Design and setting
A cross-sectional survey was conducted in the paediatric inpatient ward for acute care at the Aga Khan University Hospital, Karachi, Pakistan. The tertiary care teaching hospital has over 700 beds and caters to diverse ethnic and religious groups from at least 3 of 4 provinces in the country. Nationally there is limited focus on play and stimulation practices in childcare and health, with little to no training for healthcare professionals or parents on engaging with sick or typically developing children under 5 years of age [27].
Sample and sampling strategy
Data was collected between October and December 2019. The inclusion criteria were children admitted between the age range of 15 days (0 months) and 6 years, with a hospital stay of minimum 24 hours, admission in the special care unit (SCU), general ward, semi-private ward, and/or a private ward. A population sampling strategy was employed. The study was approved as an exemption and the need for informed consent was waived (as a QI project) by the Ethics Research Committee of the Aga Khan University (AKU). Eligible families were approached for participation by one of 4 departmental research assistants (Psychology graduates). Data was collected on paper-based forms. No refusals were reported by the data collection team.
Tools and materials
Parents were interviewed using a structured questionnaire, with questions based on demographic details such as parental level of education, area of residence, and primary language spoken at home. The child’s length of stay at the hospital was obtained from the patient’s hospital records.
The Caregiver Knowledge of Child Development Inventory (CKCDI) was used to assess maternal knowledge of milestones [29]. The Cronbach’s alpha for the tool was 0.88. A total score of 20 was possible on the scale.
To measure child health status, an item from the Child Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) was used [30]. This indicator has shown to be valid in other studies [31, 32]. Parents were asked to report their child’s general health (not just the hospitalization episode) on a 5-point scale: excellent, very good, good, fair or poor.
Maternal and paternal caregiving practices were measured using a key item from the ECD module of the UNICEF Multiple Indicator Cluster Surveys [33] (In the past 3 days, did you or any household member over 15 years of age engage in any of the following activities with your child: read books or looked at pictures together, told stories, sang songs, took child outside of the home compound, play with child, named or counted or drew things to or with child?). The scale has been previously used in a responsive stimulation intervention study in Pakistan [34]. Where fathers were not available for an interview, mothers reported the paternal practices.
Data Analysis
Data was analysed for descriptive and inferential statistics in Stata v16.0. Continuous variables included the child’s length of stay at the hospital and maternal knowledge of childhood developmental milestones. Categorical variables included child age (6-month intervals from 0 to 5 years of age), gender (male or female), disease group (department of admission: general paediatrics, cardiology, neurology, NICU or surgery), health status (excellent, very good, good, fair, poor), level of maternal education and the level of parental engagement (high – 4 or more activities daily; or low – 3 or fewer activities daily) based on the number of stimulation activities practised with the child (0 to 6 in the last 3 days). To examine the association between the parental and child variables with level of parental engagement, Chi-square tests were conducted.