Sustainable Model of Early Intervention and Telerehabilitation for Children With Cerebral Palsy in Rural Bangladesh
Authors: Mahmudul Hassan Al Imam, Israt Jahan, Nuruzzaman Khan, Delwar Akbar, Shafiul Islam, Mohammad Muhit, Nadia Badawi, Gulam Khandaker
Journal: JAMA Pediatrics (2025)

Importance Access to early intervention and rehabilitation services among children with cerebral palsy (CP) remains limited in Bangladesh, which demands an innovative and sustainable service delivery model. Objective To evaluate the effectiveness of the Sustainable Model of Early Intervention and Telerehabilitation for Children With CP (SMART-CP) model compared with usual care in improving access to and utilization of early diagnosis, early intervention, and rehabilitation services in rural Bangladesh. Design, Setting, and Participants This was a 2-arm cluster randomized clinical trial, with 8 clusters (ie, subdistricts) randomly allocated to the intervention (SMART-CP model) or control arm. The setting was in Sirajganj, Bangladesh, and included children with CP 18 years or younger. Outcomes were measured at 0 and 12 months, and an intention-to-treat analysis was conducted. Data were analyzed from December 2023 to May 2024. Interventions The SMART-CP model comprised (1) a rural referral network involving key informants and caregiver peer groups (called mPower or mothers’ power), (2) subdistrict level SMART-CP centers, and (3) telerehabilitation services. Children in the intervention arm received weekly goal-directed therapy, mPower group meetings every 2 weeks, and monthly telerehabilitation sessions. Main Outcomes and Measures The primary outcome was whether a child with CP accessed any form of rehabilitation services, with secondary outcomes analyzed as hypothesis generating. Results Overall, 968 children with CP (mean [SD] age, 7.9 [4.9] years; 581 male [60.0%]) were enrolled, with 500 in the intervention arm and 468 in the control arm. Between baseline and endline, rehabilitation services uptake significantly increased in the intervention arm (70.2% [351 of 500] vs 99.4% [497 of 500]), compared with the control arm (63.9% [299 of 468] vs 68.2% [319 of 468]; P &amp;amp;lt;.001). Children in the intervention arm were 1.5 times more likely to access rehabilitation than the control arm. Secondary analyses suggested that the intervention arm also facilitated early CP diagnosis (mean [SD] diagnosis time, 2.0 [2.0] years vs 3.8 [3.3] years; Cohen d = −0.7) and initiation of rehabilitation (mean [SD] rehabilitation time, 1.8 [1.8] years vs 3.6 [2.4] years; Cohen d = −0.9). Additionally, higher therapy session counts (mean [SD] session counts, 23.4 [31.7] vs 4.3 [20.8]; Cohen d = 0.7), increased assistive device utilization (20.8% [104 of 500] vs 3.0% [14 of 468]; risk ratio, 0.82; 95% CI, 0.78-0.86; P &amp;amp;lt; .001), and lower out-of-pocket expenditure per month (mean [SD] expenditure, $1.5 [$1.6] vs $2.9 [$5.1]; Cohen d = −0.4) were found in the intervention arm. No significant difference in clinical outcomes and mortality rates was observed between the intervention and control groups. Conclusions and Relevance Results of this cluster randomized clinical trial reveal that the SMART-CP model improved access to and utilization of early diagnosis and intervention services for children with CP in rural Bangladesh. This model holds promise for global scalability. Trial Registration ANZCTR Trial Identifier: ACTRN12622000396729