Innovation summary

In Pakistan rates of depression particularly in women are high, as well as other risks to the growth and development of young children and child mortality.  Numerous studies provide compelling evidence that maternal depression not only effects mothers health but is also associated with long term emotional, cognitive and behavioural problems in children.  Depressed mothers are often unable to provide care necessary for the optimum growth of their children during the first 3-years of life, a critical period for child development.

The aim of the project was to test the efficacy of Learning through Play (LTP) Plus program in low resource settings. The LTP research-based activities enhance children’s development while simultaneously promoting attachment security through building parents’ ability to read and be sensitive to their children’s cues and through active involvement in their children’s development. The Thinking Healthy Program (THP) adopts ‘here and now’ problem-solving approach, THP uses cognitive behaviour therapy (CBT) techniques of active listening, changing negative thinking, and collaboration with the family.

Impact summary

  • 1074 patients were screened by Edinburgh Postnatal Depression Scale (EPDS) and diagnosis was confirmed by Clinical Interview Schedule Revised (CISR). In this cluster RCT 402 mothers received the intervention and 372 were in routine care
  • EPDS scores, PHQ scores and EQ-5D scores reduced significantly at post intervention (three months from baseline) among mothers in the intervention group as compared to routine care group
  • The project cost is 248,400 CAD over two years.  Preliminary cost effectiveness will be measured at the end of the project

" I liked the part related to children because I feel happy when my child is happy"

- Participant 6

This innovation is funded by Grand Challenges Canada. 

Innovation details

The LTP Plus program is a 12-session group intervention that integrates two evidence based, culturally relevant interventions: Learning Through Play (LTP) and the Thinking Healthy Programme (THP).

The ‘Learning through Play programme is intended to stimulate early child development. The central feature of the programme is a pictorial calendar devised for parents, depicting eight successive stages of child development from birth to 3 years, with illustrations of parent-child play and other activities that promote parental involvement, learning, and attachment. In each stage, five key areas of child development are depicted: sense of self, physical, relationships, understanding, and communication. Information about each area is written in simple, low-literacy language, with accompanying pictures that act as visual cues.

The programme can be carried out by a variety of non-specialist staff (e.g., health workers, day care workers, lay home visitors) after appropriate training. The programme can be delivered in a variety of formats with individual parents or groups of parents. The ‘Learning Through Play’ calendar is a relatively inexpensive and simple tool that relies minimally on the literacy of the parents.

Thinking Healthy Programme: The intervention Thinking Healthy Program adopts ‘here and now’ problem-solving approach. It uses cognitive behaviour therapy techniques of active listening, changing negative thinking, collaboration with the family, guided discovery (i.e., style of questioning to both gently probe for family’s health beliefs and to stimulate alternative ideas), and homework (i.e. trying things out between sessions, putting what has been learned into practice), while educating them about depression symptoms, correlates and management, social support and in practical advice on using healthcare. So this two-pronged psychosocial intervention will help mothers to cope up with their depression and provide the information and strategies that they need to foster their children’s health and development.

The LTP Plus program will be delivered over a three months period weekly. Each session will range from 60-90 minutes after the baseline assessment.

Key drivers

The sessions were conducted in local language (Sindhi/Urdu/Pushto). Stakeholders and community elders engagement was crucial for the success of the project.

  • This project is designed for a low resource setting. Only those activities were included which could be integrated into existing primary and mental health care services and which were sustainable after completion of the project.
  • All the interventions were empirically based and culturally relevant. The Lancet commission report (Napier et al, 2014) suggests that neglecting culture is one of the biggest barriers in improving the standards of health care and addressing culture may not only improve quality of life but will also save costs.
  • The pictorial information in the LTP calendar on healthy growth and development of child relied minimally on literacy of parents.
  • The programme can be delivered by non-specialist staff e.g. community health workers and health visitors after appropriate training.
  • Strong engagement between the facilitators and the participants kept the sessions going. Attendance at the sessions remained high. Transport was provided to the participants.


Terrorist attacks

The biggest difficulty was the very uncertain law and order situation with multiple terrorist attacks and death of thousands of people in Karachi during the period of the study. We had developed security policies in close partnership with the research site community to ensure safety of the research team and the participants. Despite being very careful, the research team was stopped at gun point on two occasions but fortunately no one was hurt.

Heat wave

During the study period there was a very severe heat wave in Karachi which killed more than a 1000 people in the city. It was quite challenging for team members to carry out the fieldwork and travel in a transport with no cooling system. Some of our team members were affected and were granted leave and we had to stop our field work for a couple of days.

Data collection

We have collected a lot of quantitative and qualitative data as part of the project. Though we have a data manager who manages the data, but most of the data entry is completed by all research team members which does require a lot of their time besides collecting data from the field, assigning ID codes to the forms and do the scoring. We have learnt that in future we will be hiring more data entry staff that can focus on data entry and data cleaning from the very beginning.


Another challenge faced was the loss of anticipated funded amount due to change in conversion rate. We had to cut down our cost in many areas, PILL stepped in to address the short fall of the project to full fill the commitments made during the project.

Child care

Child care arrangements were in place at the venue and all participants came to one home to attend the session. Another challenge was the conservative environment of the community, where female participants were often not allowed to go out of home. So, community health workers of each village who command a lot of respect from the community talked to the male members of the family and convinced them to allow their women to attend the sessions.


The plan is to scale up the intervention from the one Gadap town to across all 18 towns of Karachi (population 22 million). The addition of towns across Karachi will allow us to recruit much larger number of participants needed for us to properly answer the question of whether the LTP plus group intervention is clinically effective to improve mother and child outcomes and is value for money. It will also mean that we will be including a range of communities in the study to better reflect the diverse population in Karachi and potentially Pakistan. We aim to recruit sufficient number of depressed mothers into the study to allow us to determine whether the LTP Plus approach is effective in terms of helping women recover from depression and improve child outcomes. We will also look into important areas such as the impact of the innovation on anxiety and ability to live confidently, to help women improve their self-esteem and self-confidence.

Evaluation methods

Participants who completed the intervention were assessed after the completion of intervention (3 months) and then at 6 months on following outcome measures.

 Following measures were used for assessment;

  • Patient Health Questionnaire (PHQ) to assess reduction in severity of depression
  • Generalized Anxiety Disorder (GAD) 7 to assess reduction in severity of anxiety
  • World Health Organisation Quality of Life scale and EQ-5D to measure improvement in health related quality of life
  • Ages and Stages Questionnaire (ASQ) to assess child’s development in areas of communication, gross motor, fine motor, problem solving and personal-social at different time points
  • Knowledge of Expectation and Child Development to assess maternal knowledge and expectations for child development in the first three years.
  • Maternal Attachment Inventory (MAI) to assess level of mother’s attachment with the child.
  • Eyberg Child Behaviour Inventory (ECBI) to assess intensity of child’s behavioural problems.
  • Parenting stress index to assess reduction in parenting stress
  • Home Observation for Measurement of the Environment (HOME)was used for the assessment of environment in which the child is reared
  • Multidimentional Scale of Perceived Social Support (MSPSS) to assess level of social support
  • Focus groups were conducted with the participants to ask their feedback about intervention sessions.

Cost of implementation

The project cost is 248,400 CAD over two years.  Preliminary cost effectiveness will be measured at the end of the project.

We have not analysed the health economics but some of the preliminary results show that the number of visits to doctor among the LTP plus group reduced compared to the routine care group at the end of the intervention. The expenditure on health care for the LTP Plus group was less compared to the routine care group at the end of the intervention.

Impact details

A total 1074 women were screened for depression using the Edinburgh Postnatal Depression Scale (EPDS) and diagnosis was confirmed by Clinical Interview Schedule Revised (CISR). In this cluster RCT 402 mothers received the intervention and 372 were in routine care.

There was no significant difference in variables between the two groups at baseline. However, women in the intervention group showed significant improvement in depressive symptomology at the end of LTP Plus intervention compared to the routine treatment group which was sustained at 6 months.

Scores of mothers on WHOQOL and KAP scores improved significantly among mothers in the intervention group as compared to routine care group. Preliminary analysis of focus groups shows intervention to be positively received and culturally appropriate.

Expenditure on health of mother and child reduced significantly in the LTP plus group as compared to the routine care group. At the end of the intervention mothers in the LTP plus group reported higher satisfaction with their ability to perform their daily activities and their capacity for work compared to the routine care group.

Following are comments of mothers after completion of the sessions;

  • “Now I have become more confident”
  • “This is the first time someone is asking about me, about my health so thoroughly”
  • “I liked the part related to children because I feel happy when my child is happy”
  • “We shall keep on looking for other solutions”
  • “there is a change in playing and eating habits of my child…before we were not doing this”.


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