development irrespective of child gender among the older age group and with some heterogeneity by gender in the younger age group illustrates the need for interventions to start early (from pregnancy), and they may protect against gender-based differences in development and school readiness levels emerging later in life. As yet, large-scale parenting education programs promoting psychosocial stimulation from pregnancy to 3 years are missing in Pakistan. While research in Pakistan and other South Asian countries such as India, Nepal, and Bangladesh have proven the effectiveness of supportive parenting programs on early stimulation and responsive care in improving ECD (Aboud et al., 2013; ARNEC, 2019; Devercelli et al., 2022; Hamadani et al., 2019; Yousafzai et al., 2014), there is need to expand these programs to scale.

Furthermore, given that parents’ distress and depression levels in Pakistan are high (Atif et al., 2021; Fisher et al., 2012; Henstchel et al., 2023), increased access to mental health care for parents during the perinatal and early years could promote improved child development levels for all children and for girls in particular. Interventions through health systems in Pakistan have been proven effective at improving parental wellbeing and child development levels (Yousafzai et al., 2014; Yousafzai et al., 2015).

The use of existing community-based structures and delivery mechanisms that have strong local linkages have demonstrated positive results. Research across South Asia (Nahar et al., 2012; Andrew et al., 2020; Hamadani et al., 2019) has found community-based psychosocial stimulation initiatives that model play activities and beneficial caregiving approaches improved child-rearing practices of mothers and the quality of home environments. In Pakistan, the Lady Health Worker (LHW) Program could be one platform to leverage for operationalizing similar interventions. Recruiting local community members and respected health care workers has also been established as a successful approach (Rabanni et al., 2023; Yousafzai et al., 2014; Yousafzai et al., 2018). Mobilizing trained facilitators (such as LHWs) to impart parenting support could greatly benefit both children and parents, especially in vulnerable and hard-to-reach communities.

This study contributes to the limited knowledge base around ECD in Pakistan by shedding light on the presence and patterns of risk and protective factors and child outcomes as moderated by gender in the early years. Notably, the study focuses on a representative sample of households across four provinces, even during the era of COVID-19 closures, providing a rare snapshot of a uniquely stressful time. However, there are caveats that may limit the generalizability of the study. Data were collected during the pandemic. As such, additional research is needed to examine how the dynamics reported here may have changed in the aftermath of the pandemic. Because of the phone-based nature of data collection, responses were based on caregiver-report rather than direct observation (e.g., the psychosocial stimulation tool was developed for in-person data collection and adapted for the current study). Methodological reliance on access to a phone for participation in this survey systematically excluded the 6 percent of Pakistan that does not have a mobile phone (Pakistan Bureau of Statistics, 2021), and, because men are more likely than women to own and manage phones in Pakistani households, a large share of respondents in this survey were men who may not have been the target child’s primary caregiver. As such, the data were most often not collected from the primary caregiver, and caregiver variables, such as parental distress, were most often paternal distress instead of maternal distress.

Other constraints in measurement should also be noted. For example, the measure for parental distress was developed for use in the survey and no additional evidence for validity is available, though Cronbach’s alpha coefficient estimates indicate adequate internal consistency. Additionally, the measure of psychosocial stimulation focuses on activities conducted in the previous 24 hours, which may vary depending on the caregiver’s scheduling or day of the week of 13