Objectives: Nurturing Care (NC) and growth during early childhood are critical for human capital formation, but less is known about the patterns and role of NC. We used data from a Vietnamese birth cohort to identify trajectories of NC and growth in early childhood and evaluate their associations with cognitive development and academic achievement in early adolescence.
Lan Mai Tran, Phuong Hong Nguyen, Usha Ramakrishnan et al.
Background: Investing in parents and children during the critical period between birth and five years of a child’s life can have long-lasting benefits in the life of the child. Recently, the 2016 Lancet Series estimated that 250 million children aged less than five years in low- and middle-income countries (LMICs) are at risk of not reaching their developmental potential. Over 66 % of these, who live in sub-Saharan Africa and are at risk due to poor nutrition, exposure to poverty, high HIV prevalence as well as under stimulation in the home environment. Methods: The study will employ a cluster-randomized control trial design and will use a mixed-methods approach combining quantitative and qualitative methodologies (Concurrent Triangulation Design). This will be a two-arm study, where the first arm will participate in the parenting empowerment program implemented by the faith-based organizations, while the second (control) will not receive the parenting interventions. A total of 510 mother/primary caregiver-child dyads will be recruited into this study. We will estimate the causal effect of the intervention using mixed linear models and the Difference-in-Differences (DID) estimator. Conclusions: This implementation research will provide greater scientific rigor and a deeper process and outcome evaluation including measurement of child development outcomes. The findings will be useful for early childhood practitioners, multilateral stakeholders and funders as they provide information on the factors to consider in the implementation of high quality ECD interventions. Trial Registration: Ethical approval: ESRC P467/2018 and IRB No.00005948).
Patricia Kitsao-Wekulo, Elizabeth Wambui Kimani-Murage, Hermann Pythagore Pierre Donfouet et al.
PURPOSE: Given the importance of developing appropriate measures for assessing social norm change, this article documents the process, results, and lessons learned from a baseline survey measuring social norms related to child marriage in Phalombe and Thyolo districts in Southern Malawi. METHODS: A quantitative questionnaire was administered to a representative sample of all adults (age ≥18 years) who self-identified as a decision-maker for at least one girl between the ages of 10 and 17 years, for a total sample size of 1,492 respondents. Measures of empirical expectations, normative expectations, and sanctions related to child marriage were modeled after previously developed measures and social norm theory. RESULTS: Using an established social norm diagnostic process, this study found that, despite Southern Malawi having the lowest median age of first marriage in the country, child marriage may not be a strong social norm in the intervention communities. Specifically, although 89.3% of respondents expressed the empirical expectation that "Most girls in this community marry before the age of 18," agreement with the normative expectation that "Most people in this community expect girls to marry before the age of 18" was just 53.2% overall and fear of sanctions was just 36.4%. CONCLUSIONS: Taken together, the presence of prudential reasons for child marriage and the weak evidence of normative expectations and sanctions indicate that child marriage may not be a social norm in these communities although it may be indirectly perpetuated by other norms related to adolescent sexuality and access to contraception.
Mara C. Steinhaus, Laura Hinson, A. Theodore Rizzo et al.
Selecting indicators to monitor nurturing care (NC) environments that support decision-making and guide the implementation of integrated early childhood development (ECD) programmes has become a priority globally. Several population-based approaches have been attempted to create a set of indicators or a composite index methodology to measure the NC environment using existing secondary data. However, they have not been systematized. Our scoping review aimed to analyse the population-based approaches for monitoring the domains of the NC (e.g. good health, adequate nutrition, responsive caregiving, security and safety, and opportunities for early learning). ECD experts, peer-reviewed, and grey literature were systematically searched with no year or language restrictions. Data extraction used a standard predefined protocol. Thirty-two population-based approaches were identified. Most approaches were composed of a set of indicators (53.1%, n = 17) versus composite indexes (46.9%, n = 15) and had the country as their unit of analysis (68.8%, n = 22). Twenty-seven approaches were applied in middle-income countries (84.4%) and thirteen in low-income countries (40.6%). Four approaches were guided by the NC framework (12.5%), and 56.3% (n = 18) did not include any indicator representing responsive caregiving. NC indicators (n = 867) were sorted into 100 groups of indicators. Twenty of the 32 approaches had some kind of methodological validation (62.5%). We identified six methodological challenges to build a population-based approach. Standardized methods for selecting and validating indicators, and coordinated efforts to share findings/data with stakeholders should be prioritized. Given the great variability in methods and indicators used to measure NC environments, valid approaches should be flexible to work well across different contexts.
Jéssica Pedroso, Stefanie Eugênia dos Anjos Coelho Kubo, Priscila Olin Silva et al.
PURPOSE: Child marriages and unions can infringe upon adolescent and youth sexual and reproductive health (AYSRH). Interventions increasingly promote strategies to transform social norms or foster the agency of adolescent girls. Recent empirical studies call for further understanding of how social norms and agency interact in ways that influence these practices, especially in contexts where girls' agency is central. METHODS: A secondary cross-case analysis of three qualitative studies (in Brazil, Guatemala, Honduras) was conducted to inform the investigation of how norms and agency may relate in sustaining or mitigating child marriage. RESULTS: Social norms dictating how girls/young women and how men should act indirectly led to child marriages and unions. The data showed that (1) social norms regulated girls' acceptable actions and contributed to their exercise of "oppositional" agency; (2) social norms promoted girls' "accommodating" agency; and (3) girls exercised "transformative" agency to resist harmful social norms. CONCLUSIONS: Research should advance frameworks to conceptualize how social norms interact with agency in nuanced and context-specific ways. Practitioners should encourage equitable decision-making; offer confidential, adolescent-friendly AYSRH services; and address the social norms of parents, men and boys, and community members.
Alice Y. Taylor, Erin E. Murphy-Graham, Julia Van Horn et al.
Background: The period between 6 and 24 months represents a critical window for child growth, during which vulnerability to acute illness is high. Acute illness may disrupt normal growth trajectories; however, evidence on the role of nurturing care practices in supporting weight gain during illness remains limited. Objective: This study aimed to examine the association between maternal nurturing care practices and weight gain among acutely ill children aged 6–24 months. Method: A cross-sectional study was conducted at Banguntapan II Primary Health Center, Bantul District, Indonesia. A total of 58 mother–child dyads were recruited using consecutive sampling. Maternal nurturing care practices were assessed using a modified Knowledge, Attitude, and Practice questionnaire based on the World Health Organization nurturing care framework. Child weight gain was evaluated using World Health Organization growth standards. Associations were analyzed using chi-square tests and odds ratios with 95% confidence intervals. Results: No statistically significant association was observed between nurturing care practices and weight gain (p = 0.069; OR = 0.371; 95% CI: 0.126–1.091). However, a higher proportion of children receiving good nurturing care achieved normal weight gain (70.0%) compared with those receiving poor care (46.4%), indicating a potential protective trend. Maternal education and family income were not significantly associated with nurturing care practices or child weight gain. Conclusion: Although no statistically significant association was identified, nurturing care practices showed a potential protective trend in supporting weight gain during acute illness. These findings highlight the importance of integrating nurturing care into sick-child management and underscore the need for longitudinal studies to better understand growth recovery following illness episodes.
Cechillia Icha Putri, Fitri Haryanti, Ayyu Sandhi et al.
INTRODUCTION: Child marriage, formal and informal unions when one or both spouses are under 18, disproportionately affects adolescent girls over boys. It has serious consequences for girls' health, wellbeing, and development. Little is known about the ways in which girls' agency and contextual social norms - unwritten rules of (un)acceptable behaviour in a group - intersect to affect child marriage practices. This paper investigates norms and agency as facilitators and obstacles to adolescent girls' marriage in Somaliland and Puntland. METHODS: Participants (n = 156) were men and women living in Somaliland and Puntland. We conducted 36 qualitative semi-structured individual interviews (12 men and 24 women). We also held 15 focus group discussions (8 in Somaliland and 7 in Puntland) with 6-10 people each (n = 120). Mixed focus groups were conducted with men and women together, and were segregated by age. RESULTS: Technology and economic deprivation were important contextual factors in explaining the prevalence of child marriage. Participants reported that adolescent girls' and boys' increased agency contributed to, rather than decreased, child marriage. Access to technology expanded adolescents' freedom from their parents' control. Adolescents used that freedom within the existing system of social norms that rewarded early (as opposed to later) marriage. CONCLUSIONS: Effective interventions that aim to reduce marriage among adolescents living in Somalia (where marriage can be a protective strategy) should integrate a social norms perspective to avoid increasing adolescent-led marriage.
BACKGROUND: The Nurturing Care Framework (NCF) is a comprehensive approach that enhances early childhood development (ECD). Due to the paucity of personnel skilled in nurturing care for ECD (NC-ECD), Indian Academy of Pediatrics (IAP) developed IAP-NURTURE (NC-ECD) aimed at training paediatricians to incorporate nurturing care into office practice. A systems approach was employed: needs assessment; development of resources and training strategy; implementation of 200 workshops across India (2022-2024), and; impact evaluation. The study objectives were to (a) document the context of IAP NURTURE (NC-ECD); (b) assess trainee capacity enhancement and (c) identify challenges and suggestions for improvement. METHODS: A triphasic mixed-methods study was conducted based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation- Maintenance) framework. The study population included organisers, trainers and trainees, recruited by purposive sampling. Phase 1 (qualitative) used key informant interviews (KIIs) of organisers to understand context. Phase 2 focused on participants' training. In the quantitative component, workshop documents and online survey findings were reviewed. The qualitative component included in-depth interviews (IDIs) of trainees. Phase 3 (qualitative) employed focused group discussions (FGDs) of trainers. Data management included descriptive statistics (quantitative) and Braun and Clarke's methodology for thematic analysis (qualitative). Data integration identified areas of convergence, complementarity and expansion. RESULTS: IAP NURTURE (NC-ECD) trained 7047 paediatricians. Data was retrieved from: 9 KII (phase 1); 4155 (58.9%) pretests, 2596 (36.8%) post-tests, 1506 (21.3%) feedback forms, 205 (5%) online survey respondents, and 18 (36.7%) IDIs (phase 2) and 15 FGDs (phase 3). Data integration indicates IAP NURTURE (NC-ECD) had a positive impact on the trainees: high satisfaction with training and resources provided; helpful in practice (skill enhancement, involving staff, using well-child visit schedule), and; receiving positive feedback from clientele. Challenges and solutions were identified. CONCLUSIONS: The IAP NURTURE (NC - ECD) model (based on systems approach, NCF strategic actions and principles of adult learning) and lessons learnt from this study can guide development of similar capacity building initiatives.
Sharmila Banerjee Mukherjee, Samir Hasan Dalwai, Digant D. Shastri et al.
Background: Girl child, early, and forced marriage (CEFM) persists in South Asia, with long-term effects on well-being. CARE's Tipping Point Initiative (TPI) sought to address the gender norms and inequalities underlying CEFM by engaging participant groups on programmatic topics and supporting community dialogue to build girls' agency, shift power relations, and change norms. We assessed impacts of the CARE TPI on girls' multifaceted agency and risk of CEFM in Nepal. Methods: The quantitative evaluation was a three-arm, cluster-randomized controlled trial (control; Tipping Point Program [TPP]; Tipping Point Plus Program [TPP+] with emphasized social-norms change). Fifty-four clusters of ∼200 households each were selected from two districts (27:27) with probability proportional to size and randomized evenly to study arms. A pre-baseline census identified unmarried girls 12-16 years (1,242) and adults 25 years or older (540). Questionnaires covered marriage; agency; social networks/norms; and discrimination/violence. Baseline participation was 1,140 girls and 540 adults. Retention was 1,124 girls and 531 adults. Regression-based difference-in-difference models assessed program effects on 15 agency-related secondary outcomes. Cox-proportional hazard models assessed program effects on time to marriage. Sensitivity analyses assessed the robustness of findings. Results: At follow-up, marriage was rare for girls (<6.05%), and 10 secondary outcomes had increased. Except for sexual/reproductive health knowledge (coef.=.71, p=.036) and group membership (coef.=.48, p=.026) for TPP + versus control, adjusted difference-in-difference models showed no program effects on secondary outcomes. Results were mostly unmoderated by community mean: gender norms, household poverty, or women's schooling attainment. Cox proportional hazard models showed no program effect on time-to-marriage. Findings were robust. Discussion: Null findings of the Nepal TPI may be attributable to low CEFM rates at follow-up, poor socio-economic conditions, COVID-19-related disruptions, and concurrent programming in control areas. As COVID-19 abates, impacts of TPP/TPP + on girls' agency and marriage, alone and with complementary programming, should be assessed. Trial registration number: NCT04015856.
Kathryn M. Yount, Robert L. Durr, Irina Bergenfeld et al.
Child marriage has adverse consequences for young girls. Cross-sectional research has highlighted several potential drivers of early marriage. We analyse drivers of child marriage using longitudinal data from rural Malawi, where rates of child marriage are among the highest in the world despite being illegal. Estimates from survival models show that 26% of girls in our sample marry before age 18. Importantly, girls report high decision-making autonomy vis-à-vis the decision to marry. We use multivariate Cox proportional hazard models to explore the role of 1) poverty and economic factors, 2) opportunity or alternatives to marriage, 3) social norms and attitudes, 4) knowledge of the law and 5) girls' agency. Only three factors are consistently associated with child marriage. First, related to opportunities outside marriage, girls lagging in school at survey baseline have significantly higher rates of child marriage than their counterparts who were at or near grade level. Second, related to social norms, child marriage rates are significantly lower among respondents whose caregivers perceive that members of their community disapprove of child marriage. Third, knowledge of the law has a positive coefficient, a surprising result. These findings are aligned with the growing qualitative literature describing contexts where adolescent girls are more active agents in child marriages.
Rachel C. Kidman, Etienne Breton, James Mwera et al.
