Respectful Maternal Care Experience in Low- and Middle-Income Countries: A Systematic Review.

Background and Objectives: Respectful maternity care promotes practices that acknowledge women's preferences and women and newborns' needs. It is an individual-centered strategy founded on ethical and human rights principles. The objective of this systematic review is to identify the impact of income on maternal care and respectful maternity care in low- and middle-income countries. Materials and Methods: Data were searched from Google Scholar, PubMed, Web of Science, NCBI, CINAHL, National Library of Medicine, ResearchGate, MEDLINE, EMBASE database, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL), and Maternity and Infant Care database. This review followed PRISMA guidelines. The initial search for publications comparing low- and middle-income countries with respectful maternity care yielded 6000 papers, from which 700 were selected. The review articles were further analyzed to ensure they were pertinent to the comparative impact of income on maternal care. A total of 24 articles were included, with preference given to those published from 2010 to 2023 during the last fourteen years. Results: Considering this study's findings, respectful maternity care is a crucial component of high-quality care and human rights. It can be estimated that there is a direct association between income and maternity care in LMICs, and maternity care is substandard compared to high-income countries. Moreover, it is determined that the evidence for medical tools that can enhance respectful maternity care is sparse. Conclusions: This review highlights the significance of improving maternal care experiences, emphasizing the importance of promoting respectful practices and addressing disparities in low- and middle-income countries.

Effectiveness of a health education intervention on the use of long-lasting insecticidal nets for the prevention of malaria in pregnant women of Pakistan: a quasi-experimental study.

BACKGROUND: About one quarter of pregnant women in the population of Pakistan are using long-lasting insecticide-treated bed nets (LLINs) for prevention of malaria. Past research reported that adequate information and education would act as mediator to change behaviour among patients for prevention of malaria infection. The effective use of LLINs would contribute to reduction of disease burden caused by malaria. The aim of this study was to determine the effectiveness of health education on the adoption of LLINs among pregnant women living in Tharparkar, a remote district in Sindh Province, Pakistan. METHODS: A quasi-experimental study design with control and intervention groups was conducted with 200 pregnant women (100 in each group). Women in the intervention group were provided with health education sessions on malaria for 12 weeks, while those in the control group obtained routine information from lady health workers (LHWs). Pre- and post-intervention assessment was done of knowledge about malaria and use of LLIN, which was statistically analysed using descriptive statistics and difference in difference (DID) multivariable regression analysis to test effectiveness of the intervention. RESULTS: Baseline was conducted with 200 pregnant women. Demographic characteristics were similar in both groups with slight differences in age, education, income, type of latrine, and source of drinking water. There were no significant differences between mean knowledge and use of LLINs scores between groups at baseline. However, the estimated DID value after the intervention was 4.170 (p < 0.01) and represents an increase in scores of knowledge in the intervention group compared to control. Similarly DID value of 3.360 (p < 0.05) showed an increase in use of LLINs score after the intervention which was significant, showing that the intervention had a positive effect. CONCLUSIONS: Results proved that health education could be an effective intervention for improving knowledge and usage of LLINs among pregnant women for the prevention of malaria. Such educational interventions have a positive potential to be implemented at larger scale by incorporating them into routine health sessions provided by health workers.

Effectiveness of health literacy intervention on cardiovascular diseases among university students of Pakistan.

BACKGROUND: Global burden of cardiovascular diseases is alarming which is intricately linked with health literacy. To what extent improvement in health literacy can lower down cardiovascular diseases occurrence has not yet properly documented. This study focused on assessing the knowledge and existing lifestyle behavior about cardiac diseases among university students. We further aimed to improve this awareness after imparting an educational intervention among undergraduate non-medical students to sensitize them about risk factors. METHOD: A pre and post approaches with cross sectional study design was conducted in University of Gujrat during April-September 2017. Using structured questionnaire comprising of response items about hypertension, heart attack, stroke and preventive practices, data was randomly collected from students (n = 100). Survey respondents were also given a lecture regarding cardiovascular diseases awareness and a post test evaluation was also conducted on same group of students. RESULTS: With response rate of 86.95%, mean age of participating students was 21.2 (SD ± 1.34) years. Female students comprised of 53% out of which 57% were from rural background. Assessment of cardiovascular disease knowledge revealed maximum mean pre test score 30.53 (SD ± 7.61) and for post test 40.65 (SD ± 4.34) (p < 0.00). Mean score for using preventive practices was 13.02 (SD ± 2.97) for pre test whereas for post test it was 14.09 (SD ± 2.90) (p < 0.00). Intervention impact was significant on hypertension related complications (p < 0.000), symptoms of heart attack (p < 0.000), symptoms of stroke (p < 0.000) and preventive practices (p < 0.00). CONCLUSION: Findings presented here show a fair degree of awareness among university students about study title prior to any educational intervention. However, by attending educational session, a significant increase in the positive lifestyle behavior and knowledge was noticed. We conclude that health promotion activities in educational institutes to sensitize students can bring rational changes in Pakistani society to promote healthy behavior and minimize cardiovascular disease risks.

System within systems: challenges and opportunities for the Expanded Programme on Immunisation in Pakistan.

BACKGROUND: Pakistan has one of the highest infant and child mortality rates in the world, half of these occurring due to vaccine-preventable diseases. The country started its Expanded Programme on immunisation (EPI) in 1978. However, the programme's performance is often questioned, as the Immunisation rates have been chronically low and on-time vaccination unsatisfactory. We explored the programme's insights about its structural and implementation arrangements within the larger governance system, and the ensuing challenges as well as opportunities. METHODS: We carried out a qualitative case study comprised of semi-structured, in-depth interviews with 34 purposively selected key informants from various tiers of immunisation policy and programme implementation. The interviews revolved around WHO's six building blocks of a health system, their interactions with EPI counterparts, and with the outer ecological factors. Interviews were transcribed and content analysed for emergent themes. RESULTS: The EPI faces several challenges in delivering routine immunisation (RI) to children, including lack of clarity on whether to provide vaccination through fixed centres or mobile teams, scarcity of human resource at various levels, lack of accurate population data, on-ground logistic issues, lack of a separate budget line for EPI, global pressure for polio, less priority to prevention by the policy, security risks for community-based activities, and community misconceptions about vaccines. CONCLUSIONS: The fulcrum for most of the challenges lies where EPI service delivery interacts with components of the broader health system. The activities for polio eradication have had implications for RI. Socio-political issues from the national and global environment also impact this system. The interplay of these factors, while posing challenges to effective implementation of RI, also brings opportunities for improvement. Collective effort from local, national and global stakeholders is required for improving the immunisation status of Pakistani children, global health security and the sustainable development goals.

Capacity building on health diplomacy: a training experience from Pakistan.

Modern-day globalization means that many health issues cannot be resolved by the affected country alone, and this necessitates political consultations, diplomatic negotiations and cross-border solutions. A few examples that require health diplomacy efforts are: halting resentment towards immunization, addressing the burden of noncommunicable diseases, enabling access to drugs and technology, and liberalizing trade to reduce the cost of drugs. The agenda of Sustainable Development Goals (SDGs) demands a concerted effort to achieve the ambitious targets. This article reports the experience of health diplomacy training imparted to mid-level and senior officials in the public as well as private sector in Pakistan. Training was geared to inculcate an understanding of global health diplomacy and governance, and to develop an appreciation of the relationship of global health with other disciplines such as foreign affairs, economics, trade, climate change and human rights. Participants included health professionals, experts from departments other than health, government officials and diplomats. This training was expected to enhance their knowledge of health systems dynamics that are influenced by foreign policy and diplomatic discourses.

Determinants of severe acute malnutrition among children under five years in a rural remote setting: A hospital based study from district Tharparkar-Sindh, Pakistan.

OBJECTIVES: To understand and catalogue the specific determinants of this alarming rate of malnutrition among children of Tharparkar district, Sindh Pakistan. METHODS: This was a hospital based analytical survey. Data was collected through a semi-structured questionnaire by interviewing mothers of the children (age 6-59 months), admitted in the hospital. Following WHO guidelines, weight and length/ height of 105 children were recorded. Study was conducted in District Headquarters Hospital, Tharparkar district of Sindh province. RESULTS: Almost 48% children admitted in the hospital were identified with severe acute malnutrition. More males (55%) were malnourished as compared to females (45%). Maternal education, household income, family size, breastfeeding, vaccination status, and frequent infections were found to be significantly associated with the severe acute malnutrition. CONCLUSION: Specific interventions on promoting exclusive breastfeeding, vaccination, and timely health care seeking behaviors would definitely improve the outcomes. Nevertheless, sector wide approaches would be needed on girls' education, poverty, and food security in the district in order to address the issue of malnutrition.

Assessing the capacity of ministries of health to use research in decision-making: conceptual framework and tool.

BACKGROUND: The capacity to demand and use research is critical for governments if they are to develop policies that are informed by evidence. Existing tools designed to assess how government officials use evidence in decision-making have significant limitations for low- and middle-income countries (LMICs); they are rarely tested in LMICs and focus only on individual capacity. This paper introduces an instrument that was developed to assess Ministry of Health (MoH) capacity to demand and use research evidence for decision-making, which was tested for reliability and validity in eight LMICs (Bangladesh, Fiji, India, Lebanon, Moldova, Pakistan, South Africa, Zambia). METHODS: Instrument development was based on a new conceptual framework that addresses individual, organisational and systems capacities, and items were drawn from existing instruments and a literature review. After initial item development and pre-testing to address face validity and item phrasing, the instrument was reduced to 54 items for further validation and item reduction. In-country study teams interviewed a systematic sample of 203 MoH officials. Exploratory factor analysis was used in addition to standard reliability and validity measures to further assess the items. RESULTS: Thirty items divided between two factors representing organisational and individual capacity constructs were identified. South Africa and Zambia demonstrated the highest level of organisational capacity to use research, whereas Pakistan and Bangladesh were the lowest two. In contrast, individual capacity was highest in Pakistan, followed by South Africa, whereas Bangladesh and Lebanon were the lowest. CONCLUSION: The framework and related instrument represent a new opportunity for MoHs to identify ways to understand and improve capacities to incorporate research evidence in decision-making, as well as to provide a basis for tracking change.

Stillbirths: What Can Be Done To Confront An Invisible Public Health Problem In Pakistan?

Pakistan has been ranked highest and appears worst in stillbirths' rate according to the recent global estimates. Reasons could be manifold; socio-cultural, health system related country specific, and some of these of course déjà vu, i.e., the biomedical causes. Yet, a fresh stocktaking is necessary to understand the complex phenomenon in a country, awfully affected by this menace. Maternal, neonatal and child health program needs to be informed and geared up toward addressing the actual reasons behind this heavy toll of stillbirths in Pakistan. Maternal health indicators would never be improved, if the issue of stillbirths is not stalled at the earliest. Besides known medical reasons, this account attempts to document the health systems related factors, and more so the social determinants behind the whole scenario, so that appropriate and customized interventions could be suggested, developed and implemented. This paper will be a piece of evidence for policy corridors, program managers, development partners, non-governmental organizations, public health institutions, students, and researchers to enhance their understanding of a major public health problem, and to recognize the strengths and opportunities in the health system of Pakistan to cope with this challenge.

A randomized controlled trial comparing Pentazocine and Chamomilla recutita for labor pain relief.

BACKGROUND: Traditional birth attendants in Pakistan sometimes use a homeopathic remedy, Chamomilla for labor pain relief. Our study compares this homeopathic remedy for pain relief in labor with a commonly used parenteral analgesic in a hospital setting. No systematic study has been conducted previously to study the effect of chamomile, which may be affordable and available in community settings. METHODS: A double blind randomized controlled trial was carried out at Islamic International Medical College Trust. Ninety-nine normal pregnant women were randomly assigned into three groups. Each group received one of the three trial drugs; Chamomile, Pentazocine or placebo. The efficacy of labor analgesia was assessed by using Visual Analogue Scale (VAS) for pain intensity. Indicators of maternal and child health were recorded as were adverse effects of the drugs. RESULTS: Mean pain scores in the three groups were calculated and compared. The difference in mean VAS scores in Pentazocine and Chamomilla recutita group as compared with placebo was not statistically significant. No significant adverse effects were noticed in any group except slight headache and dizziness in three parturients in Pentazocine group. CONCLUSION: Neither Pentazocine, or Chamomilla recutita offer substantial analgesia during labor.

The impact of perinatal depression on exclusive breastfeeding: a cohort study.

Perinatal depression is associated with infant undernutrition. We hypothesised that perinatal depression was associated with early cessation of exclusive breastfeeding and reduced quantity of breast milk in rural Pakistan. We used a prospective cohort design to study a population-based sample of 132 depressed and 147 non-depressed women from the third trimester of pregnancy to 6 months post-natal. Current major depressive episode was measured in the third trimester and 6 months post-natal using the Structured Clinical Interview for DSM-IV Diagnosis. In a convenience sample of 24 depressed and 31 non-depressed exclusively breastfeeding mothers, breast milk quantity was assessed (mL kg(-1) infant weight per 24 h) at 4 months using the dose-to-mother deuterium dilution method. We administered also the Perception of Insufficient Milk questionnaire at 6 months post-natal. Depression was associated with fewer days of exclusive breastfeeding (91.8 (SD = 47.1) vs. 108.7 days (SD = 54.3) (95% CI: 3.4 to 30.3 P = 0.014). Women with persistent depression ceased exclusive breastfeed earliest. There was no difference in the quantity of breast milk produced by depressed and non-depressed mothers: 89.3 (SD = 38.1) vs. 83.9 (29.0) ml/kg infant wt/24 hours, P = 0.57. Depressed mothers were significantly more likely to report insufficient milk: PIM scores were 34.4 (SD = 14.3) for depressed and 39.7 (SD = 10.4) for non-depressed women (P = 0.004). In Cox regression PIM score mediated the association between depression and early cessation of breastfeeding. In this area of rural Pakistan, perinatal depression is associated with early cessation of exclusive breastfeeding and this is associated with mothers' perceptions of insufficiency of breast milk but not reduced milk production.

What can Pakistan do to address maternal and child health over the next decade?

Pakistan faces huge challenges in meeting its international obligations and agreed Millennium Development Goal targets for reducing maternal and child mortality. While there have been reductions in maternal and under-5 child mortality, overall rates are barely above secular trends and neonatal mortality has not reduced much. Progress in addressing basic determinants, such as poverty, undernutrition, safe water, and sound sanitary conditions as well as female education, is unsatisfactory and, not surprisingly, population growth hampers economic growth and development across the country. The devolution of health to the provinces has created challenges as well as opportunities for action. This paper presents a range of actions needed for change within the health and social sectors, including primary care, social determinants, strategies to reach the unreached, and accountability.

Reproductive, maternal, newborn, and child health in Pakistan: challenges and opportunities.

Globally, Pakistan has the third highest burden of maternal, fetal, and child mortality. It has made slow progress in achieving the Millennium Development Goals (MDGs) 4 and 5 and in addressing common social determinants of health. The country also has huge challenges of political fragility, complex security issues, and natural disasters. We undertook an in-depth analysis of Pakistan's progress towards MDGs 4 and 5 and the principal determinants of health in relation to reproductive, maternal, newborn, and child health and nutrition. We reviewed progress in relation to new and existing public sector programmes and the challenges posed by devolution in Pakistan. Notwithstanding the urgent need to tackle social determinants such as girls' education, empowerment, and nutrition in Pakistan, we assessed the effect of systematically increasing coverage of various evidence-based interventions on populations at risk (by residence or poverty indices). We specifically focused on scaling up interventions using delivery platforms to reach poor and rural populations through community-based strategies. Our model indicates that with successful implementation of these strategies, 58% of an estimated 367,900 deaths (15,900 maternal, 169,000 newborn, 183,000 child deaths) and 49% of an estimated 180,000 stillbirths could be prevented in 2015.

Job satisfaction among public health professionals working in public sector: a cross sectional study from Pakistan.

BACKGROUND: Job satisfaction largely determines the productivity and efficiency of human resource for health. It literally depicts the extent to which professionals like or dislike their jobs. Job satisfaction is said to be linked with the employee's work environment, job responsibilities and powers and time pressure; the determinants which affect employee's organizational commitment and consequently the quality of services. The objective of the study was to determine the level of and factors influencing job satisfaction among public health professionals in the public sector. METHODS: This was a cross sectional study conducted in Islamabad, Pakistan. Sample size was universal including 73 public health professionals, with postgraduate qualifications and working in government departments of Islamabad. A validated structured questionnaire was used to collect data from April to October 2011. RESULTS: Overall satisfaction rate was 41% only, while 45% were somewhat satisfied and 14% of professionals highly dissatisfied with their jobs. For those who were not satisfied, working environment, job description and time pressure were the major causes. Other factors influencing the level of satisfaction were low salaries, lack of training opportunities, improper supervision and inadequate financial rewards. CONCLUSION: Our study documented a relatively low level of overall satisfaction among workers in public sector health care organizations. Considering the factors responsible for this state of affairs, urgent and concrete strategies must be developed to address the concerns of public health professionals as they represent a highly sensitive domain of health system of Pakistan. Improving the overall work environment, review of job descriptions and better remuneration might bring about a positive change.

Non-Participatory Observation Of Integrated Management Of Childhood Illness Practices At Selected Basic Health Units Of District Abbottabad, Kp, Pakistan: A Qualitative Hermeneutic Study.

BACKGROUND: It was in 1995 when a strategy was devised to reduce under-five mortality in countries with a prevalence of child mortality above 40/1000 live births. This strategy is called "Integrated Management of Childhood Illness" (IMCI). Improvement in the skills of healthcare workers (HCWs) depends on the IMCI training received by them. To make IMCI training more effective and scale up, a global technical consultation committee in Geneva recommended implementing an innovative training approach in 2014: the distance learning IMCI (dIMCI). This study was conducted to observe qualitatively the practices of IMCI-trained HCWs at their respective workplaces. METHODS: This qualitative hermeneutic study was conducted through non-probability criterion sampling in the district Abbottabad of Pakistan on all 26 basic health units trained in IMCI (either standard or distance learning) from December 9, 2019, to March 9, 2020. Data collection was done by qualitatively observing consultations and interactions of caretakers of under-five children at basic health units. Inductive thematic analysis was used. This qualitative exploration was underpinned by Hans Georg Gadamer's philosophy of hermeneutics. RESULTS: Four themes emerged from the observation notes. These themes are gratification after consultation, altercation for medication, non-observance of protocol, and methodical consultation. CONCLUSIONS: Improvement in the skills of HCWs in the form of IMCI training, either through distance learning or the common eleven-day standard method, can improve caretakers' satisfaction. However, awareness at the community level is needed for better compliance.

A Randomized Controlled Trial of Blood Pressure Reduction Based on Disease Control Priorities 3 in Pakistan to Manage and Control Hypertension.

INTRODUCTION: According to American Heart Association standards, hypertension is classified into three stages based on blood pressure measurements: essential hypertension, stage 1 hypertension, and stage 2 hypertension. The global target is to reduce the prevalence of high blood pressure by 25% by the year 2025. Worldwide, the prevalence of high blood pressure among men and women aged 18 and above reported to be 24% and 20%, respectively. AIM: The aim of this study was to overall reduce high blood pressure of hypertensive patients to the recommended level of 140/90 mm of Hg through implementing a non-pharmacological and multi-component intervention based on Disease Control Priorities (3rd edition). METHODS: A randomized controlled trial in which a multi-component intervention for lowering high blood pressure was tested. This was pilot-tested for its acceptance, appropriateness, and relevance, explored through an earlier formative research and desk review conducted from the available evidence. A total of 240 study participants were enrolled after obtaining informed consent. Ethical approval was obtained from the Institutional Review Board of Health Services Academy and the trial was registered in clinicaltrials.gov number NCT04336631. SPSS software version 21 was used to enter and analyze the data. RESULTS: High blood pressure of hypertensive patients in a hospital setting during 03 months yielded -23.9 mm Hg of systolic blood pressure reduction (95% confidence interval, p ≤ 0.005). A significant reduction was observed in intervention group after delivering the intervention. Compared to patients in the usual care group, improved health outcomes were achieved for diet control, reducing salt intake and increased physical exercise. In the intervention group, the mean blood pressure among male hypertensive patients was 145/90 mm Hg and in female hypertensive patients, the mean blood pressure was recorded as 140/100 mm Hg. CONCLUSION: High blood pressure was significantly reduced in hypertensive patients who adhered to a low salt diet, weight loss measures, and increased physical activity.

Can home visits for early child development be implemented with sufficient coverage and quality at scale? Evidence from the SPRING program in India and Pakistan.

Introduction: There is limited evidence from low and middle-income settings on the effectiveness of early child development interventions at scale. To bridge this knowledge-gap we implemented the SPRING home visiting program where we tested integrating home visits into an existing government program (Pakistan) and employing a new cadre of intervention workers (India). We report the findings of the process evaluation which aimed to understand implementation. Methods and materials: We collected qualitative data on acceptability and barriers and facilitators for change through 24 in-depth interviews with mothers; eight focus group discussions with mothers, 12 with grandmothers, and 12 with fathers; and 12 focus group discussions and five in-depth interviews with the community-based agents and their supervisors. Results: Implementation was sub-optimal in both settings. In Pakistan issues were low field-supervision coverage and poor visit quality related to issues scheduling supervision, a lack of skill development, high workloads and competing priorities. In India, issues were low visit coverage - in part due to employing new workers and an empowerment approach to visit scheduling. Coaching caregivers to improve their skills was sub-optimal in both sites, and is likely to have contributed to caregiver perceptions that the intervention content was not new and was focused on play activities rather than interaction and responsivity - which was a focus of the coaching. In both sites caregiver time pressures was a key reason for low uptake among families who received visits. Discussion: Programs need feasible strategies to maximize quality, coverage and supervision including identifying and managing problems through monitoring and feedback loops. Where existing community-based agents are overstretched and system strengthening is unlikely, alternative implementation strategies should be considered such as group delivery. Core intervention ingredients such as coaching should be prioritized and supported during training and implementation. Given that time and resource constraints were a key barrier for families a greater focus on communication, responsivity and interaction during daily activities could have improved feasibility.

Effect of the SPRING home visits intervention on early child development and growth in rural India and Pakistan: parallel cluster randomised controlled trials.

Introduction: Almost 250 million children fail to achieve their full growth or developmental potential, trapping them in a cycle of continuing disadvantage. Strong evidence exists that parent-focussed face to face interventions can improve developmental outcomes; the challenge is delivering these on a wide scale. SPRING (Sustainable Programme Incorporating Nutrition and Games) aimed to address this by developing a feasible affordable programme of monthly home visits by community-based workers (CWs) and testing two different delivery models at scale in a programmatic setting. In Pakistan, SPRING was embedded into existing monthly home visits of Lady Health Workers (LHWs). In India, it was delivered by a civil society/non-governmental organisation (CSO/NGO) that trained a new cadre of CWs. Methods: The SPRING interventions were evaluated through parallel cluster randomised trials. In Pakistan, clusters were 20 Union Councils (UCs), and in India, the catchment areas of 24 health sub-centres. Trial participants were mother-baby dyads of live born babies recruited through surveillance systems of 2 monthly home visits. Primary outcomes were BSID-III composite scores for psychomotor, cognitive and language development plus height for age z-score (HAZ), assessed at 18 months of age. Analyses were by intention to treat. Results: 1,443 children in India were assessed at age 18 months and 1,016 in Pakistan. There was no impact in either setting on ECD outcomes or growth. The percentage of children in the SPRING intervention group who were receiving diets at 12 months of age that met the WHO minimum acceptable criteria was 35% higher in India (95% CI: 4-75%, p = 0.023) and 45% higher in Pakistan (95% CI: 15-83%, p = 0.002) compared to children in the control groups. Discussion: The lack of impact is explained by shortcomings in implementation factors. Important lessons were learnt. Integrating additional tasks into the already overloaded workload of CWs is unlikely to be successful without additional resources and re-organisation of their goals to include the new tasks. The NGO model is the most likely for scale-up as few countries have established infrastructures like the LHW programme. It will require careful attention to the establishment of strong administrative and management systems to support its implementation.

Using cognitive-behavioural techniques to improve exclusive breastfeeding in a low-literacy disadvantaged population.

Despite being an important component of Pakistan's primary health care programme, the rates of exclusive breastfeeding at 6 months remain among the lowest in the world. Low levels of literacy in women and deeply held cultural beliefs and practices have been found to contribute to the ineffectiveness of routine counselling delivered universally by community health workers in Pakistan. We aimed to address this by incorporating techniques of cognitive-behavioural therapy (CBT) into the routine counselling process. We conducted qualitative studies of stakeholders' opinions (mothers, community health workers, their trainers and programme managers) and used this data to develop a psycho-educational approach that combined education with techniques of CBT that could be integrated into the health workers' routine work. The workers were trained to use this approach and feedback was obtained after implementation. The new intervention was successfully integrated into the community health worker programme and found to be culturally acceptable, feasible and useful. Incorporating techniques of CBT into routine counselling may be useful to promote health behaviours in traditional societies with low literacy rates.