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We evaluated the feasibility and effectiveness of utilising government health supervisors to train and supervise primary health care workers (HWs) in community clinics to deliver parenting sessions as part of their usual duties.We randomly allocated 16 unions in the Mymensing district of Bangladesh 1:1 to an intervention or control group. HWs in clinics in the eight intervention unions (n=59 health workers, n=24 clinics) were trained to deliver a group-based parenting intervention, with training and supervision provided by government supervisors. In each of the twenty-four intervention clinics, we recruited twenty-four mothers of children aged 6-24 months to participate in the parenting sessions (n=576 mother/child dyads). Mother/child dyads attended fortnightly parenting sessions at the clinic in groups of four-to-five participants for six months (13 sessions). We collected data on supervisor and HW compliance in implementing the intervention, mothers' attendance and the observed quality of parenting sessions in all intervention clinics and HW burnout at endline in all clinics. We randomly selected 32 clinics (16 intervention, 16 control), and 384 mothers (192 intervention, 192 control) to participate in the evaluation on mother-reported home stimulation, measured at baseline and endline.Supervisors and HWs attended all training, 46/59 health workers (78%) conducted the majority of parenting sessions, (only two HWs (3.4%) refused), and mothers' attendance rate was 86%. However, supervision levels were low: only 32/57 (56.1%) of HWs received at least one supervisory visit. Intervention HWs delivered the parenting sessions with acceptable levels of quality on most items. The intervention significantly benefitted home stimulation (effect size=0.53SD, 95% confidence interval: 0.50, 1.56, p0.001). HW burnout was low in both groups.Integration into the primary health care service is a promising approach for scaling early childhood development programmes in Bangladesh, although further research is required to identify feasible methods for facilitator supervision.

This paper describes the process of adapting an early childhood development programme, with proven effectiveness in Bangladesh, for integration into government health services in rural Bangladesh. Through a three-stage process, we adapted an evidence-based, home-visiting, programme (Reach-Up and Learn) for delivery in government health clinics by government health staff as part of their regular duties. Stage one involved preparing an initial draft of two parenting interventions for use with: (1) pairs of mother/child dyads, and (2) small groups of mother/child dyads. In stage two, we piloted the adapted interventions in nine clinics with a total of twenty-seven health staff and 357 mother/child dyads. We used data from mothers' attendance, feedback from participating mothers and health staff and observations of parenting sessions by the research team to revise the interventions. Stage three involved piloting the revised interventions in six clinics with eighteen health staff and 162 mother/child dyads. We gathered additional data on mothers' attendance and used observations by the research team to finalize the interventions. Through this three-stage process, adaptations were made to the intervention content, process of delivery, materials, and engagement strategies used. The largest challenges were related to incorporating the parenting programme into health staff's existing workload and promoting mothers' engagement in the programme. We also simplified the content and structure of the curriculum to make it easier for health staff to deliver and to ensure mothers understood the activities introduced. This iterative piloting was used prior to implementing and evaluating the interventions through an effectiveness trial.

Background There is sufficient evidence that psychosocial stimulation (PS) benefits children’s neurocognitive behavior, however, there is no information on how it works when delivered through an Unconditional Cash Transfer (UCT) platform for poor rural population in developing countries. The objective of this study is to measure effects of adding PS for children of lactating mothers enrolled to receive UCT with health education (HE) on neurocognitive behavior of children in rural Bangladesh. Methods The study will be conducted at 11 unions of Ullapara sub-district in Bangladesh. The study is a cluster randomized controlled trial with three-arms; (i) PS and UCT with HE (ii) UCT with HE and iii) Comparison arm. The cluster will be considered as an old Ward of a Union, the lowest tier of local government system in rural Bangladesh. There are three old Wards in a union. These three clusters will be randomized to one of the three arms. Similarly, randomization will be done for each 11 Unions and then 11 clusters will be assigned to an arm. Eighteen participants will be recruited from each cluster randomly (n = 196 in each arm). The intervention designed for one year includes UCT with HE for the poor as a safety net program in rural Bangladesh with or without PS. An age-based curriculum of PS is already available for Bangladeshi children and this will be administered by trained local women; play leaders (PL) in intervention clusters. The government of Bangladesh is providing UCT of taka 500 ($6.25) as maternity allowance per month with HE. The primary outcomes will be cognitive, motor and language composite scores measured by Bayley-III and behavior using Wolke’s behavior rating scale. The secondary outcomes will be children and mothers’ growth, family food security status, health seeking behavior, mothers’ depressive symptoms and self-esteem and violence against mothers. Discussion The study will provide a unique opportunity to assess an integrated early childhood development intervention using UCT platform to mitigate developmental delays in poor vulnerable children of rural Bangladesh. Trial registration number ClinicalTrials.gov NCT03281980, registered on September 13, 2017.