Upload
dr-m-qamar-ul-hassan-mbti
View
241
Download
0
Embed Size (px)
Citation preview
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