At the halfway mark for implementation of the Sustainable Development Agenda, progress towards achieving targets centred on child health and development has decelerated, impeding the survival and potential of many children. The Lancet Series on optimising child and adolescent health and development called for renewed efforts to nurture the health and development of all children.1 To accomplish this, it is necessary to expand implementation of evidence-based interventions that address factors jeopardising optimal outcomes, spanning from pre-conception into adulthood.
Children are disproportionately impacted by humanitarian disasters, which cause toxic stress. When a crisis overwhelms the capacity of health and social systems to meet the needs of a population, external crisis response teams working in a range of sectors may offer support to save lives and meet the affected populations' basic needs. Gaps have been identified in health sector interventions for children in humanitarian contexts, including lack of routine interventions to protect and promote early child development (ECD). To address this gap and improve the quality of humanitarian responses for girls and boys, the Global Health Cluster, Child Health Task Force, and the Inter-Agency Network for Education in Emergencies held a webinar series on Strengthening Nurturing Care in Humanitarian Response. It concluded that incorporating interventions to support nurturing care for ECD into health responses in acute phase emergencies is lifesaving. In crisis contexts, even simple interventions can be the difference between life and death, and when systematically applied, they can dramatically improve a child's life opportunities as well as national recovery and economic growth.
Ayesha Kadir, Linda Doull, James McQuen Patterson et al.
Child-focused education and nurturing care interventions provide learning support directly to the child. In line with the International Standard Classification of Education (ISCED Level 0), the support is typically provided by either centre- or home-based Early Childhood Education and Care (ECEC) services outside the child’s family and includes an educative and caring component with an active child development element. The 35 child-focused interventions in this review (of a total of 109 studies; see further details under background) occurred in 29 countries in five regions – the widest geographical spread of all intervention types under consideration. The most frequently represented countries were China (five studies) and Bangladesh (four studies) while three interventions occurred in Indonesia and Ethiopia. The child-focused interventions targeted three groups, namely preschool for children in the one or two years before starting school (20 studies), programs for younger children and programs without an explicit educational focus (11 studies) and short-term interventions for disadvantaged children (4 studies). Twenty-seven of the 35 interventions had positive effects on learning. The impact of these interventions – one of six types of interventions in the review – confirmed previous results showing the largest effects for child focused interventions compared with other ECEC interventions (Rao et al., 2017).
Jen Jackson, Syeda Kashfee Ahmed, Toby Carslake et al.
Providing an enabling nurturing care environment for early childhood development (ECD) that cuts across the five domains of the Nurturing Care Framework (i.e., good health, adequate nutrition, opportunities for early learning, security and safety and responsive caregiving) has become a global priority. Brazil is home to approximately 18.5 million children under 5 years of age, of which 13% are at risk of poor development due to socio-economic inequalities. We explored whether the Early Childhood Friendly Municipal Index (IMAPI) can detect inequities in nurturing care ECD environments across the 5570 Brazilian municipalities. We examined the validity of the IMAPI scores and conducted descriptive analyses for assessing sociodemographic inequities by nurturing care domains and between and within regions. The strong correlations between school achievement (positive) and socially vulnerable children (negative) confirmed the IMAPI as a multidimensional nurturing care indicator. Low IMAPI scores were more frequent in the North (72.7%) and Northeast (63.3%) regions and in small (47.7%) and medium (43.3%) size municipalities. Conversely, high IMAPI scores were more frequent in the more prosperous South (52.9%) and Southeast (41.2%) regions and in metropolitan areas (41.2%). The security and safety domain had the lowest mean differences (MDs) among Brazilian regions (MD = 5) and population size (MD = 3). Between-region analyses confirmed inequities between the North/Northeast and South/Southeast. The biggest within-region inequity gaps were found in the Northeast (from -22 to 15) and the North (-21 to 19). The IMAPI distinguished the nurturing care ECD environments across Brazilian municipalities and can inform equitable and intersectoral multilevel decision making.
Gabriela Buccini, Stefanie Eugênia dos Anjos Coelho Kubo, Jéssica Pedroso et al.
In Malawi, 38% of children under five are stunted, and only 36% are developmentally on track. An ethnographic study using the Reality Check Approach was conducted in four villages in Ntcheu and Balaka districts in Malawi to understand caregiving-related drivers of malnutrition and poor child development. Researchers immersed themselves in 12 rural households with a pregnant woman or a child under 2 years for 4 days and nights, and gathered information through informal conversations, participation in daily activities, observations, and group sessions. They assessed current behaviours and the factors driving these behaviours in five recommended nurturing care domains essential for a child to both survive and thrive. The study revealed that children were not receiving the nurturing care they needed. Caregiving-related issues identified included poor maternal, child, and family diets; inadequate infant and young child feeding; poor hygiene environment and practices; low use of health and nutrition services; limited responsive care, stimulation and learning opportunities, and early pregnancies. Caregiving determinants included chronic poverty and food insecurity, climate and economic shocks, low access to quality health, nutrition and early childhood development services, poor maternal wellbeing, gender inequality and harmful social norms. The research underscores the need for a multi-sector approach to improve maternal and child nutrition and development. It also stresses the importance of understanding the contextual determinants of caregiving behaviours to inform multi-sector programmes and policies and meet Malawi's Sustainable Development Goals and World Health Assembly targets for maternal and child health, nutrition, and development.
In Kenya, millions of children have limited access to nurturing care. With the Coronavirus disease 2019 (COVID-19) pandemic, it is anticipated that vulnerable children will bear the biggest brunt of the direct and indirect impacts of the pandemic. This review aimed to deepen understanding of the effects of COVID-19 on nurturing care from conception to four years of age, a period where the care of children is often delivered through caregivers or other informal platforms. The review has drawn upon the empirical evidence from previous pandemics and epidemics, and anecdotal and emerging evidence from the ongoing COVID-19 crisis. Multifactorial impacts fall into five key domains: direct health; health and nutrition systems; economic protection; social and child protection; and child development and early learning. The review proposes program and policy strategies to guide the reorientation of nurturing care, prevent the detrimental effects associated with deteriorating nurturing care environments, and support the optimal development of the youngest and most vulnerable children. These include the provision of cash transfers and essential supplies for vulnerable households and strengthening of community-based platforms for nurturing care. Further research on COVID-19 and the ability of children's ecology to provide nurturing care is needed, as is further testing of new ideas.
Constance Sibongile Shumba, Rachel Kimani, Sheila Shaibu et al.
This cross-sectional study examines whether provision of nurturing care in 31 countries over 10 years was associated with improvements in countries’ child development outcomes.
Dana Charles McCoy, Jorge A. Cuartas, Jonathan Seiden
Nurturing care encompasses five components that are crucial for supporting early childhood development: good health, adequate nutrition, opportunities for early learning, responsive caregiving, and safety and security. While there has been increasing attention in global public health towards designing and delivering programs, services, and policies to promote nurturing care, measurement has focused more on the components of health and nutrition, with less attention to early learning, responsive caregiving, and safety and security. We conducted a scoping review to identify articles that measured at least one nurturing care outcome in a sample of caregivers and/or children under-5 years of age in low- and middle-income countries (LMICs). We systematically searched five electronic bibliographic databases for peer-reviewed articles published from database inception until November 30, 2020. We first classified outcomes to their respective nurturing care component, and then applied an inductive approach to organize key constructs within each nurturing care component and the specific measures and indicators used across studies. We identified 239 total articles representing more than 50 LMICs for inclusion in the review. The majority of included studies reported a measure of nutrition (N = 166), early learning (N = 140), and health (N = 102), followed by responsive caregiving (N = 78) and lastly safety and security (N = 45). For each nurturing care component, we uncovered multiple constructs relevant to children under-5: nutrition (e.g., anthropometry, complementary feeding), early learning (e.g., stimulation practices, early childhood education), health (e.g., birth outcomes, morbidity), responsive caregiving (e.g., parental responsivity, parent-child interactions), and safety and security (e.g., discipline, inadequate supervision). Particularly for outcomes of early learning and responsive caregiving, there was greater variability with regards to the measures used, reported indicators, and analytic construction of variables than the other three nurturing care components. This study provides a comprehensive review of the current state of measurement of nurturing care. Additional research is needed in order to establish the most optimal measures and indicators for assessing nurturing care, especially for early learning and responsive caregiving.
Joshua Jeong, Lilia Bliznashka, Eileen Sullivan et al.
Abstract Background Training program for home visitors on early child development was developed and implemented within UNICEF supported projects involving 25 primary health centers. Training content was notably based on resource modules “Supporting Families for Nurturing Care”, adapted according to the local context. Health professionals are seen as the critical actors to support development of young children and their families. Family-centered approach that addresses social as well as medical dimensions of problems became priority in their practice with a special focus on working with children from socially deprived settings and children with disabilities. Objectives The main objective was to improve knowledge and practice of home visitors on early child development based on most recent scientific evidence. Broad spectrum of topics was covered including engaging fathers, early detection of postpartum depression, attachment, developmental monitoring, age-appropriate play, home safety, stigma and discrimination. Training were organized as interactive face to face sessions and online courses and attendees were actively engaged in reflection. Comprehensive check list with various assessment instruments was developed to provide guidance to home visitors in implementation of gained skills. Results Increase in knowledge of 150 home visitors was between 57.6% and 82.9%. Enhanced knowledge and skills have been applied in 14912 families of which socially deprived was 34.5% during 2-year period of implementation. Parent-child interactions, assessed by visiting nurses, were improved by 32.6%, responsive feeding practices by 27.4%, while age-appropriate play by 34.4% after interventions during home visits. Conclusions Well-developed monitoring system was crucial for implementation of gained knowledge and skills in practice of home visitors. Key messages Home visitors were empowered to take a strengths-based approach in their work with families. Developed tools facilitated prioritization of most vulnerable families and tailoring support according to needs.
Svetlana Mladenović Janković, Dušanka Matijević, Gordana Tamburkovski et al.
Research on early childhood development has focused on child health, nutrition and stimulation. However, less attention has been given to the role of caregiver nutrition in shaping caregiving behaviours. Suboptimal caregiver nutrition may impair the ability to provide responsive and nurturing care. This scoping review aimed to summarise the existing evidence on the link between caregiver nutrition and nurturing care, specifically responsive caregiving and early learning opportunities. Database (Medline) and citation searches yielded 23 articles meeting inclusion criteria (n = 17 observational; n = 6 randomised controlled trials [RCTs]). The majority (n = 15) were conducted in low- and middle-income countries. Observational studies measured caregiver anthropometry (n = 8), dietary intakes/diversity/quality (n = 6), anaemia (n = 6) and vitamin B6 status (n = 1). RCTs supplemented pregnant and/or postpartum women with iron (n = 2), multiple micronutrients (n = 2), fish oil (n = 1) and food-based snacks (n = 1). Most articles (n = 18) measured caregiving through live or videotaped observations of caregiver-child interactions; the remaining used caregiver self-reported measures of stimulation or caregiver-child bonding/relationship. Overall, suboptimal diets, food insecurity, caregiver under- and overnutrition, anaemia and low vitamin B6 status were associated with less responsive caregiving and fewer opportunities for early learning. Providing anaemic or food-insecure caregivers with iron or food-based supplements positively altered caregiver-child interactions. Supplementation trials that did not specifically target undernourished caregivers found no effects on caregiving behaviours. More research specifically targeting undernourished caregivers is needed to understand how nutritional interventions might benefit caregiving. Interventions aimed at enhancing nurturing care should consider both caregiver and child nutrition as potential targets to improve outcomes for both children and their caregivers.
