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Research

Delivering integrated child development care in Pakistan: protocol for a clustered randomised trial

Muhammad Amir Khan, Syeda Somyyah Owais, Claire Blacklock, Shirin Anil, Sehrish Ishaq, Shazia Maqbool, Haroon Jehangir Khan, Fareed A Minhas and John Walley
BJGP Open 2017; 1 (1): bjgpopen17X100677. DOI: https://doi.org/10.3399/bjgpopen17X100677
Muhammad Amir Khan
1Chief Coordinating Professional, Association for Social Development, , Pakistan
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Syeda Somyyah Owais
2Project Manager, Association for Social Development, , Pakistan
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  • For correspondence: gcc@asd.com.pk
Claire Blacklock
3Lecturer in International Public Health, Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, , UK
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Shirin Anil
4Project Coordinator and Consultant, Association for Social Development, , Pakistan
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Sehrish Ishaq
5Project Coordinator, Association for Social Development, , Pakistan
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Shazia Maqbool
6Professor of Developmental Paediatrics, Institute of Child Health and The Children’s Hospital, , Pakistan
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Haroon Jehangir Khan
7Focal Person (Non-Communicable Diseases), Directorate General of Health Services Punjab, , Pakistan
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Fareed A Minhas
8Head, Institute of Psychiatry, , Pakistan
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John Walley
9Professor of International Public Health, Nuffield Centre for International Health and Development, Leeds Institute of Health Sciences, University of Leeds, , UK
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Article Figures & Data

Figures

  • Tables
  • Figure 1.
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    Figure 1. Trial flow diagram

Tables

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    Box 1. Early child development care in private GP clinics
    Control clinicsIntervention clinics
    Mother–child care Usual care
    • Standard counselling session on childhood nutrition, development, and maternal mental health, using pictorial flipbook.

    • Monitoring and screening of child growth and maternal mental health.

    • Assessment and treatment (including referral to specialist) of childhood nutrition, development, or maternal depression.

    • Follow-up of mother–child pairs in clinic at 3, 6 and 9 months (including SMS or telephone reminder, if required)

    Low dose vitamin A YesYes
    Community advocates YesYes
    Branding of clinic by Directorate General Health Services YesYes
    Training of private doctors (GPs) and clinic assistants Control clinic staff will receive basic training only, focused on the correct use of study recording forms, with a general overview of the importance of childhood development and maternal health; that is, they will not receive any specific training on intervention activities.
    • Clinic assistants will be trained by project field coordinator (under supervision of project manager and specialist doctor) using the study clinical assistant training protocol (CATP), which includes:

      • how to conduct a standardised counselling session using the flipbook;

      • how to administer the PHQ-2; and

      • how to measure and record child length and weight.

    • Private GPs will be trained by an experienced specialist according to the study private doctor training protocol (PDTP), which includes:

      • clinical management of children with malnutrition and developmental delay in the private clinic setting;

      • how to use PHQ-9 for the diagnosis of maternal depression; and

      • how to assess the mother–child pair for a specialist referral, when required, to the appropriate public tertiary care facility.

    • The training protocols, both CATP and PDTP, are developed by a group of local experts and specialists, adapted from international best-practice guidelines and standards.16,17

    • Training will last approximately 2 hours, and will include a mixture of explanation by the project field coordinator, and role-play exercises by participants.

    • View popup
    Box 2. Logic model for proposed intervention mechanisms/theory of change (adapted from Bonell and colleagues 2015)38
    InputsProcesses and actionsIntended changes (Theoretical domains framework)21 Intended outputsIntended health outcomes
    InterventionFormative research: interviews with providers, mothers, and key stakeholders

    Consultation with experts to develop technical materials:
     • Training protocols and manuals
     • Counselling flipbook
     • Community advocate leaflets

    Training of private GPs and clinic assistants: theoretical and practical training
    Quarterly counselling sessions for mothers (child development, child nutrition, maternal mental health)

    Quarterly child growth monitoring

    Text message/SMS reminders to mothers for quarterly follow-up appointments

    Assessment and treatment of chid developmental delay (may include referral)

    Assessment and treatment of maternal depression (may include)
    Mother
    Social influences
    Knowledge
    Beliefs about consequences
    Environmental context and resources
    Reinforcement

    Private GP and clinic assistant
    Social influences
    Knowledge
    Skills
    Environmental context and resources
    Social and professional role and identity
    Mother
    Mother–child health services are accessible and desirable to mother

    Increased capability and confidence to support child nutrition and development in the home environment

    Increased capability and confidence to protect own mental health in the home environment

    Private GP and clinic assistant
    Motivated and skilled to provide mother–child health services
    Reduced developmental delay at 12 months of age (primary outcome)

    Improved childhood nutrition

    Reduced maternal depression
    Both intervention and control arms DGHS endorsement of intervention and control clinics

    Identification and orientation of community advocates

    Growth Monitoring Cards to intervention and control clinics

    Standard calibrated equipment to intervention and control clinics

    Supervision of data entry on Growth Monitoring Card by clinic assistant (Field research officer)
    Recruitment of mothers by community advocates

    Vitamin A supplement
    Adequate participant recruitment

    High quality data
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Delivering integrated child development care in Pakistan: protocol for a clustered randomised trial
Muhammad Amir Khan, Syeda Somyyah Owais, Claire Blacklock, Shirin Anil, Sehrish Ishaq, Shazia Maqbool, Haroon Jehangir Khan, Fareed A Minhas, John Walley
BJGP Open 2017; 1 (1): bjgpopen17X100677. DOI: 10.3399/bjgpopen17X100677

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Delivering integrated child development care in Pakistan: protocol for a clustered randomised trial
Muhammad Amir Khan, Syeda Somyyah Owais, Claire Blacklock, Shirin Anil, Sehrish Ishaq, Shazia Maqbool, Haroon Jehangir Khan, Fareed A Minhas, John Walley
BJGP Open 2017; 1 (1): bjgpopen17X100677. DOI: 10.3399/bjgpopen17X100677
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Keywords

  • primary care
  • primary health care
  • general practice
  • Pakistan
  • child development
  • Nutrition
  • Depression

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