World Health Organisation-Caregiver Skills Training (WHO-CST) Program: Feasibility of Delivery by Non-Specialist Providers in Real-World Urban Settings in India
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| Title: | World Health Organisation-Caregiver Skills Training (WHO-CST) Program: Feasibility of Delivery by Non-Specialist Providers in Real-World Urban Settings in India |
|---|---|
| Language: | English |
| Authors: | Sengupta, Koyeli (ORCID |
| Source: | Journal of Autism and Developmental Disorders. Apr 2023 53(4):1444-1461. |
| Availability: | Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/ |
| Peer Reviewed: | Y |
| Page Count: | 18 |
| Publication Date: | 2023 |
| Document Type: | Journal Articles Reports - Research |
| Descriptors: | International Organizations, Caregiver Training, Early Intervention, Urban Areas, Foreign Countries, Pilot Projects, Lay People, Program Evaluation, Young Children, Communication Problems, Fidelity, Feasibility Studies, Intervention, Stress Management, Child Development, Interpersonal Competence |
| Geographic Terms: | India |
| DOI: | 10.1007/s10803-021-05367-0 |
| ISSN: | 0162-3257 1573-3432 |
| Abstract: | The World Health Organization-Caregiver Skills Training Program, a parent-mediated early intervention facilitated by non-specialist providers piloted in urban India was evaluated using mixed-methods for feasibility and effects on child and caregiver outcomes. Caregivers (n = 22) of children (2-9 years) with social-communication delays participated in a single-group pre-post study. High rates of caregiver attendance, improved caregiver fidelity, and facilitator competency suggested program feasibility. Caregivers voiced acceptability of various intervention-components. The intervention was associated with improved caregiver-reported skills and knowledge (p < 0.00), reduction in stress (p = 0.03), improved child developmental outcomes on communication and social interaction (p < 0.00), and adaptive behaviors (p < 0.00). Challenges about logistics and availability of time were highlighted. Implications of results in resource-poor settings and recommendations for future feasibility trials are discussed. [The WHO-CST Team contributed to the writing of this article.] |
| Abstractor: | As Provided |
| Entry Date: | 2023 |
| Accession Number: | EJ1372102 |
| Database: | ERIC |
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| FullText | Links: – Type: pdflink Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHj0k_4E0hTGH8RJwT4gCJyBsGNe_WN95AvKlDbXJGqwxwFfeVnvNwz2Mn4dnepepJUBAAAA4jCB3wYJKoZIhvcNAQcGoIHRMIHOAgEAMIHIBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDMXtuVo5KZ6U5K839AIBEICBmrPqpgn-k6c54AB_T31Hxgsh9ZVKAY5LkJjOZG_68WzFuScQZhga8l9UDneVRJbs9C0mUFgQBX5_Iw5A9nDg-BgwCQ5T6L--9Ifm0OGFAabH9cBg7GGrapAxmwzYoxq7gQyDRT5TVpwz3thOELbUOooLWayClRtZyEI7hfCEgHwjiMNq6dPpQnEsLdtY9_VfZynuwKkQi1_vBkQ= Text: Availability: 1 Value: <anid>AN0162852012;aut01apr.23;2023Apr04.06:38;v2.2.500</anid> <title id="AN0162852012-1">World Health Organisation-Caregiver Skills Training (WHO-CST) Program: Feasibility of Delivery by Non-Specialist Providers in Real-world Urban Settings in India </title> <p>The World Health Organization-Caregiver Skills Training Program, a parent-mediated early intervention facilitated by non-specialist providers piloted in urban India was evaluated using mixed-methods for feasibility and effects on child and caregiver outcomes. Caregivers (n = 22) of children (2–9 years) with social-communication delays participated in a single-group pre-post study. High rates of caregiver attendance, improved caregiver fidelity, and facilitator competency suggested program feasibility. Caregivers voiced acceptability of various intervention-components. The intervention was associated with improved caregiver-reported skills and knowledge (p &lt; 0.00), reduction in stress (p = 0.03), improved child developmental outcomes on communication and social interaction (p &lt; 0.00), and adaptive behaviors (p &lt; 0.00). Challenges about logistics and availability of time were highlighted. Implications of results in resource-poor settings and recommendations for future feasibility trials are discussed.</p> <p>Keywords: Parent-mediated intervention; Non-specialist; WHO-CST; Feasibility; LMIC; India</p> <p>Parts of findings from the pilot phase of the program were presented as a poster at INSAR-Virtual, 2021.</p> <hd id="AN0162852012-2">Introduction</hd> <p>Access to early diagnosis and intervention continues to be a challenge for children with neurodevelopmental disorders (NDD) and their families globally (Patel et al., [<reflink idref="bib36" id="ref1">36</reflink>]). These inequities in access are higher in Low and Middle-Income Countries (LMICs) (World Bank, [<reflink idref="bib51" id="ref2">51</reflink>]), where a significant proportion of children with NDD reside (Olusanya and Kassebaum, [<reflink idref="bib34" id="ref3">34</reflink>]; Patel et al., [<reflink idref="bib36" id="ref4">36</reflink>]).</p> <p>Scenario in India.</p> <p>A lower-middle-income country like India has approximately 340 million children in the age group of 0–14 years (Tiwari et al., [<reflink idref="bib47" id="ref5">47</reflink>]), of which almost one in eight children is likely to have an NDD (Arora et al., [<reflink idref="bib4" id="ref6">4</reflink>]). Like in other LMICs, most of these children are likely to encounter inadequacies in early detection and intervention (Daley, [<reflink idref="bib13" id="ref7">13</reflink>]; Mahapatra et al., [<reflink idref="bib31" id="ref8">31</reflink>]) attributable to multiple systemic and contextual factors (Leeuw et al., [<reflink idref="bib30" id="ref9">30</reflink>]). First is the limited availability of physicians trained to diagnose a child with a NDD. Second, caregivers are often reluctant to acknowledge the diagnosis due to the stigma of disability (Leeuw et al., [<reflink idref="bib30" id="ref10">30</reflink>]). Third, early intervention services are expensive and limited in availability (Barua et al., [<reflink idref="bib5" id="ref11">5</reflink>]). Trained providers are primarily concentrated in urban areas and provide costly services within the private healthcare system and are likely to be unaffordable and inaccessible (Dababneh et al., [<reflink idref="bib12" id="ref12">12</reflink>]). Fourth, programs that offer comprehensive training for professionals working with children diagnosed with complex NDDs like Autism Spectrum Disorder (ASD) are minimal and are concentrated in few urban areas (Duggal et al., [<reflink idref="bib16" id="ref13">16</reflink>]). Therefore, it is not surprising that even providers who care for NDDs feel ill-equipped to work with children with specific developmental difficulties like ASD due to inadequate training in interventions that address social-communication and behavioral challenges (Tiwari &amp; John, [<reflink idref="bib48" id="ref14">48</reflink>]).</p> <p>In the absence of affordable and accessible early intervention services in LMIC, parents are left unto themselves to care for a child with NDD (Brezis et al., [<reflink idref="bib9" id="ref15">9</reflink>]). This treatment gap impedes optimal developmental outcomes among children with NDD (Zuckerman et al., [<reflink idref="bib53" id="ref16">53</reflink>]). Furthermore, it leaves caregivers bereft of the necessary skills and resources to care for a child with NDD, which may negatively impact parental mental health and well-being (Catalano et al., [<reflink idref="bib10" id="ref17">10</reflink>]; Picardi et al., [<reflink idref="bib37" id="ref18">37</reflink>]). The World Health Organisation (2008) considers a 'task-sharing approach' (Patel, [<reflink idref="bib35" id="ref19">35</reflink>]) essential to address the services gap in LMICs, wherein skilled professionals train non-specialist community-based providers to deliver culturally and contextually appropriate interventions to increase access to services.</p> <p>Evidence of feasible interventions rooted in the task-sharing approach is emerging in South Asia. For example, Rahman et al. ([<reflink idref="bib39" id="ref20">39</reflink>]) showed the feasibility of recruiting non-specialist providers, like college graduates and training them to facilitate a parent-mediated intervention for ASD in South Asia (PASS) in India and Pakistan. In the intervention, non-specialist providers used video-mediated feedback (Divan et al., [<reflink idref="bib15" id="ref21">15</reflink>]) to teach strategies to parents of children who met the criteria for ASD from a culturally- adapted version of the UK-based Preschool Autism Communication Therapy (PACT). The success of the PASS model bears evidence to the demand for similar innovative community-based low-cost interventions validated and adapted to local contexts to ensure both optimal developmental outcomes for children with NDD and positive well-being for their caregivers. The unique challenges of LMIC contexts can be potentially circumvented by interventions that (<reflink idref="bib1" id="ref22">1</reflink>) do not require a formal diagnosis of any specific NDD as a mandatory condition to participate, to allow for absence, delay, or denial of a diagnosis (<reflink idref="bib2" id="ref23">2</reflink>) can be offered in a group session format due to the proven effectiveness of groups in maximizing resource utilization (Tekola et al., [<reflink idref="bib46" id="ref24">46</reflink>]) and ensuring social support for parents (Sengupta et al., [<reflink idref="bib43" id="ref25">43</reflink>]) and (<reflink idref="bib3" id="ref26">3</reflink>) utilize curriculum and tools that are open-access or low-cost to facilitate scale-up (Durkin et al., [<reflink idref="bib17" id="ref27">17</reflink>]).</p> <hd id="AN0162852012-3">The WHO-CST Program for Children with Developmental Delays and Disabilities</hd> <p>The World Health Organization (WHO) has developed a novel caregiver-mediated program, the 'WHO Caregivers Skills Training (CST) for Families of Children with Developmental Delays and Disabilities' (Salomone et al., [<reflink idref="bib42" id="ref28">42</reflink>]) to address the treatment and services gap for children with DDs in LMICs. Based on principles of nurturing care for all children, the WHO-CST program is an open-access manualized curriculum, informed by applied behavior analysis, developmental science, social communication interventions, positive parenting, and self-care methods. It aims to support caregivers of children with DD between the ages of two and nine. The WHO-CST program relies on a task-sharing approach to ensure effective scale-up, wherein non-specialist providers (hereby referred to as facilitators) such as community workers, teachers, and peer-caregivers, deliver the caregiver-mediated intervention, with supervision from skilled trainers (hereby referred to as master-trainers or MTs) in the community.</p> <p>The program is designed to be used globally and adapted in different socio-economic, cultural, geographic settings to ensure local relevance and effectiveness. It has been adapted and translated for field testing in more than 30 countries (Salomone et al., [<reflink idref="bib42" id="ref29">42</reflink>]), with feasibility and acceptability reported from Ethiopia (Tekola et al., [<reflink idref="bib46" id="ref30">46</reflink>]) and Italy (Salomone et al., [<reflink idref="bib41" id="ref31">41</reflink>]). Each of the countries that have piloted the WHO-CST program is culturally, economically, and linguistically disparate. Therefore, as different countries adopt, implement, and evaluate the WHO-CST program's feasibility and preliminary impact, examining common learnings across regions and highlighting the unique culture and context-specific feasibility challenges is crucial.</p> <p>WHO proposes the following three-step consecutive process to evaluate the feasibility, acceptability, and relevance of the WHO-CST program: (<reflink idref="bib1" id="ref32">1</reflink>) Adaptation, (<reflink idref="bib2" id="ref33">2</reflink>) Pre-pilot, and (<reflink idref="bib3" id="ref34">3</reflink>) Pilot. In Phase 1 (Adaptation phase), the aim is to ensure cultural and contextual adaptation of the WHO-CST program before initial implementation. Phase 2 (Pre-pilot phase) assesses the program's feasibility when delivered by MTs and requirements for further adaptations. The acceptability and relevance of the WHO-CST from the pre-pilot stage have already been demonstrated in a low-income country like Ethiopia (Tekola et al., [<reflink idref="bib46" id="ref35">46</reflink>]). In addition, caregivers in the study reported improvements in their skills and knowledge, psychological well-being, and perception of their children when specialist-MTs like community psychiatrists delivered the intervention. Finally, the goal of phase 3 (Pilot phase) is to (<reflink idref="bib1" id="ref36">1</reflink>) assess the feasibility and acceptability of the adapted CST program in the local setting when delivered by non-specialist providers with supervision from MTs and (<reflink idref="bib2" id="ref37">2</reflink>) assess the preliminary impact of the program, i.e., test whether the program led to gains for children and their caregivers using a pre-and post-study design. The three-step evaluation of the Caregivers' Skills Training (CST) program was launched in India between 2018 and 2020 and included local adaptation and pre-piloting by skilled professionals. The current study focuses on the pilot phase (Phase 3) of India's WHO-CST program to assess feasibility, acceptability, and preliminary impact when non-specialist providers deliver it in real-world urban settings.</p> <hd id="AN0162852012-4">Methods</hd> <p>The methods section briefly describes the intervention, the cultural and contextual adaptation, and initial feasibility testing of the WHO-CST program (Phase 1) and focuses primarily on feasibility, acceptability, and preliminary impact of the pilot program (Phase 2) when delivered by non-specialist providers in India.</p> <hd id="AN0162852012-5">Intervention</hd> <p>Salomone et al. ([<reflink idref="bib42" id="ref38">42</reflink>]) provide details of the development, content, structure, theoretical framework and methodology of the WHO-CST intervention. In brief, it consists of nine group sessions, each 2 h in duration, and three home visits, all building on the use of shared activities between caregivers and children ("home" and "play routines") as opportunities for promoting learning and development. During the group sessions, trainers utilize vignettes depicting typical communication and behavioral challenges with accompanying key developmental messages and strategies, modeling strategies, and role-play by parents to teach new content, review homework after previous sessions, and plan for home practice. Sessions 1–5 focused on promoting engagement between the caregiver and the child with DD, spoken and nonverbal communication to request and share attention, while sessions 6–9 included addressing challenging behavior, teaching daily living skills, and promoting caregiver well-being. 3 h-long home visits are conducted at the beginning, midway and end of the intervention in which facilitators assist caregivers with goal setting (Home-visit 1), implementing the strategies (Home-visit 2) across play and home-routines, and problem-solving and planning for independent practice (Home-visit 3).</p> <hd id="AN0162852012-6">Phase 1: Cultural Adaptation of the WHO-CST Program</hd> <p>The field-testing of the WHO-CST program in India was spearheaded by a child development center in Mumbai, a major metropolis in western India, in 2018.</p> <hd id="AN0162852012-7">Step 1: Translation and Review by Local Stakeholders</hd> <p>Step one of the process (January–March 2018) included forward-translating the WHO-CST material into the national language Hindi by a single translator familiar with child development concepts. Training material included participant booklets for families and facilitator guides, which enlist the Key Messages and Tips, along with vignettes and suggestions for program facilitation. 2 MTs with proficiency in both English and Hindi reviewed the translated material to verify accuracy and consistency of translation and to ensure that significance of messages and strategies were preserved, rather than a direct literal translation. Local multi-sectoral stakeholders, including parents, community workers, organizational heads, and therapists working in NDD (n = 15), were invited to review the program structure, content, and material. Feedback was collected in guided group discussions and by the research team members (KS, SG, DS). The program was unanimously considered valuable and relevant. Prominent feedback from this stage was to additionally translate material into the state language Marathi and use Indian names in the vignettes ("stories") as part of the material but retain the images depicting families of diverse ethnic origin.</p> <hd id="AN0162852012-8">Step 2: Training of Master-Trainers</hd> <p>At step 2, trainers from the international WHO-Autism Speaks CST team conducted a five-day intensive training of trainers (ToT) for a cohort of master trainers (MTs) belonging to the local CST team in Mumbai in June 2018. (The details of the training cascade and trainer qualifications are provided in Table 1). Subsequently, MTs video recorded segments of themselves practicing CST strategies with a minimum of 2 children with communication delays in their caseload, which were reviewed and scored for fidelity by the WHO-AS trainers on the Adult–Child Interaction Fidelity Scale (WHO-CST team unpublished). (Please refer to Table 4 for components of the Adult–Child Interaction Fidelity Scale).</p> <p>Graph</p> <hd id="AN0162852012-9">Phase 2: Pre-pilot</hd> <p>From January to March 2019, three MTs conducted a pre-pilot with nine families to assess the preliminary feasibility of delivering the WHO-CST material to Indian parents in its current format and identify potentially significant issues that required redressal before training non-specialist facilitators. Focus-group discussions were conducted by an independent interviewer (LA), with parents and MTs at the pre-pilot round completion. SG performed thematic analyses using Bernal's Ecological Validity framework (Bernal et al., [<reflink idref="bib6" id="ref39">6</reflink>]), frequently used to develop psychosocial interventions sensitive to the unique needs of specific ethnic communities. Outcomes from the mixed-methods evaluation, relevant adaptations from phase 1, and early indication of program feasibility from phase 2 are provided in Table 2. The changes identified were communicated to the WHO-CST team and included as country-level adaptations before piloting the next phase of training non-specialist workers to deliver the intervention.</p> <p>Table 2 Evaluation of Adaptation and Pre-pilot phases of WHO-CST program in India</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left" colspan="4"&gt;&lt;p&gt;Phase 1: Cultural adaptation of the WHO-CST program to the local context (January&amp;#8211;April 2018)&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;tr&gt;&lt;th align="left" colspan="4"&gt;&lt;p&gt;Objective: Cultural &amp; contextual adaptations prior to initial implementation&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;tr&gt;&lt;th align="left"&gt;&lt;p&gt;Activities&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Research-method&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Outcomes&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Adaptations made using Bernal's Ecological Validity framework**&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;1. Translation of the WHO-CST material into Hindi&lt;/p&gt;&lt;/td&gt;&lt;td align="left" rowspan="2"&gt;&lt;p&gt;Formative qualitative research&lt;/p&gt;&lt;/td&gt;&lt;td align="left" rowspan="2"&gt;&lt;p&gt;Local stakeholders considered the program essential and relevant&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Content and overall delivery-process unchanged. Names in stories in participant handouts changed to Indian-sounding names, original images of diverse families retained&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;2. FGDs* with local multi-sectoral stakeholders to review the program structure, content, and material&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Translation of material into Marathi&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p>Table 2 Evaluation of Adaptation and Pre-pilot phases of WHO-CST program in India</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left" colspan="4"&gt;&lt;p&gt;Phase 2: Pre-Pilot program implementation (June 2018&amp;#8211;March 2019)&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;tr&gt;&lt;th align="left" colspan="4"&gt;&lt;p&gt;Objective: Assess program acceptability and feasibility when delivered by master-trainers and gauge requirement for further adaptations&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;tr&gt;&lt;th align="left"&gt;&lt;p&gt;Activities&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Research- method&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Outcomes&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Adaptations made using Bernal's Ecological Validity framework&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left" rowspan="6"&gt;&lt;p&gt;3. MTs of local CST team trained by WHO-CST trainers conducted a pre-pilot with 9 families of 2&amp;#8211;9 years old children with communication delays&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Mixed-methods:&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;(1) Attendance&lt;/p&gt;&lt;/td&gt;&lt;td align="left" rowspan="2"&gt;&lt;p&gt;All primary caregivers completed the program. Significant improvement in parental knowledge and fidelity to strategies&lt;/p&gt;&lt;/td&gt;&lt;td align="left" rowspan="2" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Parent knowledge&lt;sup&gt;a&lt;/sup&gt; &amp; fidelity scores&lt;sup&gt;b&lt;/sup&gt;&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" rowspan="3"&gt;&lt;p&gt;(2) Qualitative data from FGDs with MTs and participant caregivers&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;italic&gt;Parent and child outcomes:&lt;/italic&gt; Enhanced parental sense of competence, perceived improvement in child social communication skills and behaviors&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Concepts and delivery methods retained unchanged&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;italic&gt;Programmatic challenges:&lt;/italic&gt; MT: Logistical challenges of doing home visits in distant suburbs&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Inclusion criteria modified to include families within a limited geographical area (&amp;#8804; 10 kms)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;&lt;italic&gt;Recommendations for adaptation:&lt;/italic&gt; MTs recommended strategies for improving content -delivery&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Concepts made culturally salient by addressing associated issues of societal expectations and stigma during group-sessions&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p> <sups>a</sups>Measured using Caregivers' Skills &amp; Knowledge tool <sups>b</sups>Adult-Child Interaction Fidelity scores *Focus-group discussions **Bernal et al. ([<reflink idref="bib6" id="ref40">6</reflink>])</p> <hd id="AN0162852012-10">Phase 3: Intervention Pilot</hd> <p>The Indian version of the WHO-CST version 2.0 was piloted between September 2019 and January 2020 at two sites in Mumbai, a prominent metropolitan city in India. In addition, every caregiver received a set of developmentally appropriate toys that they could use for play routines with their children and travel vouchers of INR 500 (USD 7). The Ethics Review Committee of Kasturba Hospital, Mumbai, and B.Y.L. Nair Ch. Hospital &amp; T. N. Medical College in Mumbai approved the intervention and evaluation.</p> <hd id="AN0162852012-11">Sites</hd> <p>The intervention sites for the pilot were two special schools for children with communication and developmental delays, serving low-income communities. One of the schools was within the premises of a government hospital's child development unit (CDU), while the other was a not-for-profit organization. The facilitators conducted the caregiver group sessions in a separate room within the school premises during usual school hours and home visits for all families.</p> <hd id="AN0162852012-12">Facilitators</hd> <p>The adaptation guidelines for the WHO-CST (unpublished) recommend selection criteria for facilitators as (i) diverse set of skills and backgrounds such as community workers, teachers, and peer-caregivers (ii) previous experience with children with developmental disorders and possibly early childhood development programs and (iii) well-recognized and trusted in the community. Two pairs of facilitators independently delivered the WHO-CST intervention in Hindi at the two sites between December 2019 and January 2020. The facilitators included three teachers employed by the schools and a psychologist conducting psychoeducational testing at the CDU, with a minimum of two years (range 2–10 years) of experience working with children with special needs. None of the facilitators had prior training in delivering interventions with children with communication delays.</p> <p>The facilitators participated in a phased training process conducted by three Master Trainers (MTs), similar in content to what MTs received but divided into two modules over eight days. The facilitators received five days of initial training, followed by six to eight weeks of supervised practice with a minimum of 2 children (age 2–9 years) with communication delays in their caseloads. During these sessions, facilitators were expected to set goals and implement CST strategies one-on-one with the children. MTs rated session videos on the Adult–Child Interaction Fidelity Scale developed by the WHO-CST team (Salomone et al., [<reflink idref="bib42" id="ref41">42</reflink>]), where 2 = demonstrates strategies up to 50% of the time, and 4 = demonstrates strategies 75–100% of the time. Facilitators delivered modules 1–5 of the WHO-CST intervention after using CST strategies accurately in the range of 62–74% of the time (average rating of 2.5–3). Subsequently, they participated in the second training module of 3 days, which equipped them to conduct the rest of the intervention (modules 6–9). MTs met with facilitators thrice for an hour each (MT 1 with Facilitators 1 and 2, MT 2 with facilitator 3, MT 3 with facilitator 4) to debrief and provide supervision on delivering group and coaching sessions during the intervention<bold><emph>.</emph></bold></p> <hd id="AN0162852012-13">Sample and Recruitment</hd> <p>A non-probability sampling strategy was used to recruit caregivers into the intervention. First, to be eligible to participate, caregivers of students enrolled at the two schools had to have communication as the primary concern for their children in the age range of 2–9 years, with or without a formal diagnosis of neurodevelopmental delays, including ASD, global developmental delays and intellectual disability. Second, caregivers had to agree to participate in both group and home-based sessions. The study excluded caregivers of children with significant motor difficulties, visual or hearing impairment since the training module for facilitators did not cover strategies to address challenges arising out of primary motor or sensory impairments. Based on the inclusion criteria, twenty-two caregivers enrolled in the study, site 1 (n = 9) and site 2 (n = 13). All the caregivers provided written, informed consent to participate in the intervention.</p> <hd id="AN0162852012-14">Evaluation Framework of the WHO-CST</hd> <p>As indicated earlier, WHO recommended a three-step evaluation plan, of which the pilot was the last of the three phases.</p> <hd id="AN0162852012-15">Design of Evaluation of Phase 3, Pilot</hd> <p>A concurrent mixed-methods pre-post research design was used to assess intervention feasibility on the following dimensions-acceptability, demand, implementation, practicality, and preliminary impact, frequently used to evaluate program feasibility of evidence-based public health interventions (Bowen et al., [<reflink idref="bib8" id="ref42">8</reflink>]).</p> <p>Quantitative data for program evaluation were collected at baseline and the completion of the intervention from (a) Caregivers (n = 22) and (b) Facilitators (n = 4) who delivered the intervention in the schools. An independent bilingual translator translated all quantitative measures into Hindi, which were back-translated into English to ensure validity. In addition, qualitative data were collected at the end of the program through focus group discussions (FGDs) with caregivers, facilitators, and MTs. Three FGDs were conducted with approximately seven to eight caregivers each in Hindi, and two FGDs were held with facilitators and MTs separately. The FGDs with caregivers focused on caregivers' lived experiences of attending the WHO-CST program, their insights into the process, engagement, and suggested strategies to improve the intervention. The FGD with facilitators focused on their experience of delivering the programmatic components at the training center and the caregivers' homes, while the FGD with MTs focused on intervention delivery by the facilitators. The discussions were facilitated by a trained, independent interviewer with more than ten years of professional experience conducting focus groups and interviews. The interviewer was not involved in the program's design or delivery. On average, the FGDs with caregivers lasted for an hour and thirty minutes, while those with facilitators and MTs lasted for 60 min. The FGDs were recorded with permission, stored digitally, transcribed, and translated into English. Participant names were changed during coding and analysis, and confidentiality was ensured throughout recording and data storage.</p> <hd id="AN0162852012-16">Measures</hd> <p>Program feasibility was measured on the following domains as outlined by Bowen et al. ([<reflink idref="bib8" id="ref43">8</reflink>]):</p> <p> <emph>Demand</emph>, defined as the extent to which a new idea, program, process, or measure is likely to be used, was assessed by asking caregivers, "What motivated you to come and if other caregivers would want to attend?".</p> <p> <emph>Acceptability</emph> was defined as the extent to which a program is perceived as appropriate and helpful to caregivers. Open-ended questions such as "Did you find what was taught in CST relevant to your needs? Were there parts that you felt were not relevant or not applicable to your child or your family or where you live?" were used to assess the program's acceptability.</p> <p> <emph>Implementation</emph>, defined as the extent to which the program could be fully delivered, was assessed using the following measures:</p> <p>Caregiver Attendance was recorded by research assistants for all group sessions as well as home visits.</p> <p>Caregiver Fidelity was assessed using the Adult–Child Interaction Fidelity Scale (WHO-CST team, unpublished), earlier used to record facilitator fidelity. Developed by the WHO-CST team (Salomone et al., [<reflink idref="bib42" id="ref44">42</reflink>]), the scale assesses the implementation of strategies across thirteen core domains addressed in the program (e.g., set up the environment, offer choices, and promote child's efforts to communicate to request, supports engagement and positive behavior). Facilitators recorded twelve-minute video clips of parents interacting with their children without any guidance or prompt at the beginning of individual sessions with families. Trained raters, with inter-rater reliability established before implementation (Cohen's <emph>k</emph> = 0.8) and blinded to the recordings' time-point to offset bias, rated the use of different strategies that constituted the core domains on a 5-point Likert Scale (0 = Strategies not demonstrated or inappropriately applied and 4 = Strategies applied appropriately in 75–100% opportunities) for each of the three home-visits.</p> <p>Parents' self-reported adherence to strategies at home was assessed by asking parents to fill in relevant sections of the Caregiver Diary (adapted from Kasari et al., [<reflink idref="bib26" id="ref45">26</reflink>]) at the midpoint and the end of the intervention. Caregivers selected their most appropriate response to questions about frequency—"How many times during the last four weeks were you able to practice using the strategies in daily routines/playtime?" and duration of practice—"How much time did you, on average, spend each time you practiced?" Options provided ranged from 1–2 times weekly to more than once daily (Frequency) and &lt; 5 min to &gt; 60 min each time (Duration).</p> <p>Facilitator competency in leading group sessions and caregiver coaching was measured by the Adapted ENACT (ENhancing Assessment of Common Therapeutic factors) (Kohrt et al., [<reflink idref="bib27" id="ref46">27</reflink>]). The Adapted-ENACT-Child tool (WHO-CST team, unpublished) has two domains—(a) Group sessions and (b) Home visits. Competencies assessed included facilitator behaviors like paraphrasing, reflection, summarizing, and responding to caregiver feelings with rationalization/normalization. In addition, facilitator competencies during home visits were assessed using the following: 'provides positive feedback and suggestions for improvement' and 'collaborative goal-setting,' while items in the group-facilitation domain examined 'focus on session content' and 'structuring and managing the session.' Two MTs rated the facilitators' competencies by observing three 10–12-min segments of video recordings, chosen at random, of all nine group sessions, and a 10-min segment of the home visits on a scale of 1–4, where '1' represents the inability to complete any skills with competency and '4' denotes ideal competency in all domains. Ratings were conducted by MT 1 for facilitators 3&amp;4, while MT 2 rated facilitators 1 &amp;2. Average scores were computed separately for group and home sessions for each facilitator by summing all the items and dividing by the number of applicable items.</p> <p>The <emph>preliminary impact</emph> of the program was assessed by examining changes in parental skills, knowledge, stress, and child outcomes on adaptive behavior and social-communication skills using the following measures.</p> <hd id="AN0162852012-17">The Caregivers Skills and Knowledge Measure (WHO-CST Team)</hd> <p>This scale comprises 24 items administered at the beginning and end, evaluating changes in parental skills and knowledge related to the session contents. For example, parents rated their agreement on a scale of 1–5 on items related to their child's challenging behaviors (e.g., When my child has a tantrum, he may be trying to avoid something"), the importance of praise (e.g., "It is important to praise children during playtime"), learning opportunities (e.g., "My child has more opportunities to learn when he is left alone to play freely"), and self-care (e.g., "Caregivers should take time to care for themselves"). The total score on the scale could range from 1 to 120, with higher scores indicating greater knowledge of the concepts and strategies included in the intervention, with internal consistency found to be ɑ = 0.87.</p> <hd id="AN0162852012-18">The Parenting Stress Index-Short Form (PSI-SF)—3rd edition (Abidin, 1995)</hd> <p>The PSI-SF is a widely-used self-reported measure of parenting stress and was administered at the beginning and after completing the WHO-CST program. The tool consists of 36 items divided into three domains: Parental Distress (PD), Parent–Child Dysfunctional Interaction (P-CDI), and Difficult Child (DC). Items across the three domains were combined to form a Total Stress scale (Cronbach's ɑ = 0.84).</p> <hd id="AN0162852012-19">Vineland Adaptive Scales (VABS)—2nd edition (2005)</hd> <p>The VABS is a widely-used scale used to assess children's adaptive behavior in four domains: Communication, Daily Living Skills, Socialization, and Motor Skills, and appropriate for use in caregivers of children with ASD in India (Anjum et al., [<reflink idref="bib3" id="ref47">3</reflink>]). The scale rates responses to open-ended questions by asking caregivers about their child's skills in different developmental domains, at baseline and after completing the program. The Adaptive Behavior Composite score has been found to have an internal consistency of 0.94–0.97 across age ranges (CUP, [<reflink idref="bib11" id="ref48">11</reflink>]).</p> <hd id="AN0162852012-20">Social Communication Checklist (SCC) (Ingersoll &amp; Dvortcsak, 2010)</hd> <p>The 47-item SCC was used to assess children's social-communication abilities in five domains: Social Engagement, Language (Expressive -form and function, and Receptive), Understanding and Following Directions, Social Imitation, and Play. The items are scored as 1 = rarely or not yet, 2 = sometimes but not consistently, 3 = at least 75% of the time, with lower scores suggesting higher impairment. The SCC was completed at the beginning and the completion of the intervention by both caregivers and two independent clinical psychologists with prior training in the use of the SCC (Sengupta et al., [<reflink idref="bib43" id="ref49">43</reflink>]). Inter-rater reliability amongst the trained raters was 0.85. Internal consistency was reported to be high for both caregivers (Cronbach's ɑ = 0.89) and trained raters' version (Cronbach's ɑ = 0.95).</p> <p>In addition to the quantitative measures, focus groups with caregivers, facilitators, and MTs inquired of various aspects of the intervention using semi-structured focus group guides. The research team minimally revised the questions in the guides to adapt to emerging themes. The focus-group guide had questions such as, "What changes have you found in your/caregivers' way of thinking about/interacting with your child post the training program?" and "What changes have you noticed in the child /children and caregivers after the program?".</p> <p> <emph>Practicality</emph>, defined (Bowen et al., [<reflink idref="bib8" id="ref50">8</reflink>]) as the extent to which a program or process is carried out with intended participants using existing means, resources, and circumstances, was explored by questions like "Were there any challenges you faced in being part of/ delivering this program?" For example, "Did you face any barrier with attending group sessions or being available for home visits?" and "Did you face any challenge with implementing these strategies at home with your child?".</p> <p> <emph>Integration,</emph> the extent to which a new idea or program can be integrated within an existing system, and <emph>Expansion</emph>, the extent to which a previously tested program can be expanded to provide a new program or service (Bowen et al., [<reflink idref="bib8" id="ref51">8</reflink>]) were elicited briefly by asking facilitators and master trainers, "Do you see yourselves continue to implement this program in the future? How can this be done"?</p> <hd id="AN0162852012-21">Data Analysis</hd> <p></p> <hd id="AN0162852012-22">Quantitative Data Analysis</hd> <p>SPSS version 25.0 (2017) was used for quantitative analysis. Demographic characteristics were analyzed using descriptive statistics. Due to the small sample size, all statistical analyses of feasibility and outcome variables were conducted using nonparametric tests. In addition, pre-post change in outcome variables was examined using Wilcoxon- signed-rank test for paired samples (caregivers' skills and knowledge, parenting stress, adaptive child behavior, and social communication) and Friedman's test to examine differences in adult–child interaction fidelity across three home visits. The significance level was set at p &lt; 0.05.</p> <hd id="AN0162852012-23">Qualitative Data Analysis</hd> <p>Qualitative data were digitally recorded and transcribed in English. A qualitative software program Dedoose was used to code the transcripts. The transcribed data were coded using deductive coding processes by SG, an experienced mixed-methods researcher specializing in the study of caregivers to children with NDDs. Bowen et al.'s ([<reflink idref="bib8" id="ref52">8</reflink>]) domains were used as a framework to primarily code the data. Detailed code descriptions were created by SG, which were validated by OD and KS, both researchers and practitioners, who independently read the transcripts and coded. Any discrepancies between the three coders were resolved by either revising the code or revising the code description if two of the three coders did not agree to either of the two. Throughout the coding process, a constant comparative method was used to assess similarities and differences within and between focus groups (Glaser &amp; Strauss, [<reflink idref="bib21" id="ref53">21</reflink>]). Once coded, the primary analytic strategy was qualitative deductive content analysis (Elo &amp; Kyngäs, [<reflink idref="bib18" id="ref54">18</reflink>]). Once coded, categories were created to meaningfully group codes that could explain a theme.</p> <hd id="AN0162852012-24">Results</hd> <p>The subsequent section describes results of WHO-CST feasibility on the following dimensions-acceptability, demand, implementation, practicality, and preliminary impact (Bowen et al., [<reflink idref="bib8" id="ref55">8</reflink>]).</p> <hd id="AN0162852012-25">Sample Description (see Table 3)</hd> <p>Table 3 Demographic characteristics of Caregiver-Child dyads</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left"&gt;&lt;p&gt;Variable&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;N (%) (Mean, SD)&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Caregiver&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Relationship of primary caregiver&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Mother&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;21 (95.45%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Father&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1 (4.55%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Average age&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;33.68 (SD = 5.13)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Education&lt;/p&gt;&lt;/td&gt;&lt;td align="left" /&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Secondary (10 years of formal schooling)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;7 (31.8%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Higher secondary (12 years of formal schooling)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;2 (9.09%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Undergraduate degree/diploma&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;13 (59.09%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Marital status (% married)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;100%&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="2"&gt;&lt;p&gt; Work outside the home&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; No&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;18 (81.81%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Yes, part-time&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;2 (9.09%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Yes, full time&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;2 (9.09%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="2"&gt;&lt;p&gt; Other family members involved in child's caregiving&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; The child's other parent or step parent&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;17 (77.27%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; The child's grandparents&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;9 (41%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; The child's siblings (e.g. brother or sister)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;4 (18.18%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Paid nanny or other paid caregiver&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;1 (4.54%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="2"&gt;&lt;p&gt;Children&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" rowspan="2"&gt;&lt;p&gt; Age of child (in months)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;61.95 months (SD = 22.21)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Range: 36 months to 108 months&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="2"&gt;&lt;p&gt; Gender of child&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Male&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;19 (86.36%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Female&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;3 (13.64%)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="2"&gt;&lt;p&gt; Main language spoken in the home of the child&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Marathi (%)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;68.18% (n = 15)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Hindi (%)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;22.72% (n = 5)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Others (%)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;9.02% (n = 2)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="2"&gt;&lt;p&gt; Diagnosis of child as per records&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Autism&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;81.81% (n = 18)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Communication disorder&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;4.54% (n = 1)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; ASD &amp; ADHD&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;4.54% (n = 1)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; ASD + ID&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;4.54% (n = 1)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; ADHD&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;4.54% (n = 1)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Services received currently&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;Mean Duration/week (SD.)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Special school (including remedial services)&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;6 h&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Occupational therapy&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;52.89 min (31.76)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Speech therapy&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;30 min (19.63)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p>The sample included twenty-two caregivers; all except one were mothers. The average age of caregivers was 33.6 years (SD = 5.1), all being married, with a minimum of ten years of formal schooling, and the majority (81%) not employed. The children had a mean age of 61.95 months (SD = 22.21, Range: 36 months to 108 months). The majority of them were male (n = 19), spoke Marathi as the primary language at home (n = 15), had received a diagnosis of ASD (n = 20) with or without ID or ADHD, while two children had received non-specific diagnoses. Additionally, data on feasibility were collected from the four facilitators and three MTs.</p> <hd id="AN0162852012-26">Feasibility</hd> <p>The results from the quantitative measures and qualitative themes for the key focus areas of the feasibility of the WHO-CST intervention are as follows.</p> <hd id="AN0162852012-27">Demand</hd> <p>Qualitative themes revealed that the program filled a gap that was perceived acutely by both caregivers and facilitators.</p> <hd id="AN0162852012-28">A Felt Need</hd> <p>Parents referred to their helplessness about supporting their children with communication and behavioral difficulties and their need for "parent-training" as the primary motivation for joining the program. For example, a parent explained, <emph>"earlier I took my son to therapy for two months. But I could not understand what he needed. They never told us what to do, how to play with him...."</emph></p> <p>The facilitators reflected on how before joining the program, their focus was solely on teaching the child. They perceived a gap in their skills to address parent queries which they felt was filled by this program. As a result, one of them recalled, <emph>"we would not be able to explain to the parents what they can teach their children at home."</emph></p> <hd id="AN0162852012-29">Acceptability</hd> <p></p> <hd id="AN0162852012-30">Course Contents and Modalities Relevant, Crucial, and Helpful</hd> <p>Caregivers received the program contents and modalities positively. According to a parent, <emph>"Everything that was there in this program- those are the same situations we face with all our kids."</emph> All parents unanimously found the different session topics crucial and relevant, though, at times, the strategies did not appear immediately applicable to their child or their concerns. For instance, two mothers spoke about how they initially found the process of imitating their child's actions to build engagement <emph>"surprising."</emph> One of them clarified how "<emph>later I understood that we have to start doing whatever he is doing initially and then slowly gradually... we have to move him towards something else."</emph> They commented on how the group sessions added value due to the mutual camaraderie and peer support generated during those sessions. One mother described how <emph>"In the group, we come to know about the problems of the other children as well... how their parents handle their child. We get an idea like how we should handle our kid."</emph></p> <p>Parents reported that the didactics built new learning, while the therapists' live modeling (demonstrations) enabled them to visualize the strategies. They appreciated the relevance of the stories or vignettes highlighting critical concepts in the participant booklets to their own experiences. They could relate to the stories despite the varied nationalities of children and families represented in the pictures. One of them remarked, <emph>"We were not thinking about things like what is the name of the child or whose picture is there in the notes</emph> (participant booklets)<emph>. When I looked at the expression of the mother in the picture, I felt that the mother in the picture is me."</emph></p> <p>The most highly recommended part of the program was the home visits. Parents and facilitators found it mutually beneficial when the facilitators observed their interactions with their children and supported them in individualizing strategies to their child, using toys and activities they engage in at home. A mother clarified why she found the home visit especially beneficial<emph>, "Initially, I tried to teach him things I was taught in the group. But he did not do well with me. I would take everything, keep that in front of him and then sit and play with him. Then madam (facilitator) showed me how it should be done... I came to know what I shouldn't be doing... I understood that from the home visit."</emph></p> <p>Facilitators recalled being skeptical at the beginning of the caregiver training whether parents would cope with <emph>"all the additional responsibility that we are asking them to do at home"</emph> as part of the program and were encouraged by the acceptance and motivation demonstrated by the parents right from the beginning.</p> <hd id="AN0162852012-31">What Did Not Work</hd> <p>Only two parents reported using visual supports, especially picture schedules, introduced as strategies to help children understand routines and stay regulated. Others found it <emph>"cumbersome," "time-consuming</emph>," and did not attempt. In addition, the component of having caregivers conduct role-plays of their children during the group sessions received mixed reviews, with half of the caregivers finding it challenging to relate to other children's challenges and tailoring strategies impromptu.</p> <hd id="AN0162852012-32">Implementation</hd> <p></p> <hd id="AN0162852012-33">Attendance</hd> <p>All caregivers completed the program, including all three home visits. Only two caregivers missed one group session each.</p> <hd id="AN0162852012-34">Caregiver Adherence</hd> <p>75% of the parents reported practicing CST strategies between 3 times a week to every day, during home and play routines. On average, parents reported practicing the strategies with their children 4.77 times after week three and 4.32 times seven weeks into the program. Fifty percent of the parents reported spending between 10 and 15 min each time they practiced the strategies, while another 25% spent between 15 and 30 min on average.</p> <hd id="AN0162852012-35">Caregiver Fidelity</hd> <p>The coding of video segments of caregiver-child interaction during home visits shows a significant difference between caregivers' total fidelity scores measured during home visits 1, 2, and 3, <emph>X</emph><sups>2</sups><subs><emph>F</emph></subs><emph> (<reflink idref="bib2" id="ref56">2</reflink>)</emph> = 33.95, p &lt; 0.001on the Adult–Child Interaction Fidelity scale. Caregivers demonstrated strategies with accuracy approximately 60% of the time (Mean rank 2.39) during home-visit one and about 65% of the time (Mean rank 2.61) during home-visit 3. Caregivers Post-hoc tests using a Dunn-Bonferroni correction showed that total caregiver fidelity scores after home visit 2 (Mean rank 2.39) were significantly higher (p &lt; 0.001) than scores after home visit 1(Mean rank 1.00). After visit 3 (Mean rank 2.61), fidelity scores were higher than after visit two but not statistically significant. (Table 4).</p> <p>Table 4 Adult–Child Interaction Fidelity scores for Caregivers during home-visits</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left" rowspan="2"&gt;&lt;p&gt;Components of score&lt;/p&gt;&lt;/th&gt;&lt;th align="left" colspan="3"&gt;&lt;p&gt;Mean rank&lt;/p&gt;&lt;/th&gt;&lt;th align="left" rowspan="2"&gt;&lt;p&gt;Chi square&lt;/p&gt;&lt;/th&gt;&lt;th align="left" rowspan="2"&gt;&lt;p&gt;&lt;italic&gt;p&lt;/italic&gt; value&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;tr&gt;&lt;th align="left"&gt;&lt;p&gt;Visit 1&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Visit 2&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Visit 3&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Sets up the environment&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.20&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.32&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.48&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;25.51&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Moves to be face to face&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.36&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.16&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.48&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;17.94&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Builds &amp; sustains routines&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.11&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.25&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.64&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;21.79&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Expands communication&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.25&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.14&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.61&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;33.23&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Pauses for communication&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.11&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.20&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.68&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;24.40&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Models appropriately&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.16&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.23&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.61&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;33.81&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Promotes requesting&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.23&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.48&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.30&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;28.92&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Promotes sharing&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.39&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.05&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.57&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;23.87&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Supports engagement &amp; positive behavior&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.27&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.12&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.62&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;14.56&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Supports regulation&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.14&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.50&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.36&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;8.07&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.02*&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Promotes learning of new skills&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.31&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.10&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.60&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;20.30&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Notices encourages and praises&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.25&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.23&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.52&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;22.91&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;Caregiver Fidelity Total&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.00&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.39&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.61&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;33.95&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p>0 = Strategies is not demonstrated or inappropriately applied throughout segment, 1 = Strategies applied appropriately in 25% of opportunities, 2 = Strategies applied appropriately in 50% of opportunities and 4 = Strategies are applied appropriately in 75–100% of opportunities *Not significant at p &lt; 0.05</p> <hd id="AN0162852012-36">Facilitator Competency</hd> <p>Group and home- video segments coded on the adapted ENACT revealed that competencies required to facilitate group training sessions improved, with facilitators exhibiting competencies only partially at the beginning of the intervention (M = 2.21, SD = 0.31) and adequately in the last group session (M = 3.12, SD = 0.27). Mean competency scores during the third home visit (M = 2.86, SD = 0.36) were higher than scores recorded during the first home visit (M = 2.24, SD = 0.23) (Table 5).</p> <p>Table 5 Facilitator Competency scores on adapted ENACT (Enhancing Assessment of Common Therapeutic factors)—Child tool*</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left" rowspan="2"&gt;&lt;p&gt;Group session*&lt;/p&gt;&lt;/th&gt;&lt;th align="left" colspan="6"&gt;&lt;p&gt;ENACT-Group session scores&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;tr&gt;&lt;th align="left"&gt;&lt;p&gt;F-1&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;F-2&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;F-3&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;F-4&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Mean&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;S.D.&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.09&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.00&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.08&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.67&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.21&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.31&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;2&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.33&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.17&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.64&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.67&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.45&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.24&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.33&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.08&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.08&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.75&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.66&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;4&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.92&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.83&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.33&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.92&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.89&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.05&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.58&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.67&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.82&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.45&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.63&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.16&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;6&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.67&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.17&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.42&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.67&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.48&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.24&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;7&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.00&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.00&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.64&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.42&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.02&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.32&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.08&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.83&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.25&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.42&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.90&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.72&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;9&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.08&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.75&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.33&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.33&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.12&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.27&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p>Table 5 Facilitator Competency scores on adapted ENACT (Enhancing Assessment of Common Therapeutic factors)—Child tool*</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left" rowspan="2"&gt;&lt;p&gt;Home-visit#&lt;/p&gt;&lt;/th&gt;&lt;th align="left" colspan="6"&gt;&lt;p&gt;Average ENACT-Home visit/child scores&lt;sup&gt;a&lt;/sup&gt;&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;tr&gt;&lt;th align="left"&gt;&lt;p&gt;F-1&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;F-2&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;F-3&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;F-4&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Mean&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;S.D&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.01&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.36&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.50&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.07&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.24&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.23&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;2&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.43&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.33&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.34&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.56&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.67&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.46&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt;3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.68&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.57&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.37&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.80&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.86&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.36&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p>1 = Needs improvement (inability to complete any skills with competency), 2 = Done partially, 3 = Done adequately and 4 = Done well (ideal competency in all domains) *WHO-CST M &amp; E framework, 2017 <sups>a</sups>Average Adapted ENACT scores per home visit for each facilitator were calculated as Sum of ENACT-Home visit/Child scores divided by total number of caregivers coached by each facilitator for that home-visit#</p> <hd id="AN0162852012-37">Preliminary Impact</hd> <p></p> <hd id="AN0162852012-38">Caregiver Outcomes</hd> <p>A statistically significant improvement was observed over two time-points in Caregivers' Skills and Knowledge (z = 3.87, p &lt; 0.001) on the Wilcoxon signed-rank test. Overall, Parenting Stress decreased significantly (z = 2.21, p = 0.03), with the dysfunctional interaction component showing the most significant reduction (z = 2.7, p = 0.01, ES = − 0.41) (Table 6).</p> <p>Table 6 Caregiver and child outcomes</p> <p> <ephtml> &lt;table frame="hsides" rules="groups"&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left" rowspan="2"&gt;&lt;p&gt;Outcome variables&lt;/p&gt;&lt;/th&gt;&lt;th align="left" colspan="2"&gt;&lt;p&gt;Pre-training&lt;/p&gt;&lt;/th&gt;&lt;th align="left" colspan="2"&gt;&lt;p&gt;Post-training&lt;/p&gt;&lt;/th&gt;&lt;th align="left" rowspan="2"&gt;&lt;p&gt;z-value&lt;/p&gt;&lt;/th&gt;&lt;th align="left" rowspan="2"&gt;&lt;p&gt;p-value&lt;/p&gt;&lt;/th&gt;&lt;th align="left" rowspan="2"&gt;&lt;p&gt;Effect size&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;tr&gt;&lt;th align="left"&gt;&lt;p&gt;Median&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;IQR&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;Median&lt;/p&gt;&lt;/th&gt;&lt;th align="left"&gt;&lt;p&gt;IQR&lt;/p&gt;&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td align="left" colspan="8"&gt;&lt;p&gt;Caregiver outcomes&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Caregiver skills &amp; knowledge&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;84.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;10.5&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;96.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;8.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 3.87&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.58&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="8"&gt;&lt;p&gt; Parenting Stress Index&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Distress&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;83.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;41.0&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;67.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;38.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 1.69&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.09&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.26&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Dysfunctional interaction&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;95.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;13.0&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;84.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;19.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 2.70&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.01*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.41&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Difficult child&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;83.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;23.5&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;71.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;29.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 1.75&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.08&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.26&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Overall Parent Stress Index&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;86.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;24.0&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;74.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;16.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 2.21&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.03*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.33&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="8"&gt;&lt;p&gt;Child outcomes&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="8"&gt;&lt;p&gt; Vineland Adaptive Behavior Scale&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Communication&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;19.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.5&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;21.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;9.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 3.10&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.47&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Motor skills&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;26.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;11.5&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;27.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;9.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 1.69&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.09&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.25&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Social skills&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;21.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.0&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;23.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;7.3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 3.00&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.45&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Daily living skills&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;17.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.0&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;19.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;7.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 3.37&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.51&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Adaptive behavior composite&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;55.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;14.3&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;59.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;17.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 3.67&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.55&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="8"&gt;&lt;p&gt; Social communication checklist (Caregiver version)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Social engagement&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;28.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;8.5&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;32.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;6.3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 3.76&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.57&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Expressive language form&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;21.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.0&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;21.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;4.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 2.84&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.01*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.43&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Expressive language function&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;22.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.5&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;24&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;9.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.70&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.49&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.10&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Understanding and following directions&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;15.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.5&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;15&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;7.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 2.78&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.01*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.42&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Social imitation&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;8.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;4.0&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;10&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;5.3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 2.78&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.01*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.42&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Play&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;16.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.0&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;17.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 2.96&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.45&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Overall SCC&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;104&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;23.9&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;124.25&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;28.1&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 3.46&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.52&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left" colspan="8"&gt;&lt;p&gt; Social communication checklist (Expert rater version)&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Social engagement&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;16.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;4.3&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;23.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;8.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 3.33&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.50&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Expressive language form&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;17.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.3&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;19.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;8.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 3.63&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.55&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Expressive language function&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;17.2&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.1&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;19.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;6.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 3.12&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.47&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Understanding and following directions&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;8.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;1.3&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;10.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;3.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 4.02&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.61&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Social imitation&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;6.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.3&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;8.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;4.8&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 2.53&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.01*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.38&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Play&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;13.5&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;4.0&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;16.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;2.3&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 3.06&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.46&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td align="left"&gt;&lt;p&gt; Overall SCC&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;79&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;19.4&lt;/p&gt;&lt;/td&gt;&lt;td align="left"&gt;&lt;p&gt;93&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;30.0&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 3.67&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;0.00*&lt;/p&gt;&lt;/td&gt;&lt;td char="." align="char"&gt;&lt;p&gt;&amp;#8722; 0.55&lt;/p&gt;&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <p>*Significant at p &lt; 0.05</p> <hd id="AN0162852012-39">Child Outcomes</hd> <p>On the Vineland Adaptive Behavior Scales, children's adaptive behavior composite scores showed a statistically significant improvement on the completion of the intervention, with significant improvement in communication (z = 3.10, p &lt; 0.001, ES = 0.47), social skills (z = 3.0, p &lt; 0.001, ES = 0.45) and daily living skills (z = 3.37, p &lt; 0.001, ES = 0.51).</p> <p>Total Social Communication scores as measured by the SCC improved significantly on completing the intervention, both on the caregiver (z = 3.46, p &lt; 0.001, ES = 0.52) and trained-rater (z = 3.67, p &lt; 0.001, ES = 0.55) versions (Table 6).</p> <p>Qualitative data also revealed impact across caregivers, their children, and other family members. The following themes were identified:</p> <hd id="AN0162852012-40">Enabled New Knowledge</hd> <p>All parents described how the program enabled new knowledge, which equipped them to understand their child's behaviors in the context of their developmental stage. For example, the mother of a 6-year-old boy who enjoyed spinning steel kitchen utensils described what she learned, <emph>"From our perspective, we think why is he doing this? Why is he behaving like mad? But nowadays we don't think like that. It's the way he plays. And he enjoys it. We are now able to understand the needs of our kids."</emph></p> <hd id="AN0162852012-41">Change to a Responsive-Parenting Style</hd> <p>Parents stated that participating in the program changed their parenting style to be more responsive to their child's needs. Parents described how they desisted from forcing their child and instead have started observing and following their children's cues and choices. A parent expressed it succinctly, <emph>"We should not teach these kids what we want them to learn. Instead, we need to observe what they are doing, and we need to reciprocate."</emph></p> <p>Facilitators also noted similar changes in caregivers. According to one, <emph>"they have stopped asking their children questions. Earlier they would use a lot of questions—that has stopped."</emph></p> <hd id="AN0162852012-42">Positive Impact on Child Skills</hd> <p>Caregivers, facilitators, and master-trainers identified positive changes in the children after the parents participated and attributed those shifts to caregiver interaction styles. For example, according to a mother, <emph>"I would get irritated because I cannot work when he comes into the kitchen. But now I understand that, if he comes, he would take out a utensil, stand on it and observe what I am doing. And I would tell him things- like I am adding salt...spices. And he understands the names now."</emph> Additionally, mothers and facilitators reported changes in their children's expressive skills- like starting to point or use more words, improved understanding of instructions and social interaction, better self-regulation, and increased participation in self-help skills.</p> <hd id="AN0162852012-43">Impact on Other Family Members</hd> <p>Two mothers explained how they felt empowered to advocate for changes in how other family members behaved or interacted with the child. As one mother shared, <emph>"Earlier, my family members would get irritated. I made them understand that if we hit him every time, he doesn't listen to you, then that's not a solution."</emph></p> <p>Facilitators described how additional caregivers (e.g., grandmother, aunts) expressed interest and participated in the home sessions with three families.</p> <hd id="AN0162852012-44">Improved Parental Well-being</hd> <p>Overall, participating parents emerged with a strong sense of well-being on completing the program. The focus groups brought to the fore an improvement in caregivers' levels of confidence. One mother appeared to express a common sentiment when she remarked, <emph>"The confusion we had whether we are working (with our child) correctly or not, that is gone."</emph> Another mother spoke about how her levels of stress are lower now because <emph>"if we tell him to go and do something, then he does it. Earlier, we had to bring everything to him."</emph> Three mothers in the group spoke about distressing episodes of stigma and social isolation and how they have been able to cope better after participating in the program as they realize <emph>"there are others like us."</emph></p> <hd id="AN0162852012-45">Practicality</hd> <p>The responses about the practicality of implementing the WHO-CST program in India highlighted both the strengths as well as inherent challenges. Mothers appreciated the duration of the course and felt it was adequate. Holding the group sessions within the school premises while the children attended school made it possible for all the mothers to participate without worrying about childcare. However, one father and one mother who held full-time jobs had to leave work to attend. Some parents spoke about how travel vouchers supported regular and punctual attendance by utilizing a cab to travel instead of public transport.</p> <p>Caregivers brought up different challenges that they faced during the duration of the program. Lack of time to practice routines and strategies with their children because of competing demands was oft-heard. <emph>"The main problem was I was not getting time to spend with my son. So out of 7 days, I was getting time on two or three days to spend with my son."</emph></p> <p>Mothers felt that fathers' limited participation was a challenge, and more active efforts like adding a Sunday session, especially for fathers, may be helpful. Finally, parents spoke about their experience of stigma. They expressed a need to create spaces and ways for their children to come together and play and for parents to continue meeting and supporting each other even though the WHO-CST sessions are over.</p> <p>From the facilitators' perspective, delivering the module on Challenging Behaviors was difficult. A facilitator with two years of experience commented, <emph>"Sometimes the parents would ask me what they should do when their child shows this behavior? Unfortunately, I didn't have an answer for most of their questions on this topic."</emph></p> <hd id="AN0162852012-46">Integration and Expansion</hd> <p>Facilitators described <emph>"Time as the only constraint."</emph> They found it hard to include time for preparing and conducting sessions and traveling for home visits in their work days alongside their regular responsibilities. One of them specifically mentioned the need for significant planning and preparation to deliver the sessions. The time spent practicing live demonstrations and didactic material required them to work extended hours. The school timings had to be reorganized at one of the sites to accommodate the training sessions and previously scheduled school activities.</p> <p>MTs highlighted two important facilitator-related factors worth consideration during subsequent implementation- the novelty of concepts emphasized during the program and the requirement for additional group facilitation and training skills. An MT explained, <emph>"It was difficult for the facilitators to explain these concepts, especially those on behaviors and routines. It was so new to them that it became difficult for them to explain it. Because they were also, I mean, they were just learning the information themselves."</emph> MTs highly recommended intermittent supervision sessions as opportunities to review and scaffold these skills.</p> <hd id="AN0162852012-47">Discussion</hd> <p>Low and middle-income countries like India struggle to find solutions to the enormous treatment gap for most children with developmental disabilities, including ASD, residing in these regions. With its evidence-informed, open-access, manualized curriculum and a cascading supervision system to enable task-sharing with non-specialist workers, the WHO-CST program is an important option to bridge this gap. The current study adds to the extant literature on the feasibility of implementing the WHO-CST program and, at the time of writing, is the first to report on the intervention's acceptability and relevance when delivered by non-specialists in urban settings in an LMIC.</p> <hd id="AN0162852012-48">Feasibility and Acceptability of the Intervention in Real-World Settings</hd> <p>Our study shows that the WHO-CST intervention was acceptable to both parents and non-specialist providers. Overall, caregivers perceived the course duration as appropriate, with all caregivers completing the program with excellent attendance rates. Our experience has been that parents can accommodate such programs into their schedules when they last from six to twelve weeks (Sengupta et al., [<reflink idref="bib43" id="ref57">43</reflink>]). Attrition rates may increase if such programs extend beyond this time frame, considering the multiple demands on caregivers' time (Prata et al., [<reflink idref="bib38" id="ref58">38</reflink>]). Parents found the course content helpful, applicable, and relevant to their contexts. They perceived the images and drawings included in the original WHO-CST parent manuals as universal and unifying, thereby justifying retaining the diversity of races depicted and refraining from expending effort in recreating culturally similar images.</p> <p>The program's current structure, emphasizing supervised delivery by non-specialist facilitators, highlighted both advantages and challenges in our context. When the facilitators commenced delivery, their levels of clinical fidelity were lower than what is described as the benchmark (using different kinds of techniques with at least 75% fidelity) for intervention skill mastery (Stahmer &amp; Gist, [<reflink idref="bib45" id="ref59">45</reflink>]), despite their employment status as teachers in special schools. Our finding is not surprising in the context of extant literature from India (Duggal et al., [<reflink idref="bib16" id="ref60">16</reflink>]; Tiwari &amp; John, [<reflink idref="bib48" id="ref61">48</reflink>]) demonstrating that even in-service specialist providers like special educators, occupational and speech therapists may not possess the pre-requisite knowledge and skills for addressing specific issues like social-communication and challenging behaviors. Similarly, facilitators' lack of experience in facilitating parent training and coaching using a reflective, collaborative approach became evident from the low levels of competency demonstrated during group sessions and caregiver coaching at the start of the intervention. Lower competency scores at the beginning may also reflect skills that had to be unlearned, for instance, adopting a supportive, reflective style of parent-coaching instead of a more directive, authoritarian role (Venkatesan, [<reflink idref="bib50" id="ref62">50</reflink>]) that clinicians and helpers rely on in the Indian context. While the facilitator competency scores increased during the intervention, implying that skills improved with supervised practice opportunities (Kohrt et al., [<reflink idref="bib27" id="ref63">27</reflink>]), it also underscored (a) the need to explore whether non-specialists, who by definition possess lesser levels of clinical training and experience should be held to similar stringent standards of fidelity and competence as trained clinicians while delivering brief interventions, (b) the value of incorporating training for facilitators on using reflective and collaborative group facilitation and coaching practices before they deliver the intervention to caregivers and (c) the possible role of sustained mentoring to enhance clinical skills in future. Both (b) and (c) potentially necessitate an increase in intensity and duration of training for non-specialists, which may have further implications for feasibility in low-resource settings.</p> <p>Caregiver fidelity scores increased significantly from baseline to the third home visit, suggesting that caregivers who demonstrated CST strategies less than 25% of the time at the start could do so 65% of the time by the end of the intervention. Interestingly, in their study on parents' adoption of social-communication intervention strategies, Shire et al. ([<reflink idref="bib44" id="ref64">44</reflink>]) found that parents mastered 70% of the strategies on average, even when coached by therapists who met the criteria for high fidelity. Additionally, they found that parents' adoption of strategies may vary with their complexity, similar to our results which showed no significant difference between parent fidelity scores during home-visits 2 and 3, suggesting that caregivers may have found it challenging to acquire strategies taught during the later sessions, including expanding on play and home routines and using visual supports to regulate behavior. It is also likely that lower parent fidelity scores in our study were influenced by a propensity for a more directive, instructional parenting approach prevalent in eastern cultures (Krupa et al., [<reflink idref="bib28" id="ref65">28</reflink>]). This finding is consistent with the Eco-cultural theory proposed by Gallimore et al. ([<reflink idref="bib20" id="ref66">20</reflink>]), according to which cultural values and beliefs may influence how families implement intervention strategies in daily routines. Future studies should consider (a) the need for ongoing support for parents to build their competence in implementing strategies in the form of booster sessions after the intervention is over and (b), more importantly, whether similar standards for parent fidelity hold across different cultures.</p> <p>Quantitative reports of adherence to strategies or therapy enactment in home settings (McConachie &amp; Fletcher-Watson, [<reflink idref="bib32" id="ref67">32</reflink>]) suggest that while parents could implement strategies at home, time spent on them was brief. It is interesting to compare this data to the rich qualitative narratives from caregivers about how they incorporated CST learnings during their daily routines, reflecting the naturalistic techniques taught in the intervention. We hypothesize that parents under-reported time spent on home practice, which could be attributable to parents' inability to quantify the time they integrated strategies during their routines.</p> <p>Though our small sample size and absence of a control group preclude claims of effectiveness, our data revealed positive trends in child developmental outcomes across communication, social skills, and daily living skills, substantiating the intervention's role in promoting children's developmental outcomes. In addition, it is encouraging to note that our results of preliminary impact are in the same direction as that of other PMIs tested in developed and resource-poor regions (Blake et al., [<reflink idref="bib7" id="ref68">7</reflink>]; Ingersoll &amp; Wainer, [<reflink idref="bib24" id="ref69">24</reflink>]).</p> <hd id="AN0162852012-49">Relevance of the Intervention in LMICs</hd> <p>Most of our participant caregivers were aware of their children's diagnosis; a few were not. However, the absence of a formal diagnosis did not restrict caregivers and their children from participating or benefitting from this program. On the contrary, in LMICs, where the lacuna of culturally appropriate screening and diagnostic tools is often a significant barrier to accessing early intervention, the diagnosis-agnostic access to intervention that the WHO-CST provides is a commendable advantage.</p> <p>The WHO-CST program resulted in a notable impact on caregivers. Quantitative caregiver scores showed improvement in their knowledge and skills, and their reported overall stress levels decreased significantly. The qualitative data captured the gamut of changes that underscored the intervention's impact on parents and were similar to benefits perceived by caregivers during the pre-pilot phase of the WHO-CST program in Ethiopia (Tekola et al., [<reflink idref="bib46" id="ref70">46</reflink>]). Facilitators and caregivers consistently endorsed how differences in parenting strategies and styles after participating in the intervention improved their children's skills, leading to positive perceptions of their children. The change in caregiver insight about how they mediate the impact on their children and are themselves impacted by it (Estes et al., [<reflink idref="bib19" id="ref71">19</reflink>]) assumes great significance, as in many LMICs, professionals often adopt an 'expert' stance (Ramachandran, [<reflink idref="bib40" id="ref72">40</reflink>]) without necessarily empowering the parent to develop self-efficacy. The WHO -CST program pilot in India successfully provided caregivers opportunities to observe and experience themselves as agents of change in their child's life, thereby enhancing their confidence to adopt a stance against more conventional practices like hitting by other family members to manage child behaviors. Further, they experienced greater well-being and decreased stress as an outcome of their participation.</p> <p>The vital and multi-dimensional contribution of both group sessions and home visits to the program's perceived benefits emerged strongly from the qualitative data. Caregivers of children with special needs in LMICs find themselves isolated and stigmatized, even more so in financially disadvantaged sections (Zhou et al., [<reflink idref="bib52" id="ref73">52</reflink>]). As part of supportive peer-group sessions during the WHO-CST program, parents experienced increased social cohesiveness and belonging, highly valued in collectivistic cultures (Akkuş et al., [<reflink idref="bib2" id="ref74">2</reflink>]). We concur with Tekola et al. ([<reflink idref="bib46" id="ref75">46</reflink>]) that program implementers should consider ways to promote caregivers' continued participation in parent groups, either with peers of the same cohort or a more extensive network of CSTrained-parents.</p> <p>Caregivers in our study endorsed that receiving direct feedback, especially in home -settings helped them individualize and implement strategies correctly and improved child engagement and compliance, keeping with findings from parent-mediated programs (Catalano et al., [<reflink idref="bib10" id="ref76">10</reflink>]; Kaminski et al., [<reflink idref="bib25" id="ref77">25</reflink>]). However, home-visits by health workers are a difficult proposition in urban parts of India and other LMICs, because of contextual barriers like the inconvenience of travel as described by the facilitators, fears about the safety of women health-workers (Dasgupta et al., [<reflink idref="bib14" id="ref78">14</reflink>]), and social discomfort associated with health workers' home visits (Divan et al., [<reflink idref="bib15" id="ref79">15</reflink>]). Nevertheless, considering the emphatic support it received in our study, home-based coaching should be retained as an essential element of the WHO-CST program. When required, implementers should consider alternative options like telehealth, which circumvents many of the barriers mentioned earlier and has been explored in other PMIs (Guler et al., [<reflink idref="bib22" id="ref80">22</reflink>]; Leadbitter et al., [<reflink idref="bib29" id="ref81">29</reflink>]).</p> <hd id="AN0162852012-50">Strengths and Limitations</hd> <p>The study has several limitations. <emph>First</emph> is the small sample size and non-experimental study design, limiting the generalizability of the findings and analysis. For example, our small sample size limited us from conducting any mediator or moderator analyses (Trembath et al., [<reflink idref="bib49" id="ref82">49</reflink>]). Similarly, we have not examined the role of confounding factors like therapies that children received in addition to the WHO-CST. <emph>Second</emph>, most caregivers in the study (~ 68%) had more than ten years of schooling, and it is unclear how effective the intervention would be with the average Indian caregiver in semi-urban or rural areas who is likely to be less-educated (as per the National Census 2011 data). <emph>Third</emph>, though the intervention is meant to address social-communication and behavioral difficulties across a range of DDs, the study sample was skewed towards children diagnosed with ASD. <emph>Fourth,</emph> the group sessions were conducted in school settings where mothers were accustomed to traveling, and teachers meaningfully engaged the participating caregivers' children. Though childcare provision has been a vital adaptation (Sengupta et al., [<reflink idref="bib43" id="ref83">43</reflink>]), it is unlikely that similar arrangements may be available in every setting. <emph>Fifth</emph>, it is unsure whether the study outcomes measured immediately after the intervention will sustain over time. <emph>Finally</emph>, facilitators in the pilot included teachers and a psychologist, who though not specialists in developmental disabilities, possessed training and experience working with children with diverse capabilities. It is yet to be known if lay-community workers without prior expertise, knowledge, or skills can be trained to deliver the intervention at scale in real-world settings effectively. A comprehensive implementation of the WHO-CST program in the community will thereby require consideration of factors like the feasibility of training multiple and diverse facilitators, financial costs, logistics of recruiting participants, and provision of organizational support to facilitators in integrating the WHO-CST alongside other key responsibilities (Murray et al., [<reflink idref="bib33" id="ref84">33</reflink>]).</p> <p>Despite these limitations, our study offers several advantages. First, it expands extant literature about the feasibility of delivering parent-mediated interventions by non-specialist workers in LMICs by highlighting demand, acceptability, and promising caregiver and child outcomes of the WHO-CST model. Second, the real-world settings of the study and qualitative inquiry enabled insights into the strengths and challenges that will influence future scaling up. Finally, findings from this research are likely to be generalizable to similar socio-cultural contexts.</p> <hd id="AN0162852012-51">Conclusion</hd> <p>The pilot study demonstrates that the WHO-CST program is acceptable and feasible as a brief, diagnosis-agnostic, low-dose parent-mediated intervention in an urban Indian setting when adapted to our context. In addition, it was associated with improved child developmental outcomes, especially social communication, and adaptive behaviors, and enabled caregiver agency and decreased stress. These outcomes are especially heartening given those non-specialist providers with relatively brief training delivered the program. Finally, we hope that our study results will encourage researchers in similar socio-cultural settings in other LMICs to conduct future feasibility trials, thus paving the way to successfully implementing the WHO-CST and bridging the treatment gap for children with developmental disabilities.</p> <hd id="AN0162852012-52">Acknowledgments</hd> <p>The authors would like to gratefully acknowledge Azim Premji Philanthropy Institute (APPI), Autism Speaks, Andy Shih and Cecilia Montiel-Nava for supporting the adaptation, MT training and field-testing of the WHO-CST in India. We gratefully acknowledge the invaluable contribution of Gopika Kapoor, Aakankshi Jhaveri, Cristabelle Mascarenhas, Ojaswita Khaparde, Shilpa Taula &amp; Praphul Sudarshan during adaptation and field-testing, Lakshmi Ananthanarayanan for conducting the FGDs, and all the families and children who participated.</p> <hd id="AN0162852012-53">Author Contributions</hd> <p>KS conceived, designed, supervised and drafted the manuscript of the study, part of the WHO CST initiative led by CS. LP, ES, SS, FB and CS contributed to the development of the CST program materials and field-testing materials. SG and HS contributed equally to study design, field-testing, data acquisition, analysis and interpretation, drafting and critical review of manuscript. PD contributed to data analysis and interpretation and critical review of the manuscript; DS, SM, AD and OD contributed to study execution, acquisition of data, and drafting of the manuscript.</p> <hd id="AN0162852012-54">Funding</hd> <p>This work was made possible due to a Corporate Social Responsibility (CSR) grant from Azim Premji Philanthropy Institute (APPI).</p> <hd id="AN0162852012-55">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0162852012-56"> <title> References </title> <blist> <bibl id="bib1" idref="ref22" type="bt">1</bibl> <bibtext> Abidin, R. R. (1995). Manual for the parenting stress index. Odessa-Psychological Assessment Resources</bibtext> </blist> <blist> <bibl id="bib2" idref="ref23" type="bt">2</bibl> <bibtext> Akkuş B, Postmes T, Stroebe K. Community collectivism: A social dynamic approach to conceptualizing culture. 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| Items | – Name: Title Label: Title Group: Ti Data: World Health Organisation-Caregiver Skills Training (WHO-CST) Program: Feasibility of Delivery by Non-Specialist Providers in Real-World Urban Settings in India – Name: Language Label: Language Group: Lang Data: English – Name: Author Label: Authors Group: Au Data: <searchLink fieldCode="AR" term="%22Sengupta%2C+Koyeli%22">Sengupta, Koyeli</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-7497-6079">0000-0002-7497-6079</externalLink>)<br /><searchLink fieldCode="AR" term="%22Shah%2C+Henal%22">Shah, Henal</searchLink><br /><searchLink fieldCode="AR" term="%22Ghosh%2C+Subharati%22">Ghosh, Subharati</searchLink><br /><searchLink fieldCode="AR" term="%22Sanghvi%2C+Disha%22">Sanghvi, Disha</searchLink><br /><searchLink fieldCode="AR" term="%22Mahadik%2C+Sanchita%22">Mahadik, Sanchita</searchLink><br /><searchLink fieldCode="AR" term="%22Dani%2C+Allauki%22">Dani, Allauki</searchLink><br /><searchLink fieldCode="AR" term="%22Deshmukh%2C+Oshin%22">Deshmukh, Oshin</searchLink><br /><searchLink fieldCode="AR" term="%22Pacione%2C+Laura%22">Pacione, Laura</searchLink><br /><searchLink fieldCode="AR" term="%22Dixon%2C+Pamela%22">Dixon, Pamela</searchLink><br /><searchLink fieldCode="AR" term="%22Salomone%2C+Erica%22">Salomone, Erica</searchLink><br /><searchLink fieldCode="AR" term="%22Servili%2C+Chiara%22">Servili, Chiara</searchLink> – Name: TitleSource Label: Source Group: Src Data: <searchLink fieldCode="SO" term="%22Journal+of+Autism+and+Developmental+Disorders%22"><i>Journal of Autism and Developmental Disorders</i></searchLink>. Apr 2023 53(4):1444-1461. – Name: Avail Label: Availability Group: Avail Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/ – Name: PeerReviewed Label: Peer Reviewed Group: SrcInfo Data: Y – Name: Pages Label: Page Count Group: Src Data: 18 – Name: DatePubCY Label: Publication Date Group: Date Data: 2023 – Name: TypeDocument Label: Document Type Group: TypDoc Data: Journal Articles<br />Reports - Research – Name: Subject Label: Descriptors Group: Su Data: <searchLink fieldCode="DE" term="%22International+Organizations%22">International Organizations</searchLink><br /><searchLink fieldCode="DE" term="%22Caregiver+Training%22">Caregiver Training</searchLink><br /><searchLink fieldCode="DE" term="%22Early+Intervention%22">Early Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Urban+Areas%22">Urban Areas</searchLink><br /><searchLink fieldCode="DE" term="%22Foreign+Countries%22">Foreign Countries</searchLink><br /><searchLink fieldCode="DE" term="%22Pilot+Projects%22">Pilot Projects</searchLink><br /><searchLink fieldCode="DE" term="%22Lay+People%22">Lay People</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Evaluation%22">Program Evaluation</searchLink><br /><searchLink fieldCode="DE" term="%22Young+Children%22">Young Children</searchLink><br /><searchLink fieldCode="DE" term="%22Communication+Problems%22">Communication Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Fidelity%22">Fidelity</searchLink><br /><searchLink fieldCode="DE" term="%22Feasibility+Studies%22">Feasibility Studies</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Stress+Management%22">Stress Management</searchLink><br /><searchLink fieldCode="DE" term="%22Child+Development%22">Child Development</searchLink><br /><searchLink fieldCode="DE" term="%22Interpersonal+Competence%22">Interpersonal Competence</searchLink> – Name: Subject Label: Geographic Terms Group: Su Data: <searchLink fieldCode="DE" term="%22India%22">India</searchLink> – Name: DOI Label: DOI Group: ID Data: 10.1007/s10803-021-05367-0 – Name: ISSN Label: ISSN Group: ISSN Data: 0162-3257<br />1573-3432 – Name: Abstract Label: Abstract Group: Ab Data: The World Health Organization-Caregiver Skills Training Program, a parent-mediated early intervention facilitated by non-specialist providers piloted in urban India was evaluated using mixed-methods for feasibility and effects on child and caregiver outcomes. Caregivers (n = 22) of children (2-9 years) with social-communication delays participated in a single-group pre-post study. High rates of caregiver attendance, improved caregiver fidelity, and facilitator competency suggested program feasibility. Caregivers voiced acceptability of various intervention-components. The intervention was associated with improved caregiver-reported skills and knowledge (p < 0.00), reduction in stress (p = 0.03), improved child developmental outcomes on communication and social interaction (p < 0.00), and adaptive behaviors (p < 0.00). Challenges about logistics and availability of time were highlighted. Implications of results in resource-poor settings and recommendations for future feasibility trials are discussed. [The WHO-CST Team contributed to the writing of this article.] – Name: AbstractInfo Label: Abstractor Group: Ab Data: As Provided – Name: DateEntry Label: Entry Date Group: Date Data: 2023 – Name: AN Label: Accession Number Group: ID Data: EJ1372102 |
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| RecordInfo | BibRecord: BibEntity: Identifiers: – Type: doi Value: 10.1007/s10803-021-05367-0 Languages: – Text: English PhysicalDescription: Pagination: PageCount: 18 StartPage: 1444 Subjects: – SubjectFull: International Organizations Type: general – SubjectFull: Caregiver Training Type: general – SubjectFull: Early Intervention Type: general – SubjectFull: Urban Areas Type: general – SubjectFull: Foreign Countries Type: general – SubjectFull: Pilot Projects Type: general – SubjectFull: Lay People Type: general – SubjectFull: Program Evaluation Type: general – SubjectFull: Young Children Type: general – SubjectFull: Communication Problems Type: general – SubjectFull: Fidelity Type: general – SubjectFull: Feasibility Studies Type: general – SubjectFull: Intervention Type: general – SubjectFull: Stress Management Type: general – SubjectFull: Child Development Type: general – SubjectFull: Interpersonal Competence Type: general – SubjectFull: India Type: general Titles: – TitleFull: World Health Organisation-Caregiver Skills Training (WHO-CST) Program: Feasibility of Delivery by Non-Specialist Providers in Real-World Urban Settings in India Type: main BibRelationships: HasContributorRelationships: – PersonEntity: Name: NameFull: Sengupta, Koyeli – PersonEntity: Name: NameFull: Shah, Henal – PersonEntity: Name: NameFull: Ghosh, Subharati – PersonEntity: Name: NameFull: Sanghvi, Disha – PersonEntity: Name: NameFull: Mahadik, Sanchita – PersonEntity: Name: NameFull: Dani, Allauki – PersonEntity: Name: NameFull: Deshmukh, Oshin – PersonEntity: Name: NameFull: Pacione, Laura – PersonEntity: Name: NameFull: Dixon, Pamela – PersonEntity: Name: NameFull: Salomone, Erica – PersonEntity: Name: NameFull: Servili, Chiara IsPartOfRelationships: – BibEntity: Dates: – D: 01 M: 04 Type: published Y: 2023 Identifiers: – Type: issn-print Value: 0162-3257 – Type: issn-electronic Value: 1573-3432 Numbering: – Type: volume Value: 53 – Type: issue Value: 4 Titles: – TitleFull: Journal of Autism and Developmental Disorders Type: main |
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