Evidence from integrated ECD-Health interventions in low- and middle-income country contexts

Group Submission Type: Formal Panel Session

Proposal

The first five years are the most important in a child’s life. Not only is it the most critical for early nutrition and growth, but it is also during this period that the brain grows most quickly and is most responsive to the outside world (Black et al., 2016). In 2018, the WHO, UNICEF and the World Bank launched the Nurturing Care Framework to call attention to the variety of inputs required to ensure children’s holistic, healthy development (World Health Organization et al., 2018). Recent global estimates find that 75 percent (181.9 million) of 3-4-year-old children living in low- and middle-income countries are not receiving adequate nurturing care (McCoy et al., 2022). On average, 33 million 3-4-year-old children are wasted and 79.8 million are stunted. These indicators are far from achieving the Sustainable Development Goals set for young children’s nutrition, but progress toward indicators for other aspects of child development are even further behind. On average, 163.7 million children are not experiencing adequate maternal stimulation and 165.2 million experience physical punishment from caregivers. In addition, all indicators demonstrate the inequality in children’s access to nurturing care, with those from poorer families and countries less likely to receive these critical inputs than their wealthier peers.
There is an increasing amount of evidence that health and nutrition interventions can become even more effective when paired with early childhood development messages. A meta-analysis of 21 interventions in low- and middle-income countries which focused on improving nutrition and stimulation for young children, found that enhancing stimulation improved children’s cognitive development more than nutrition services on their own (0.09 standard deviation effect size for nutrition interventions, compared to 0.42 standard deviations for stimulation) (Aboud & Yousafzai, 2015). In addition, longitudinal data from Jamaica found that stunted children who received both nutrition supplements and stimulation weekly over a two year period had higher developmental scores than groups who received only one of the two interventions (Grantham-McGregor et al, 1991). Children who received the nutrition intervention alone had the weakest cognitive outcomes at the time of the study (children approx. 2-years-old), and a longitudinal analysis of children’s outcomes found no effect of the nutrition intervention on children’s cognitive development in adolescence, while the effect of stimulation was still present when the children were 17-18 years old (Walker et al., 2005). In summary, current evidence suggests that interventions combining cognitive stimulation with nutritional inputs are the most effective for supporting children to develop to their full potential, including developing the cognitive skills that will enable them to participate critically in their communities.
Integrated ECD programs are also attractive from a systematic and financial perspective. Health system integration has been identified as a key entry point for the expansion of ECD services for children living in low and middle-income countries due to the relatively broad coverage that has been achieved by health systems over the past 30 years and the existing mandate to serve young children (Black et al., 2016). However, health systems and frontline workers are often overburdened by competing initiatives from various governmental and non-governmental actors, and demands have only increased since the onset of the COVID-19 pandemic (Nores & Fernandez, 2018).
Children living in humanitarian contexts face the greatest challenges to experiencing adequate nurturing care, and funding support for these children is extremely limited. In crisis-affected areas, the established networks of care that normally protect the health, stimulation and safety of the child are disrupted, and displaced, exhausted parents are less able to provide the nurturance and care that their children need (World Health Organization et al. 2020). It is the combined effects that occur in such settings which contribute to poor outcomes for children. This makes the efficiency and effectiveness of integrated programs especially important. However, the high need across multiple sectors in humanitarian contexts presents additional challenges for quality implementation of ECD services.
This proposal is for a two-part series sharing evidence from integrated ECD-health programs implemented in low-and middle-income countries. The first panel will focus on integrated ECD programs in development settings, and the second will focus on implementation in humanitarian contexts. All papers presented in this series represent original research from organizations implementing ECD models that focus on responsive caregiving, playful parenting strategies, and positive discipline techniques. Delivery modalities range from technology-assisted messaging to home visiting, all with links to health and nutrition systems or programs.
The first panel includes three papers focused on implementation of integrated ECD programs in relatively stable low- and middle-income country contexts. The first paper presents evidence from the experience of scaling an ECD program for children aged 0-3 years into health services in Bhutan. The program began as a pilot in 2017 and is now being scaled nationally. Implementation is led by community health workers in the form of parenting groups, with some additional one-on-one counseling depending on family need. Quantitative results from two impact evaluations detail the effectiveness of the program for influencing parenting practices and child outcomes at different phases of scaling. The second paper presents results of research conducted in Uganda and Nepal related to the implementation of the “Inclusive Playful Parenting for Brighter Childhood” program for children aged 0 – 6 years. Programming in Nepal leveraged existing mothers’ groups, whereas Uganda employed a targeted home visiting model for maternal and newborn child health and nutrition in the first 1000 days, implemented by village health workers. Results from a quasi-experimental study assess the impact of different parenting packages on child and caregiver outcomes. Finally, the third paper will present a systematic review of evidence from Save the Children’s Building Brain approach, as well as a meta-analysis to evaluate its effectiveness. The model has been used in more than thirty countries, with ten impact evaluations conducted across nine countries. Results of the analyses will present results for all child and caregiver outcomes and discuss implications for the current knowledge base around the importance of investing in high-quality caregiving interventions in LMICs.

Sub Unit

• Early Childhood Development SIG

Chair

• Lauren Pisani, The Palladium Group

Individual Presentations

• From Little Things, Big Things Grow: The experience of scaling a playful parenting program through government health systems in Bhutan - Thomas Brown, Save the Children; Emily Weiss, Save The Children International; Filipa de Castro, Save the Children; Sara Dang Dang, Save the Children

• Benefits and experiences of integrating playful parenting into health and nutrition programmes: A comparative study of Uganda and Nepal - Viktorya Sargsyan, World Vision International; Ana Tenorio, World Vision International

• Improving early childhood outcomes through caregiving interventions: Effectiveness of Building Brains in seven low- and middle-income countries - Filipa de Castro, Save the Children; Emily Weiss, Save The Children International; Sara Dang Dang, Save the Children