Supplementary appendix
This appendix formed part of the original submission and has been peer reviewed.
We post it as supplied by the authors.
Supplement to: Yousafzai AK, Rasheed MA, Rizvi A, Armstrong R, Bhutta ZA. Effect
of integrated responsive stimulation and nutrition investigations in the Lady Health
Worker programme in Pakistan on child development, growth, and health outcomes:
a cluster-randomised factorial effectiveness trial. Lancet 2014; published online June 17.
http://dx.doi.org/10.1016/S0140-6736(14)60455-4.
1
Web-appendix: Summary of Interventions
The intervention design drew from the literature on responsive stimulation (play, feeding, and care), what we know works from efficacy studies
on early child development (ECD) interventions, supportive supervision, and behavioural change techniques. 8-16, 21 The final implementation
strategy was agreed after stakeholder consultations with the Lady Health Worker programme, and formative research.
Features of Intervention
1.
2.
3.
4.
5.
6.
7.
8.
Programme Integration: New and enhanced intervention strategies should align with existing responsibilities and delivery pathways of the
Lady Health Workers (LHWs).
Content Integration: New and enhanced messages should be introduced by highlighting connection with existing messages; for example,
‘Hand washing before preparing food and feeding your child is essential for the prevention of illnesses.’
Responsive Interaction: Interventions should enhance the quality of caregiver-child interactions which influence early child development:
(1) Sensitivity- the capacity of the caregiver to observe and understand the infant and young child’s needs and wants); and (2)
Responsiveness- the capacity of the caregiver to respond in a timely and developmentally appropriate manner to the infant and young
child’s signals.
Contextual Messages: The messages should build on local non harmful knowledge and practices. The content would consider the reality of
the lives of the caregivers- keeping messages clear and easy to follow, offering diversity to keep caregivers engaged and repetition so
caregivers are not obliged to participate in a set number of sessions.
Caregivers and Children Together: The intervention strategy should encourage caregivers and children to try activities for play, care, and
feeding together. The sessions should be supported by coaching (prompts to enhance interaction during the activity), feedback,
demonstrations, and praise by the LHWs.
Supporting Caregivers (Mothers): Interventions should engage all female caregivers; however, a particular focus on the mother should be
encouraged because of expected high levels of maternal depression and greater caregiving responsibilities. The LHWs should be helped to
learning to talk with mothers (listening, asking and encouraging questions, problem solving) and build a good relationship with mothers.
Supportive Supervision: The skills of LHWs should be actively promoted through on job coaching (observing and guiding LHWs at work),
experiential learning, constructive feedback, and problem solving.
Behavioural Change Techniques: (a) Information sharing such as providing knowledge about recommended practices and benefits to
healthy development and growth; (b) Performance/Skills Enhancement such as modeling, practice, coaching, and feedback; (c) Problem
solving; (d) Social support such as encouragement, praise and peer -to-peer exchange.
Intervention Support Team
An effective training and supervision strategy was integral to the delivery of the new and enhanced interventions. Previous studies have argued
the introduction of ECD interventions in existing health systems would require support to ensure that new interventions are not lost in the
system.12 Previous literature provided evidence on who could deliver ECD interventions and delivery techniques, but not on training, supervision
or successful integration. We introduced a team of six ECD Facilitators to support the intervention delivery by LHWs. Their role was to train,
coach and mentor the LHWs, and to liaise with and support the government Lady Health Supervisors. They were local women with at least 12
years of formal education, and previous work experience was either community/social work or teaching (experience in community health was
less than the regular government LHW programme supervisors).
The number of trainings and supervisory approach were aligned with the existing expectations of the LHW programme. The expected ratio of
government Lady Health Supervisors is 1: 25, but is often a poorer ratio because e of vacant posts. The governments Lady Health Supervisors are
expected to have a minimum of two supervisory contacts per month, including one in the field where they observe the LHW at work and
complete a supervisory checklist. The governments Lady Health Supervisors also have access to a vehicle. However, often the number of
contacts with LHWs is not met, supervisory checklists are not maintained, and vehicles are not functioning in the routine programme.
The ratio of ECD Facilitator: LHW was 1:10. The ECD Facilitators received three months of centre and field based training prior to the roll of the
interventions. The aim was to follow the expected number of contacts and use similar tools (e.g. supervisory checklists) that government
supervisors were expected to use. However, a great emphasis was placed on content and quality of supervisory contacts in order to build the skills
of the LHWs through monthly on job coaching to supplement the basic training, feedback, mentorship sessions for motivation and problem
solving, motivational phone calls, and use of supervisory checklists to show progress and guide recommendations for improvement. The level of
training and supervision support was of high intensity and quality to build the skills of, and empower the LHWs. The lessons learned from this
model can support supervisory strategies for integrated ECD programmes. A gradual development of skills was observed over time with
improved engagement of the family around child health, nutrition and development care benefitting routine and new messages. This strategy was
integral to the intervention packages and drew on the same concepts of modeling interactions, problem solving, encouragement and praise and
experiential learning to build the relationship between the ECD Facilitator and the LHW, in much the same way it was expected that the
relationship would develop between the LHW and the family, and the family and child.
2
Intervention Groups
The Control group received the standard of care services provided by LHWs including health, hygiene and basic nutrition education The
remaining three groups continued to receive the standard of care services provided by the LHWs in addition to the new and enhanced
interventions:
Intervention Group
Content
Delivery
Job Aides
Enhanced Nutrition
Nutrition education
using standard infants
and young children
feeding messages. The
existing basic nutrition
messages in the LHWs’
curriculum were
connected with
information on healthy
development and growth
of child. A new set of
messages on responsive
feeding included.
Routine monthly home
visits (aligned with the
delivery of basic
nutrition education
services provided by the
LHWs).
Illustrated nutrition job
aide, counseling guide,
and problem solving
checklist.
Supportive supervision
included at least two
contacts per month with
an ECD Facilitator.
The LHW was expected
to deliver a one month
dosage of Sprinkles®
during her home visit,
and repeat, if consumed,
in the next month
Strategies included on
job coaching, feedback
guided by supervisory
checklist, modeling, and
mentorship.
Problem solving around
feeding
Responsive Stimulation
Children aged six to 24
months received
Sprinkles® (Genera
Pharmaceuticals
Pakistan) containing
iron, folic acid, vitamin
A, and vitamin C.
Curriculum adapted from
UNICEF and WHO
‘Care for Child
Development’.36 Age
appropriate play and
communication activities
which help young child
learn cognitive, motor,
social and affective
skills. These activities
also provide a context to
enhance the caregiverchild interactions
whereby the caregiver is
guided to observe and
respond to her child’s
signals through play.
In this approach,
caregivers try an activity
with their child while the
LHW observes, coaches
and provides feedback to
enhance the quality of
the interactions.
Communication during
feeding interactions
included.
Parenting messages (e.g.
praise and discipline,
making homemade toys).
Onetime picture book
given to all families.
Problem solving
Delivered in monthly
parenting group
meetings and supported
by routine monthly home
visits. LHWs are
expected to conduct
monthly community
groups in the routine
programme; however,
they often do not
conduct these due to a
lack of objectives. The
new intervention was an
opportunity to provide
structure to the
community groups, and
also allayed concerns
from the LHW
programme managers
that new content may not
be effectively integrated
with basic messages in
home visits alone.
Refreshments (Juice/tea)
served in group sessions
for caregivers and young
children.
Training and
Supervision
Basic training was for
two days followed by a
one-day refresher every
six months.
Illustrated play and
communication activity
guide, resource kit with
examples of homemade
toys or readily available
play materials (e.g.
aluminum cups for
stacking), parenting
group meeting topic
guide, counseling guide,
and a problem solving
checklist.
Basic training was for
two days followed by a
one-day refresher every
six months.
Supportive supervision
included at least two
contacts per month with
an ECD Facilitator.
Strategies included on
job coaching, feedback
guided by supervisory
checklist, modeling, and
mentorship.
3
Responsive Stimulation
& Enhanced Nutrition
A combination of both
enriched interventions.
A combination of both
enriched interventions.
A combination of both
enriched interventions.
Basic training was for
five days followed by a
one-day refresher every
six months.
Supportive supervision
included at least two
contacts per month with
an ECD Facilitator.
Strategies included on
job coaching, feedback
guided by supervisory
checklist, modeling, and
mentorship.
Monitoring of Interventions
An independent monitoring team was responsible for collecting information on services received from LHWs from 10% of randomly selected
households at the cluster level each month. The purpose was to document data about the LHWs delivery and reach within the entire cluster (her
catchment population) in order to evaluate the implementation of enriched interventions in the LHW programme. Topic areas included for
monitoring were:



Frequency, of LHW visits
Information about the last LHW visit; e.g. duration and purpose
Recall about advice provided pertaining to basic curriculum and enriched interventions
o
Advice for pregnant women (if any in the household)
o
Advice for newborn care (if any in the household)
o
Advice for sick child (if child was sick)
o
Infant and young child feeding advice
o
Invitation to a community group meeting
o
Medication distributed
o
Referrals made
o
Child supplementation distributed