Pre-Testing the Who Caregiver Skills Training Programme for Implementation in Urban and Rural Ethiopia

Background: The World Health Organization (WHO)’s Caregiver Skills Training Programme (CST) aims to teach caregivers of children with developmental disorders (DD) strategies to help them support their child’s development and learning. The programme, delivered over nine group sessions and three home visits, is developed to suit low-resource settings. We recently adapted the programme for implementation in Ethiopia (Tekola et al., 2018), characterised by limited autism awareness, high levels of stigma and a severe lack of service provision (Tekola et al., 2016; Tilahun et al., 2016).

Objectives: Pre-test the adapted CST programme in an urban clinical setting and a rural community setting, and explore the perspectives of participating caregivers, CST facilitators and supervisors.

Methods: The programme was pre-tested in: i) one group (n=10) in Addis Ababa, delivered by a specialist CST facilitator; ii) two groups (n=20) in rural Butajira, delivered by non-specialist facilitators under supervision of two specialists. Feasibility and acceptability data were collected, including enrolment and attendance rates and programme fidelity ratings. In-depth interviews were conducted with participating caregivers (n=9 in both settings), CST facilitators (n=3 in Addis Ababa, n=2 in Butajira), and CST observers (n=2 in Addis Ababa); a focus group discussion was held with six trainee facilitators in Butajira. Qualitative data were analysed using thematic analysis.

Results: Both pre-pilots had excellent participation (100% in both locations) and retention rates (90% in Addis Ababa, 100% in Butajira). Participating families completed at least 7/9 group sessions and all home visits. All essential CST training elements were fully or mostly completed. The competencies of the specialist facilitator as rated using the ENACT scale (Kohrt et al., 2015) were higher than those of non-specialist facilitators. Four themes were developed from the qualitative data: 1) Programme acceptability and relevance: Caregivers indicated the programme was highly relevant to their needs. CST facilitators and observers commented on the eagerness of caregivers to attend the training, reflected in high attendance rates and in caregivers arriving at sessions on time. 2) Perceived programme benefits: Caregivers described how the programme helped promote their child’s communication and self-help skills and in managing their child’s challenging behaviours. Caregivers also indicated the programme improved their own wellbeing and helped them to manage their stress. 3) Challenges and barriers: Caregivers raised that travel and finding childcare were barriers to attending sessions. Facilitators highlighted the long preparation time needed to deliver the group sessions well, especially the role play demonstration activities. Another challenge was the variation in caregivers’ level of understanding and education and making sure the caregivers with little education understood all strategies and tips presented in the CST. 4) Suggested revisions: Some suggestions were offered to simplify the materials, including simpler Amharic translations for some key terms and simplifying the role play activities.

Conclusions: The CST programme is highly acceptable to Ethiopian caregivers. It is feasible to deliver the programme in both urban and rural settings. Before the programme can be fully implemented in low-resource settings, further research needs to determine what constitutes ‘good enough’ fidelity for non-specialist CST facilitators.