Intervention Development and Implementation In addition to adopting a co-design approach to tailor the content of the intervention, our team emphasized the importance of co-designed implementation strategies to address anticipated implementation barriers. This approach was key for achieving success in this initiative. Accordingly, INPRFM and PLH led five co-design workshops with partners from UNICEF, each of the 4 state-level DIF agencies, national DIF representatives, caregivers, facilitators, and representatives from PLH. Our goal was to not just collect feedback on program content, but to create a space for local actors and national implementers to define how implementation ought to work in practice. This included how caregivers would be invited to the program, how facilitators would integrate the additional work into their regular duties, and how recruitment could proceed when election-related disruptions occurred. It also helped the research team to understand how additional relevant outer contextual factors, such as limited resources from the government due to recent natural disasters, impacted capacity for delivery. A similar process guided the development of the mental health and emotional well-being content. Participating mothers and fathers emphasized the need for strategies that would help them recognize and regulate their own emotions, cope with daily stressors, and model these skills for their children. Most importantly, the capacity to anticipate barriers identified by DIF (e.g., facilitator workload, caregiver childcare needs during onboarding, and focus group discussions) helped us to refine, with high contextual relevance, our recruitment and training approaches of facilitators, reduce attrition, improve adherence to the intervention, and ensure retention. Based on these examples, by embracing a highly collaborative approach to identify barriers and corresponding implementation strategies, we were able to implement training and intervention delivery approaches that were realistic throughout the course of the study, as well as for future sustainment once CC + was transferred to UNICEF and Mexican leaders. Furthermore, based on feedback from our study partners, embracing co-design approaches also created a sense of ownership for the entire duration of the project, which greatly facilitated a smoother transfer of the program to Mexican leaders at the completion of the study. A Trusted Bridge Institution is Indispensable UNICEF’s role as a trusted intermediary was indispensable to the success of CC+. In politically complex and resource-constrained settings, prevention initiatives can be seriously compromised without an actor capable of convening partners, legitimizing collaboration, and buffering against institutional volatility. From the earliest stages, UNICEF served as a bridge that connected the research team with federal and state government systems, offering credibility and awareness of the larger nation-wide agenda for improving family wellbeing. This knowledge was critical for helping the research team implement in a manner that was collaborative and consistent with government objectives. Throughout this prevention initiative, UNICEF’s position as both a transnational organization and an embedded national office allowed us to navigate rigid institutional boundaries that neither government, implementing, nor academic partners could have crossed alone. For example, when stop-orders related to the political ban period were issued, UNICEF supported maintaining lines of communication between key government officials at federal and state levels. UNICEF also provided invaluable in-country knowledge and helped ensure the project remained visible to key stakeholders in the public and private sectors. They also played a critical role in convening stakeholders during periods of uncertainty, supporting coordination between DIF systems, researchers, and national authorities. This bridging function embedded an additional layer of support and comfort to both government and researchers, particularly when UNICEF acted as a translator between scientific and political spheres. They also opened doors that academic credibility alone could not have facilitated, ensuring that the coalition’s efforts were seen not only as external research, but most importantly, as a shared national initiative with intersectoral Mexican leadership. Practicing Collective Leadership is Tricky, But Creates Mutual Engagement A critical lesson from this initiative is that collective leadership fosters resilience at multiple levels. In our view, cultivating a shared sense of leadership across stakeholders is not only an ethical and social justice guiding principle, but is also a pragmatic strategy for sustaining prevention initiatives amid instability. While this principle is often applied only after implementation and evaluation begin, our experience suggests that collective leadership practices are most effective when embedded from the very beginning of a partnership. From the outset, the coalition treated communities, facilitators, and local research teams as the experts in their own realities. They understood what worked—and what didn’t—within their settings far better than any external team could. Our role was to bring evidence and implementation experience that could be combined with that local knowledge to build something stronger together. This approach reflected our belief that meaningful prevention work depends on mutual respect, shared decision-making, and recognition of the ingenuity and expertise that already exist within local systems. At the most immediate level, this principle extended to caregivers themselves, who could choose which in-chatbot courses to take, in what order, and at which pace. Similarly, caregivers were encouraged to engage in child-directed activities through one-on-one time and play. Caregivers and Mexican subject matter experts in child and adolescent psychiatry supported the development of mental health topics, content, and framing to create experiences better aligned with how Mexican families live and parent in challenging environments. Local DIF managers and facilitators were central to implementation success. Their decision to co-adopt the initiative as their own, motivated by a conviction that it would benefit Mexican families, transformed CC+ from an external research project into a shared national endeavor. This sense of ownership strengthened resilience across participating agencies and organizations. State DIF systems viewed CC + not as a research-driven mandate from external institutions (e.g., INPRFM, University of Oxford), but as a practical tool for advancing their institutional missions. As a result, implementation decisions were made through consensus among all partners rather than directed unilaterally, ensuring that adaptations reflected both scientific priorities and service realities. Carefully structured collective leadership also enhanced resilience in data quality and policy engagement. Because state implementers and facilitators understood the research objectives and maintained open lines of communication with the research team, reporting remained consistent even amid political, social, and environmental disruptions. Team members shared a common understanding that data collection was not merely a technical task, but a foundation for promoting policy change on behalf of Mexico’s most vulnerable families. Local leaders became some of the most effective advocates for CC+, communicating its value to state and federal authorities in ways that external researchers could not. This early and intentional power-sharing approach helped the coalition overcome a frequent bottleneck in scaling prevention programs: the tendency to seek government buy-in only after producing evidence. By embedding leadership and decision-making within Mexican institutions from the beginning, our partnership built resilience into the implementation system itself, preparing the program for scale while strengthening national ownership and sustainability. Partnerships Should Be Designed for Disruption A central lesson from this initiative is that partnership and resilience building must be proactive rather than reactive to potential (and eventual) implementation and contextual crises. By adopting the guiding assumption that disruption was inevitable and intrinsic to implementation, rather than an anomaly to be weathered and managed around, we were able to create systems that could pause, pivot, and restart while minimizing overall impact on the project. To the best of our ability, we operationalized this mindset through several key adjustments to our work strategy. First, activities were designed to be modular from the beginning of the initiative. Where possible, partners’ responsibilities were structured so that if one component stalled, other components could continue independently, reducing interdependencies and bottlenecks that often paralyze research–government partnerships. This approach allowed us to work flexibly in each state and respond to different needs. In one state, for example, partners requested a formal agreement to ensure continuity through a government transition, which required conducting the pilot two months after implementation had already begun in the other three states and reducing the time between intervention end and post-intervention evaluation. Second, project timelines and deliverables were intentionally developed to accommodate disruption. Despite the already compressed project window, milestones were treated as flexible intervals rather than fixed deadlines, allowing for ongoing adaptation. The research team met frequently to reassess scope, feasibility, and sequencing as new constraints arose, maintaining forward momentum without sacrificing quality. This flexibility proved critical when the content development and piloting activities of the intervention had to be reorganized to overcome the electoral ban. Finally, the research design itself was built to absorb shocks and allow for iterative learning. Although many implementation barriers were anticipated at the outset, we developed tracking protocols to monitor emerging obstacles and consensus-building procedures to support real-time decision-making. These mechanisms allowed the partnership to make adjustments collaboratively across all project phases. Consensus building, however, was not always smooth. The interdisciplinary nature of the team which spanned research institutions, government agencies, and service delivery systems naturally produced competing priorities, such as balancing scientific rigor with the practical demands of large-scale service provision. Our ability to navigate these tensions rested on the strength of an intersectoral alliance grounded in clear communication, mutual respect, and a shared commitment to compromise. Impacts and Potential Future Directions Indicators of Feasibility and Acceptability Navigating multiple and considerable implementation challenges helped generate clear signals that CC + was both feasible to deliver and acceptable to caregivers and facilitators. Recruitment was the earliest indicator. Specifically, initial enrollment lagged when outreach was attempted through standard government channels, but once state DIF facilitators were assigned as lead recruiters, recruitment accelerated dramatically, exceeding pre-registered progression criteria by over 50%. Facilitators’ investment in program delivery, helped in part by the implementation of co-design workshops, led to strong engagement, with 80.6% retained from intervention start to finish despite competing responsibilities. Caregiver and facilitator feedback provided further evidence of acceptability. Post-program surveys indicated that 98.3% of caregivers rated the intervention as easy to understand, and 95.3% of caregivers reported that the content improved their emotional wellbeing and mental health over the course of the intervention. This sentiment was echoed amongst facilitators, who described the materials as practical, straightforward to deliver, and adaptable to families’ needs. Additionally, we scored adverse events and overall acceptability amongst facilitators and caregivers using the Implementation Outcomes Scale for Digital Mental Health scale ( Obikane et al., 2022 ). Results indicated low rates of intervention burden, no significant adverse events, as well as positive perceptions of CC+’s delivery format and overall accessibility. Qualitative reports from DIF staff about caregiver enthusiasm and engagement corroborated that CC + was well-received by both implementers and caregivers. In fact, across several implementation sites, caregivers continued to use the chatbot informally and caregiver groups continued after formal evaluation activities ended. We also saw positive changes in caregiver and child mental health in addition to reductions in violence against children. Though these indicators do not provide evidence of effectiveness, the data demonstrate that CC+ reached a level of high acceptability, critical to facilitate future scalability, despite the considerable challenges we encountered. Initial Adoption and Promising Readiness The highly promising feasibility and acceptability indicators observed during the evaluation phase of the study have translated into rapid initial adoption by implementing partners, with the understanding that permanent sustainment can only be claimed after multiple years of continuous adoption by government services, as well as sustained financial viability. With this clarification in mind, and based on the promising initial findings, we are enthusiastic to note the strong interest by additional DIF state systems to adopt CC+, including expansion of the pilot into Guerrero and Puebla. We believe that this initial interest is facilitated by the sense of “intervention ownership” reported by DIF facilitators, which constitutes a key factor to facilitate adoption processes as professionals in the frontline do not perceive CC + as a bureaucratic imposition, but rather, an alternative to improve the lives of Mexican families. Furthermore, we consider that the current implementation model holds high promise for sustainment because the design and implementation process with state leaders and service professionals was tailored according to the specific service structures and priorities of participating state DIF agencies. In addition to continuing to explore sustainment across DIF agencies, additional prominent federal agencies are expressing interest in exploring the feasibility of integrating CC + in alternative systems such as the health and education sector, including a new engagement with the Ministry of Education. For example, the National Institute of Pediatrics is currently exploring alternatives to incorporate CC+ across clinical settings in an effort to strengthen initiatives aimed at promoting family health. Based on this, the INP is designing a pragmatic evaluation protocol to examine implementation feasibility in pediatric clinics across the country. If these efforts lead to subsequent implementation initiatives sponsored by the Mexican federal government, CC+ could operate effectively across multiple sectors. Promising Policy Traction This initiative also holds promise for increasing momentum in regard to policy initiatives aimed at supporting the implementation and sustainment of parenting interventions at a national level. Specifically, in February 2025, UNICEF in collaboration with key federal government agencies, rapidly convened a national forum on positive parenting and the relevance of scaling evidence-based parenting interventions. This meeting brought together government agencies, academic partners, and civil society stakeholders to discuss family wellbeing priorities. Results from the evaluation were highlighted at the forum to advocate for the inclusion of digital parenting and caregiver wellbeing interventions in Mexico’s social development agenda. Shortly thereafter, UNICEF designated Mexico a “pioneer country” in positive parenting, highlighting CC + as a flagship program for advancing a national family wellbeing strategy ( Hacia un programa nacional de crianza positiva | UNICEF , 2025.) Building on this momentum, representatives from the National System of Integral Protection of Girls, Boys, and Adolescents (SPINNA) via the Ministry of the Interior and the Ministry of Women expressed interest in embedding CC+ within broader public health and education systems, citing its fit with government priorities for scalable, cost-effective prevention programming. These developments are highly promising and integrate key factors to continue to promote political buy-in, adoption across service agencies, and potential scientific expansion. Our team will continue to closely collaborate with UNICEF Mexico and key Mexican leaders towards solidifying these efforts into effective policy initiatives focused on comprehensive child maltreatment prevention. We will also continue to emphasize throughout these efforts that although the current CC+ initiative is relevant, effective national policy should be broad in nature and not restrictive to the promotion of a single intervention but rather, to a set of interventions and initiatives aimed at achieving multiple levels of prevention impact (i.e., universal, selective, and indicated). Conclusion Partnerships between research institutions, NGOs, UN agencies, and governmental agencies are indispensable for translating prevention science into sustainable policy and practice, but they are also inherently fragile. The Crianza con Conciencia+ initiative in Mexico demonstrates that effective collaboration requires as much attention to partnership building and infrastructure, as to intervention development and implementation. By working through a national welfare system amid political transition, our coalition learned that disruption is not an obstacle to be managed but rather a context to be designed for. By embedding power-sharing and trust building, distributed leadership, and flexible decision structures from the beginning of the initiative, the partnership maintained momentum and integrity despite uncertainty. We offer three conclusions with high potential to extrapolate useful principles for promoting prevention science in challenging contexts. First, collective leadership and trust-building early in prevention initiatives promote a sense of ownership and resilience among all participating actors, including key government implementers who are critical for creating legitimacy prior and throughout scale. Second, bridge institutions such as UNICEF and INPRFM are critical to identify scientific and political priorities according to context, buffer volatility, and sustain collaboration even in adverse conditions. Third, designing both intervention and implementation with disruption in mind is critical and well established implementation frameworks are indispensable to carefully evaluate context of implementation, as well as to guide adaptations and implementation while preserving scientific rigor with contextual and cultural relevance. We also recognize that these principles would not have succeeded without the extraordinary dedication of our Mexican partners, who consistently exceeded expectations under demanding circumstances. In particular, we recognize the exceptional leadership of DIF at federal and state levels, the commitment of trainers and supervisors, and, above all, the frontline DIF service professionals responsible for recruitment, data collection, and program delivery. Their deep trust within the communities they served, which was built over years of consistent engagement, was instrumental in overcoming implementation barriers and ensuring the success of this initiative, even amid adversity. More broadly, our experience emphasizes that prevention science cannot be confined to controlled settings. Rather, this work often takes place amid uncertainty, where stakes are high, partnerships are complex, and the path forward seems to shift at every turn. Building and sustaining partnerships in such contexts is challenging, but it is precisely in these contexts that our field’s commitment to collaboration, equity, and rigor is most urgently tested. By leaning into these complexities, we can generate the kind of knowledge and relationships that make population-level change possible, at a time when it is most profoundly needed across the globe. Declarations Funding This initiative was supported by UNICEF Mexico through a service contract with Parenting for Lifelong Health. The preparation of this manuscript received no additional external funding. UNICEF Mexico had no role in data analysis or the decision to submit this manuscript for publication. MCK is supported by the UK Economic and Social Research Council (Award No: ES/P000649/1) Disclosure of Potential Conflicts of Interest JML is the CEO of Parenting for Lifelong Health (PLH), a charitable organization based in the United Kingdom that developed the program which is open access and licensed under a Creative Commons 4.0 Attribution Share-Alike license. JML has (and is participating) in a number of research studies involving the program, as an investigator, and the University of Oxford, and University of Cape Town receive research funding for these. The INPRFM engaged in a limited working contract with PLH during the implementation of this project. INPRFM-affiliated researchers declare no conflicts of interest related to this contract. Ethical Approval All evaluation procedures were reviewed and conducted in accordance with the National Institute of Psychiatry Ramón de la Fuente Muñiz and the University of Oxford’s guidelines for ethical research. Institutional approval from both INPRFM Human Research Ethics Board (Ref: CEI/P/041/2024) and the University of Oxford Social Sciences and Humanities Interdivisional Research Ethics Committee (Ref: R94486/RE001) was received. Informed Consent Informed consent was obtained from all individual participants prior to participation. Participants were informed about study procedures, risks, benefits, confidentiality protections, and voluntary participation. Caregivers provided consent for their own participation; no identifiable child data were collected. Authorship Contribution M.C.K. led the conceptualization, writing, and revisions of the original manuscript draft and contributed to the study conceptualization. J.R.P.C. contributed to the conceptualization, writing, and revisions of the original manuscript. N.B.A., J.M.L., and J.R.P.C. co-led the study conceptualization, funding acquisition, and project administration. A.P.A., D.B., L.M., and M.C.K. contributed to software, digital adaptation activities, and implementation. N.B.A., G.R., L.V., M.L.G.L., and M.C.K. contributed to investigation and resource provision through contextual adaptation, stakeholder engagement, and data collection. R.A.D. and J.A.R. coordinated government partnerships and supported resource mobilization. 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Child Youth Serv Rev 112:104878. https://doi.org/10.1016/j.childyouth.2020.104878 Wandersman A, Duffy J, Flaspohler P, Noonan R, Lubell K, Stillman L, Blachman M, Dunville R, Saul J (2008) Bridging the Gap Between Prevention Research and Practice: The Interactive Systems Framework for Dissemination and Implementation. Am J Community Psychol 41(3–4):171–181. https://doi.org/10.1007/s10464-008-9174-z Yardley L, Morrison L, Bradbury K, Muller I (2015) The Person-Based Approach to Intervention Development: Application to Digital Health-Related Behavior Change Interventions. J Med Internet Res 17(1):e4055. https://doi.org/10.2196/jmir.4055 Tables Table 1. Sample Barriers and Facilitators to the Prevention Initiative Identified Using the EPIS Framework . Context Level Barrier or Facilitator Description Impact on Implementation Outer context National election ban (barrier) During the 3 months prior to the presidential elections, all public institutions must suspend any congregational or proselytizing activities that involve interacting with the general public. Limited recruitment and government staff-public interactions in the adaptation and evaluation phases. Recovery from natural disaster (barrier) Due to Hurricane John in September 2024, most of the nation's public servants were assigned to support the affected areas. Limited government capacity and slowed delivery timelines in affected states; the Secretaría de Bienestar (Secretariat of Wellbeing) was eventually unable to participate in the initiative due to resource provision in support of disaster relief. Episodes of violence (barrier) Cartel activity related violence created a very dangerous environment for the data collection teams. Required suspension of in-person activities including delivery and data collection high-risk areas. Inner context Service agency capacity constraints (barrier) Each year, institutions establish their work plans based on specific goals. New activities imply changes in scheduling and, above all, a greater workload. Required pragmatic adaptation to how project activities were paced. Facilitator motivation and commitment to initiative (facilitator) The facilitators showed openness, a high need for parenting interventions, and strong willingness to participate despite their workload. Core enabling factor for recruitment and sustained engagement during implementation. Bridging factor UNICEF convening power (facilitator) UNICEF's advocacy, service, and established credibility with partners in both research and government were crucial for institutional openness, trust, and commitment. Supported rapid problem-solving and secured political support during challenging periods throughout the initiative. INPRFM’s dual service provider-research role (facilitator) A prestigious public institution and research team specializing in parenting and mental health issues. Critical intermediary between academic, policy, and implementation stakeholders; national reputation is important for public and partner buy-in. Table 2. Examples of Implementation Strategies Guided by the RE-AIM Framework RE-AIM Domain Strategy/Adaptation Application to the Initiative Outcome Reach Shifting recruitment to be led by DIF facilitators and supervisors within communities Shifted recruitment from more formal government outreach to recruiting through community networks, ongoing programs, local schools, and word-of-mouth, rather than formal government channels Maintained program reach and overperformed recruitment expectations despite election ban Effectiveness Monitoring indications of harm and rapid short-term feedback Rapid user testing was conducted prior to formal evaluation for early-stage feasibility and acceptability; a validated implementation outcomes measure was used to assess adverse events We were able to make quick content adjustments between design and full implementation; adverse event tracking was thorough and evaluated against criteria consistent with other similar digital interventions. Although effectiveness was not a goal of this project based on priorities established by UNICEF-Mexico, pre-post analyses indicated improvement on key outcomes. Adoption Early involvement of state facilitators, implementors, and government officials Design workshops included both intervention components and implementation pathway across different contexts High buy-in and sense of ownership from government partners as implementation began, creating a stronger sense of partnership and co-investment, even with reduced capacity Implementation Flexibility during implementation to adapt to anticipated constraints from government partners Reduced supervisory sessions with facilitators due to limited time; delayed one study site endpoint data collection by 2 months due to government delays and adjusted analysis post-hoc; measured consistency of implementation across sites Stronger understanding of barriers that could arise when scaling; demonstrated flexibility and pragmatism to government partners, critical for building trust Maintenance Began discussions about sustainment and needs for scale during design and adaptation phase Oriented coalition towards long-term planning; allowed inclusion of measures in evaluation needed for building the case for subsequent scale up (e.g., definitive trial, expansion to other states) Rapid expansion into an additional state post-evaluation, groundwork for formal evaluation in place, government partners oriented towards sustainment efforts as initial pilot concludes Additional Declarations The authors declare potential competing interests as follows: JML is the CEO of Parenting for Lifelong Health (PLH), a charitable organization based in the United Kingdom that developed the program which is open access and licensed under a Creative Commons 4.0 Attribution Share-Alike license. JML has (and is participating) in a number of research studies involving the program, as an investigator, and the University of Oxford, and University of Cape Town receive research funding for these. The INPRFM engaged in a limited working contract with PLH during the implementation of this project. INPRFM-affiliated researchers declare no conflicts of interest related to this contract. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Klapow","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-0946-2581","institution":"University of Oxford","correspondingAuthor":true,"prefix":"","firstName":"Maxwell","middleName":"C.","lastName":"Klapow","suffix":""},{"id":586916485,"identity":"a83a9dfe-7c66-447b-86e4-e46aeca46ccc","order_by":1,"name":"J. Ruben Parra-Cardona","email":"","orcid":"","institution":"University of Tennessee Knoxville","correspondingAuthor":false,"prefix":"","firstName":"J.","middleName":"Ruben","lastName":"Parra-Cardona","suffix":""},{"id":586916488,"identity":"c46a0370-6a9a-4a33-a1aa-25ef10d4427f","order_by":2,"name":"Nancy B. Amador","email":"","orcid":"","institution":"Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Mexico","correspondingAuthor":false,"prefix":"","firstName":"Nancy","middleName":"B.","lastName":"Amador","suffix":""},{"id":586916490,"identity":"b31e03d2-c40c-4c62-86a8-9ef815255ef1","order_by":3,"name":"Ana Pro Alcantára","email":"","orcid":"","institution":"Parenting for Lifelong Health","correspondingAuthor":false,"prefix":"","firstName":"Ana","middleName":"Pro","lastName":"Alcantára","suffix":""},{"id":586916492,"identity":"fe5e92e9-41e7-4487-a18e-5361d9a61c73","order_by":4,"name":"Guadalupe Ramírez","email":"","orcid":"","institution":"Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Mexico","correspondingAuthor":false,"prefix":"","firstName":"Guadalupe","middleName":"","lastName":"Ramírez","suffix":""},{"id":586916494,"identity":"50f949cf-937b-4e33-bc36-291197efa741","order_by":5,"name":"Rocío Aznar Daban","email":"","orcid":"","institution":"UNICEF","correspondingAuthor":false,"prefix":"","firstName":"Rocío","middleName":"Aznar","lastName":"Daban","suffix":""},{"id":586916497,"identity":"9c319916-9de7-4898-97cc-8e604654049b","order_by":6,"name":"José Antonio Ruiz Hernández","email":"","orcid":"","institution":"UNICEF","correspondingAuthor":false,"prefix":"","firstName":"José","middleName":"Antonio Ruiz","lastName":"Hernández","suffix":""},{"id":586916500,"identity":"b1352de2-bb6a-40fa-baf6-3f8ec3849b47","order_by":7,"name":"Deepali Baraptre","email":"","orcid":"","institution":"Parenting for Lifelong Health","correspondingAuthor":false,"prefix":"","firstName":"Deepali","middleName":"","lastName":"Baraptre","suffix":""},{"id":586916501,"identity":"800bf2ca-51e4-4eb1-9cc2-18978a2b394d","order_by":8,"name":"Laurie Markle","email":"","orcid":"","institution":"Parenting for Lifelong Health","correspondingAuthor":false,"prefix":"","firstName":"Laurie","middleName":"","lastName":"Markle","suffix":""},{"id":586916503,"identity":"a0236850-9b58-4a60-bbc9-8ac4be50e7cb","order_by":9,"name":"Lucia Vásquez","email":"","orcid":"","institution":"Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Mexico","correspondingAuthor":false,"prefix":"","firstName":"Lucia","middleName":"","lastName":"Vásquez","suffix":""},{"id":586920070,"identity":"d0f3d3ca-c8b6-406c-9400-1f06f28e1808","order_by":10,"name":"María de Lourdes Gutíerrez López","email":"","orcid":"","institution":"Instituto Nacional de Psiquiatría Ramón de la Fuente Muñiz, Mexico","correspondingAuthor":false,"prefix":"","firstName":"María","middleName":"de Lourdes Gutíerrez","lastName":"López","suffix":""},{"id":586920071,"identity":"960bcec8-922f-45ed-a4aa-73ad55cd61d2","order_by":11,"name":"Mariana Ruiz Briones","email":"","orcid":"","institution":"Parenting for Lifelong Health","correspondingAuthor":false,"prefix":"","firstName":"Mariana","middleName":"Ruiz","lastName":"Briones","suffix":""},{"id":586920072,"identity":"2f0e5715-5c7a-411b-8e4d-e8058687d83b","order_by":12,"name":"Cathy Creswell","email":"","orcid":"https://orcid.org/0000-0003-1889-0956","institution":"University of Oxford","correspondingAuthor":false,"prefix":"","firstName":"Cathy","middleName":"","lastName":"Creswell","suffix":""},{"id":586920073,"identity":"4c42b6d1-390a-4861-8509-991d8dfeb8db","order_by":13,"name":"Jamie M. Lachman","email":"","orcid":"https://orcid.org/0000-0001-9475-9218","institution":"University of Oxford","correspondingAuthor":false,"prefix":"","firstName":"Jamie","middleName":"M.","lastName":"Lachman","suffix":""}],"badges":[],"createdAt":"2026-02-06 09:49:48","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":true,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8805265/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8805265/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102428046,"identity":"df066e28-bf13-4d70-94c1-2ce290e75572","added_by":"auto","created_at":"2026-02-11 14:55:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":312887,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eCC+ Caregiver Intervention Components\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Fig1PS.png","url":"https://assets-eu.researchsquare.com/files/rs-8805265/v1/ab0f95904eacf90ec832b0c4.png"},{"id":102428353,"identity":"95196ce8-e4c1-40ea-a3e9-cc8bfb08343e","added_by":"auto","created_at":"2026-02-11 14:56:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":596166,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eCC+ Sample Interaction\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Fig2PS.png","url":"https://assets-eu.researchsquare.com/files/rs-8805265/v1/fc14540f144b940341a86f08.png"},{"id":102428346,"identity":"5d9fbc0d-ac6d-49e6-ab01-5b82d9d10969","added_by":"auto","created_at":"2026-02-11 14:56:38","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":419281,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eExploration, Preparation, Implementation, and Sustainment framework\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Fig3PS.png","url":"https://assets-eu.researchsquare.com/files/rs-8805265/v1/5c59f67b6a3fc792dc4defc1.png"},{"id":102428061,"identity":"60a68dd8-4309-43b0-a644-92a3b6f00376","added_by":"auto","created_at":"2026-02-11 14:55:47","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":70017,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eReach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFigure adapted from the Cummings Graduate Institute\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Fig4PS.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8805265/v1/62fd8bca464556966ca6bd0c.jpg"},{"id":102745740,"identity":"a4f80efc-0a3e-4c21-950b-f39e4376f309","added_by":"auto","created_at":"2026-02-16 08:53:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2506355,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8805265/v1/5c94674a-b2a4-43d9-90a9-08ad71d9426d.pdf"}],"financialInterests":"The authors declare potential competing interests as follows: JML is the CEO of Parenting for Lifelong Health (PLH), a charitable organization based in the United Kingdom that developed the program which is open access and licensed under a Creative Commons 4.0 Attribution Share-Alike license. JML has (and is participating) in a number of research studies involving the program, as an investigator, and the University of Oxford, and University of Cape Town receive research funding for these. The INPRFM engaged in a limited working contract with PLH during the implementation of this project. INPRFM-affiliated researchers declare no conflicts of interest related to this contract.","formattedTitle":"\u003cp\u003eWhen Everyone Said “Don’t Start”: Implementing a Digital Parenting and Family Wellbeing Program Through Political Uncertainty in Mexico’s National Family Health System\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eThe Global Need for Partnerships to Promote Prevention Initiatives\u003c/h2\u003e \u003cp\u003eIn the wake of the COVID-19 pandemic, caregiver mental health and parenting stress have emerged as critical public health challenges with profound implications for child development and wellbeing \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eParental Mental Health \u0026amp; Well-Being | HHS.Gov\u003c/span\u003e, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e2024;\u003c/span\u003e Prime et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Common mental health disorders (CMDs) such as depression and anxiety are among the leading causes of disability globally, disproportionately affecting caregivers in low- and middle-income countries (LMICs) \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eGBD 2019 Mental Disorders Collaborators, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e)\u003c/span\u003e. Violence against children is similarly elevated in LMIC settings, strongly associated with cultural norms supporting corporal punishment that are intensified by contextual adversity such as poverty, high illiteracy rates, and community violence. In addition, low-income families in LMICs commonly lack opportunities to access evidence-based parenting interventions \u0026mdash; often delivered in-person by trained professionals \u0026mdash; that can accommodate their strenuous life and working conditions \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eKnerr et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). These factors have a high likelihood of becoming predictors of an array of caregiver and child mental health problems, as well as multi-generational cycles of interpersonal violence \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003ePatel et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Toth \u0026amp; Cicchetti, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2013\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e)\u003c/span\u003e. Within this context, parenting programs focused on primary prevention have been consistently identified by leading global health agencies including the World Health Organization (WHO) and UNICEF as key public health strategies to promote child, adolescent, and caregiver wellbeing.\u003c/p\u003e \u003cp\u003ePrevention and implementation science offer powerful tools to address this need, particularly when implementing large-scale prevention initiatives that integrate key stakeholders such as child protection systems, practitioners, and governments. Over the past two decades, expanding evidence has demonstrated that parenting programs and caregiver mental health interventions can improve parenting skills, reduce violence against children, improve child development outcomes, and reduce caregiver distress \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eGardner \u0026amp; Backhaus, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Jeong et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). In addition, efforts to develop digital and blended models for delivery and lay-facilitator led programs have further extended the potential reach and reduced the cost of such programs, making the possibility of true population-level interventions more feasible \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eCluver et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; J\u0026auml;ggi et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Despite this progress, the gap between what is known to be effective and what is available to families exposed to intense adversity in LMICs remains wide. Although several evidenced-based parenting interventions have demonstrated robust effectiveness \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eGardner \u0026amp; Backhaus, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e)\u003c/span\u003e, few have achieved meaningful scale nor sustainment within service delivery systems by governments at local and national levels in LMICs.\u003c/p\u003e \u003cp\u003eIn this paper, we present a multisectoral global partnership designed to adapt and scale a universal, parenting and caregiver mental health support program within Mexico\u0026rsquo;s existing institutional systems. Specifically, we describe the rapid cultural and contextual adaptation and implementation of the \u003cem\u003eParenting for Lifelong Health\u003c/em\u003e (PLH) blended digital-human programs for parents of both adolescents and young children into \u003cem\u003eCrianza con Conciencia+ (CC+)\u003c/em\u003e through a partnership between UNICEF, the National Institute of Psychiatry Ram\u0026oacute;n de la Fuente Mu\u0026ntilde;iz (INPRFM), Parenting for Lifelong Health, the University of Oxford, the University of Tennessee at Knoxville (UTK), and state-level \u003cem\u003eSistema Nacional para el Desarrollo Integral de la Familia\u003c/em\u003e (DIF) systems.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePartnerships as the Foundation of Global Collaboration\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003eAddressing Positionality\u003c/h2\u003e \u003cp\u003eThe promise of prevention science to address these interlinked challenges is dependent on the ability of researchers and institutions to work collaboratively with governments and communities. Translating evidence into sustainable policy and practice requires confronting longstanding questions of power, equity and ownership that shape global partnerships \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eBaumann et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Parra-Cardona et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).Thus, prevention researchers committed to global prevention must be keenly aware of the risks of engaging in and perpetuating scientific imperialism, particularly when considering the historical oppression that LMICs have experienced throughout their development as nations. For example, the \u0026ldquo;America for Americans\u0026rdquo; Monroe doctrine, represented a guiding foreign policy embraced by the US in the 1800s, emphasizing the need to protect the American continent (South-, Central-, and North-) from European interference. As such, the United States was identified as the primary and exclusive source of influence and dominance for the continent \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eGilderhus, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2006\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e)\u003c/span\u003e. As global prevention scientists, we consider it essential to begin any initiative by examining the positionality of all participating collaborators in light of historical legacies of imperialism and dominance exerted by high-income countries. Otherwise, dynamics of dominance and oppression\u0026mdash;although unintended\u0026mdash;can be replicated in subtle but damaging ways. Global prevention scientists therefore have a responsibility to remain accountable for these legacies to ensure that collaborations are guided by the needs and priorities established by LMICs \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eBaumann et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Our team approaches this work from an epistemological stance shaped by conducting prevention research in both Latin American and non-Latin American settings, including extensive experience with prevention trials, rigorous evaluation, and a longstanding bias toward partnering with government systems. We recognize that these experiences and preferences have inevitably influenced how we engaged in this collaboration.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eEstablishing Global Partnerships\u003c/h3\u003e\n\u003cp\u003eGlobal partnerships must be grounded in clear communication aimed at overtly addressing power positionality of involved partners. This process leads to establishing mutual accountability and trust. Whereas we recognize this process is aspirational based on the complexities associated with establishing multisectoral global collaborations, we firmly believe that efforts to achieve these goals must guide all phases of collaboration including co-design, co-implementation, and collaborative evaluation. This foundation is critical to facilitate prevention initiatives to be situated within the structures and systems that will ultimately deliver them in sustainable ways.\u003c/p\u003e \u003cp\u003eThe challenge, however, is that these structures and systems have multiple actors. Community organizations and frontline providers carry the local credibility and relationships necessary to build trust with families. Academic and technical partners contribute scientific stewardship, mechanisms for evaluation, and theoretical expertise. Technologists carry expertise in user experience design to create products populations want to use. Governments control the policy levers, financing streams, and delivery platforms that determine scale. Thus, while each of these actors bring indispensable assets, none can achieve population-level impact alone.\u003c/p\u003e \u003cp\u003eEstablishing partnerships that integrate and promote these complementary strengths are thus critical for advancing prevention science. They enable translation of evidence into practice and policy, promote co-ownership of initiatives between stakeholders, and build legitimacy for interventions. Partnerships are, however, inherently fragile, particularly in initial phases of implementation. Even with the best of intentions, no matter how well-aligned, they are vulnerable to shifting political priorities, resource constraints, and fluctuating power dynamics amongst institutions with differing mandates \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eHailemariam et al., \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Sarkies et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The field of prevention science has repeatedly observed that the scalability of prevention interventions does not exclusively depend on their effectiveness, but primarily, in the capacity of all parties involved to create partnerships that support them. In our experience, this success lies in mutual trust and the capacity to maintain active and transparent lines of communication in which competing agendas (e.g., research vs service) can be overtly and continuously addressed, as well as negotiated.\u003c/p\u003e \u003cp\u003eThe following section describes the national context in which these ideas were operationalized. By understanding the scale and nature of child maltreatment and caregiver mental health challenges in Mexico, we clarify why a partnership between researchers and government focused on a national prevention initiative was both necessary and urgent.\u003c/p\u003e \u003cp\u003e \u003cb\u003eChild Maltreatment, Punitive Parenting Practices, and Caregiver Mental Health: A Brief Overview of the Mexican Context\u003c/b\u003e \u003c/p\u003e \u003cp\u003eUNICEF recently reported that across Latin America and the Caribbean, violence continues to be part of everyday life, including high rates of violence against children, with two in three children aged 1\u0026ndash;14 in Latin America and the Caribbean experiencing violent discipline at home \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eUNICEF, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e)\u003c/span\u003e. With only 11 countries in the region having laws that fully prohibit corporal punishment, 73\u0026nbsp;million children remain without legal protections in the region.\u003c/p\u003e \u003cp\u003eViolence against children remains widespread within Mexican households. National estimates indicate that at least 63% of families employ punitive disciplinary practices, with over half of children experiencing psychological aggression, 38% physical punishment, and 6% severe punishment. In practice, many children are disciplined through shouting, yelling, or other forms of verbal hostility. Importantly, these high rates of maltreatment contrast sharply with caregivers\u0026rsquo; underlying attitudes: fewer than 10% of Mexican mothers surveyed by UNICEF in 2022 endorsed corporal punishment as a desirable or acceptable form of discipline. In contrast to other contexts (such as the US in which corporal punishment in schools is still legal in 17 states) corporal punishment in schools has been fully prohibited across all Mexican states. Existing legislation has also partially prohibited corporal punishment at home, though has not been approved by all relevant federal entities \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eValencia Corral et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This discrepancy between the existing legal protections for children and elevated maltreatment rates suggest that punitive parenting practices may persist less from cultural endorsement and more from stress, limited knowledge and skills of alternative discipline strategies, and limited access to programs aimed at promoting nurturing and non-punitive parenting practices.\u003c/p\u003e \u003cp\u003eThese patterns are closely intertwined with caregiver mental health. Depression, anxiety, and chronic stress are well-established predictors of harsh and inconsistent parenting, and Mexico continues to face substantial gaps in meeting the mental health needs of its adult population. Depression and anxiety remain the most common mood disorders\u0026mdash;disproportionately affecting women\u0026mdash;yet the country has just 3.71 psychiatrists and 2.23 psychiatric nurses per 100,000 people, with even fewer available in rural and low-resource regions \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eGBD 2019 Mental Disorders Collaborators, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e)\u003c/span\u003e. An estimated 87.4% of adults with mild to moderate conditions, such as depression or anxiety, do not receive treatment \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eKohn et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). These mental-health service constraints have direct implications for child protection: caregiver distress and emotional dysregulation increase the likelihood of harsh discipline, while reducing caregivers\u0026rsquo; capacity to engage in consistent, nurturing practices.\u003c/p\u003e \u003cp\u003eParenting programs represent a promising dual-benefit strategy for both reducing violence against children and strengthening caregiver mental health. Evidence from a recent WHO review found that parenting programs produced larger reductions in parental depression than pharmacological approaches alone \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eGardner \u0026amp; Backhaus, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). This growing body of evidence signals the potential of scalable parenting interventions, specifically hybrid digital delivery, to simultaneously promote nurturing caregiving and address mental-health gaps as part of broader national prevention systems.\u003c/p\u003e\n\u003ch3\u003eThe Current Study\u003c/h3\u003e\n\u003cp\u003eThe objectives of this manuscript are three-fold. First, we document how a deliberately structured, multisectoral coalition adapted, implemented, and sustained our partnership to deliver CC+ during a period of exceptional political, environmental, and institutional volatility. Second, we analyze the formal and informal mechanisms that enabled this partnership to function effectively, including co-design processes, shared leadership, and the pragmatic use of implementation science frameworks. Finally, we extract lessons for prevention scientists and policymakers working in similarly complex environments, including designing for disruption, utilizing trusted bridge institutions, and embedding interventions within systems that are themselves in flux. By detailing both the scientific and relational dimensions of this initiative, we illustrate that successful government-research partnership depends not only on intervention effectiveness, but also on coalition design, ethical partnership, and the capacity to manage disruption.\u003c/p\u003e \u003cp\u003eTo contextualize the partnership, we begin with a brief overview of the CC+ intervention model and phases, followed by a description of the study\u0026rsquo;s design and implementation process. We then reflect on the sequential development of the collaboration and highlight the enabling conditions that supported partnership resilience and sustainment.\u003c/p\u003e\n\u003ch3\u003eCC+ Program Overview\u003c/h3\u003e\n\u003cp\u003e \u003cem\u003eCrianza con Conciencia Positiva\u003c/em\u003e is a blended digital, in-person, and remotely delivered parenting and caregiver wellbeing program co-developed by INPRFM, UNICEF Mexico, PLH, DIF, and the University of Oxford. The intervention is built on \u003cem\u003eParentText\u003c/em\u003e, a rule-based parenting chatbot developed by PLH \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eAmbrosio et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Cooper et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSchafer et al., 2023)\u003c/span\u003e. Prior research has demonstrated that blended and digital approaches to delivering parenting support can be feasible, acceptable, and effective \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eJ\u0026auml;ggi et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Klapow et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In addition to content aimed at enhancing parenting practices, CC+ includes a universal caregiver mental health component focused on strengthening protective factors for positive mental health and improving psychological wellbeing to address the high rates of caregiver psychological distress in addition to promoting positive and nonviolent parenting practices.\u003c/p\u003e \u003cp\u003eCC\u0026thinsp;+\u0026thinsp;was co-developed with Mexican stakeholders to reach families through existing government channels with minimal infrastructure demands. Caregivers of children aged 2 to 17 years participate in a six-week hybrid program consisting of:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAn in-person onboarding session led by DIF facilitators, introducing families to the CC+ materials and WhatsApp tools;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSix chatbot-led parenting courses delivered via WhatsApp focused on positive discipline, communication, and caregiver and child/adolescent mental health;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFacilitator-led WhatsApp group sessions providing asynchronous weekly lessons on building parents\u0026rsquo; psychological wellbeing, conducting check-ins on comprehension of parenting content, and facilitating peer support; and\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHome practice activities designed to help caregivers apply new strategies between sessions.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eCaregivers selected a primary parenting goal (e.g., improving parent-child communication) and completed daily self-paced modules within the chatbot including short videos, comics, and multiple-choice quiz interactions that allowed for personalization of content based on caregiver responses (e.g., child age, stress level, or parenting challenges). Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents a sample interaction from the chatbot interface, while Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates the components of the intervention over time from onboarding through group sessions.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e[FIGURE \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e]\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e[FIGURE \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e]\u003c/h2\u003e \u003cp\u003eDespite a short implementation timeline, partners agreed that contextual and cultural adaptation was critical for the initiative to succeed. INPRFM led this process based on their vast experience implementing large scale prevention and mental health initiatives in Mexico. Thus, the cultural adaptation of CC\u0026thinsp;+\u0026thinsp;for the Mexican context was conducted by following established frameworks for cultural adaptation \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eBarrera et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Baumann et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) and human-centered design principles \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eYardley et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) to ensure that all materials reflected the lived experiences, language, and values of Mexican families. Over six months, PLH, INPRFM, UNICEF, and the University of Oxford teams conducted co-design workshops and rapid user-testing exercises with caregivers, facilitators, and government implementers across four states. The process localized content at multiple levels:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eLanguage and tone: All materials were rewritten in Mexican Spanish with attention to regional dialects, humor, and conversational rhythm typical of WhatsApp communication.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eContent contextual and cultural relevance: Parenting examples were reframed to align with common family structures and stressors including multigenerational households, economic pressures, and community-level stressors such as community violence. Parenting and mental health content also emphasized cultural strengths and values such as the protective effect of social support (i.e., community) and strong commitment to family (i.e., \u003cem\u003efamilismo).\u003c/em\u003e\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eMedia adaptation: Illustrations, emojis, and videos were redesigned by a Mexican illustrator to create three distinct illustrative styles which caregivers gave feedback on and refined.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eThis process helped ensure that the intervention was appropriately adapted for Mexico\u0026rsquo;s sociocultural and institutional context. It also addressed an ethical imperative to center local expertise, avoiding the extractive tendencies that can arise when global interventions are implemented into new contexts.\u003c/p\u003e \u003cp\u003eFinally, INPRFM and Oxford jointly led an evaluation of the intervention, which included a single-group feasibility study in Baja California, Chihuahua, Mexico City, and Michoacan, as well as a pre\u0026ndash;post evaluation assessing program acceptability, usability, and potential signals of harm and change. Across the four participating states, 296 caregivers enrolled, primarily mothers of children aged 2\u0026ndash;10. Data collection included chatbot usage logs, facilitator fidelity reports, caregiver and facilitator pre/post-intervention surveys, including the Implementation Outcomes Scale for Digital Mental Health Interventions (iOSDMH; Obikane et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) adapted for Spanish, as well as qualitative focus group discussions. In total, 77% of caregivers completed the post-intervention follow-up survey at between two and four weeks post-intervention, depending on the study site, indicating good retention. Full feasibility, acceptability, and signals of change findings are reported in a forthcoming manuscript.\u003c/p\u003e \u003cp\u003eThe following sections reflect on our partnership, challenges and strategies, and lessons learned for future research-government partnerships for prevention initiatives.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Reflecting Back on the Process: From Inception to Implementation and Evaluation","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eA Collaborative Partnership Established in the Midst of a Challenging Context\u003c/h2\u003e \u003cp\u003eThis partnership emerged from years of advocacy and stakeholder engagement led by UNICEF Mexico in collaboration with the Mexican government aimed at reducing the prevalence of violence against children. It also grew out of ongoing collaborations amongst the consortium members, including existing partnerships between UNICEF and PLH, research collaborations between academics at the University of Oxford and UTK, and previous work in Mexico between UTK and INPRFM. Although the available resources had to be used within a short timeframe, these stakeholders agreed that implementing a parenting initiative at scale could make a meaningful contribution to the Mexican government\u0026rsquo;s ongoing efforts to eradicate child maltreatment and improve caregiver mental health. With the specification of an 18-month timeline for the entire project, the group reached a consensus to submit a concise proposal for a scaling feasibility study focused on four states, representing northern and central regions of Mexico. The multisectoral stakeholders selected the PLH\u0026rsquo;s \u003cem\u003eParentText\u003c/em\u003e chatbot as the core intervention to be adapted and implemented, recognizing both its non-commercial, open-access model and prior success in other LMIC settings which made CC+ particularly suitable for large-scale delivery in Mexico.\u003c/p\u003e \u003cp\u003eThe timing of implementing this prevention initiative, however, was characterized by significant contextual challenges. First and most notably, the peak of the implementation phase overlapped with Mexico\u0026rsquo;s federal \u0026ldquo;election ban\u0026rdquo; lasting March through June 2024. In Mexico, this period is characterized by rigorous restrictions for government employees to prevent any type of political influence on the populations they serve. Thus, we foresaw that recruitment and retention efforts were going to be deeply impacted by the context experienced by providers of services affiliated with welfare agencies in Mexico, as these agencies were restricted in the amount and type of interactions service providers could have with families with regards to nonessential services. Within this regulatory framework, participation in the prevention initiative would be considered nonessential and thus subject to these restrictions. Despite these anticipated challenges, the group agreed that the potential lessons learned from conducting the study under such conditions far outweighed the risks. Accordingly, the collaboration was formally established, with UNICEF facilitating both funding and convening authority for the initiative\u0026rsquo;s implementation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eNegotiated Governance\u003c/h2\u003e \u003cp\u003eDue to the funding restrictions and limited timeline, the group agreed on the need to have a governance agreement in which roles were clearly differentiated. UNICEF Mexico was designated as the leading policy support partner, responsible for facilitating funding for the initiative and serving as a key convener among all stakeholders. In addition, UNICEF Mexico established parameters to ensure the intervention could be effectively transferred to local partners to support long-term sustainability within national systems.\u003c/p\u003e \u003cp\u003ePLH and the INPRFM served as joint lead coordinating institutions based on their complementary strengths in research and implementation. PLH was the original developer of \u003cem\u003eParentText\u003c/em\u003e and brought extensive experience implementing large-scale digital parenting solutions in LMICs, including under conditions of fiscal constraint and contextual instability. INPRFM\u0026rsquo;s longstanding leadership in community-engaged mental health research and its history of rigorous, service-oriented partnerships made its involvement essential within the Mexican context. The University of Oxford team, through the Global Parenting Initiative, brought expertise in the adaptation and evaluation of blended, digital, and in-person parenting interventions in resource-limited settings and led the development of the digital mental health component. Finally, the UTK, represented by the second author, provided expert consulting throughout all the phases of the study based on his understanding of the Mexican welfare system having worked in DIF Chihuahua as the state coordinator for children in vulnerable contexts, as well as his expertise having led NIH-funded cultural adaptation trials of prevention parenting programs for Latine populations across the US, Mexico, and Chile.\u003c/p\u003e \u003cp\u003eIn Mexico, the National System for Integral Family Development (DIF) was identified as the ideal adopter for the intervention as DIF is the primary service agency in the country charged with offering a variety of direct services to promote wellbeing of disadvantaged families. Thus, represented by state agencies, DIF was identified as a highly strategic co-leader for all the core activities of this project, including recruitment, service delivery, and evaluation. DIF\u0026rsquo;s deep roots in local communities and longstanding trust its personnel have built with families was instrumental for engaging community leaders and caregivers, ensuring adequate inclusion of local community leaders and caregivers who would give voice to the needs of local implementation sites and populations.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eNavigating Challenges by Utilizing Implementation Frameworks and Strategies\u003c/h2\u003e \u003cp\u003eUtilizing comprehensive implementation frameworks with distinct objectives was essential for achieving positive outcomes. This was particularly the case when considering several contextual barriers faced throughout the study. Among the most salient ones, the study was impacted by the political ban period, directives from federal agencies to restrict non-essential services to providers across government agencies, natural disaster recovery in the central and southwest regions of the country, and episodes of increased community violence in one of the participating states, among others. The cumulative impact of these challenges could have easily stalled the implementation of this study across all phases by making it impossible to conduct rigorous research, creating disagreements between partners too difficult to navigate, or exceeding the resources available within the coalition.\u003c/p\u003e \u003cp\u003eThe precise utilization of two complementary frameworks was essential to the success of this project. First, the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework pictured in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eMoullin et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) allowed us to identify factors at multiple systems levels, including outer-context (e.g., elections, natural disasters, political ban, security threats), inner-context factors (e.g., DIF limited service capacity during a political ban period, the intervention being delivered during summer holidays when caregivers had less bandwidth to participate, existing government programs in progress, government staff changes across all levels, individual state institutions\u0026rsquo; specific processes, facilitator readiness and high motivation to support the project), and bridging factors (e.g., UNICEF and DIF\u0026rsquo;s respective convening power; INPRFM\u0026rsquo;s dual service\u0026ndash;research role). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e displays a sample of key implementation barriers and facilitators identified using EPIS. This multilevel assessment was essential for us to plan multi-level strategies in response to the multiple inner- and outer-context challenges.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e[FIGURE \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e]\u003c/h2\u003e \u003cp\u003eAdditionally, the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, pictured in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eGlasgow et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e1999\u003c/span\u003e) complemented EPIS by guiding how the team designed and adjusted implementation strategies in response to those challenges. Whereas EPIS provided a diagnostic lens to understand what factors were influencing implementation, RE-AIM allowed the team to structure how we could respond pragmatically while preserving core research and program goals. Thus, the framework helped us prioritize and track key dimensions of delivery: \u003cem\u003eReach\u003c/em\u003e, through community-based recruitment led by DIF facilitators and supervisors during the election ban; \u003cem\u003eEffectiveness\u003c/em\u003e, by monitoring short-term indicators of intervention impact such as satisfaction with the intervention, improvement of key family interactions, and signals of harm; \u003cem\u003eAdoption\u003c/em\u003e, by coordinating facilitator training and government engagement across multiple states; \u003cem\u003eImplementation\u003c/em\u003e, by maintaining fidelity monitoring and adaptive supervision; and \u003cem\u003eMaintenance\u003c/em\u003e, by embedding CC+ within UNICEF\u0026rsquo;s national parenting agenda and national policies to strengthen family well-being to support long-term sustainability. Table\u0026nbsp;2 provides a summary of key strategies grouped by RE-AIM domain used to overcome barriers within the initiative. This lens helped us balance rigor with contextual realities and maintain confidence when making necessary adaptations.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e[FIGURE \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e]\u003c/h2\u003e \u003cp\u003eTogether, EPIS and RE-AIM served as guardrails that helped reduce reactive decision-making, fostered a common language between partners, and strengthened trust when navigating difficult decisions. Rather than improvising midway through disruption, the coalition drew on these frameworks to ensure that pivots were both principled and credible.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLeaning on Coalition Members to Lead Within Their Respective Areas of Leadership and Influence\u003c/h2\u003e \u003cp\u003eEPIS and RE-AIM were most effective when Mexican coalition members served as the stewards of leadership, influence, and credibility. For example, when election stop-orders halted federal public-facing work, DIF staff shifted to community-driven strategies, such as organizing small group information sessions and encouraging word-of-mouth referrals between caregivers, which not only sustained recruitment and retention in Mexico City but also exceeded targets by more than 50%. Thus, a central reason for the initiative\u0026rsquo;s success was the extraordinary dedication of DIF service providers, who, despite already carrying full workloads, routinely extended their hours to ensure the project\u0026rsquo;s progress.\u003c/p\u003e \u003cp\u003eAt the policy level, UNICEF-Mexico helped secure access to state-level delivery channels at a time when many agencies were significantly constrained. As the national research partner, INPRFM adapted the evaluation protocol to improve accessibility for families in rural areas with low literacy rates, while balancing ethics committee requirements with government data-collection protocols. These adjustments streamlined recruitment and implementation processes, which proved critical when outer-context factors threatened the project. The University of Oxford led the development and embedding of caregiver mental health content into the parenting intervention and safeguarded research fidelity by adjusting timelines and developing analytic pipelines to allow for quicker turnaround of findings as the project timeline grew more compressed. Furthermore, drawing on prior experience delivering digital parenting interventions in resource-limited settings, PLH coordinated project management across partners and reorganized research workflows into shorter sprint cycles, enabling rapid integration of partner-led adaptations without extending timelines.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eManaging With the Expectation of Disruption\u003c/h2\u003e \u003cp\u003eThe careful examination of barriers and facilitators achieved with the use of the EPIS framework, led the team to recognize early on that disruptions to implementation would not be occasional obstacles to avoid, but instead predictable features of the implementation environment for this project. The team subsequently recognized that managing CC+ would therefore require planning for pauses, pivots, and restarts. This reframing was critical in two respects. First, technical and research team members were able to establish project management workflows designed to absorb shocks: organizing short cycles with clear deliverables, contingency timelines embedded within evaluation plans, and communication protocols aligned with the EPIS framework helped pre-specify how decisions should be made as challenges emerged. Second, this approach allowed for more productive engagement with the government. Rather than generating friction when delays occurred, the coalition built trust by recognizing that multifaceted constraints would be a core characteristic of this initiative. This led to a shared commitment and acceptance that rigorous science would be pursued without insisting on ideal conditions.\u003c/p\u003e \u003cp\u003eViewing disruption as a predictable feature also shaped how adaptations to the project work plan were made. Instead of treating research and implementation plan changes as threats to the initiatives, the team worked with government partners to identify categories of \u003cem\u003ecritical\u003c/em\u003e data (e.g., recruitment and attrition rates, chatbot usage, adverse events), \u003cem\u003eideal\u003c/em\u003e data (e.g., acceptability ratings, pre/post surveys, facilitator fidelity scores), and \u003cem\u003ebonus\u003c/em\u003e data (e.g., post-intervention focus groups). While difficult to identify prior to implementation, these categories were essential for making adjustments to implementation without jeopardizing core research objectives. For instance, when it became clear that many caregivers would likely not be able to participate in post-intervention qualitative data collection, the team adopted the Implementation Outcomes Scale for Digital Mental Health Interventions measure (iOSDMH; Obikane et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). INPRFM reviewed the psychometric properties and adapted items for Spanish, providing a more feasible way to capture \u003cem\u003ecritical\u003c/em\u003e data (adverse events) and \u003cem\u003eideal\u003c/em\u003e data (acceptability, user perceptions) than reliance on focus groups alone.\u003c/p\u003e \u003cp\u003eA similar adaptive mindset was reflected at the community level. In one rural setting, local leaders and facilitators transformed barriers such as limited internet connectivity, poor road access, and safety concerns into opportunities for collaboration and family engagement. Because most families lacked home internet access, the facilitator partnered with the local school to host onboarding and focus group sessions. They also conducted calls and info sessions for recruitment and joined weekly meetings to provide ongoing support, while families opted in some cases to travel to the nearest town to download intervention materials. This flexibility allowed the program to be tested in an otherwise hard-to-reach context without compromising the integrity of its components, and it underscored the pressing need for scalable interventions designed with remote rural communities in mind.\u003c/p\u003e \u003cp\u003eImportantly, anticipating volatility in this way created confidence among government partners that the research team could remain flexible, while reassuring researchers that adaptations would not erode scientific integrity. It also helped the research team to approach implementation challenges as opportunities to generate more data about constraints likely to exist at scale. Thus, managing with the expectation of disruption helped the coalition recognize that flexibility could not rely on ad hoc adjustments; it needed to be embedded from the start. This realization led directly to co-designing not only the intervention content but also the implementation approach and strategies, from recruitment to training to data collection, so that intervention delivery could remain feasible even under volatile conditions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLessons Learned\u003c/h2\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003eCo-Design is Essential for Intervention Development and Implementation\u003c/h2\u003e \u003cp\u003eIn addition to adopting a co-design approach to tailor the content of the intervention, our team emphasized the importance of co-designed implementation strategies to address anticipated implementation barriers. This approach was key for achieving success in this initiative. Accordingly, INPRFM and PLH led five co-design workshops with partners from UNICEF, each of the 4 state-level DIF agencies, national DIF representatives, caregivers, facilitators, and representatives from PLH. Our goal was to not just collect feedback on program content, but to create a space for local actors and national implementers to define how implementation ought to work in practice. This included how caregivers would be invited to the program, how facilitators would integrate the additional work into their regular duties, and how recruitment could proceed when election-related disruptions occurred. It also helped the research team to understand how additional relevant outer contextual factors, such as limited resources from the government due to recent natural disasters, impacted capacity for delivery.\u003c/p\u003e \u003cp\u003eA similar process guided the development of the mental health and emotional well-being content. Participating mothers and fathers emphasized the need for strategies that would help them recognize and regulate their own emotions, cope with daily stressors, and model these skills for their children. Most importantly, the capacity to anticipate barriers identified by DIF (e.g., facilitator workload, caregiver childcare needs during onboarding, and focus group discussions) helped us to refine, with high contextual relevance, our recruitment and training approaches of facilitators, reduce attrition, improve adherence to the intervention, and ensure retention.\u003c/p\u003e \u003cp\u003eBased on these examples, by embracing a highly collaborative approach to identify barriers and corresponding implementation strategies, we were able to implement training and intervention delivery approaches that were realistic throughout the course of the study, as well as for future sustainment once CC\u0026thinsp;+\u0026thinsp;was transferred to UNICEF and Mexican leaders. Furthermore, based on feedback from our study partners, embracing co-design approaches also created a sense of ownership for the entire duration of the project, which greatly facilitated a smoother transfer of the program to Mexican leaders at the completion of the study.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eA Trusted Bridge Institution is Indispensable\u003c/h2\u003e \u003cp\u003eUNICEF\u0026rsquo;s role as a trusted intermediary was indispensable to the success of CC+. In politically complex and resource-constrained settings, prevention initiatives can be seriously compromised without an actor capable of convening partners, legitimizing collaboration, and buffering against institutional volatility. From the earliest stages, UNICEF served as a bridge that connected the research team with federal and state government systems, offering credibility and awareness of the larger nation-wide agenda for improving family wellbeing. This knowledge was critical for helping the research team implement in a manner that was collaborative and consistent with government objectives.\u003c/p\u003e \u003cp\u003eThroughout this prevention initiative, UNICEF\u0026rsquo;s position as both a transnational organization and an embedded national office allowed us to navigate rigid institutional boundaries that neither government, implementing, nor academic partners could have crossed alone. For example, when stop-orders related to the political ban period were issued, UNICEF supported maintaining lines of communication between key government officials at federal and state levels. UNICEF also provided invaluable in-country knowledge and helped ensure the project remained visible to key stakeholders in the public and private sectors. They also played a critical role in convening stakeholders during periods of uncertainty, supporting coordination between DIF systems, researchers, and national authorities. This bridging function embedded an additional layer of support and comfort to both government and researchers, particularly when UNICEF acted as a translator between scientific and political spheres. They also opened doors that academic credibility alone could not have facilitated, ensuring that the coalition\u0026rsquo;s efforts were seen not only as external research, but most importantly, as a shared national initiative with intersectoral Mexican leadership.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003ePracticing Collective Leadership is Tricky, But Creates Mutual Engagement\u003c/h2\u003e \u003cp\u003eA critical lesson from this initiative is that collective leadership fosters resilience at multiple levels. In our view, cultivating a shared sense of leadership across stakeholders is not only an ethical and social justice guiding principle, but is also a pragmatic strategy for sustaining prevention initiatives amid instability. While this principle is often applied only after implementation and evaluation begin, our experience suggests that collective leadership practices are most effective when embedded from the very beginning of a partnership.\u003c/p\u003e \u003cp\u003eFrom the outset, the coalition treated communities, facilitators, and local research teams as the experts in their own realities. They understood what worked\u0026mdash;and what didn\u0026rsquo;t\u0026mdash;within their settings far better than any external team could. Our role was to bring evidence and implementation experience that could be combined with that local knowledge to build something stronger together. This approach reflected our belief that meaningful prevention work depends on mutual respect, shared decision-making, and recognition of the ingenuity and expertise that already exist within local systems. At the most immediate level, this principle extended to caregivers themselves, who could choose which in-chatbot courses to take, in what order, and at which pace. Similarly, caregivers were encouraged to engage in child-directed activities through one-on-one time and play. Caregivers and Mexican subject matter experts in child and adolescent psychiatry supported the development of mental health topics, content, and framing to create experiences better aligned with how Mexican families live and parent in challenging environments.\u003c/p\u003e \u003cp\u003eLocal DIF managers and facilitators were central to implementation success. Their decision to co-adopt the initiative as their own, motivated by a conviction that it would benefit Mexican families, transformed CC+ from an external research project into a shared national endeavor. This sense of ownership strengthened resilience across participating agencies and organizations. State DIF systems viewed CC\u0026thinsp;+\u0026thinsp;not as a research-driven mandate from external institutions (e.g., INPRFM, University of Oxford), but as a practical tool for advancing their institutional missions. As a result, implementation decisions were made through consensus among all partners rather than directed unilaterally, ensuring that adaptations reflected both scientific priorities and service realities.\u003c/p\u003e \u003cp\u003eCarefully structured collective leadership also enhanced resilience in data quality and policy engagement. Because state implementers and facilitators understood the research objectives and maintained open lines of communication with the research team, reporting remained consistent even amid political, social, and environmental disruptions. Team members shared a common understanding that data collection was not merely a technical task, but a foundation for promoting policy change on behalf of Mexico\u0026rsquo;s most vulnerable families. Local leaders became some of the most effective advocates for CC+, communicating its value to state and federal authorities in ways that external researchers could not.\u003c/p\u003e \u003cp\u003eThis early and intentional power-sharing approach helped the coalition overcome a frequent bottleneck in scaling prevention programs: the tendency to seek government buy-in only after producing evidence. By embedding leadership and decision-making within Mexican institutions from the beginning, our partnership built resilience into the implementation system itself, preparing the program for scale while strengthening national ownership and sustainability.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003ePartnerships Should Be Designed for Disruption\u003c/h2\u003e \u003cp\u003eA central lesson from this initiative is that partnership and resilience building must be proactive rather than reactive to potential (and eventual) implementation and contextual crises. By adopting the guiding assumption that disruption was inevitable and intrinsic to implementation, rather than an anomaly to be weathered and managed around, we were able to create systems that could pause, pivot, and restart while minimizing overall impact on the project. To the best of our ability, we operationalized this mindset through several key adjustments to our work strategy.\u003c/p\u003e \u003cp\u003eFirst, activities were designed to be modular from the beginning of the initiative. Where possible, partners\u0026rsquo; responsibilities were structured so that if one component stalled, other components could continue independently, reducing interdependencies and bottlenecks that often paralyze research\u0026ndash;government partnerships. This approach allowed us to work flexibly in each state and respond to different needs. In one state, for example, partners requested a formal agreement to ensure continuity through a government transition, which required conducting the pilot two months after implementation had already begun in the other three states and reducing the time between intervention end and post-intervention evaluation.\u003c/p\u003e \u003cp\u003eSecond, project timelines and deliverables were intentionally developed to accommodate disruption. Despite the already compressed project window, milestones were treated as flexible intervals rather than fixed deadlines, allowing for ongoing adaptation. The research team met frequently to reassess scope, feasibility, and sequencing as new constraints arose, maintaining forward momentum without sacrificing quality. This flexibility proved critical when the content development and piloting activities of the intervention had to be reorganized to overcome the electoral ban.\u003c/p\u003e \u003cp\u003eFinally, the research design itself was built to absorb shocks and allow for iterative learning. Although many implementation barriers were anticipated at the outset, we developed tracking protocols to monitor emerging obstacles and consensus-building procedures to support real-time decision-making. These mechanisms allowed the partnership to make adjustments collaboratively across all project phases. Consensus building, however, was not always smooth. The interdisciplinary nature of the team which spanned research institutions, government agencies, and service delivery systems naturally produced competing priorities, such as balancing scientific rigor with the practical demands of large-scale service provision. Our ability to navigate these tensions rested on the strength of an intersectoral alliance grounded in clear communication, mutual respect, and a shared commitment to compromise.\u003c/p\u003e \u003c/div\u003e"},{"header":"Impacts and Potential Future Directions","content":"\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003cdiv id=\"Sec24\" class=\"Section4\"\u003e \u003ch2\u003eIndicators of Feasibility and Acceptability\u003c/h2\u003e \u003cp\u003eNavigating multiple and considerable implementation challenges helped generate clear signals that CC\u0026thinsp;+\u0026thinsp;was both feasible to deliver and acceptable to caregivers and facilitators. Recruitment was the earliest indicator. Specifically, initial enrollment lagged when outreach was attempted through standard government channels, but once state DIF facilitators were assigned as lead recruiters, recruitment accelerated dramatically, exceeding pre-registered progression criteria by over 50%. Facilitators\u0026rsquo; investment in program delivery, helped in part by the implementation of co-design workshops, led to strong engagement, with 80.6% retained from intervention start to finish despite competing responsibilities.\u003c/p\u003e \u003cp\u003eCaregiver and facilitator feedback provided further evidence of acceptability. Post-program surveys indicated that 98.3% of caregivers rated the intervention as easy to understand, and 95.3% of caregivers reported that the content improved their emotional wellbeing and mental health over the course of the intervention. This sentiment was echoed amongst facilitators, who described the materials as practical, straightforward to deliver, and adaptable to families\u0026rsquo; needs. Additionally, we scored adverse events and overall acceptability amongst facilitators and caregivers using the Implementation Outcomes Scale for Digital Mental Health scale \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eObikane et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Results indicated low rates of intervention burden, no significant adverse events, as well as positive perceptions of CC+\u0026rsquo;s delivery format and overall accessibility. Qualitative reports from DIF staff about caregiver enthusiasm and engagement corroborated that CC\u0026thinsp;+\u0026thinsp;was well-received by both implementers and caregivers. In fact, across several implementation sites, caregivers continued to use the chatbot informally and caregiver groups continued after formal evaluation activities ended. We also saw positive changes in caregiver and child mental health in addition to reductions in violence against children. Though these indicators do not provide evidence of effectiveness, the data demonstrate that CC+ reached a level of high acceptability, critical to facilitate future scalability, despite the considerable challenges we encountered.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eInitial Adoption and Promising Readiness\u003c/h2\u003e \u003cp\u003eThe highly promising feasibility and acceptability indicators observed during the evaluation phase of the study have translated into rapid initial adoption by implementing partners, with the understanding that permanent sustainment can only be claimed after multiple years of continuous adoption by government services, as well as sustained financial viability. With this clarification in mind, and based on the promising initial findings, we are enthusiastic to note the strong interest by additional DIF state systems to adopt CC+, including expansion of the pilot into Guerrero and Puebla. We believe that this initial interest is facilitated by the sense of \u0026ldquo;intervention ownership\u0026rdquo; reported by DIF facilitators, which constitutes a key factor to facilitate adoption processes as professionals in the frontline do not perceive CC\u0026thinsp;+\u0026thinsp;as a bureaucratic imposition, but rather, an alternative to improve the lives of Mexican families. Furthermore, we consider that the current implementation model holds high promise for sustainment because the design and implementation process with state leaders and service professionals was tailored according to the specific service structures and priorities of participating state DIF agencies.\u003c/p\u003e \u003cp\u003eIn addition to continuing to explore sustainment across DIF agencies, additional prominent federal agencies are expressing interest in exploring the feasibility of integrating CC\u0026thinsp;+\u0026thinsp;in alternative systems such as the health and education sector, including a new engagement with the Ministry of Education. For example, the National Institute of Pediatrics is currently exploring alternatives to incorporate CC+ across clinical settings in an effort to strengthen initiatives aimed at promoting family health. Based on this, the INP is designing a pragmatic evaluation protocol to examine implementation feasibility in pediatric clinics across the country. If these efforts lead to subsequent implementation initiatives sponsored by the Mexican federal government, CC+ could operate effectively across multiple sectors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003ePromising Policy Traction\u003c/h2\u003e \u003cp\u003eThis initiative also holds promise for increasing momentum in regard to policy initiatives aimed at supporting the implementation and sustainment of parenting interventions at a national level. Specifically, in February 2025, UNICEF in collaboration with key federal government agencies, rapidly convened a national forum on positive parenting and the relevance of scaling evidence-based parenting interventions. This meeting brought together government agencies, academic partners, and civil society stakeholders to discuss family wellbeing priorities. Results from the evaluation were highlighted at the forum to advocate for the inclusion of digital parenting and caregiver wellbeing interventions in Mexico\u0026rsquo;s social development agenda. Shortly thereafter, UNICEF designated Mexico a \u0026ldquo;pioneer country\u0026rdquo; in positive parenting, highlighting CC\u0026thinsp;+\u0026thinsp;as a flagship program for advancing a national family wellbeing strategy \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003e\u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003eHacia un programa nacional de crianza positiva | UNICEF\u003c/span\u003e, \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e2025.)\u003c/span\u003e\u003c/p\u003e \u003cp\u003eBuilding on this momentum, representatives from the National System of Integral Protection of Girls, Boys, and Adolescents (SPINNA) via the Ministry of the Interior and the Ministry of Women expressed interest in embedding CC+ within broader public health and education systems, citing its fit with government priorities for scalable, cost-effective prevention programming. These developments are highly promising and integrate key factors to continue to promote political buy-in, adoption across service agencies, and potential scientific expansion. Our team will continue to closely collaborate with UNICEF Mexico and key Mexican leaders towards solidifying these efforts into effective policy initiatives focused on comprehensive child maltreatment prevention. We will also continue to emphasize throughout these efforts that although the current CC+ initiative is relevant, effective national policy should be broad in nature and not restrictive to the promotion of a single intervention but rather, to a set of interventions and initiatives aimed at achieving multiple levels of prevention impact (i.e., universal, selective, and indicated).\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003ePartnerships between research institutions, NGOs, UN agencies, and governmental agencies are indispensable for translating prevention science into sustainable policy and practice, but they are also inherently fragile. The \u003cem\u003eCrianza con Conciencia+\u003c/em\u003e initiative in Mexico demonstrates that effective collaboration requires as much attention to partnership building and infrastructure, as to intervention development and implementation. By working through a national welfare system amid political transition, our coalition learned that disruption is not an obstacle to be managed but rather a context to be designed for. By embedding power-sharing and trust building, distributed leadership, and flexible decision structures from the beginning of the initiative, the partnership maintained momentum and integrity despite uncertainty.\u003c/p\u003e \u003cp\u003eWe offer three conclusions with high potential to extrapolate useful principles for promoting prevention science in challenging contexts. First, collective leadership and trust-building early in prevention initiatives promote a sense of ownership and resilience among all participating actors, including key government implementers who are critical for creating legitimacy prior and throughout scale. Second, bridge institutions such as UNICEF and INPRFM are critical to identify scientific and political priorities according to context, buffer volatility, and sustain collaboration even in adverse conditions. Third, designing both intervention and implementation with disruption in mind is critical and well established implementation frameworks are indispensable to carefully evaluate context of implementation, as well as to guide adaptations and implementation while preserving scientific rigor with contextual and cultural relevance.\u003c/p\u003e \u003cp\u003eWe also recognize that these principles would not have succeeded without the extraordinary dedication of our Mexican partners, who consistently exceeded expectations under demanding circumstances. In particular, we recognize the exceptional leadership of DIF at federal and state levels, the commitment of trainers and supervisors, and, above all, the frontline DIF service professionals responsible for recruitment, data collection, and program delivery. Their deep trust within the communities they served, which was built over years of consistent engagement, was instrumental in overcoming implementation barriers and ensuring the success of this initiative, even amid adversity.\u003c/p\u003e \u003cp\u003eMore broadly, our experience emphasizes that prevention science cannot be confined to controlled settings. Rather, this work often takes place amid uncertainty, where stakes are high, partnerships are complex, and the path forward seems to shift at every turn. Building and sustaining partnerships in such contexts is challenging, but it is precisely in these contexts that our field\u0026rsquo;s commitment to collaboration, equity, and rigor is most urgently tested. By leaning into these complexities, we can generate the kind of knowledge and relationships that make population-level change possible, at a time when it is most profoundly needed across the globe.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis initiative was supported by UNICEF Mexico through a service contract with Parenting for Lifelong Health. The preparation of this manuscript received no additional external funding. UNICEF Mexico had no role in data analysis or the decision to submit this manuscript for publication. MCK is supported by the UK Economic and Social Research Council (Award No: ES/P000649/1)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDisclosure of Potential Conflicts of Interest\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eJML is the CEO of Parenting for Lifelong Health (PLH), a charitable organization based in the United Kingdom that developed the program which is open access and licensed under a Creative Commons 4.0 Attribution Share-Alike license. JML has (and is participating) in a number of research studies involving the program, as an investigator, and the University of Oxford, and University of Cape Town receive research funding for these. The INPRFM engaged in a limited working contract with PLH during the implementation of this project. INPRFM-affiliated researchers declare no conflicts of interest related to this contract.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEthical Approval\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll evaluation procedures were reviewed and conducted in accordance with the National Institute of Psychiatry Ramón de la Fuente Muñiz and the University of Oxford’s guidelines for ethical research. Institutional approval from both INPRFM Human Research Ethics Board (Ref: CEI/P/041/2024) and the University of Oxford Social Sciences and Humanities Interdivisional Research Ethics Committee (Ref: R94486/RE001) was received.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInformed Consent\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants prior to participation. Participants were informed about study procedures, risks, benefits, confidentiality protections, and voluntary participation. Caregivers provided consent for their own participation; no identifiable child data were collected.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthorship Contribution\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eM.C.K. led the conceptualization, writing, and revisions of the original manuscript draft and contributed to the study conceptualization. J.R.P.C. contributed to the conceptualization, writing, and revisions of the original manuscript. N.B.A., J.M.L., and J.R.P.C. co-led the study conceptualization, funding acquisition, and project administration. A.P.A., D.B., L.M., and M.C.K. contributed to software, digital adaptation activities, and implementation. N.B.A., G.R., L.V., M.L.G.L., and M.C.K. contributed to investigation and resource provision through contextual adaptation, stakeholder engagement, and data collection. R.A.D. and J.A.R. coordinated government partnerships and supported resource mobilization. C.C., J.M.L., and J.R.P.C provided supervision and contributed to intervention development. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical Trial\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmbrosio MDG, Lachman JM, Zinzer P, Gwebu H, Vyas S, Vallance I, Calderon F, Gardner F, Markle L, Stern D, Facciola C, Schley A, Danisa N, Brukwe K, Melendez-Torres GJ (2024) A Factorial Randomized Controlled Trial to Optimize User Engagement With a Chatbot-Led Parenting Intervention: Protocol for the ParentText Optimisation Trial. 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J Med Internet Res 17(1):e4055. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.2196/jmir.4055\u003c/span\u003e\u003cspan address=\"10.2196/jmir.4055\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cem\u003eTable 1.\u0026nbsp;\u003c/em\u003e\u003cem\u003eSample Barriers and Facilitators to the Prevention Initiative Identified Using the EPIS Framework\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eContext Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBarrier or Facilitator\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eImpact on Implementation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOuter context\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNational election ban (barrier)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDuring the 3 months prior to the presidential elections, all public institutions must suspend any congregational or proselytizing activities that involve interacting with the general public.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLimited recruitment and government staff-public interactions in the adaptation and evaluation phases.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRecovery from natural disaster (barrier)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDue to Hurricane John in September 2024, most of the nation\u0026apos;s public servants were assigned to support the affected areas.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eLimited government capacity and slowed delivery timelines in affected states; the \u003cem\u003eSecretar\u0026iacute;a de Bienestar\u003c/em\u003e (Secretariat of Wellbeing) was eventually unable to participate in the initiative due to resource provision in support of disaster relief.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEpisodes of violence (barrier)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCartel activity related violence created a very dangerous environment for the data collection teams.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRequired suspension of in-person activities including delivery and data collection high-risk areas.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInner context\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eService agency capacity constraints (barrier)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEach year, institutions establish their work plans based on specific goals. New activities imply changes in scheduling and, above all, a greater workload.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRequired pragmatic adaptation to how project activities were paced.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFacilitator motivation and commitment to initiative (facilitator)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eThe facilitators showed openness, a high need for parenting interventions, and strong willingness to participate despite their workload.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCore enabling factor for recruitment and sustained engagement during implementation.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBridging factor\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUNICEF convening power (facilitator)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eUNICEF\u0026apos;s advocacy, service, and established credibility with partners in both research and government were crucial for institutional openness, trust, and commitment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSupported rapid problem-solving and secured political support during challenging periods throughout the initiative.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eINPRFM\u0026rsquo;s dual service provider-research role (facilitator)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eA prestigious public institution and research team specializing in parenting and mental health issues.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCritical intermediary between academic, policy, and implementation stakeholders; national reputation is important for public and partner buy-in.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 2.\u0026nbsp;\u003c/em\u003e\u003cem\u003eExamples of Implementation Strategies Guided by the RE-AIM Framework\u003c/em\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRE-AIM Domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eStrategy/Adaptation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eApplication to the Initiative\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShifting recruitment to be led by DIF facilitators and supervisors within communities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eShifted recruitment from more formal government outreach to recruiting through community networks, ongoing programs, local schools, and word-of-mouth, rather than formal government channels\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMaintained program reach and overperformed recruitment expectations despite election ban\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEffectiveness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMonitoring indications of harm and rapid short-term feedback\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRapid user testing was conducted prior to formal evaluation for early-stage feasibility and acceptability; a validated implementation outcomes measure was used to assess adverse events\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWe were able to make quick content adjustments between design and full implementation; adverse event tracking was thorough and evaluated against criteria consistent with other similar digital interventions. Although effectiveness was not a goal of this project based on priorities established by UNICEF-Mexico, pre-post analyses indicated improvement on key outcomes.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAdoption\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEarly involvement of state facilitators, implementors, and government officials\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDesign workshops included both intervention components and implementation pathway across different contexts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHigh buy-in and sense of ownership from government partners as implementation began, creating a stronger sense of partnership and co-investment, even with reduced capacity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eImplementation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFlexibility during implementation to adapt to anticipated constraints from government partners\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReduced supervisory sessions with facilitators due to limited time; delayed one study site endpoint data collection by 2 months due to government delays and adjusted analysis post-hoc; measured consistency of implementation across sites \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStronger understanding of barriers that could arise when scaling; demonstrated flexibility and pragmatism to government partners, critical for building trust\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMaintenance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBegan discussions about sustainment and needs for scale during design and adaptation phase\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOriented coalition towards long-term planning; allowed inclusion of measures in evaluation needed for building the case for subsequent scale up (e.g., definitive trial, expansion to other states)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRapid expansion into an additional state post-evaluation, groundwork for formal evaluation in place, government partners oriented towards sustainment efforts as initial pilot concludes\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Oxford","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"partnership, LMIC, government, digital, behavioral science","lastPublishedDoi":"10.21203/rs.3.rs-8805265/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8805265/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSuccessful prevention initiatives in low- and middle-income countries depend on strong government\u0026ndash;research partnerships, yet these collaborations are often tested by political volatility, limited service capacity, and competing institutional priorities. This paper describes the multisectoral coalition that co-developed and implemented Crianza con Conciencia+ (CC+), a digital parenting and caregiver wellbeing program delivered through Mexico\u0026rsquo;s national family health system. Multiple research institutions partnered with a UN child welfare agency and Mexican state and federal government to rapidly adapt, implement, and evaluate CC+ across four states during a period marked by election restrictions, natural disasters, and shifting institutional conditions. Guided by the EPIS and RE-AIM frameworks, partners used co-design, shared leadership, and flexible implementation structures to navigate these disruptions. We highlight three key lessons for future prevention partnerships: co-design and collective leadership strengthen ownership and resilience; trusted bridge institutions are crucial for navigating political and bureaucratic barriers; and partnerships and implementation plans must be intentionally designed for disruption rather than stability.\u003c/p\u003e","manuscriptTitle":"When Everyone Said “Don’t Start”: Implementing a Digital Parenting and Family Wellbeing Program Through Political Uncertainty in Mexico’s National Family Health System","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-11 14:53:19","doi":"10.21203/rs.3.rs-8805265/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f491c839-caf1-49ac-9f5a-9ae07c2f5231","owner":[],"postedDate":"February 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":62545272,"name":"Preventive Medicine"},{"id":62545273,"name":"Psychology"},{"id":62545274,"name":"Health Policy"},{"id":62545275,"name":"Other Public Policy"}],"tags":[],"updatedAt":"2026-02-11T14:53:19+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-11 14:53:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8805265","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8805265","identity":"rs-8805265","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}