This paper will seek to discuss aspects of adaptation, fidelity and program quality improvement, in designing and implementing successful caregiver support interventions toward holistic early childhood development (ECD) in low resource communities in Low and Middle Income Countries (LMIC). Using primarily qualitative methods, it will discuss perceptions and practices of designers, home-visitors, participating families and other community members to learn from implementing a caregiver-support intervention for holistic child development, in 200 rural families in Rajnandgaon, Chhattisgarh, India.
India has the largest number of children in the world; 60 million children under five who live in poverty and around 30 percent of the world’s poor children. Chhattisgarh, India’s ninth largest state, has over 3.6 million children between 0 to 6 years of age (Census 2011). In Rajnandgaon district of Chhattisgarh, 82.27% of the population lives in rural areas, with most people engaged in agriculture or animal husbandry. A Poverty Impact Assessment report (2011) cites that Rajnandgaon is among 9 underserved districts in Chhattisgarh which have the lowest ranking in Human Development Indicators. Only 10.1% children between 6 to 23 months in rural Rajnandgaon are known to have adequate diet and over 50% children under 5 are stunted, as per the National Family Health Survey 4 (2015-16). While child development and well-being indicators are unavailable, it is known that large numbers of young children in Rajnandgaon are exposed to the typical risks associated with poverty such as malnutrition, poor health and development.
While ECD is central to the health, well-being and life opportunities of every single child, and the SDGs have prompted action world-over on access to quality ECD services, recent research suggests that key elements and processes for implementation (and scale‐up) of ECD interventions, particularly in LMIC, are not well understood. (Banerjee et al., 2019) In this context, this paper will aim to provide insight on 1) the role of context in adaptation and implementation and 2) fidelity and program quality improvement, toward implementation research for ECD. (Britto et al., 2018)
Since 2014, two para-professionals trained by us (CLR) have been repeatedly visiting homes of approximately 200 children in 11 villages of Rajnandgaon. These para-professionals have primarily delivered content on nurturing care of young children and coached caregivers on responsive care and early learning practices during home-visits using manuals, home-made toys, and everyday resources as aids and through group-meetings. The children were enrolled in the program when they were between 0-4 years of age and are now between 4-8 years of age, most of them currently in government pre-schools or schools. Several elements of the program were purposefully designed as ‘suitable for scaling’, such as capacity of frontline worker, frequency of frontline worker – caregiver contact and design of communication content etc. To examine the extent of intervention effectiveness, two key parameters have been previously studied: a) quality of psycho-social stimulation in the home environment, using a contextualised version of the Infant – Toddler HOME inventory (Caldwell & Bradley, 1984, 2003), and b) status of holistic child development, using an integrated developmental milestones assessment tool developed by CLR to measure holistic development of children between birth to five years of age across four developmental domains. The sample included 150 families and children in control and treatment groups each. Preliminary analyses had revealed significantly better performance by the treatment group on several aspects of psychosocial stimulation in the home environment as well as on child development milestones, which has been encouraging. In terms of process, the program has over the years modified content and the practices of frontline worker – caregiver interaction, as per contextual requirements. As designers we feel it has shifted our lens from designing a ‘caregiver education program’ to a ‘caregiver capacity-building program’.
All these experiences have prompted us to document our learnings, share the same through this paper and initiate a deliberation on our findings. To this end, the paper will attempt to answer the following questions:
1) How do different stakeholders perceive the value of the program in terms of its relevance and effectiveness?
2) How have caregivers’ understanding and practices of child care been influenced, and how have personal and/or contextual factors enabled or hindered the adaptation of their childcare practices?
3) How have home-visitors understanding and practices of caregiver-interaction been influenced, and how have personal and/or contextual factors enabled or hindered the adaptation of their caregiver-interaction practices?
4) How have designers and program leaders understanding of program outcomes, content and process been influenced, and how have personal and/ or contextual factors enabled or hindered the adaptation of their practices?
5) To what extent, and in what ways has the home-visiting intervention influenced the larger community’s beliefs and practices with reference to child care and holistic child development?
6) What are the key recommendations that emerge from the program in terms of design and implementation?
Data collection, guided by literature review, will include program document analysis, and primary data collection from caregivers, community members and workers, home-visitors, and CLR’s design and management team, through in-depth semi-structured interviews. The study sample would include caregivers, who were part of the intervention, from all eleven villages. Two families whose children are in pre-school (4-6 years of age) and two families whose children are in school (6-8 years of age), will be randomly selected from each of the villages, such that it ensures equal representation of families visited by both home-visitors; a total of forty-four participating caregivers. To study perceptions of community members and workers, investigators will interview neighbours, pre-school and school teachers of children of approximately half the number of interviewed caregivers. Data will be analysed using thematic analyses.
Through participation at CIES we seek to add to the understanding of what modalities help caregivers from under-resourced backgrounds provide nurturing care. Further, we hope to exchange experiences around similar interventions and explore new partnerships in the area of funding and research, especially those that may help in more robust evaluation of our interventions.
Manasi Chandavarkar provides research and design support in the area of Early Childhood Care and Development at Centre for Learning Resources, Pune (CLR). CLR designs and implements large-scale systemic capacity building programs to strengthen quality of early childhood and elementary education provided by public health and education systems.
Anandita Ghosh provides research support in the area of Early Childhood Care and Education at CLR, Pune.
Aparna Chakravorty provides research support in the area of Early Childhood Care and Education at CLR, Pune.
Harini Raval leads Programs at CLR, Pune.
Chittaranjan Kaul is the Director at CLR, Pune.