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– by Susan Walker
© Jessie North
Toddlers learn a lot when caregivers show and explain things – and eveyone involved enjoys it.
Approximately 250 million children in low- or middle-income countries – 43 % of the world’s under-five-year old population – do not develop according to their full potential because of poverty and associated disadvantages. Early childhood is a critical period for development. Inadequate nutrition hampers physical growth, and early experiences can have long-term effects on brain functions, cognitive ability and behaviour. Children who miss out on appropriate early experiences are at a disadvantage when they go to primary school. For example, they are likely to make slow progress and are at risk of lower educational attainment. That has further impacts on adult cognition, behaviour and incomes. The poverty cycle is not broken.
Promoting development among children in the early years requires nurturing care with attention to nutrition, health, safety and security. Children need quality interactions with caregivers who provide them with varied learning experiences.
Usually, the family is the main provider of care for children under the age of three. Working with parents to build their care-giving abilities boosts children’s learning and behaviour. Policies and programmes that support disadvantaged parents’ capacity to provide nurturing care contribute to providing children with a good foundation in early childhood. They add up to a critical strategy to promote equity.
Two specific ways to enhance the capacity of parents to provide stimulation and quality interaction were developed in the Caribbean. They are called “Reach up: An Early Childhood Parenting Programme” and “What You Do with Baby Matters”. Both interventions are designed to be feasible in low-resource settings and focus on empowering parents to be better parents.
Reach Up is based on the Jamaica Home Visit (JHV) programme which was designed in the 1970s and 80s by Sally Grantham-McGregor, a prominent British child-development scholar. It was originally devised to boost the development of malnourished children and was shown to benefit stunted children, children with low birth weight and children in general. The JHV programme has also been implemented and evaluated in other countries such as Bangladesh, Colombia and Peru. It is delivered by community workers and can be delivered along with health services.
The JHV comprises weekly home visits by community health workers (CHW) who are trained to conduct play sessions with mother and child. The main goal is to increase mothers’ ability to promote development through play. The visits are interactive, involving CHW, mother and child. The play session use games, homemade toys, songs and language activities. Mother-child interaction is emphasised, the visits are fun, and both mother and child get praise. The CHW builds a supportive relationship with the mother and encourages her to make this kind of play part of her daily routines. Toys are left with the family and exchanged at the next visit.
Even though evaluations have shown that this kind of evidence-based parenting intervention is effective, scale-up has been limited. One reason is that civil-society organisations and government agencies lack the skills needed to implement them. To address this gap, the Child Development Research Group at the University of the West Indies developed the Reach Up Early Childhood Parenting Programme in cooperation with international partners and funded by Grand Challenges Canada, a government-funded health initiative.
Reach Up materials comprise a curriculum, manuals for training CHWs and supervisors, films, a toy-making manual and a guide on adaptation and implementation. The films facilitate training of CHWs by illustrating the key steps in a home visit and highlighting particular activities and techniques. Films were produced in collaboration with Development Media International, UK, with filming done in Jamaica, Peru and Bangladesh. The films are available in English, Spanish, French and Bengali.
The training manual includes objectives and activities for each session. Training is interactive with brainstorming sessions and small-group practice. The curriculum is designed to be used by persons with a minimum of complete primary-level education.
To further improve the package, the Reach Up team is now working with colleagues in Brazil, Zimbabwe and Guatemala. The goal is to better understand implementation challenges so better support can be offered. Reach Up is adaptable. The training can be delivered either weekly or fortnightly and is being used in Asia, Africa and Latin America.
What You Do with Baby Matters
In much of the Caribbean, government-run primary health centres include free child-health clinics which are staffed by nurses and CHWs. Children are brought here for check-ups and immunisation five times from the ages of three to 18 months. What You Do with Baby Matters was developed to use time parents spend waiting at the centres. It was implemented and evaluated in Antigua, Jamaica and St. Lucia with the support of the Inter-American Development Bank.
The CHWs who measure the infants’ growth at the clinics were asked to deliver the programme to parents in the clinic waiting area. CHW training was done in a similar way as in the Reach Up programme. Workshops were held, content and methods were discussed and small-group practice was done. The CHWs were given a manual with guidelines, and nurses also received training so they could ensure the parenting sessions took place. The programme was supervised by a team from the University of the West Indies.
Short films were shown in the clinic waiting areas. They showed mothers practising the behaviours that need to be encouraged. Nine films of approximately three minutes each were produced in Jamaica with five mother-child pairs. Three films with different topics were shown at every session during a clinic visit. Afterwards, the CHW discussed the films with the mothers, demonstrated specific behaviours and activities and encouraged parents to try the activities with their babies. The CHWs also demonstrated how to make simple toys from household materials.
At each visit, nurses gave the mothers message cards with simple language and pictures that reinforced the topics of the films. They reviewed the cards with the mothers and encouraged them to do the activities. The nurses gave parents a simple picture book when children were aged nine to 12 months and a puzzle and some building blocks at age 18 months.
Mothers and CHWs valued the programme and felt the children benefited. Mothers said they showed more love and talked and played more with their baby. “I didn’t use to play with her before,” one mother said. “Since I got to know the programme, I sit with her, and I sing and play with her.” They also talked about how they felt their child gained from the programme and was learning more.
The CHWs themselves felt they benefited too. One CHW said: “I feel so proud of myself knowing that I can stand up and ask them and get persons to answer. It is so good when you can talk to persons. I feel wonderful doing it.”
The evaluation showed parents gained knowledge of how to support their child’s development. Children who attended clinics with the programme gained in cognitive development compared with children attending clinics that only offered the usual services. This group intervention provides another approach to increasing parents’ ability to promote their children’s development that is feasible in the Caribbean and other low- and middle-income countries.
Susan Walker is director of the University of the West Indies’ Caribbean Institute for Health Research. She lives in Kingston, Jamaica, and was co-author of the “What You Do with Baby Matters” manual.
What You Do with Baby Matters (available in English and Spanish):
Grand Challenges Canada: