Adaptation and Integration of Psychosocial Stimulation, Maternal Mental Health and Nutritional Interventions for Pregnant and Lactating Women in Rural Bangladesh

Reaching the unreachable: a mixed-method evaluation of multidimensional healthcare model addressing the healthcare service gaps in hard-to-reach Northern riverine Bangladesh

BACKGROUND

Hard-to-reach riverine communities of northern Bangladesh face unique challenges in healthcare services. Friendship, an international social purpose organization, implemented a 3-tier healthcare model addressing these unique challenges over the past 20 years. This study evaluated Friendship's 3-tier healthcare model in the northern riverine area, assessing service-seeking practices, experiences, stakeholders' perceptions, and cost benefits for beneficiaries.

METHODS

A concurrent mixed-method approach was employed, including desk reviews, a cross-sectional quantitative survey, facility mapping, and qualitative interviews with service recipients, community representatives, healthcare providers, and health managers. Data were collected from five hard-to-reach riverine sub-districts across the Kurigram, Gaibandha, Bogura, Sirajganj, and Jamalpur districts of Bangladesh between April 2022 and July 2023. Data analysis followed major thematic domains for a comprehensive and complementary understanding.

RESULTS

A significant proportion (43.0%) of survey participants had no formal education, were aged 18-35 (57.5%), and earned less than 1,620 USD yearly (66.6%). Friendship's healthcare services at the doorstep through satellite clinics and Female Community Medic Aides were widely accepted and preferred within the community for convenience, affordability (0.05-0.09 USD service charges), and superior quality, particularly the specialized treatments available on the hospital ships.

CONCLUSION

Friendship's 3-tier healthcare model made the accessibility and affordability of primary healthcare. Upon implementing a robust referral mechanism, continuing collaboration with the Government of Bangladesh, and expanding community awareness sessions to include topics such as mental health and disaster response, this model has the potential to be effective in similar settings in Bangladesh and other developing countries, as well as during emergency responses.

Effect of the thinking healthy programme-based internet intervention model for maternal perinatal depression: A pilot study

BACKGROUND

Thinking Healthy Programme (THP) is an evidence-based psychosocial intervention that can be delivered by non-psychologists and does not require the implementer to have a mental health background or field experience. The THP has been tested in maternal health in many countries. However, the application of the THP model in Chinese maternal and child health has not been reported.

OBJECTIVE

This study aimed to explore the feasibility of the Thinking Healthy Programme (THP) model for improving perinatal depressive symptoms and infant growth when implemented by non-psychologists (e.g., nurses) for Chinese pregnant women.

METHODS

122 pregnant women with Edinburgh Postnatal Depression Scale (EPDS) ≥ 10 were selected from a tertiary hospital in Fujian Province between January 2022 to May 2022. Participants were randomly assigned to the intervention group (n = 61) and the control group (n = 61). The intervention group received the THP-based online delivery intervention and enhanced usual care (EUC), while the control group only received EUC. The outcomes were maternal depressive symptoms, infant growth, and other maternal and infant outcomes. Outcomes were assessed at baseline (during pregnancy), 3 months postpartum, and 6 months postpartum.

RESULTS

The Generalized Linear Mixed Model (GLMM) showed that there were significant time effects for EPDS scores and PHQ-9 scores between the two groups over time (p < 0.001, p = 0.040). The depression subscale of EPDS and PHQ-9 scores decreased significantly only within the intervention group between 6 months postpartum and baseline (p = 0.003, p = 0.023), the comparison group did not. Compared with the control group, the intervention group had a statistically significantly longer breastfeeding time (5.52 ± 1.25 vs. 4.50 ± 1.69, p = 0.012) at 6 months postpartum, and a lower absolute value of BMI-for-age z-score at post intervention and follow up post intervention (3 and 6 months post-delivery) (-0.87 ± 1.41 vs. -1.41 ± 2.53, p = 0.229; -0.14 ± 1.19 vs. -0.29 ± 1.11, p = 0.539) although no statistically significant difference.

LIMITATIONS

This study had several limitations. First, it was a single-center study and the sample size was small, which may limit the results. This finding needs to be confirmed by further large multicenter studies. Second, the outcomes were based on maternal self-report alone, which was subjected to social desirability and recall bias. Third, the study only monitored the effects up to the 6-month endpoint. Future studies should incorporate a longer-term evaluation of its effects on infant behavioral and temperament outcomes.

CONCLUSION

The THP-based online delivery intervention model helped to improve maternal perinatal depressive symptoms, with important benefits for improving maternal and infant health. This suggested the feasibility for non-psychologists to implement the THP model.

A Call for the Implementation of Physical Activity as a Vital Sign (PAVS) During Pregnancy

Despite decades of research and clinical insights on the importance of physical activity during pregnancy for maternal and infant health, over 75% of pregnant individuals do not meet general physical activity guidelines of 150 minutes of moderate-intensity physical each week. This may be due to several barriers that restrict engagement in physical activity during pregnancy. Without providing individualized facilitators to overcome these respective barriers, physical activity engagement during pregnancy may be severely limited and/or reduced. This literary review presents the challenges specific populations face and strategies to facilitate the inclusion of physical activity as a vital sign (PAVS) during pregnancy to assist individuals to engage in and maintain physical activity throughout pregnancy. Additionally, the Exercise is Medicine's global initiative's ability to assist in implementing PAVS during pregnancy is discussed. We conclude by defining recommendations for routine prenatal care to consider PAVS to aid pregnant individuals in meeting physical activity guidelines.

Mental disorders during pregnancy and postpartum in Bangladesh: A narrative review

Background and Aims

Bangladesh has made significant progress in declining maternal mortality in recent decades. However, the available evidence on the various maternal mental disorders in the country has not been comprehensively and critically reviewed to date. This narrative review aimed to assess the mental disorders and associated factors during pregnancy and postpartum in Bangladesh.

Methods

A thorough search was performed in PubMed, Scopus, Google, Google Scholar, and BanglaJOL with search terms at the end of January 2024 to identify the original articles published on psychiatric morbidities during pregnancy and postpartum.

Results

This review included 28 empirical studies published between 2007 and 2023 with a sample size ranging from 100 to 39,434. Two studies were published before 2010, 16 studies were published between 2011 and 2020, and 10 studies were published between 2021 and 2023. No countrywide study was noted, the Bangla Edinburgh Postnatal Depression Scale (EPDS-B) was used in 57% of studies, suicidal behavior was assessed in three studies, postpartum depression (PPD) was featured in 16 studies, and three qualitative studies were noted. The prevalence of PPD ranged from 9% to 51.7%. About 46% of mothers had positive scores for common mental disorders. The prevalence of mental disorders was 14.2%; among them mood disorders were present at 6.1% and psychoses were noted at 4.5%.

Conclusions

There are wide variations in the prevalence of maternal mental disorders in Bangladesh from study to study; a lower prevalence was noted when diagnostic tools were used even though no nationwide study with confirmatory diagnostic tools was noted. Studies with nationwide distribution and diagnostic tools are warranted to understand the problem precisely.

Coproduced, arts interventions for nurturing care (0-5 years) in low-income and middle-income countries (LMICs): a realist review

OBJECTIVES

Community-based arts interventions have the potential to support contextually relevant nurturing care programmes and policies that adapt to different settings. Understanding the distinctive features of using the arts in local, culturally specific ways in low/middle-income countries (LMICs); how this varies by context; and gaining a better understanding of the perspectives on desirable outcomes for communities is important evidence that this review generates.

DESIGN

We conducted a realist review of papers that covered outcomes related to child health or development (0-5 years) AND arts-based approaches AND community-based, participatory approaches AND based in LMICs using a range of databases and other networks. A coding framework was developed covering context, intervention, outcomes, mechanisms, study, sustainability, transferability and scalability.

RESULTS

The included papers reported 18 unique interventions. Interventions covered 14 countries, with evidence lacking for South America, Arab countries and parts of Africa. Lead authors came from mostly clinical science-based disciplines and from institutions in a different country to the country/countries studied. Intended outcomes from interventions included clinical, health systems/organisation, changes in practices/behaviours/knowledge/attitudes, and wider social and educational goals. We identified three demi-regularities (semi-predictable patterns or pathways of programme functioning): participatory design based on valuing different sources of expertise; dynamic adaptation of intervention to context; and community participation in arts-based approaches.

CONCLUSIONS

Our findings suggest that arts-based, nurturing care interventions have greater potential when they include local knowledge, embed into existing infrastructures and there is a clear plan for ongoing resourcing of the intervention. Studies with better documentation of the lessons learnt, regarding the intervention delivery process and the power dynamics involved, are needed to better understand what works, for whom and in which contexts.

Health equity in action: using community-engaged research to update an intervention promoting a healthy home food environment to Black/African American families

PURPOSE

Describe the method for conducting community-engaged research to identify needed changes for an existing evidence-based intervention, and prepare it for implementation in a community setting within the Dan L Duncan Comprehensive Cancer Center catchment area in an effort to achieve more equitable outcomes in diet-related disease risk factors.

METHODS

The intervention, Family Eats, was developed over 10 years ago. It works directly with parents of Black/African American 9-12 year old children to create a healthy home food environment to support prevention of obesity and related cancers. Data collection with community stakeholders occurred through a series of  Community Advisory Board (CAB) meetings guided by the Delphi Technique, an iterative approach for gaining group consensus on a topic.

RESULTS

Key information on needed changes and potential implementation strategies were identified. Perceived level of engagement among CAB members was high overall and in terms of both quantity and quality.

CONCLUSION

The Delphi Technique shows promise as a method for conducting community-engaged research that promotes engagement and identifies key information needed to adapt and implement an existing intervention in a community setting.

Pathways to scale up early childhood programs: A scoping review of Reach Up and Care for Child Development

Evidence-based early childhood development (ECD) programs that strengthen nurturing parenting skills and promote early stimulation, such as Reach Up (RU) and Care for Child Development (CCD), are critical investments for interrupting cycles of intergenerational poverty; however, the implementation impact of these programs varies greatly globally. Analyzing systematically the evidence on the implementation pathways based on contexts (i.e., external and internal influences on intervention implementation), implementation strategies (i.e., mechanisms used to promote program initiation, design, and delivery with existing systems), and implementation outcomes (i.e., related to the implementation goals) can increase the likelihood of implementation success. Our scoping review aimed to identify implementation pathways of RU and CCD programs in low- and middle-income countries. A search in English, Spanish, and Portuguese of grey literature and five databases of peer reviewed literature; from inception through July 16, 2022, yielded 2,267 publications. Using predetermined eligibility criteria, 75 records yielded implementation details for 33 programs across 23 low- and middle-income countries. Two reviewers independently extracted program data on context, implementation strategies, and implementation outcomes following a program theory. A thematic analysis identified 37 implementation strategies across six "building blocks of implementation": program emergence, intersectoriality, intervention characteristics, workforce, training, and monitoring systems. Implementation pathways across building blocks are highly influenced by contextual factors, such as infrastructure, social norms, and the target population's demand and interest, which may shape different implementation outcomes. Six 'building blocks' shaping implementation pathways of CCD and RU in LMICs were identified. The careful consideration of context and use of intentional evidence-based planning can enable the successful implementation of ECD nurturing care interventions. We recommend the use of the ECD Implementation Checklist for Enabling Program Scale Up to guide decision-making regarding context and implementation strategies to support implementation outcomes and subsequent ECD program success.

Scaling up community-delivered mental health support and care: A landscape analysis

Introduction

The mental health crisis has caused widespread suffering and has been further exacerbated by the COVID-19 pandemic. Marginalized groups are especially affected, with many concerns rooted in social determinants of mental health. To stem this tide of suffering, consideration of approaches outside the traditional biomedical model will be necessary. Drawing from task-sharing models of mental health care that have been pioneered in low-resource settings, community-initiated care (CIC) represents a potentially promising collection of approaches. This landscape analysis seeks to identify examples of CIC that have been implemented outside of the research context, with the aim of identifying barriers and facilitators of scale up.

Methods

A narrative review approach was used for this landscape analysis in which the PubMed database was searched and further supplemented with Google Scholar. Promising programs were then discussed over multiple rounds of meetings with the research team, consisting of collaborators with varied experiences in mental health. Using the selection criteria and feedback derived from group meetings, a final list of programs was identified and summarized according to common characteristics and features.

Results

The initial PubMed search yielded 16 results, supplemented by review of the first 100 entries in Google Scholar. Through 5 follow-up meetings among team members, consensus was reached on a final list of 9 programs, which were grouped into three categories based on similar themes and topics: (1) approaches for the delivery of psychosocial interventions; (2) public health and integrative approaches to mental health; and (3) approaches for addressing youth mental health. Key facilitators to scale up included the importance of sustainable financing and human resources, addressing social determinants and stigma, engaging diverse stakeholders, leveraging existing health infrastructure, using sustainable training models, ensuring cultural relevance and appropriateness, and leveraging digital technologies.

Discussion

This landscape analysis, though not an exhaustive summary of the literature, describes promising examples of efforts to scale up CIC outside of the research context. Going forward, it will be necessary to mobilize stakeholders at the community, health system, and government levels to effectively promote CIC.

Cultural adaptations of obesity-related behavioral prevention interventions in early childhood: A systematic review

Interventions for obesity prevention can effectively reduce obesity-related behaviors in young children. Understanding how to leverage and adapt evidence-based interventions is needed to improve reach among culturally and linguistically diverse families. This systematic review aimed to synthesize the approaches and outcomes of culturally adapted early childhood obesity-related behavioral prevention interventions. Multiple electronic databases were systematically searched in March 2021. All study designs were included if they reported cultural adaptations of an intervention targeting at least one obesity-related behavior (infant feeding, nutrition, physical activity, and/or sleep) among children aged 0-5 years. Studies that only conducted language translations or that developed new interventions were excluded. Two authors independently conducted critical appraisals using the Mixed Method Appraisal Tool. Findings were synthesized narratively, based on the Stages of Cultural Adaptation theoretical model and the Framework for Reporting Adaptations and Modifications-Enhanced. Twelve interventions met the inclusion criteria, with varied study designs. Few reported all aspects of cultural adaptation processes, and the cultural adaptation strategies documented varied. The results suggest that cultural adaptation of obesity-related behavioral prevention interventions targeting young children increases acceptability among target cultural groups, yet effectiveness is inconclusive due to a lack of trials. More detailed reporting of cultural adaptation processes and further effectiveness trials are needed to evaluate future work.

Risk Preference, Health Risk Perception, and Environmental Exposure Nexus: Evidence from Rural Women as Pig Breeders, China

Rural women are an integral part of the agricultural economy. Still, their exposure to environmental pollution, especially in the context of risk preference and health risk perception, has not gained much attention in the existing literature. So to explore this notion, a survey and experimental data of 714 rural Chinese women as pig breeders are taken, we innovatively evaluate the degree of environmental exposure from the pre-exposure, in-exposure, post-exposure intervention of women breeders, and two-stage least squares (2SLS) method is employed to address the endogeneity issue between health risk perception and environmental exposure. The results show that rural women breeders suffer from severe environmental exposure, and the degree of environmental exposure is up to 72.102(Min = 0, Max = 100). Risk preference also emerges as a crucial determinant behind their environmental exposure, but health risk perception significantly deters the degree of environmental exposure. The health risk perception can offset risk preference effects on women breeders' environmental exposure by 15.15%. Moreover, considering the heterogeneity of the breeding scale, it is found that the impact of risk preference and health risk perception on women breeders' environmental exposure is an inverted U-shaped relationship, i.e., the results are at the turning stage when the breeding scale is 31-40 heads. Based on the empirical findings, the study offers guidelines for policymakers to enhance awareness amongst women breeders regarding health and pollution and encourage them to opt for environment-friendly breeding. Moreover, this research also has substantial guiding significance for related research on environmental exposure of rural women in other developing countries.

Success Factors for Community Health Workers in Implementing an Integrated Group-Based Child Development Intervention in Rural Bangladesh

Community Health Workers (CHWs) can effectively implement maternal and child health interventions, but there is paucity of evidence on how to integrate child stimulation into these interventions, and their delivery at scale. In rural Bangladesh, CHWs implemented an intervention integrating psychosocial stimulation, nutrition, maternal mental health, water, sanitation, hygiene (WASH) and lead exposure prevention. In each of 16 intervention villages, one CHW worked with 20 households. CHWs bi-weekly held group meetings or alternated group meetings and home visits with pregnant women and lactating mothers. We assessed the intervention through five focus groups, four interviews and one group discussion with CHWs and their supervisors to explore success factors of implementation. CHWs’ training, one-on-one supervision and introduction by staff to their own community, and adoption of tablet computers as job aids, enabled successful session delivery to convey behavioral recommendations. CHWs reported difficulties delivering session due to the complexity of behavioral recommendations and struggled with age-specific intervention material. Young children’s attendance in group sessions generated distractions that undermined content delivery. We identified ways to minimize the difficulties to strengthen intervention-delivery during implementation, and scale-up. Iterative revisions of similarly integrated interventions based on qualitative evaluation findings could be delivered feasibly by CHWs and allow for implementation at scale.

A holistic approach to promoting early child development: a cluster randomised trial of a group-based, multicomponent intervention in rural Bangladesh

Introduction

In low- and middle-income countries, children experience multiple risks for delayed development. We evaluated a multicomponent, group-based early child development intervention including behavioural recommendations on responsive stimulation, nutrition, water, sanitation, hygiene, mental health and lead exposure prevention.

Methods

We conducted a 9-month, parallel, multiarm, cluster-randomised controlled trial in 31 rural villages in Kishoreganj District, Bangladesh. Villages were randomly allocated to: group sessions (‘group’); alternating groups and home visits (‘combined’); or a passive control arm. Sessions were delivered fortnightly by trained community members. The primary outcome was child stimulation (Family Care Indicators); the secondary outcome was child development (Ages and Stages Questionnaire Inventory, ASQi). Other outcomes included dietary diversity, latrine status, use of a child potty, handwashing infrastructure, caregiver mental health and knowledge of lead. Analyses were intention to treat. Data collectors were independent from implementers.

Results

In July–August 2017, 621 pregnant women and primary caregivers of children<15 months were enrolled (group n=160, combined n=160, control n=301). At endline, immediately following intervention completion (July–August 2018), 574 participants were assessed (group n=144, combined n=149, control n=281). Primary caregivers in both intervention arms participated in more play activities than control caregivers (age-adjusted means: group 4.22, 95% CI 3.97 to 4.47; combined 4.77, 4.60 to 4.96; control 3.24, 3.05 to 3.39), and provided a larger variety of play materials (age-adjusted means: group 3.63, 3.31 to 3.96; combined 3.81, 3.62 to 3.99; control 2.48, 2.34 to 2.59). Compared with the control arm, children in the group arm had higher total ASQi scores (adjusted mean difference in standardised scores: 0.39, 0.15 to 0.64), while in the combined arm scores were not significantly different from the control (0.25, –0.07 to 0.54).

Conclusion

Our findings suggest that group-based, multicomponent interventions can be effective at improving child development outcomes in rural Bangladesh, and that they have the potential to be delivered at scale.

Trial registration number

The trial is registered in ISRCTN (ISRCTN16001234).

Exploration of Attendance, Active Participation, and Behavior Change in a Group-Based Responsive Stimulation, Maternal and Child Health, and Nutrition Intervention

Delivery of interventions through group sessions allows for in-depth discussions and creates opportunities for group members to work together to identify and solve common problems. However, low attendance may limit impact. We explored factors affecting attendance, active participation, and behavior change in an integrated group-based child development and maternal and child health intervention in Bangladesh. Community health workers (CHWs) facilitated two sessions a month including material on child stimulation; water, sanitation, and hygiene; nutrition, maternal depression, and lead exposure prevention. Sessions were conducted with 320 pregnant women and mothers with children younger than 24 months, in 16 villages in Kishoreganj district. After 4 and 9 months of intervention, we conducted focus group discussions and in-depth interviews with mothers (n = 55 and n = 48) to identify determinants of attendance and behavior change, and to examine potential for intervention scale-up. Recruiting family members to assist with childcare resulted in improved attention during sessions. Adopting a storytelling format for presentation of session materials resulted in more engaged participation during courtyard sessions. Session attendance and behavior change, especially purchasing decisions, were difficult for participants without the support of male heads of the household. Selecting a rotating leader from among the group members to remind group members to attend sessions and support CHWs in organizing the sessions was not successful. Facilitating self-appraisals and planning for water and sanitation allowed participants to identify areas for improvement and track their progress. Key determinants of a participant’s attendance were identified, and the resulting intervention shows promise for future implementation at scale.

Adapting an Evidence-Based, Early Childhood Parenting Programme for Integration into Government Primary Health Care Services in Rural Bangladesh

This paper describes the process of adapting an early childhood development programme, with proven effectiveness in Bangladesh, for integration into government health services in rural Bangladesh. Through a three-stage process, we adapted an evidence-based, home-visiting, programme (Reach-Up and Learn) for delivery in government health clinics by government health staff as part of their regular duties. Stage one involved preparing an initial draft of two parenting interventions for use with: (1) pairs of mother/child dyads, and (2) small groups of mother/child dyads. In stage two, we piloted the adapted interventions in nine clinics with a total of twenty-seven health staff and 357 mother/child dyads. We used data from mothers' attendance, feedback from participating mothers and health staff and observations of parenting sessions by the research team to revise the interventions. Stage three involved piloting the revised interventions in six clinics with eighteen health staff and 162 mother/child dyads. We gathered additional data on mothers' attendance and used observations by the research team to finalize the interventions. Through this three-stage process, adaptations were made to the intervention content, process of delivery, materials, and engagement strategies used. The largest challenges were related to incorporating the parenting programme into health staff's existing workload and promoting mothers' engagement in the programme. We also simplified the content and structure of the curriculum to make it easier for health staff to deliver and to ensure mothers understood the activities introduced. This iterative piloting was used prior to implementing and evaluating the interventions through an effectiveness trial.