Learning Through Play (LTP) Parenting Program: Capacity Building of Traditional Birth Attendants in Pakistan

The present study aimed to train Traditional Birth Attendants (TBAs) in a parenting program called Learning through Play (LTP) to improve their Knowledge, Attitude, and Practices regarding child development after completion of training, for them to be better able to support parents during their routine practice. Quasi experimental design was used. A total of 330 TBAs meeting study eligibility criteria were included and data was collected in a group setting. LTP training was comprised of weekly sessions delivered over 1 month. LTP includes knowledge about child development for children from 0 to 3 years. The Knowledge, Attitude, and Practices (KAP) questionnaire was used to measure change. Statistical analysis was done through Paired Sample T-test. There was a significant difference between pre-post scores t = -29.36 (p < .05). Capacity building of TBAs in LTP program and integrating LTP into existing health care systems may contribute to reducing the child development gaps in Pakistan. Plain Language Summary Purpose: This study was designed to train the Traditional Birth Attendants (TBAs) in a parenting intervention programme called Learning through Play (LTP) to improve their Knowledge, Attitudes and Practices regarding children’s physical, cognitive, and socioemotional development. This training would give them skills to support parents efficiently as a part of their routine practices. Methods: A total of 330 TBAs participated in this study and data was collected in a group setting. LTP training included weekly sessions given over a period of 1 month. The LTP training programme includes information about child development for children from birth to 3 years. The Knowledge, Attitude and Practices (KAP) questionnaire was used to measure change in knowledge after this training. Results: Results showed that there was significant difference between pre training and post training scores. The TBAs scored higher on KAP questionnaire after completing the LTP training as compared to the KAP scores before attending this programme. Conclusion and implications: Training TBAs in LTP programme and integrating LTP into existing health care systems may contribute to reducing the child development gaps in Pakistan. Limitations: Post assessment was conducted immediately after completion of the training; we would recommend for future studies to conduct a follow up assessment to find out how well they remember the information and to what extent they implement the gained knowledge into their routine practice.


Introduction
Early child development forms the foundation of adult health and wellbeing and is a key component of the Sustainable Development Goals (SDGs) (Lu et al., 2016).Around 250 million children (43%) younger than 5 years in Low and Middle Income Countries (LMICs) do not develop to their full potential (Black et al., 2017).Nurturing care is supported by a number of social contexts but the most powerful one is the immediate home where parents and other family members need to provide a care setting that is emotionally supportive and developmentally stimulating (Britto et al., 2017).Studies conducted in Pakistan (Yousafzai et al., 2014), Jamaica (Gertler et al., 2014;Walker et al., 2005), and Turkey (Kagitcibasi et al., 2009) have shown significant improvements in child development as well as later adulthood by including nurturing care elements in interventions.
One of the key factors causing negative health-related behavior outcomes in youth is childhood poverty (Najman et al., 2010).Some studies have identified positive parenting as one of the protective strategies that may buffer the impact of poverty on child development (Kiernan & Mensah, 2011).Parenting programs have been designed to enhance positive parenting skills to increase physical, behavioral, cognitive, and emotional well-being of children and have proved their effectiveness across a range of child outcomes (Cartwright-Hatton et al., 2011;Mejia et al., 2012;Wallander et al., 2014).Learning through Play (LTP) program is a parenting intervention developed in Toronto, Canada for health visitors to train parents for healthy upbringing of their children and to stimulate early child development.The central feature of the LTP intervention is a pictorial calendar devised for parents which depicts eight successive stages of child development from birth to 3 years along with illustrations of parent-child play and other activities that promote parental involvement, learning, and attachment.The theoretical underpinnings of LTP are to be found in Piaget's theory of cognitive development (Piaget & Cook, 1952), and Bowlby's theory of attachment (Bowlby, 1982).It has been adapted in various countries including LMICs (Husain, Kiran, Fatima, et al., 2021;Husain, Zulqernain, et al., 2017;Rahman et al., 2009).
A health workforce shortage was one of the main obstacles to the achievement of the Millennium Development Goals (Campbell et al., 2013) and has been further highlighted during the recent COVID-19 pandemic.Task shifting has the potential to overcome these obstacles and may help achieve the Sustainable Development Goals (Morton et al., 2017).The Traditional Birth Attendants (TBAs) in Pakistan are lay persons who attend mothers during the perinatal period, their role within task shifting initiatives can be enhanced through providing them with robust training in the delivery of context-specific, evidence based, and feasible healthcare (Owolabi et al., 2014).TBAs play a significant role in LMICs (Garces et al., 2012;Lawn et al., 2009;Vyagusa et al., 2013) particularly South-Asia and Sub-Saharan Africa, where almost half of the births take place at home (Beck et al., 2016).Randomized controlled trials conducted in Pakistan suggest that TBAs have been able to reduce maternal and child mortality after appropriate training and regular supervision (Byrne et al., 2016;Mobeen et al., 2011;Soofi et al., 2012).TBAs are essential to their communities in LMICs including Pakistan as they provide fundamental support according to the local customs, traditions, and perceptions about childbirth and newborn care (Garces et al., 2012;Vyagusa et al., 2013).Involvement of community health workers (CHW) in delivering mental health interventions and peer delivered psychosocial intervention programs have found to be feasible and acceptable in low resource settings in Pakistan (Husain, Chaudhry, et al., 2017).These interventions can be scaled up by integrating within the existing health care systems to address the mental health treatment gap (Husain, Chaudhry, et al., 2017;Vanobberghen et al., 2020;Weaver & Lapidos, 2018).
In Pakistan, Learning Through Play (LTP) parenting intervention has been successfully evaluated to reduce maternal depression while improving knowledge and practices of mothers for healthy child development (Husain, Kiran, Shah, et al., 2021;Husain, Zulqernain, et al., 2017;Rahman et al., 2009).Evidence shows that there is a strong association of parenting knowledge with improved child outcomes.Child development, including cognitive, language, motor, and socioemotional development, and play activities are the strongest mediator (Zhong et al., 2020).It is reported that early childhood stimulation interventions have the potential both to improve parent mental health and early childhood developmental outcomes (Husain, Zulqernain, et al., 2017;Jeong et al., 2018).The present study aimed at training TBAs in LTP and to assess the changes in the TBAs Knowledge, Attitude, and Practices toward child development after participating in the LTP training program.

Study Design
It was a pre-post test quasi experimental design.Assessments were completed before and after the LTP training program.Open ended comments were also received from selected participants at the end of the training.

Participants
A total 330 TBAs were approached through the Lady Health Supervisors (LHSs; Upvall et al., 2002) and all of them agreed to participate in the study.LHSs in Pakistan provide a variety of services to urban and rural communities, including basic nursing care, maternal child health services, and training of community workers.TBAs support in provision of continuum of care for perinatal women, lactating mothers, and children under the age of 5 years (Shaikh et al., 2014).The participants were divided into 16 groups for training purpose, each group was comprised of 15 to 25 participants.

Setting
The study was conducted in one of the largest cities of Pakistan, Karachi which has a population of over 23 million.
Sampling: Purposive sampling was done and only those TBAs were invited who met following eligibility criteria Inclusion Criteria: 1.

Measurements
Demographic Information Sheet.A study specific form was administered to acquire demographic data.
Knowledge, Attitude, and Practice (KAP) Questionnaire.A self-administered scale was specifically developed for LTP studies in Pakistan (Rahman et al., 2009).The internal consistency was assessed using Cronbach's alpha (a = .7)and was found to be in the acceptable range.In current study extensive form of KAP was used.This scale is divided into five age groups from birth to 3 years.Within each age group questions reflect the areas of child development covered by the LTP: (1) Sense of self, (2) Physical development, (3) Relationship, (4) Understanding of the world (cognitive development), and (5) Communication.There are only two response categories for each statement where participants mark whether the statement is correct for a child of that particular age range.Correct answer on an item is scored as ''1'' and a wrong answer is scored as ''0.''All correct answers for each age group are summed to get a total score for that group.
A pre-test was conducted on day 1 of the training and post-test was completed at completion of training program on day 4 of the training, that is, 4 weeks after pretest.

LTP Training
The LTP program, developed to encourage early child development, has eight sequential stages of child development from birth to 3 years, with illustrations of parentchild play and other activities that enhance parental involvement, learning, and attachment.The training was delivered in a group setting.The standard LTP manual was used for the study at each stage.The standard manual addresses five key areas of child development: sense of self, physical, relationships, understanding (cognitive), and communication.Information about each area is written in simple language, translated into the native language (Urdu), with accompanying pictures, which were adapted to the local culture.The training was conducted by a trained community supervisor (LTP master trainer who actively participated and co-facilitated LTP sessions in an earlier trial), for 1 day/week over a month, and completed 18-hours training (4.5 hours a day/week), at a convenient site and time for all participants.Training content was divided across 4 days, by covering two out of eight age groups of LTP training manual each day (from birth to 3 years).Written informed consent was obtained from all the participants and they were assured that they were free to discontinue the program at any stage.Discussions were held throughout the training program where participants shared different examples from their personal experiences and observations.Each training session included a presentation by the trainer, role play, group activities, and discussions.At the end of each training day some time was allocated for feedback of that day.Certificates of completion of LTP training were distributed.

Fidelity Assessment
There was assessment of fidelity for LTP parenting intervention training to assess the degree and extent to which the training is delivered as it was intended to be delivered (Sanders et al., 2020).Fidelity was measured by following different stages: (1) Intervention design: In the study, the number, length, and frequency of intervention training sessions were clearly described to the participants.Psychoeducation and purpose of training intervention was explained while defining the underlying theoretical framework of training (Borrelli, 2011).( 2) Training of Providers: To ensure fidelity, it is necessary to ensure that multiple providers administer the same intervention in the same manner; for this reason, we followed the phenomena of ''therapist drift'' to keep providers/trainers deviating from standardized procedure over time, for example, training sessions delivered to participants in different scenarios.We also considered the relevant credentials, experience, or education of the trainers.(3) Intervention Training Delivery: For evaluation of fidelity of LTP training delivery, participant observation method was used, in which the rater not just observes, but also takes an active role in that setting (Pope & Mays, 1995).Therefore, two senior researchers (raters) attended the LTP training of TBAs as delegates.LTP specific observation checklists were developed by raters that included different domains from each age range of LTP and from each area of development from five areas identified in the LTP manual.During the LTP training, rating was independently completed by two raters.There were regular discussions between the raters and the trainer at two time points; beginning and end of each training day to review the content and feedback from training participants.All scores on observation checklist were reviewed for assessment of reliability.To ensure consistency, the fidelity assessment was completed by the same two researchers at each time points.( 4

) Receipt of Intervention Training:
The fourth component of fidelity is to focus on how participants received training such as; whether they understood the training content, its relevance, and whether the intervention was feasible to administer in daily life.

Analysis
Paired sample T-test was used for quantitative statistical analysis and comments were analyzed qualitatively as per the thematic analysis (Ritchie et al., 2013).

Results
All participants completed post-assessments.The mean age of participating TBAs was 49.5 years (SD = 11.8), with mean years of education 7.15 years (SD = 3.57; Table 1).The results indicated a significant difference between pre and post test score, reflecting significant improvement in TBAs' knowledge and attitude about child development on all sub-scales of KAP from 0 to 36 months (Table 2).Table 2 shows that the post-test mean for knowledge about child development at each age group is significantly higher as compared to the pre-test mean.The negative difference in mean indicate that the pre-test mean score is less than the post-test mean score.
The attendance log showed that 100% participants attended three training sessions and 96% participants attended all four training sessions.This reflects excellent engagement with training program.
In open comments, the participants expressed positive views about the training program and requested that more extended and frequent training sessions including more role plays need to be arranged for TBAs.TBAs informed that the training helped them in acquiring accurate knowledge and understanding about early child development and in enabling them to refute false myths and assumptions.TBA's reported how this training will help them to engage better not only with mothers but also the wider family.They appreciated the efforts of the organizing body and facilitators and reported a high level of confidence in, and motivation for transferring the gained knowledge to the community.
Open Comments were provided by TBAs as feedback post training.
''The training was very interactive and extensive but we suggest including more role play and practice related activities'' (TBA: 001) ''In our culture there are too many cultural beliefs and myths that people have regarding child development and upbringing such as not showing mirror to the child.Through this training we have learned that there is no logic behind these concepts and now we have knowledge on how we can help parents to understand the importance of small activities and to make them aware of these misconceptions.''(TBA: 097) ''We have learned a lot about parenting and now we are in far better position to interact with mothers and families'' (TBA: 259)

Discussion
The study results demonstrate the positive impact of LTP training on TBAs knowledge, attitude, and practices regarding child development as evident from change on KAP scores from pre-test to post-test.Earlier studies show that LTP intervention delivered by the Lady Health Workers (LHWs) increased mothers' knowledge of child development (Rahman et al., 2009) and more than 80% of LHWs found it relevant to their routine work (Mobeen et al., 2011).Similar to LHW's, each TBA is also responsible for a large number of women in their catchment area, therefore the impact of the LTP program on the community as a whole is likely to be significant and should be evaluated in future research.The improvement in KAP scores following LTP training in the current study is supported by a previously published meta-analysis which suggests that TBA training is associated with significant increase in attributes such as TBA ''knowledge'' (90%), ''attitude'' (74%), ''behavior'' (63%), and ''advice'' (90%) as compared to the untrained TBAs (Sibley & Sipe, 2004).
Training TBAs in LTP program and integrating it into the existing health care system not only enables them to be knowledgeable, clinically competent, and confident in the field but can be an effective strategy in improving the knowledge, attitude, and practices of parents to promote development of children.This may contribute to reducing the huge development gaps in low resource settings.Not being able to implement evidence informed interventions for children can be a major hindrance in the wellbeing of children in many LMICs and also results in failure of achieving the United Nations SDGs.Not having relevant evidence base in this area does not provide policy makers and health system managers the information needed to make informed decisions (Saran et al., 2020).
This study is a valuable addition to literature on the importance of training for lay members of the community.To our knowledge this was the first study exploring the potential role of training of TBAs in a particular parenting intervention in Pakistan.This study has some limitations; post assessment was only conducted immediately after completion of training, so it is uncertain how well the participants retained the information in the long term.A follow up assessment is important to determine how well they remember the information and to what extent they included the gained knowledge into their routine practice.The present study despite its various limitations is important and has made a significant contribution in knowledge base about potential role of structured parenting training programs for nonspecialized health professionals.
The study did not consider how the variables of knowledge, attitude, and practice were correlated and their potential role as mediators and moderators that should be explored in future research.Due to lack of resources, there was no comparison made with any other group of TBAs who either did not receive any LTP training or were exposed to any other medium of training.The longitudinal and mixed method design with in depth interviews may be considered for future research as that will provide rich understanding of the relevant cultural factors and evidence for task shifting.

Table 1 .
Demographics of Participants.

Table 2 .
Comparison of Mean Scores of TBAs on KAP Scale and Its Subscale Before and After LTP Training.