Learning Through Play

We Cannot Answer Him

TomorrowHis Name is

Today

A Mentally Healthy Start

to life

An Effective way ofMental Health Promotion

and Prevention

Children Are our FUTURE

The future of Human Civilization depends on today’s Children being able to achieve their

Optimal Physical and Psychological Development

Early Childhood Psychological Development

The Importance of

Early Childhood

Psychological Development

Remain Relatively Ignored

The importance of Early Childhood Psychological Development can not be

overestimated.

Interaction of• Inherent Genetic Potential, • Environmental Nurturing and • Daily Experience

In The Earliest Years• Mould the Nature of Our Personality and • Our vulnerability to Damaging events later

in life

Importance

WHY??( Need)

Global Burden Of Psychiatric Illness

Early Childhood Psychological Interventions can Reduce

Psychiatric Illnesses Later in Life.

Background

Learning Through Play

Aim

To Support Parents in their Ability to Stimulate

Healthy Child Development

Vision

To Reach Every Mother Of Pakistan

With The Message of

Learning Through Play

LTP Programme Teaches

• Physical• Cognitive• Linguistic and• Socio-Emotional

Aspects of Child Development

LTP Programme Encourages

• Parental Involvement

• Creativity

• Learning

• Parent-Child attachment.

Stages of Child Development

1. Heads-Up Phase (0-2)2. The Looker Stage (2-5)3. Creeper-Crawler Period (5-8)4. Cruiser Stage (8-13)5. Early Walker Phase (13-15)6. Walker Period (15-18)7. The Doer Stage (18-24)8. Early Tester Phase (2-21/2)9. Tester Period (21/2-3)

S P R U C

• Sense of Self• Physical• Relationships• Understanding• Communication

Sense Of Self

Learning about ourselves and our feelings helps us become comfortable with who we are

Physical

Learning to control the way our body moves helps us improve our skills, such that grasping and walking

Relationships

Learning How to get along with the family,

friends and others helps us feel secure.

Understandings

Learning how things works helps us to

develop our intelligence

Communications

Learning how to listen, understand and express thoughts and feelings

connects us with our world

LTP Resources

LTP Calendar – birth-3 years

LTP Calendar – 3-6 years

LTP Training Manual – Dr. Bea Ashem

Resource Kit – videos, books, articles

LTP board game

Learning Through Play

Calendar

LTP Calendar

Pictorial calendar for parents Stages of child development Areas of development:

social emotional communication/linguistic physical intellectual

LTP Calendar

Fun parent-child play activities Practical, hands-on Simple, brief descriptions Low-literacy Pictures act as visual cues Culturally sensitive Translated into 11 different languages

Goals of LTP Calendar

Encourage learning about child development

Promote parental involvement and attachment

Encourage positive mother-child interaction through play which is mutually rewarding

Help mother read the infant’s cues better and develop sensitive responsiveness

Stimulate early child development

Use of LTP Calendar

Parents, teachers, childcare workers

Parent education groups parent support groups home visiting programs

Used in HBHC program in Ontario

Used in hundreds of programs in Canada 15,000 distributed in Canada in past year

Distributed internationally

LTP Research

LTP Calendar launched in 1997

Positive feedback from parents, nurses, trainers, experts in the field of child development

Evaluation needed to assess its effectiveness provide solid scientific foundation

Research focus on 5 countries: India, Pakistan, Peru, El Salvador, Canada

Research project started in Pakistan in April, 2002

LTP Project In Pakistan

Pakistan: Geo-political

• Indian-sub-continent : WN

• Borders : India, China, Afghanistan, Iran, Indian ocean

• 1947: Independence

• 1971: E. Pakistan Bangladesh

• Kashmir : dispute

• Government : civilian/ military

Pakistan: Demography

• Provinces : Punjab, Sindh, Balochistan, NWFP

• Language : Urdu, regional. English

• Religion : Islam- 97%

• Economy : agriculture

• Population : 140 million

• Rural : 70%

Pakistan: Demography

• Population: 140 m

• Birth rate: 3.7%

• Life expect.: 63 yrs

• Literacy rate: 35% (women 18%)

• Poverty : 1/3 pop (45m)

• UNDP HDI: 135th

• Corruption Index : 3rd

Pakistan: Spiral of debt (millions of $)

Cash Flow (1999-2000)

Donor In Out Net Amount

World Bank 250 514.2 -264.2

Asian

Dev.Bank

423 363.5 59.5

IMF 0 329.1 -329.1

Total 673 1206.8

-533.8

Pakistan: Expenditure

GNP : $63.6 billion

Per capita : $ 440/ annum

• Defence : 31%

• Education : 2%

• Health : < 1%

• Mental health : <0.1% ?

The UNDP’s Human Development Report 2000

Pakistan HDI consistently on the slide From 132 in 1993 it has fallen to 135.

Today 50 million adult illiterates when there were 44 million a decade ago. Literacy rate of

women is only half that of men

Today there are 50 million living in absolute poverty it was 34 million a decade ago (From 30% to 34%) Criteria is access to water, health care and adequately nourished children not income.

There are at least ten countries who have less income but are higher in human poverty index scale I.e suffer from less poverty.

deaths/1000 live births

Of every 1000 children born live in Pakistan

more than 90 will fail to see their first birthday.

Of these over half will die within the first four

weeks after birth and the majority will die

within the first few days.

“One in 13 children die, but the 12 who

survive also need care”.

Meyers R. (1992) The twelve who survive.

A Call to Action1) How do we cope with the existing burden?

2) How do we decrease future burden of Maternal & Childhood disorders?

3) How can one incorporate care for mothers & Children within existing health care systems?

The answers have to be worked out in the context that Pakistan has less than US $20 per capita for the health care.

Study Area

Rural area - Islamabad, Pakistan• 24 Union Councils

5-7 villages

10,000-15,000 inhabitants

• Subsistence farming & supplementary income

• 20 Basic Health Units, 2 Rural Health Centres

• 28 doctors, 12 midwives, 15 vaccinators

• 120 primary health care workers (LHWs)

Lady Health Workers (LHWs)

Live in local community

High school education

Preventive mother and child health care

1000 women in catchment area

Study Sample Random assignment

Last trimester of pregnancy (N=389)

93% of women agreed to participate

Intervention group (N=172)

Control group (N=153)

Informed consent

Training of Lady Health Workers

• All 30 LHWs trained

• Trained psychologist provided training

• One full-day training workshop

• One refresher session – 1 hr.

• Birth-2 month stage

• Urdu LTP manual

Training of Mothers

One half-day workshop

groups of 5-7 mothers

birth-2 month stage

Urdu Calendar to take home

Home visits every two weeks

15-20 min. – LTP concepts

Support groups encouraged

Measures• Demographics questionnaire (PIQ)

• education, income, family structure

• Infant Development Questionnaire (IDQ-3)

• knowledge & attitudes• birth-2 month stage• specially developed• 15 items • yes/no questions

Measures

• Self Reporting Questionnaire (SRQ-20)

• mental distress• standardized instrument• 20 items • yes/no questions• validated on local population

Measures

• Simple to understand

• Translated into Urdu, pre-tested

• Questions read to mothers - low literacy

• Mothers tested individually

• Workers blind to group status

Procedure

Intervention group - routine health care & LTP program

Control group - routine health care

Both groups - pre and post assessment

Baseline assessment – 3 months before birth

Follow-up - 3 months after birth

Demographics

• No differences between groups

• Age of mothers - 27 years

• Mothers’ education - 6 years

• Fathers’ education - 8 years

• Monthly income - $50 US

• Mothers – not employed

• 55% lived with extended family

OUTCOMES OFLTP PROGRAM

Infant Development Knowledge

• Knowledge of infant development increasedin group that received 6-month LTP program

• No change in control group after 6 months

Infant Development Knowledge

0

2

4

6

8

10

12

14

Baseline Follow-up

Intervention group

Control group

Mental Distress

• Mental distress symptoms decreasedin group that received 6-month LTP program

• Mental distress symptoms increased slightly

in the control group after 6 months

Mental Distress

6.4

6.6

6.8

7

7.2

7.4

7.6

7.8

8

Baseline Follow-up

Intervention group

Control group

CONCLUSIONS

Conclusions

Learning Through Play Program:

Suitable for a deprived rural populationin a developing country

Successfully integrated into existing healthinfrastructure at minimal extra cost

Increased infant development knowledge

Decreased mental distress symptoms

Conclusions

Successful training of 30 LHWs in child development

positive impact on subsequent work with mothers

Each LHW responsible for 1000 women

significant impact on community

Next Steps

Research will continue in Pakistan

Assess if LTP program results in: Additional gains in infant development knowledge Further reduction in postnatal depression Enduring improvement in mother-child interaction Positive impact on psychological development of infants Positive impact on physical development of infants

This pilot project shows that LTP can be

integrated into primary health care. Now needs to

be demonstrated at a larger scale. Suggestion of

an LTP centre which carries research into

different delivery modes (individual, groups,

through school girls), bigger settings (district and

provincial levels, urban slums), and use better

instruments.

Establishment of LTP resource center in Pakistan

4 Functions. Or priority areas

a. Further research in processes, cultural adaptation, targeting high

risk groups eg. Depressed mothers

b. Hincks DelCrest National and Regional Training centre: training

different cadres of trainers, TOT.

c. Will develop models of delivery of LTP (schools, primary health

care, child friendly hospitals)

d. Advocacy: Importance of first years of childs life based on LTP

model, utilising mass awareness media (eg. Documentary video)

and professional circles.

Pakistan: DepressionThe evidence

Women Men

N. PakistanMumford et al (1996)

46- 60% 15 - 33%

Village, PunjabMumford et al (1997)

66 - 72% 25 - 44%

Urban, PunjabMumford et al (2000)

25 - 36% 10 -18%

Village, PunjabHussain et al (2000)

57.7% 25.5%

• An estimated 121 million people currently suffer from depression

• Depression 4th leading cause of disability in 1990• 2nd leading cause in females• Women 2X more likely to develop depression • Economic burden and disability 2nd to coronary disease

by 2020 (Murray & Lopez 1996)

World Health Organisation

0

20

40

60

80

Pak

ista

n

Pak

ista

n

Pak

ista

n

Taiwan

Leso

tho

Sou

th A

frica

Uga

nda

Sud

an

Zimba

bwe

Male Female

mediators and moderators

Kraemer HC, (2002) Arch Gen Psychiatry. Vol 59. 877-883.

appropriate cultural adaptation. Although adapted, this needs to

be a contiuous process. (example of mirror). Formal feedback to

be obtained at one year Further development of the LTP.

Process (feedback of research team from LHWs, mothers)

Flip charts vs calendars? Yes. Whole family can be engaged,

older siblings can learn,

More educated, easier acceptance….more research into

processes

More useful for depressed women?

Father’s involvement

‘We are guilty of many errors and many faults,

but our worst crime is abandoning the children,

neglecting the fountain of life.

Many of the things we need can wait.

The child cannot.

Right now is the time his bones are being formed,

his blood is being made and

his Senses are being developed.

To him we cannot answer “Tomorrow”.

His name is “Today”

Gabriela Mistral

Nobel Prize winning poet from Chile