Methodology for adapting a co-created early childhood development intervention and implementation strategies for use by frontline workers in India and Guatemala: a systematic application of the FRAME-IS framework.

There is little evidence on optimizing the effectiveness and implementation of evidence-based early childhood development (ECD) interventions when task-shifted to frontline workers. In this Methods Forum paper, we describe our adaptation of the International Guide for Monitoring Child Development (GMCD) for task-shifting to frontline workers in Guatemala and India. In 2021-2022, implementers, trainers, frontline workers, caregivers, and international GMCD experts collaborated to adapt the GMCD for a task shifted implementation by frontline workers. We used an eight-step co-creating process: assembling a multidisciplinary team, training on the existing package, working groups to begin modifications, revision of draft modifications, tailoring of visual materials and language, train-the-trainers activities, pilot frontline worker trainings, final review and feedback. Preliminary effectiveness of adaptations was evaluated through narrative notes and group-based qualitative feedback following pilot trainings with 16 frontline workers in India and 6 in Guatemala. Final adaptations included: refining training techniques to match skill levels and learning styles of frontline workers; tailoring all visual materials to local languages and contexts; design of job aids for providing developmental support messages; modification of referral and triage processes for children in need of enhanced support and speciality referral; and creation of post-training support procedures. Feedback from pilot trainings included: (1) group consensus that training improved ECD skills and knowledge across multiple domains; and (2) feedback on ongoing needed adjustments to pacing, use of video-based vs. role-playing materials, and time allocated to small group work. We use the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) framework to document our adaptations. The co-creating approach we use, as well as systematic documentation of adaptation decisions will be of use to other community-based early childhood interventions and implementation strategies.

Main findings: The International Guide for Monitoring Child Development, an early childhood development support and monitoring tool, was successfully adapted for use by frontline workers in rural India and Guatemala.Added knowledge: Our Methods Forum paper uses a detailed framework to document the collaborative, co-creating process used and the adaptive decisions taken.Global health impact for policy and action: Evidence on how best to adapt and optimize early childhood interventions for frontline workers will be useful or scaling up support for children globally.

Early full-day leg movement kinematics and swaddling patterns in infants in rural Guatemala: A pilot study.

BACKGROUND: Tools to accurately assess infants' neurodevelopmental status very early in their lives are limited. Wearable sensors may provide a novel approach for very early assessment of infant neurodevelopmental status. This may be especially relevant in rural and low-resource global settings. METHODS: We conducted a longitudinal observational study and used wearable sensors to repeatedly measure the kinematic leg movement characteristics of 41 infants in rural Guatemala three times across full days between birth and 6 months of age. In addition, we collected sociodemographic data, growth data, and caregiver estimates of swaddling behaviors. We used visual analysis and multivariable linear mixed models to evaluate the associations between two leg movement kinematic variables (awake movement rate, peak acceleration per movement) and infant age, swaddling behaviors, growth, and other covariates. RESULTS: Multivariable mixed models of sensor data showed age-dependent increases in leg movement rates (2.16 [95% CI 0.80,3.52] movements/awake hour/day of life) and movement acceleration (5.04e-3 m/s2 [95% CI 3.79e-3, 6.27e-3]/day of life). Swaddling time as well as growth status, poverty status and multiple other clinical and sociodemographic variables had no impact on either movement variable. CONCLUSIONS: Collecting wearable sensor data on young infants in a rural low-resource setting is feasible and can be used to monitor age-dependent changes in movement kinematics. Future work will evaluate associations between these kinematic variables from sensors and formal developmental measures, such as the Bayley Scales of Infant and Toddler Development.

Using the project ECHO™ model to teach mental health topics in rural Guatemala: An implementation science-guided evaluation.

BACKGROUND: Mental health (MH) disorders are major causes of disability in Guatemala. Unfortunately, limited academic training and funding resources make MH care inaccessible to most people in rural Guatemala. These disparities leave many indigenous populations without care. Project ECHO™ is an educational model used globally to deliver virtual training for providers in rural/ underserved communities. The aim of this project was to implement and evaluate a Project ECHO™ program bridging MH training gaps for providers who serve rural communities in Guatemala. METHODS: The Project ECHO™ curriculum was implemented through a partnership between educational and nonprofit institutions in Guatemala City and the United States. Participants were primary care physicians and nurses working in rural Guatemala as well as medical/nursing/psychology students. Evaluation of its implementation was guided by a RE-AIM framework. Reach, effectiveness, adoption, fidelity, sustainability, acceptability, feasibility, and appropriateness were evaluated using a mixed-methods approach, using a pre-post survey and semi-structured focus groups. RESULTS: Forty unique participants attended the five sessions. Attitudes about mental health did not change quantitatively but self-efficacy improved in four of five modules. High quality fidelity scores were noted in two of five sessions. Sustainability scores across multiple domains were highly rated. Scores on instruments measuring acceptability, feasibility, and appropriateness were high. Focus groups showed two main themes: the curriculum filled a gap in education and further adaptation of the model might help improve the experience. CONCLUSION: Implementation of the Project ECHO™ educational model appeared to have good reach/adoption, showed improvements in self-efficacy, illuminated facilitators and barriers to sustainability, and was felt to be acceptable, feasible, and appropriate. Qualitative analysis supported these conclusions. Future directions would include ongoing evaluation and monitoring of further Project ECHO™ curricular experiences through this partnership and adaptation of this project to other learners and settings in Latin America.

Modelo de supervisión integrativo: Construyendo una identidad profesionalen el campo de la Consejería Psicológica en Guatemala / Integrative supervision model: Building a professional identity in Psychological Counseling in Guatemalac

Este estudio contribuye a avanzar la incipiente investigaciónsobre la supervisión en Guatemala y tiene como objetivoevaluar elmodelo utilizado en un programa de maestría en Consejería Psicológica y Salud Mental de una universidad privada del país. Es un estudio cualitativo en el que cuatro supervisoras entrevistaron a 14 mujeres profesionales egresadas o estudiantes de este programa.La entrevistaincluyópreguntas sobre el significado y propósito, beneficios e importancia, impacto en el cliente, las habilidades personales y la alianza de supervisión. Las respuestas se codificaron, agruparon y analizaron por temas de las cuales surgieron: (a) la definición de supervisión como un proceso de aprendizaje y evaluación a través del acompañamiento y realimentación; (b) la confirmación que la supervisión tiene un impacto en el cliente; (c) la necesidad de definir el modelo, guía y estandarización del formato y práctica y (d) las características relevantes de la persona quien supervisa en la relación de supervisión. Las características encontradas más relevantes son: respeto, apoyo, orientación, escucha, confianza, habilidades de comunicación, responsabilidad, empatía, apertura, respeto a la diversidad, realimentación, aprendizaje y orden.Este trabajo abre la oportunidad para continuar investigaciones similares en ambientes académicos, comunitarios, profesionales y de formación que trasciendan los límites de este programa y se apliquen a otros contextos latinoamericanos.(AU)

Este estudo contribui para o avanço da pesquisa incipiente sobre supervisão na Guatemala e visa avaliar o modelo utilizado em um programa de mestrado em Aconselhamento Psicológico e Saúde Mental de uma universidade privada do país. Trata-se de um estudo qualitativo, no qual quatro orientadores entrevistaram 14 profissionais graduadas e alunas desse programa. A entrevista incluiu perguntas sobre o significado e propósito, benefícios e importância, impacto no cliente, habilidades pessoais e a aliança de supervisão. As respostas foram codificadas, agrupadas e analisadas por tópicos dos quais emergiram: (a) a definição de supervisão como processo de aprendizagem e avaliação por meio de acompanhamento e feedback, (b) confirmação de que a supervisão tem impacto no cliente, (c) a necessidade de definir o modelo orientador e a padronização do formato e da prática e (d) as características relevantes da pessoa que supervisiona a relação de supervisão. As características mais relevantes encontradas são: respeito, apoio, orientação, escuta, confiança, habilidades de comunicação, responsabilidade, empatia, abertura, respeito à diversidade, feedback, aprendizado e ordem. Este trabalho abre a oportunidade de continuar pesquisas semelhantes em ambientes acadêmicos, comunitários, profissionais e de treinamento que transcendem os limites deste programa e se aplicam a outros contextos latino-americanos.(AU)

This research is part of a series of pioneering studies on supervision in Guatemala and aims to evaluate the model used in a psychological counseling and mental healthmaster program of a private Guatemalan University. It is a qualitative study where 14 professionals, women graduated or students from this program were interviewed. The interview included questions about the meaning and purpose of supervision, benefits and importance of the process, impact on the client and personal skills, and the supervision alliance.Answers were coded, grouped, and analyzed by themes offering: a) the definition of supervision as a learning and assessment process with companionship and feedback; b) confirmation that supervision has an impact in client, c) the need of defining a model, guidelines, and format standardization for practicum; and d) the most relevant supervisor´s characteristics in the supervision relationship. In this study, the main characteristics of the supervision relationship are: respect, support, guidance, active listening, safe space, communication abilities, responsibility, empathy, openness, respect for cultural diversity, feedback, learning and structure. This research is an opportunity to pursue similar research in academic, community, professional environments, and training that transcend the geographic borders of this program and are applicable to other LatinAmerican contexts.(AU)

Developmental outcomes of an individualised complementary feeding intervention for stunted children: a substudy from a larger randomised controlled trial in Guatemala.

OBJECTIVE: Stunting is a common cause of early child developmental delay; Guatemala has the fourth highest rate of stunting globally. The goal of this study was to examine the impact of an intensive community health worker-led complementary feeding intervention on early child development in Guatemala. We hypothesised that the intervention would improve child development over usual care. DESIGN: A substudy from a larger individually randomised (1:1 allocation ratio), parallel-group superiority trial, with blinding of study staff collecting outcomes data. SETTING: Rural, indigenous Maya communities in Guatemala. PARTICIPANTS: 210 stunted children (height-for-age z-score ≤-2.5) aged 6-24 months, previously randomised to usual care (106) or an intensive complementary feeding intervention (104). 84 in the intervention and 91 in the usual care arm agreed to participate. INTERVENTIONS: Community health workers conducted monthly home visits for 6 months, providing usual care or individualised complementary feeding education. MAIN OUTCOME MEASURES: The primary outcomes were change in z-scores for the subscales of the Bayley Scales of Infant Development (BSID), Third Edition. RESULTS: 100 individuals were included in the final analysis, 47 in the intervention and 53 in the usual care arm. No statistically significant differences in age-adjusted scores between the arms were observed for any subscale. However, improvements within-subjects in both arms were observed (median duration between measurements 189 days (IQR 182-189)). Mean change for subscales was 0.45 (95% CI 0.23 to 0.67) z-scores in the intervention, and 0.43 (95% CI 0.25 to 0.61) in the usual care arm. CONCLUSIONS: An intensive complementary feeding intervention did not significantly improve developmental outcomes more than usual care in stunted, indigenous Guatemalan children. However, both interventions had significant positive impacts on developmental outcomes. TRIAL REGISTRATION NUMBER: NCT02509936. STAGE: Results.

Complementary feeding intervention on stunted Guatemalan children: a randomised controlled trial.

OBJECTIVE/BACKGROUND: Guatemala's indigenous Maya population has one of the highest rates of childhood stunting in the world. The goal of this study was to examine the impact of an intensive, individualised approach to complementary feeding education for caregivers on feeding practices and growth over usual care. DESIGN: An individually randomised (1:1 allocation ratio), parallel-group superiority trial, with blinding of study staff collecting outcome data. SETTING: Rural Maya communities in Guatemala. PARTICIPANTS: 324 children aged 6-24 months with a height-for-age Z score of less than or equal to -2.5 SD were randomised, 161 to the intervention and 163 to usual care. INTERVENTIONS: Community health workers conducted home visits for 6 months, providing usual care or usual care plus individualised caregiver education. MAIN OUTCOMES MEASURES: The main outcome was change in length/height-for-age Z score. Secondary outcomes were changes in complementary feeding indicators. RESULTS: Data were analysed for 296 subjects (intervention 145, usual care 151). There was a non-significant trend to improved growth in the intervention arm (length/height-for-age Z score change difference 0.07(95% CI -0.04 to 0.18)). The intervention led to a 22% improvement in minimum dietary diversity (RR 1.22, 95% CI 1.11 to 1.35) and a 23% improvement in minimal acceptable diet (RR 1.23, 95% CI 1.08 to 1.40) over usual care. CONCLUSIONS: Complementary feeding outcomes improved in the intervention arm, and a non-significant trend towards improved linear growth was observed. Community health workers in a low-resource rural environment can implement individualised caregiver complementary feeding education with significant improvements in child dietary quality over standard approaches. CLINICAL TRIAL REGISTRATION NUMBER: NCT02509936. Stage: Results.

The sociocultural model of eating disorder development: application to a Guatemalan sample.

Exposure to Western ideals of appearance along with rapid societal change appears to be salient risk factors for eating disorder development. According to the sociocultural model, internalization of the thin ideal leads to body dissatisfaction and subsequent negative affect and dieting behaviors which increase the risk for eating disorder development. An expanded version of the sociocultural model was examined among an economically stratified sample of 347 girls in grades 5 and 6 from Guatemala City. Questionnaires used to measure disturbed eating attitudes and behaviors, body dissatisfaction, social sensitivity, and internalization of the thin ideal were administered and BMI was calculated following measurement of height and weight. Path analyses showed that the expanded sociocultural model was an excellent fit to the data. Both elevated adiposity and social sensitivity led to increased body dissatisfaction and thin ideal internalization. Thin ideal internalization led to body dissatisfaction and to disturbed eating attitudes and behaviors. Results suggest that developing countries are not immune to the influence of sociocultural risk factors for eating disorders.