Women's participatory groups and nurturing child care
Authors: Aisha K Yousafzai
Journal: The Lancet Global Health (2017)

Interventions that support nurturing care for young children have received global attention as potential strategies to reduce the estimated 25·7% of the world's children who are stunted and 43% who are failing to meet their developmental potential.1Black RE Victora CG Walker SP et al.Maternal and child undernutrition and overweight in low-income and middle-income countries.Lancet. 2013; 382: 427-451Summary Full Text Full Text PDF PubMed Scopus (4296) Google Scholar, 2Lu C Black MM Richter LM Risk of poor development in young children in low-income and middle-income countries: an estimation and analysis at the global, regional, and country level.Lancet Glob Health. 2016; 4: e916-e922Summary Full Text Full Text PDF PubMed Scopus (267) Google Scholar Nurturing care has been defined as “a stable environment that is sensitive to children's health and nutritional needs, with protection from threats, opportunities for early learning, and interactions that are responsive, emotionally supportive, and developmentally stimulating”.3Britto PR Lye SJ Proulx K et al.Nurturing care: promoting early childhood development.Lancet. 2017; 389: 91-102Summary Full Text Full Text PDF PubMed Scopus (694) Google Scholar Strategies to strengthen nurturing care among parents and caregivers integrate interventions that support parenting knowledge, attitudes, practices, and skills pertaining to care for young children's health, hygiene, feeding, stimulation and early learning, and protection. The effectiveness of integrated interventions that promote nurturing care have been studied with particular attention to packages of care that promote young children's growth and development.4Grantham-McGregor SM Fernald LC Kagawa R Walker S Effects of integrated child development and nutrition interventions on child development and nutritional status.Ann N York Acad Sci. 2014; 1308: 11-32Crossref PubMed Scopus (145) Google Scholar The combination of nutrition and stimulation packages has shown benefits on multiple child outcomes, with consistent small-to-medium effects; however, further research is needed on the content, behaviour-change techniques, and delivery strategies of integrated packages of nurturing care in order to optimise effectiveness on the desired early childhood outcomes.5Yousafzai AK Aboud F Review of implementation processes for integrated nutrition and psychosocial stimulation interventions.Ann N York Acad Sci. 2014; 1308: 33-45Crossref PubMed Scopus (60) Google Scholar Current evidence on the effectiveness of early childhood interventions is largely from home visiting programmes; fewer studies have assessed group-based approaches.5Yousafzai AK Aboud F Review of implementation processes for integrated nutrition and psychosocial stimulation interventions.Ann N York Acad Sci. 2014; 1308: 33-45Crossref PubMed Scopus (60) Google Scholar Women's participatory action and learning groups have been implemented as a strategy to improve maternal and newborn survival outcomes in several low-income and middle-income countries.6Prost A Colbourn T Seward N et al.Women's groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis.Lancet. 2013; 381: 1736-1746Summary Full Text Full Text PDF PubMed Scopus (377) Google Scholar By means of this approach, facilitators guide women through a learning and action cycle to identify challenges and barriers to survival and health issues and, working with key community stakeholders, implement solutions to overcome these challenges. The approach is designed to build on the strengths and capabilities of local communities, and to foster a supportive environment of care.7Houweling TA Morrison J Alcock G et al.Reaching the poor with health interventions: programme-incidence analysis of seven randomised trials of women's groups to reduce newborn mortality in Asia and Africa.J Epidemiol Commun Health. 2016; 70: 31-41Crossref PubMed Scopus (20) Google Scholar, 8Marston C Hinton R Kean S et al.Community participation for transformative action on women's, children's and adolescents' health.Bull World Health Organ. 2016; 94: 376Crossref PubMed Scopus (60) Google Scholar In The Lancet Global Health, Nirmala Nair and colleagues9Nair N Tripathy P Sachdev HS et al.Effect of participatory women's groups and counselling through home visits on children's linear growth in rural eastern India (CARING trial): a cluster-randomised controlled trial.Lancet Glob Health. 2017; 5: 1004-1016Summary Full Text Full Text PDF PubMed Scopus (64) Google Scholar adopt the approach of women's participatory action and learning groups in rural eastern India, with the primary aim of reducing the prevalence of early childhood stunting. The integrated package of nurturing care addressed maternal nutrition and care for infant and young child feeding, hygiene, health, and stimulation. The intervention was initiated during the third trimester of pregnancy and continued until children were 2 years old. The women's groups took place monthly and families also received a monthly home visit. The community-based facilitator was a nutrition worker (suposhan karyakarta) newly recruited to support the efforts of the established Anganwadi workers. The intervention was evaluated by a robust cluster-randomised controlled trial. A significant effect on the primary outcome of child linear growth was not found; however, the intervention did show a significant impact on a number of secondary nurturing care outcomes, including minimal dietary diversity, food frequency, and handwashing practices. While the benefit on feeding-related behaviours is a promising finding of an integrated nurturing care intervention, the research study did not assess the impact of the intervention on children's development or report findings on stimulation-related behaviours. In future work, the analysis of the impact of the integrated package on all key outcome variables as well as an analysis on caregiving behaviours and practices (eg, caregiver–child interactions) which may act as mediators for inter-related child growth, health, and development outcomes will better inform the evidence-based design of integrated packages. To optimise early childhood outcomes, lessons must be learned from the implementation of women's participatory action and learning groups. A strength of the intervention design was the focus on behaviour-change techniques that support the uptake of nurturing care practices (eg, use of visual aides and stories to explore challenges to nutrition care and to identify solutions; demonstrations; sharing of recipes; and toy-making). Research has shown that attention to effective behaviour-change techniques is an important consideration in the delivery of nurturing care interventions to effect practice change.10Hurley KM Yousafzai AK Lopez-Boo F Early child development and nutrition: a review of the benefits and challenges of implementing integrated interventions.Advances Nutr. 2016; 7: 357-363Crossref PubMed Scopus (41) Google Scholar Women's groups may also foster attitudinal change about nurturing care and social support. However, further lessons can be learned from a process evaluation on the implementation of the women's groups.5Yousafzai AK Aboud F Review of implementation processes for integrated nutrition and psychosocial stimulation interventions.Ann N York Acad Sci. 2014; 1308: 33-45Crossref PubMed Scopus (60) Google Scholar For example, in the curriculum design for the integrated package of nurturing care, were the number of intervention messages too many to be effective for the desired set of primary and secondary outcomes? What were the barriers to uptake of some of the identified actions to support nurturing care? In order to optimise promising nurturing care intervention packages, the reporting of findings from process and implementation evaluations is crucial. In their study, Nair and colleagues also draw attention to the need for coordination of community-based approaches on nurturing care with nutrition-sensitive programmes (eg, social safety nets, girls' and women's education and empowerment). While interventions to strengthen knowledge, behaviour, and practice of nurturing care demonstrate some benefits to young children, parents and caregivers also require resources and empowerment to invest in their young children's health, growth, and development. To create enabling environments of care for young children's health, growth, and development, cross-sector coordination of child and family services warrant further attention to advance nurturing care.11Richter LM Daelmans B Lombardi J et al.Investing in the foundation of sustainable development: pathways to scale up for early childhood development.Lancet. 2017; 389: 103-118Summary Full Text Full Text PDF PubMed Scopus (404) Google Scholar In summary, Nair and colleague's study contributes further evidence that community-based approaches such as women's groups show promise in promoting nurturing care. Future work will need to examine how to optimise outcomes with greater focus on implementation research and identifying cross-sector partnerships that can support community-based efforts. I declare no competing interests. Effect of participatory women's groups and counselling through home visits on children's linear growth in rural eastern India (CARING trial): a cluster-randomised controlled trialIntroduction of a new worker in areas with a high burden of undernutrition in rural eastern India did not significantly increase children's length. However, certain secondary outcomes such as self-reported dietary diversity and handwashing, as well as infant survival were improved. The interventions tested in this trial can be further optimised for use at scale, but substantial improvements in growth will require investment in nutrition-sensitive interventions, including clean water, sanitation, family planning, girls' education, and social safety nets. Full-Text PDF Open Access