LTP SLIDES

We Cannot Answer Him
Tomorrow
His Name is
Today

A Mentally
Healthy Start
to life

An Effective way of
Mental 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

Global Burden Of
Psychiatric Illness

Early Childhood Psychological
Interventions can Reduce
Psychiatric Illnesses Later in Life.

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

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 Action
1) 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

Infant Development
Knowledge
• Knowledge of infant development increased
in 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 decreased
in 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
Learning Through Play Program:
 Suitable for a deprived rural population
in a developing country
 Successfully integrated into existing health
infrastructure 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 infant
 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: Depression
The evidence
Women Men
N. Pakistan
Mumford et al (1996)
46- 60% 15 - 33%
Village, Punjab
66 - 72% 25 - 44%
Urban, Punjab
25 - 36% 10 -18%
Village, Punjab
Hussain 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
Pakistan
Pakistan
Pakistan
Taiwan
LesothoSouth
Africa
Uganda
Sudan
Zim
babwe
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

LTP SLIDES

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