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Health for learning: the Care for Child Development package

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.

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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

  • Adolescence and pre-conception: interventions to adopt healthy lifestyles and prepare for parenthood in adolescents; interventions to prevent maternal mortality and morbidity (e.g. pre-eclampsia, gestational diabetes) and prevent childhood mortality and morbidity (e.g. birth defects) (WHO, 2013)
  • Prenatal and perinatal: interventions to prevent poor pregnancy and birth outcomes (e.g. pre-term birth, congenital defects), optimise the course of pregnancy (e.g. management of anaemia, diet, weight gain), and promote maternal well-being and mental health
  • 0-3 years: interventions to promote responsive care and early stimulation; support optimal infant and young child feeding practices (including responsive feeding); prevent and manage childhood illnesses in a timely manner; detect developmental delays and provide remedial support; and support maternal mental health.
  • 3+ years: interventions to support transition to school (e.g. early school readiness programmes), and learning in safe and supportive preschools/primary schools.

Source: WHO, forthcoming a


 Care for Child Development

The CFigure2_ECM120-Christiansen-1are 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.

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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:

  • Determinants resulting in adversities in early childhood are across multiple areas and sectors – such as inadequate nutrition, frequent illness, lack of care and stimulation, poverty, poor environment, poor parental education, violence and conflict.
  • To move towards sustainable development and social equity, the child survival and child development agendas need to be intertwined.
  • Optimising child development requires a life-course approach with interventions during adolescence, pregnancy and childbirth, the newborn period and early childhood especially up to 3 years of age. The health sector thus has a vital role to play.
  • Intersectoral collaboration, across primary health care, social sectors, nutrition, education and environmental programmes, is crucial.
  • Tools are available and experience from large-scale programmes in high-income countries provide important translational lessons for scaling-up similar programmes in low- and middle-income countries.
  • Large number of partners and governments are committed to enabling children to thrive.
  • It is therefore imperative that all stakeholders work together to advance the early child development agenda and help children get a best start in life and unleash their full development potential. (WHO, forthcoming a)

Conclusion

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.

References

Chan, M. (2013). Linking child survival and child development for health, equity, and sustainable development. Lancet 381: 1514–15.

Engle, P.L., Black, M.M., Behrman, J.R., Cabral de Mello, M., Gertler, P.J., Kapiriri, L. et al. (2007). Strategies to avoid the loss of development potential in more than 200 million children in the developing world. Lancet, 369: 229–42.

Grantham-McGregor S., Cheung, Y.B., Cueto, S., Glewwe, P., Richter, L., Strupp, B. and International Child Development Steering Group. (2007). Developmental potential in the first 5 years for children in developing countries. Lancet 369: 60–70.

Irwin, L.G., Siddiqui, A. and Hertzman, C. (2007). Early Child Development: A powerful equalizer. Geneva: WHO.

World Health Organization. (1999). A Critical Link: Interventions for physical growth and psychological development. A review. Geneva: WHO.

World Health Organization (2004). The Importance of Caregiver–child Interactions for the Survival and Healthy Development of Young Children. A review. Geneva: WHO.

World Health Organization. (2012a). Developmental Difficulties in Early Childhood – Prevention, early identification, assessment and intervention in low-and middle-income countries. A review. Geneva: WHO.

World Health Organization. (2012b). Care for Child Development: Improving the care for young children, materials package. Available at: http://www.who.int/maternal_child_adolescent/documents/care_child_development/en/index.html (accessed April 2013).

World Health Organization. (2012c). Caring for Newborns and Children in the Community: The three-part training package for community health workers. Available at: http://www.who.int/maternal_child_adolescent/documents/caring_newborn_child_in_community_flyer.pdf (accessed May 2013).

World Health Organization (2012d) Caring for the Newborn at Home, materials package. Geneva: WHO. Available at: http://www.who.int/maternal_child_adolescent/documents/caring_for_newborn/en/ (accessed April 2013).

World Health Organization. (2013). Meeting to Develop Global Consensus on Preconception Care to Reduce Maternal and Childhood Mortality and Morbidity, report of meeting on 6–7 February 2012. Geneva: WHO.

World Health Organization. (forthcoming a). Nurturing Human Capital along the Life Course: Investing in Early Childhood Development, report of meeting on 10–11 January 2013. Geneva: WHO.

World Health Organization (forthcoming b) Caring for the Healthy Child’s Growth and Development, materials package. Geneva: WHO.

World Health Organization. (online a). Health Topics – Millennium Development Goals. Available at: http://www.who.int/topics/millennium_development_goals/en/ (accessed April 2013).

World Health Organization. (online b). Programmes and projects – Global Health Observatory. Available at: http://www.who.int/gho/child_health/mortality/mortality_under_five_text/en/ (accessed April 2013).

Notes

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.