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The Pakistan Early Child Development Scale-Up Trial- Learning Lessons for Integrating Quality ECD Interventions in Community Health Services

11 Apr 2012
Aisha K Yousafzai, PhD,
Girl playing with a green ball
The Lancet series on 'Child Development in Developing Countries'in 2007 reported that internationally at least 200 million children were not meeting their development potential in the first 5 years of life. A key recommendation from this series was to integrate early child development (ECD) interventions in existing health, nutrition, education, and child protection services in order to reach the large numbers of children at risk of poor development. However; data to inform taking ECD interventions to scale is limited. Operational research is urgently needed in order to provide evidence based models and guidelines to help practitioners better plan, integrate, train, supervise, monitor, and scale up of effective ECD interventions. The Pakistan Early Child Development Scale Up (PEDS) Trial [Protocol ID: NCT00715936, www.clinicaltrials.gov] is designed to respond to some of the knowledge gaps through examining integration of ECD interventions in an existing community health service:

Box 1: Knowledge Gaps
  • Home, Group or Clinic Approaches: The mode of delivery for ECD services may be selected based on the existing structures of health programmes, yet most available data comes from home visitation programmes. What components make ECD group meeting successful and what are the limitations of this approach?
  • Nutrition and Stimulation and Health: How can we ensure a content balance both in health worker curriculums and at the point of delivery which adequately responds to the needs of child and family?
  • Accommodation of ECD in Existing Services: What additional human resources are needed to ensure quality curriculum development, training, supervision and monitoring? What additional health worker time will be spent on delivering ECD interventions? Are suitable monitoring indicators available for measuring success of ECD integration?
  • Cost: What is the additional cost for integrating ECD interventions in health services?
  • Capacity Development: What suitable models of capacity development for local practitioners, supervisors and managers are essential for delivering effective ECD services at scale?

The PEDS Trial research is a partnership between the Aga Khan University and the 'Lady Health Worker'(LHW) programme in Pakistan, which is a government community health service. The trial has two broad aims. Firstly, to determine whether a stimulation and responsive parenting intervention delivered by LHWs to families, either alone or in combination with a nutrition intervention, can improve development and growth outcomes at age 2. Secondly, to evaluate the implementation process in order to share lessons on models of delivery, training and supervision, skills development of health workers, and the effect of integration on existing service delivery.

The ECD intervention is an adaptation of the UNICEF and WHO 'Care for Child Development'module. The nutrition intervention comprises nutrition education and the distribution of multiple micronutrients. The interventions are delivered by the LHW to all families with children less than 2 years of age in her catchment through a combination of monthly community based group meetings and home visits. The impact of the interventions is being assessed through a cluster randomized control trial.

By the end of the trial, it is expected we will be able to provide data on the impact of integrating ECD and nutrition in a health service on early child outcomes and care-giving behaviours. In addition, the trial will be able to provide evidence based:

  • Curriculum and adaptation guidelines for ECD community group meetings
  • Guidelines for training and supervision of ECD skills for community health workers
  • Guidelines for ensuring integrated counseling for health, nutrition and development
  • Implications of ECD integration on community health worker time and programme resources.

Preliminary data trends are promising. The PEDS Trial data collection will be completed in March 2012.

Box 2: Feedback from the Community
We have no problems while doing the activity rather we feel happy because when the child is feeling happy we are even happier [Mother]

My child had reached 2 years but still could not speak. I left him on his own. Then I started attending meetings and heard that if you talk to your child he will become sharp. I followed these advices and my son started to speak! He is in his third year he names things form picture book. I believe in these messages now. They are 100% true. [Mother]

The Lady Health Worker observed a malnourished child and advised the mother. She said your child needs good nutrition, love and care [Health Supervisor]

As per your advices I attend my younger daughter a lot. And when I talk to her she says 'agoo agoo'with joy and takes interest in toys. When I do the mirror activity she vocalizes a lot and tries to catch the reflection. I feel my daughter will speak very early because of your activities. [Mother]

We have tried it and seen it for ourselves. The child can learn how much you teach him/her [Lady Health Worker]