Implementing a group-based multi-component early child development intervention through the government health system in rural Bangladesh: A feasibility study.

Children in low- and middle-income countries face an increased risk of impaired cognitive development due to contaminated environments, poor nutrition, and inadequate responsive stimulation from caregivers. Implementing multi-component, community-level interventions may reduce these risks; however, there is little evidence supporting implementation of these interventions at scale. We assessed the feasibility of implementing a group-based intervention that included responsive stimulation, maternal and child nutrition, water and sanitation, and childhood lead exposure prevention through the government health system in Chatmohar, Bangladesh. After implementation, we conducted 17 in-depth interviews with frontline health service providers and 12 key informant interviews with their supervisors and managers to explore the facilitators and difficulties implementing such a complex programme within the health system. Factors facilitating implementation included: high quality training and skill level of providers, support from community members, family, and supervisors, positive relationships between providers and participants, and provision of children's toys and books free of cost. Difficulties included increased workload of the providers, complicated group-based yet stage-specific delivery where providers had to manage a large group of mother-child dyads representing many different child age-groups at once, and logistics difficulties in providing toys and books through a centralised health system process. Key informants made suggestions to ensure effective government-level scale-up including engaging relevant NGOs as partners, identifying feasible ways to make toys available, and offering providers meaningful even if non-monetary rewards. These findings can be used to shape the design and delivery of multi-component child development interventions to be delivered through the health system.

Feasibility and acceptability of home-based neonatal hyperbilirubinemia screening by community health workers using transcutaneous bilimeters in Bangladesh.

BACKGROUND: Universal screening for neonatal hyperbilirubinemia risk assessment is recommended by the American Academy of Pediatrics to reduce related morbidity. In Bangladesh and in many low- and middle-income countries, there is no screening for neonatal hyperbilirubinemia. Furthermore, neonatal hyperbilirubinemia may not be recognized as a medically significant condition by caregivers and community members. We aimed to evaluate the acceptability and operational feasibility of community health worker (CHW)-led, home-based, non-invasive neonatal hyperbilirubinemia screening using a transcutaneous bilimeter in Shakhipur, a rural subdistrict in Bangladesh. METHODS: We employed a two-step process. In the formative phase, we conducted eight focus group discussions with parents and grandparents of infants and eight key informant interviews with public and private healthcare providers and managers to explore their current knowledge, perceptions, practices, and challenges regarding identification and management of neonatal hyperbilirubinemia. Next, we piloted a prenatal sensitization intervention and home-based screening by CHWs using transcutaneous bilimeters and evaluated the acceptability and operational feasibility of this approach through focus group discussions and key informant interviews with parents, grandparents and CHWs. RESULTS: Formative findings identified misconceptions regarding neonatal hyperbilirubinemia causes and health risks among caregivers in rural Bangladesh. CHWs were comfortable with adoption, maintenance and use of the device in routine home visits. Transcutaneous bilimeter-based screening was also widely accepted by caregivers and family members due to its noninvasive technique and immediate display of findings at home. Prenatal sensitization of caregivers and family members helped to create a supportive environment in the family and empowered mothers as primary caregivers. CONCLUSION: Adopting household neonatal hyperbilirubinemia screening in the postnatal period by CHWs using a transcutaneous bilimeter is an acceptable approach by both CHWs and families and may increase rates of screening to prevent morbidity and mortality.

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.

The Lived Experiences of Community Health Workers Serving in a Large-Scale Water, Sanitation, and Hygiene Intervention Trial in Rural Bangladesh.

Community health workers (CHWs) are key to implementing community-based health interventions and quality can be enhanced by better understanding their lived experiences. The WASH Benefits, Bangladesh trial engaged 540 female CHWs to promote varying health intervention packages. We report on factors influencing their lived experiences during the trial, to aid future recruitment, training and retention of CHWs. Nine focus groups and 18 in-depth interviews were conducted with CHWs. Focus groups and interviews were transcribed and thematic content analysis performed to summarize the results. All CHWs described experiencing positive working conditions and many benefits both socially and financially; these contributed to their retention and job satisfaction. Their honorarium was commonly applied towards their children's education and invested for income generation. CHWs gained self-confidence as women, to move unaccompanied in the community and speak in public. They earned respect from the community and their family members who helped them manage their family obligations during work and were viewed as a resource for advice on health and social issues. Many participated in family decision-making from which they were previously excluded. Health programs should foster a positive experience among their CHWs to aid the recruitment, retention and development of this important human resource.

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

Supporting caregivers' mental wellbeing and ability to provide psychosocial stimulation may promote early childhood development. This paper describes the systematic approach of developing an integrated stimulation intervention, identifying the feasibility and challenges faced throughout the period. We developed an integrated curriculum by culturally adapting three interventions (Reach Up, Thinking Healthy, and general nutrition advice) and piloted this curriculum (Mar-April 2017) in courtyard groups sessions and individual home visits with pregnant women (n = 11) and lactating mothers (of children <24 months) (n = 29). We conducted qualitative interviews with the participants (n = 8) and the community health workers who delivered the intervention (n = 2). Most participants reported willingness to attend the sessions if extended for 1 year, and recommended additional visual cues and interactive role-play activities to make the sessions more engaging. Participants and community health workers found it difficult to understand the concept of "unhealthy thoughts" in the curriculum. This component was then revised to include a simplified behavior-focused story. Community health workers reported difficulty balancing the required content of the integrated curriculum but were able to manage after the contents were reduced. The revised intervention is likely feasible to deliver to a group of pregnant and lactating mothers in a low-resource setting.