The case study has been reported following the Standards for Reporting Implementation Studies (StaRI) checklist (20) (please see additional file).
Parent volunteer (provider) participation and characteristics
Out of 62 trained providers, 36 delivered the program to caregivers in local villages. Twenty-six providers were not able to deliver the program due to health problems (n=7); competing family commitments (n=7); having to work (n=6) or not achieving competency (n=6).
The mean age of the 36 participating providers was 35 (±4.38) years. For 61% of the providers, education level was 10 years (Table 3). All 36 providers were females (95% mothers and 5% paternal aunts) with the mean age of 39 years (±4.38). 81% of them were not currently employed and 70% were living in nuclear family system.
Parent (consumer) participation and characteristics
Out of 326 potential parent-child dyads in 15 Union Council, 270 parents of children with development disorders who met the eligibility criteria were enrolled in the study (see Figure 3 for the eligibility criteria and flow of the participants through study). Out of 270 caregivers enrolled 85% (230/270) of the trial participants attended 6 sessions (±1) and only 166 caregivers participated in the implementation evaluation. The mean age of the consumers was 35 (±7.6) years. Half of the consumers had less than 5 years of education or no education (50%, 83/166).
Provider delivery of the program
A total of 504 sessions of the program were delivered by 36 providers in 79 groups within the duration of 6-months. The average group size was 6 (range 5 to 7). 85% (230 /270) of the consumers attended 6 sessions (range between 5 to 7). Average duration of a group session was 102 minutes (±15). The average group size was 6 (range 3 to 7).
Cascading supervision sessions with providers
Over the period of 6-months, 10 program trainers organised 30 group supervision meetings of providers. The average attendance in the group supervision was 75%. In turn, providers conducted 178 group supervision sessions with consumers after initial training of 9 sessions. The attendance in these supervision sessions was 73%.
Fidelity of the program:
To assess the fidelity of the program, 20% of the sessions (103/504) spread over 36 providers were rated at three time-points (between program session 1-3, 4-6 and 7-9). The Cronbach’s alpha reliability of the adapted version of ENACT for all three-time points ranged between 0.70 to 0.93. The intervention sessions were delivered with good fidelity as all providers scored on an average 2.5 or more (mean [SD], 2.97±.21) out of 4 on all items of the adapted ENACT at the three time-points.
The primary clinical outcome of interest was change in child’s functioning at 6-months post intervention implementation. The results of the overall trial have been published elsewhere (7).
Acceptability, feasibility, appropriateness and reach of the program at-scale:
The data on implementation outcomes was collected from 166 consumers, 36 providers and 14 members of the program team including program trainers (Table 4).
Acceptability of the program:
Caregivers (n=166) indicated that the program was highly acceptable to them (mean scores of acceptability domain, 39.49 ±5.92). They reported high satisfaction on receiving the program training from a ‘family volunteer’ (item response ‘a lot’ 2.77±.47) as she was perceived to be a someone who listens, understands and addresses their questions or concerns about their child and program (2.74±.49) and takes interest in their concerns and problems (2.75±.49). Family volunteers were able to earn the trust of the caregivers of children with developmental disorders (2.77±.46) as she was perceived qualified enough to deliver the program (2.77±.45).
The program was perceived as highly acceptable by the providers (n=36) (mean scores of acceptability domain, 34.2±3.01). They not only liked the program materials (3.90±.31), but they also felt good while delivering the program to the families (3.70±.67). They felt the program was an appropriate intervention (3.90±.31); moreover, the skills they learnt while delivering the program were perceived to be useful for the families (3.90±.31). They were also satisfied with the amount of the training (3.90±.31) and supervision (3.60±.51) they received by the program trainers.
The program acceptability at organization level was very high (17.79±2.45). The organisers felt that delivery of the program was a source of contentment for the program team and trainers. It was not only helpful and beneficial for the reputation of the organization; but it could also create more opportunities of service delivery for the organization.
Feasibility of the program:
The caregivers perceived that participating in the parent skills training program was feasible for them (31.29±4.76). However, they reported challenges in taking time-out of their daily routine to attend weekly training sessions (1.86±.90); in managing household responsibilities; in implementing program strategies at home by themselves (2.15±.82) and in finding childcare for their other children during the time they were attending the session (2.09±1.03). Caregivers reported that community members did talk negative about the families seeking program services for their children (1.80±.75).
The program was very feasible for providers to deliver (domain score 49.7±5.73). The item wise analysis showed that they felt skilled enough to deliver the program (3.80±.422) and had appropriate time to implement all the activities of the program (3.40±.84) including organizing group; providing training and peer supervision to caregivers in their villages and continuously monitoring child’s progress during program implementation.
The program trainers perceived that implementing the parent skills training program was feasible for the organization (42.29±5.44). According to them, the organization had sufficient resources including a sufficient pool of trainers (3.86±0.53), sufficient finances (2.75±0.75), an adequate transportation system (3.57±0.75) and the necessary equipment (3.86±.36) to train non-specialists and implement the program in the study settings. Moreover, program trainers also mentioned that they received adequate administrative support (3.62±0.65) and clinical supervision (3.77±0.43) to provide supervision and support to the providers.
Appropriateness of the program:
As the intervention content was adapted into a training application with ‘real-life’ narratives (10) both the consumers and providers rated the program as highly appropriate and in keeping with the local traditions and cultural values (the mean score of consumers on the appropriateness domain was 24.62±4.17 and 31.8±4.62 for providers). The consumers perceived that the program was a good way to address their and their child’s problems (2.43±.71). The program strategies they learned helped them to deal with their worries (2.46±.63) and solve their problems related to their children (2.49±.78). The consumers agreed that these strategies would also be useful to other caregivers of their community who have similar problems (2.43±.66). However, attending group training sessions would be inconvenient for these caregivers due to their household responsibilities (1.72±.89).
Providers reported that they were satisfied with their role as a provider of the program and they will keep implementing the program to the families (3.50±.85) in their villages under the supervision of the trainers (3.20±1.1). They appreciated the idea of implementing the program through non-specialist, family volunteers; however, ‘difficulties in seeking permission from their own family to deliver program in the community and competing demands on time due to household responsibilities’ were identified as potential barriers to continue to implement the program through family volunteers.
The program trainers perceived that the program was highly appropriate to the needs and cultural values of the consumers (mean scores of the domain, 36.43±4.16). According to the program trainers, as the program content was designed to meet the needs of the consumers, it was likely to be useful to manage problems of children with developmental disorders and their caregivers. They perceived that the delivery of the program to the families of children with developmental disorders in the study area was aligned with the core values and goals of their organization and implementing this program was a priority for leaders at their organization.
Reach of the program:
Both the program trainers and providers perceived that the reach of the program was high (mean scores of reach domain for program trainers and providers were 11.07±2.84 and 10.6±2.01 respectively). The item level analysis indicated that according to the providers, the community members were fully aware that program was being delivered in the community by the family volunteers (3.50±0.70). They also perceived that all those caregivers in their community who might be in need of a parent skills training program, specifically parents from low socio-economic status, would still find this program useful and attend the training (2.40±0.69). However, according to the consumers the reach of the program was comparatively low (6.99±1.98).
We also calculated the reach of the program using RE-AIM indices. We successfully established 36 potentially self-sustaining village based ‘Family Networks’ led by 36 trained providers working under supervision of trainers from the local nongovernmental organization. The target population for the program was 270 caregivers and their children who met the eligibility criteria and were enrolled in the program. Out of 270 participants, 85% (230/270) of the population received the program training by 36 providers using the technology platform.
Most of the respondents in the qualitative study reported that the program content addressed the problems of children with developmental disorders and caregivers’ concerns that they faced in taking care of their child (see Table 5 for themes and relevant quotes). The use of a training application hosted on the tablet was appreciated by the respondents. The participants also mentioned that program illustrations (personas, scenarios and sittings) were quite reflective of their surrounding environment, people and cultural norms and helped them to effectively learn program strategies. The qualitative data analysis indicated that family support from their own family was identified as an important factor in caregivers’ involvement with the program. However, the engagement of providers with the program relied, in turn, on support they received from their own family members in delivering the program. Moreover, the household responsibilities such as looking after the children and domestic animals and working in the fields got in participants’ way to attend the program sessions. For both the providers and consumers there was reliance on their own family members to cover other household responsibilities so that they had time to participate in the program sessions.
Both providers and consumers expressed their satisfaction over the duration of the sessions and suggested to schedule the sessions a week apart so that consumers are able to attend the sessions conveniently. The respondents expressed their satisfaction on organizing the trainings at basic health units (located within their respective villages) or at the house of providers. Intervention delivery in village-based groups was regarded as an acceptable format of parent skills training by a number of respondents. According to participants, sitting together as a group served as a learning platform for them in which they could share their problems with each other. The respondents expressed that having a session in a group helped them to validate and normalize their feelings about their child’s health condition; additionally, they helped to learn from each other through this experience.