Charlotte Sigurdson Christiansen, Technical Officer, Chiara Servili, Technical Officer, Tarun Dua, Medical Officer, and Bernadette Daelmans, Coordinator, World Health Organization, Geneva1
Intersectoral collaboration is essential for reaching young children, with the health sector typically being best positioned to deliver interventions that can promote early learning among the 0–3 years age group. In this article, the authors introduce the World Health Organization and UNICEF Care for Child Development package, an evidence-based set of materials to help health sector workers to support caregivers in improving the sensitivity, responsiveness and psychosocial stimulation of their children.
At the beginning of a new millennium, world leaders made commitments to improve the life of poor people around the world in the course of one generation, from 1990 to 2015. The United Nations (UN) Millennium Development Goals include quantitative targets to improve results in poverty reduction, health, education, gender equality and the protection of the environment (WHO, online a). A necessity to achieve these goals is intersectoral collaboration – the health goals cannot be achieved without inputs from other sectors.
In the past two decades, progress has been made in improving child survival, and child mortality (under 5 years) has gone down from 12 million in 1990 to 6.9 million in 2011 (WHO, online b). However, more than 200 million children under 5 worldwide do not reach their full developmental potential. Most of these children live in sub-Saharan Africa and South Asia (Grantham-McGregor et al., 2007).
Early environments are powerful determinants of how well a child develops, and can influence long-term health, learning and behavioural trajectories. The environmental factors that influence a young child’s development may be proximal (such as families’ economies), or distal (for example, the ecological and political environment). Figure 1 shows a variety of factors influencing development in early childhood.
Programmes for disadvantaged children that are introduced during early childhood are found to have a greater impact than those introduced at a later stage (Engle et al., 2007). Whereas there is a clear recognition that the education sector plays an important role in early child development, it is the health sector that uniquely interacts with children under the age of 3 and their families. In most countries, the healthcare system is the only system that potentially can reach all young children and their families. Families and communities generally have trust in and contact with the healthcare system, especially in early years (WHO, 2012a).
The health sector is well placed to influence a range of both proximal and distal factors that affect child development, such as the quality of interaction between the parent and child; the opportunities for early stimulation; the home and community environment; and the national policy on early childhood care that will impact on the quality of day care exposure a child may receive. The health sector works through several mechanisms, including primary healthcare services, home visiting services, and other community activities and services, all of which are important in improving learning and development in the child.
Interventions influencing child development
A life course approach is essential to give young children the best start in life and unleash their full development potential. At one end of the spectrum, the physiology of foetal growth and factors influencing the embryonic, foetal and postnatal growth trajectory are being uncovered. At the other end, the long-term effects of investing in early childhood development are increasingly becoming clear. Studies have shown that disadvantaged children are likely to do poorly in school and subsequently have low incomes, high fertility, and provide poor care for their children, thus contributing to the intergenerational transmission of poverty (Grantham-McGregor et al., 2007).
Interventions across the life course influence early child development; however, there are two critical windows for intervening: the period of adolescence and preconception care, and the period from prenatal care to when the child is 3 years of age.
Adolescence is a period in which puberty and brain maturation lead to a new set of behaviours and capacities. These can modify developmental trajectories towards health and well-being. Furthermore, adolescents are potentially powerful agents of personal change and community action (WHO, forthcoming a). Adolescents, women and men should receive pre-conception care interventions with the aim of improving health and reducing the factors that can contribute to poor maternal and child health outcomes (WHO, 2013).
During early childhood years, a safe and stable environment, good health, adequate nutrition, responsive caregiving, opportunities for emotional connections and attachment, and stimulation (opportunities to learn) are important to ensure healthy development in the child. In these years, it is important also to address maternal mental health, as this influences the quality of caregiver–child interaction. Maternal depression, including in settings were HIV is prevalent, puts children at special risk of deprivation and inadequate stimulation. In return, interventions to support care for child development positively impact on the caregiver’s mental health and well-being (Engle et al., 2007).
The health sector plays an important role in delivering effective interventions across these windows of opportunity and through a continuum of care, as illustrated in Box 1.
Intervention programmes can be delivered vertically, or be integrated into current existing health systems. The interventions can be centre-based, clinic-based, delivered through home visiting or at preschools and schools. Home- or health centre-based intervention programmes providing guidance, education or care with regular frequency have been shown to be effective. The delivery of various interventions together has proved to have greater effect than when they are delivered alone. In relation to the various delivery mechanisms, the interventions can be delivered by various groups, such as early child development workers, health workers, community health workers, peers and teachers.
The WHO and UNICEF are two UN organisations with a long history of working in the area of early child development. Some of the intervention packages and programmes developed by these organisations are mentioned below.
Box 1 Interventions with an impact on early child development delivered through the health sector
The health sector plays an important role in early child development
Source: WHO, forthcoming a
Care for Child Development
The Care for Child Development package (WHO, 2012b) is an evidence-based set of materials developed by WHO and UNICEF, complementing the traditional package of child survival interventions. The intervention is based on the best available evidence of psychosocial stimulation and caregiver–child interaction. It is meant to guide health workers and other counsellors in supporting families to build stronger relationships with their children. The intervention can be used by health and community workers to provide age-appropriate guidance to caregivers of young children for stimulating cognitive, language and social-emotional development through play and communication. Ultimately, the intervention contributes to psychosocial stimulation in the child, and caregiver sensitivity and responsiveness.
The Care for Child Development package provides guidance to caregivers at various stages in the child’s life, from the newborn period up to 3 years. The package includes guidance on stimulation, advice on what to do if the household lacks toys, and guidance on how to deal with cases of maternal stress or where caregivers have little time for interaction with the child. The skills taught affect multiple caregiving practices including infant and young child feeding, protecting a child from imminent harm, and recognising and seeking care when the child is sick.
The Care for Child Development intervention is particularly effective in combination with counselling on infant and young child feeding (WHO, 1999, 2004) To increase access to essential health services and meet demands of countries for materials to train community health workers, the Care for Child Development materials have been adapted and included in the training course entitled Caring for the Child’s Healthy Growth and Development (WHO, forthcoming b). This course is for community health workers and is designed to build their skills to support integrated childcare in the community (WHO, 2012c). The course builds knowledge and skills for counselling on breastfeeding and complementary feeding; play and communication; prevention of childhood illnesses and injury; and recognising the signs of illness and when it is needed to take sick children to a health facility for care. The materials promote regular home visits in the first year of a child’s life, as a continuation of Caring for the Newborn at Home (WHO, 2012d), a training course promoting home visits during pregnancy and after childbirth.
WHO is working to improve early child development
In order to respond to the need for action, WHO is intensifying its work in the area of early child development (Chan, 2013). In January 2013, WHO convened a global consultation bringing together participants from a range of disciplines that are concerned with development across the life course.
The key messages from the meeting were:
The healthcare system has a unique role in fostering early child development as it is the system that first establishes contact with families. It is an important complement to the education sector and has a key role in stimulating and developing learning in children. Health services provide a unique platform to provide essential interventions, starting early in the child’s life and even before that, in adolescence and the pre-conception period. The health system can also serve as a gateway to other early childhood services. Intersectoral collaboration, across primary health care, social sectors, nutrition, environmental programmes, as well as with the education sector, is crucial in order to address the needs of children and reverse the burden of 200 million children who as yet are unable to reach their full developmental potential each year.
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1 WHO disclaimer: The authors (Charlotte Sigurdson Christiansen, Chiara Servili, Tarun Dua and Bernadette Daelmans) are staff members of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy, or views of the World Health Organization.