Cultural And Contextual Considerations in Designing Programs to Support The Incorporation of Early Childhood Development Within Ongoing National Nutrition Programs: A Focus on the Baby-Friendly Community Initiative (BFCI) in a Rural African Context
- Open Access
- 31-07-2025
- Original Paper
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Abstract
Delen
The Baby-Friendly Community Initiative (BFCI) is a global strategy recommended by the World Health Organization (WHO) to promote optimal maternal, infant and young child nutrition (MIYCN) at the community level (World Health Organization & UNICEF, 2018). The Baby Friendly Hospital Initiative (BFHI) (WHO Technical Staff, 2013; World Health Organization & UNICEF, 2009), the precursor to the BFCI, was adopted by Kenya in 2002 as an effective intervention for promoting optimal breastfeeding practices. However, the BFHI was found to have limited reach as more than half of the targeted women, particularly the very poor, delivered at home. The BFCI, which applies the principles of the BFHI and extends the follow up and care of the mother and child to the community, was adopted by the Kenyan government in the 2007 Infant and Young Child Feeding (IYCF) Strategy. The implementation guidelines were adopted in 2016, and the BFCI has been successfully implemented in several counties (Kavle et al., 2019; Kavle & Ahoya, 2019; Ministry of Health (MOH) Kenya, 2016). The principal objectives of the BFCI are to increase the proportion of babies who are exclusively breastfed, and to sustain breastfeeding after six months alongside the introduction of complementary foods.
The implementation of the BFCI fits well within the existing community health strategy (CHS) in Kenya that relies on a vast network of community health volunteers (CHVs) to promote healthcare at the community level (Ministry of Health Kenya, 2007). CHVs, each of whom is assigned between 10 and 100 households, are trained on various aspects of healthcare and are empowered and facilitated with knowledge, skills and job aids to provide home-based counseling to pregnant women and mothers of infants and young children (Ministry of Health Kenya, 2007). The active involvement of families and community members within such a community-based structure ensures that mothers receive adequate support and encouragement to exclusively breastfeed (Lassi et al., 2016). The BFCI thus catalyzes the creation of a strong link between healthcare service providers at the facility level and the community. Kimani-Murage and colleagues (2015; 2021) note that as the BFCI is designed to work within an existing health system where CHVs receive mentorship and supportive supervision from higher level cadres such as community health extension workers (CHEWs), it means that minimal resources are required which makes it amenable for implementation within resource-constrained settings.
In Kenya, as in many sub-Saharan African settings, young children in resource-constrained contexts live within home environments in which they may not receive opportunities for stimulation; this is likely to hamper the achievement of their developmental potential (Black et al., 2017). As early stimulation among young children is a strong determinant of future outcomes (Walker et al., 2015), it is important to ensure that these children receive the best possible chance for optimal development. Integrated interventions addressing both early child development and nutrition are essential for improving infant and young child outcomes (Grantham-McGregor et al., 2014; Powell et al., 2004; Walker et al., 2015). The home setting in which routine everyday activities unfold is one of the social environments which health workers could leverage to deliver integrated programs, with the support of family members (Christensen, 2004). Some of the advantages of integrating nutrition and ECD programs in the first two years of life are: a) it is a logical way of addressing nutrition and ECD needs given that physical growth and development occur simultaneously; b) it is possible to use the same personnel, the same platforms and the same touch points which leads to efficiencies and synergistic effects; c) it eases the burden of participation by caregivers as the opportunity costs may be prohibitive; d) it is easier for programs to communicate and repeat appropriate messages which increases chances of internalization by caregivers (Maalouf-Manasseh et al., 2015). The sixth step of the BFCI ‘encourages mothers to continue breastfeeding their children up to two years and beyond, in conjunction with the appropriate, adequate and safe complementary feeding while providing holistic care and stimulation of the child.’ This stipulation makes the BFCI ideal for incorporating messages from the Care for Child Development (CCD) package (World Health Organization & UNICEF, 2011), alongside feeding, health and nutritional messages. The recommendations within the CCD package provide ideas for play and communication activities to help children learn and grow, and help caregivers feel more important in the lives of their young children.
The African Population and Health Research Center (APHRC) conducted a pilot study from 2014 to 2016 to determine the feasibility and effectiveness of the BFCI in Kenya (Kimani-Murage et al., 2015). The study was conducted in Koibatek sub-County in Baringo County, Kenya where the BFCI has been established by the Ministry of Health (MOH). The results of the study indicated that the BFCI was effective in promoting infant breastfeeding and complementary feeding as well as in improving maternal and child health outcomes in a rural setting (Kimani-Murage et al., 2021). The results also showed that counselling by CHVs and support received through monthly group meetings enhanced women’s skills and competence in infant feeding which in turn led to better practices. Studies in other low- and middle-income as well as high-income countries have reported similar results (Bettinelli et al., 2012; Cattaneo et al., 2016; Kavle et al., 2019; Maingi et al., 2018).
The Kenyan MOH as well as other sector stakeholders seeks to support the holistic development of young children. In view of this, they questioned the focus on nutrition and health status alone by child health programs, such as the BFCI, with no attention being paid to any aspect of child stimulation and early learning opportunities. However, there is a generalized lack of knowledge around the cultural and contextual factors that need to be considered in the design of programs to support ECD, particularly in rural Kenya. The recognition of the BFCI as a unique platform for integration of IYCF messages into other health areas and offering opportunities for counseling families around ECD has been highlighted in the past (Kavle et al., 2019). Further, during an inception meeting for the study reported here, a policy stakeholder noted that integrating ECD into the BFCI would have an impact on child growth and development and it is therefore important to take advantage of such an opportunity.
A recent review noted that some of the programmatic issues in implementation of programs that incorporate ECD into healthcare delivery are that training focuses on improving competence and knowledge rather than successful integration (Ahun et al., 2023). Eliciting perspectives of different beneficiaries provides a wholistic picture in the considerations to be made in the implementation of an integrated program based on their own experiences. It is therefore necessary to understand how to efficiently deliver a program to enhance child stimulation using an existing national health and nutrition program, such as the BFCI. The follow-up study reported in this paper hence sought to determine the feasibility of integrating counselling on child stimulation into the BFCI activities in Kenya. The study had the following specific aims: 1) To describe participants’ current ECD knowledge, attitudes and practices; 2) To understand how local contexts and cultural factors influence child development and nurturing care practices; 3) To understand user, stakeholder and service provider needs for incorporating parental support for nurturing care into the BFCI; and 4) To explore opportunities for and existing gaps in program implementation.
Methods
Study Design
The feasibility study which is reported on here was qualitative in nature. An ecological approach was used to assess the social context in which the intervention operated. This study was an extension of the earlier BFCI study that was conducted in Koibatek sub-County of Baringo County in the North Rift region of Kenya between 2014 and 2016 (Kimani-Murage et al., 2015; Kimani-Murage et al., 2021). The data for the feasibility study were collected in July 2018, before this project undertook training on the CCD modules with local healthcare workers.
Researcher Description
The authors comprised the research team. PK-W, TM, KO, EK, PM, SO, JK, MW, EWK-M are Kenyan nationals who have been involved in extensive work in various rural contexts and are familiar with the issues that these communities face. In particular, PM, JK, MW and EWK-M were part of the earlier BFCI study and were therefore conversant with the cultural nuances of the region having been immersed in the study context for about two years. EH and PG are experts in children’s healthy development and global health, respectively, and are from the United Kingdom. Whereas this was the first such study that EH was involved in, PG was part of the earlier study and has been involved in similar work in other parts of rural Kenya. Our study was designed to elicit contributions from a wide range of participants and overall, we believe that knowledge about our professional background did not impact participants’ willingness to talk about their experiences.
Study Site and Participants
Koibatek sub-County is one of the six sub-counties in Baringo County. Baringo County is one of the 47 counties in Kenya and is among the largest counties in Kenya. About 80% of the county is arid or semi-arid, with an overall poverty rate of 39.6% which means it is characterized as being highly disadvantaged. The total population in 2014 was listed as 125,637 with 24% (30,203) being women of childbearing age (15–49 years), and 4% (4799) being children aged under one year. The sub-County is inhabited by the Tugen people, a Nilotic group whose main occupation and economic activity is mixed farming. The stable economic situation in the sub-County makes it relatively more secure than the surrounding sub-counties. There are 32 public health facilities within Koibatek sub-County of which 26 are dispensaries, five are health centers and one is the sub-County or District Hospital. The sub-County has one medical consultant, six medical doctors, 31 clinical officers of various specialties and 132 nurses. There are three nutrition officers serving the entire sub-County. Slightly more than half (53.8%) of the deliveries in the entire county are assisted by a skilled health professional (Kenya National Bureau of Statistics (KNBS) et al., 2015).
Participants were selected from community health units to which specific CHVs are attached. A community health unit is a health service delivery structure within a defined geographic area (equivalent to a village or sub-location) covering a population of approximately 5000 people. Each unit is assigned two CHEWs and CHVs who offer promotive, preventative and basic curative services. There are 13 community health units in Koibatek sub-County (Solian, Simotwet, Esageri, Kiptuno, Toniok, Tugumoi, Timboroa, Makutano, Poror, Shauri, Arama, Torongo and AIC). Each of these community units is linked to a health facility and participants were selected across all of them.
The feasibility study included women of reproductive age (15–49 years) who had all participated in the earlier BFCI study and with children aged between 0–36 months. Children’s primary caregivers who were mostly their biological mothers that were involved in the BFCI programming were considered the ‘users’ in the current report. Whereas fathers and grandparents who were also considered users were not direct recipients of the BFCI programming, they were involved in the community support groups through which the BFCI operates and indirectly supported mothers. Participants at the community level included CHVs (service providers), village elders, other community leaders including chiefs, women leaders, youth leaders and religious leaders (stakeholders). At the national and sub-national levels, we included members of the sub-County Health Management Team (SCHMT; considered as both service providers and stakeholders), and ECD stakeholders including government officers from the MOH, Directorate of ECD services and institutions providing ECD services. Purposive sampling was used to identify specific insights and trends among the eligible participants who were recruited based on the objectives of the study (Palinkas et al., 2015). The research team used their judgment to select the participants that were deemed to be information-rich and that would best contribute to the objectives of the research. We determined that an adequate sample size for each participant group had been achieved when the data saturation point was reached, that is, no additional issues or insights were identified and the diversity, depth and nuances of the issues under study had been captured (Hennink et al., 2017).
As shown in Table 1, participants across all the groups were mostly women and almost all of them were married. More than 80% of the participants in the key informant interviews (KIIs) had completed tertiary education and a similar proportion was employed. Seventy percent of the participants who were included in the in-depth interviews (IDIs) had completed primary school and 50% were employed. Mothers who participated in the focus group discussions (FGDs) were aged between 23 and 37 years. They had varying levels of education, with almost 63% having attained the primary school level. Eighty percent of the participants in the FGDs with fathers had completed primary school and 80% were engaged in activities such as farming. Almost three-quarters of the grandmothers who were involved in the FGDs had no education. Five out of the six participants in the FGD with CHVs were engaged in farming activities. They were aged between 31 and 47 years.
Table 1
Participant characteristics
KIIsa N = 37 | IDIs N = 6 | FGDs | ||||
|---|---|---|---|---|---|---|
Mothers N = 16 | Fathers N = 15 | Grandmothers N = 14 | CHVs N = 6 | |||
Age range (years) | 28–57 | 26–65 | 23–37 | 26–70 | 60–79 | 31–47 |
Age, N (%) | ||||||
20–29 | 4 (10.8) | 1 (16.7) | 11 (68.8) | 4 (26.7) | – | – |
30–39 | 8 (21.6) | 4 (66.7) | 5 (31.2) | 5 (33.3) | – | 1 (16.7) |
40–49 | 14 (37.8) | – | – | 5 (33.3) | – | 5 (83.3) |
50+ | 6 (16.2) | 1 (16.7) | – | 1 (6.7) | 14 (100) | – |
Marital status | ||||||
Single | 2 (6.7) | – | – | – | – | – |
Married | 30 (81.1) | 6 (100) | 16 (100) | 15 (100) | 14 (100) | 6 (100) |
Gender | ||||||
Female | 24 (64.9) | 5 (83.3) | 16 (100) | – | 14 (100) | 4 (66.7) |
Male | 13 (35.1) | 1 (16.7) | – | 15 (100) | – | 2 (33.3) |
Education level | ||||||
None | – | – | – | – | 10 (71.4) | – |
Primary completed | 5 (13.5) | 4 (66.7) | 10 (62.5) | 12 (80) | 4 (28.6) | 2 (33.3) |
Secondary completed | 1 (2.7) | 1 (16.7) | 3 (18.7) | 3 (20) | – | 4 (66.7) |
Tertiary | 31 (83.8) | 1 (16.7) | 3 (18.7) | – | – | – |
Occupationb | ||||||
Employed | 30 (81.1) | 3 (50) | 1 (6.2) | – | – | – |
Self-employed | 3 (8.1) | 2 (33.3) | 11 (68.8) | 3 (20) | – | 1 (16.7) |
Other | 4 (10.8) | 1 (16.7) | 2 ((12.5) | 12 (80) | 14 (100) | 5 (83.3) |
None | – | – | 2 (12.5) | – | – | – |
Data Collection Tools and Procedures
During the feasibility study, we conducted FGDs and IDIs with users (caregivers including fathers and grandmothers) and service providers (CHVs); and KIIs with service providers (SCHMT members) and other stakeholders. Qualitative interview guides which comprised open-ended questions were used with users and service providers to capture information on breastfeeding and young child feeding practices, knowledge, attitudes and practices on ECD and early stimulation to provide an understanding of how local contexts and prevailing cultural factors influence child development and nurturing care practices. We also explored user/ stakeholder/ service provider needs in incorporating nurturing care into the BFCI by capturing information on needs at household, community and societal levels. In addition, we asked users, stakeholders and service providers about strategies that they thought could be used to meet these needs. To enhance our understanding of the opportunities for and gaps in program implementation, we asked service providers about their experiences with other related programs. We also asked service providers and other stakeholders about potential barriers to and facilitators of implementation of an intervention that sought to incorporate parental support for nurturing care into the BFCI. Table 2 provides examples of some of the questions that were used during the interviews.
Table 2
Examples of questions used for the different participant types
Participant type | Question | Probes |
|---|---|---|
Users | What is your role in caregiving to young children? | - Child protection - Ensuring adequate nutrition - Early learning - Good health - Responsive caregiving |
What is the caregiving role of other family members? | - Role of fathers in caregiving - Role of grandmothers in caregiving - Role of siblings in care giving to young children - Role of others in caregiving (aunts, uncles etc.) | |
How are men involved in caring for young children in this community? | - Types of activities in the home - Types of activities outside the home | |
What information have you received regarding early childhood development? | - Developmental milestones - Responsive care and stimulation - Protection and rights - Care for children with developmental delays - Nutrition and immunization | |
Please tell me what you know about the Baby Friendly Community Initiative (BFCI) | ||
Which other methods do you think could be used to deliver services to support the growth, development and learning of children 0-36 months? | ||
Service providers | Could you tell us what your role as a community health worker is, regarding early childhood development? | Type of services provided |
What are the key messages you share with expectant mothers during home visits? | - Nutritional needs - Skilled delivery - Use of mosquito nets - Screening services | |
What early childhood projects that integrate child development in community-based interventions have you been involved in before? | - Timing of project - Types of activities | |
What do you think could be done to empower community health workers in their role to increase caregivers’ access to child healthcare services? | - More trainings - Incentives - Facilitation | |
What information/training do you provide as an institution/organization to enhance caregiver-child interaction and responsive caregiving? | - Content - Nature of the training | |
What kind of cultural beliefs about caring for young children have you come across in this community? | - How they were dealt with | |
What challenges, have you faced in improving the health, developmental and nutritional status of children? | - Systemic challenges - Operational challenges - How challenges were dealt with | |
What programs do you have in this institution that enhance early stimulation in young children? | - Training of caregivers - Training of CHWs - Home visits | |
What information/training do you need as a healthcare provider to help you enhance caregiver-child interaction and responsive caregiving? | - Content - Nature | |
Stakeholders | Please tell me about the National Plan of Action for early childhood development in your ministry | - Funding status - Priorities |
What are the barriers to successful implementation of ECD activities and programs? | - Policy - Structural - Financial | |
What are the facilitating factors for successful implementation of ECD activities and programs for children aged 0 – 36 months? | - Policy - Structural - Financial | |
How best, in your opinion, do you think the BFCI can contribute to the development of optimal child growth and development of children aged 0–36 months? |
Qualitative data collection was carried out by six interviewers with college-level education (at least three years post-secondary education level which takes 12 years to complete) in the fields of social science, education, ECD or health, and with experience in conducting qualitative interviews. They were also required to have had previous experience in data collection in the area of interest. All data collectors were expected to be fluent in both English and Kiswahili as well as the local language. They were also residents of the study area. After recruitment, data collectors were trained by the research team in line with APHRC’s standards in a one-week training course on ethical issues, data collection procedures, and data quality. This training was both information and problem-solving based. During the training session, the research and data collector teams reflected on expectations and assumptions around the research and the study participants, given that this was a highly disadvantaged setting, and participants may have expected some direct benefits from participation.
Qualitative interviews were conducted as follows: seven FGDs with users (including two with mothers with children under the age of 36 months, two with fathers only and two with grandmothers) and service providers (one FGD with CHVs); 37 KIIs with stakeholders (such as county and sub-county officers in the Children’s and ECD Departments) and service providers (ECD center providers and teachers, CHVs, organizations working within the ECD sector, nutrition and community health strategy departments); and, six IDIs with service providers (CHVs) and users (mothers, fathers and grandmothers). This information is summarized in Table 3.
Table 3
Number of interviews conducted per participant group
Type of interview | Participant group | Number of interviews |
|---|---|---|
Focus group discussions | Mothers (users) | 2 |
Fathers (users) | 2 | |
Grandmothers (users) | 2 | |
CHWs (service providers) | 1 | |
Key informant interviews | ECD center providers (service providers) | 13 |
ECD teachers (service providers) | 13 | |
CHVs (service providers) | 3 | |
ECD organization (stakeholders) | 1 | |
County officials (stakeholders) | 2 | |
Sub-County officials (stakeholders) | 5 | |
In-depth interviews | CHVs | 3 |
Users (including mothers, fathers and grandmothers) | 3 |
The FGDs, which had between six and eight participants, were conducted face-to-face in a group setting while the KIIs and IDIs were done in-person on an individual basis. The FGDs and IDIs were led, guided and monitored by a trained moderator who was a member of the data collector team. During the FGDs, the moderator was accompanied by a note-taker whose role was to welcome the participants, audio record the interviews and take notes. The notes highlighted participants’ comments and non-verbal gestures that added more meaning to the responses. The trained data collectors were aware that the respondents were the ‘experts’ on the study topic and were mindful of being ‘outsiders.’ They adopted a ‘back seat’ approach where respondents were given an opportunity to exercise a measure of control over the interview process and take the lead in ‘setting the pace’ of the interview.
The KIIs were conducted by a member of the research team. The research team was aware that policy stakeholders could have been biased towards a particular issue (not related to the research purpose) during the discussions and therefore emphasized the purpose of the research prior to the interviews and through the questions and probes used. The FGDs, which ranged in duration from 90 to 120 min, took on average about 100 min to complete, while the IDIs and KIIs which took between 45 and 90 min were on average 60 min long.
Appointments were made beforehand, and efforts were made to ensure that the venues used were accessible, comfortable, private, quiet and free from any distractions. Before the interviews began, the moderator established the language with which the participants were most comfortable. Each participant received reimbursement for the costs incurred for transportation to the interview venue. All the interviews were audio recorded.
During data collection, the team members that were most closely involved in fieldwork met once a week to discuss the progress of fieldwork and reflect on any issues arising from the process. Two members of the research team (SO and PK-W) accompanied by a member of the fieldwork team conducted a two-day spot-check and supervisory visit in various community units (CU) within the sub-county to monitor the progress in and quality of data collection.
Ethical Considerations
The study received ethics approval from the Amref Health Africa’s Ethics and Scientific Review Committee (ESRC) after internal review at the APHRC. We also received permission to conduct the study from the National Commission for Science, Technology and Innovation (NACOSTI) before the study began. A rigorous community mobilization process was followed to inform the community and the caregivers who had participated in the earlier study. Permission to conduct the study was sought from community chiefs and village elders. In addition, individual informed consent was sought and obtained from all adult participants following full disclosure regarding the purpose of the study and the procedures involved. Written informed consent forms were signed by the study participants. For those that could not read, oral informed consent was obtained. Women aged between 15 and 17 years old who had children were considered emancipated minors and underwent the informed consent process like the others. During and at the end of each interview, the data collection team took time to ensure that participants were not feeling distressed by their participation and none of the participants appeared uneasy or distressed.
Data Analysis
One of the goals of data analysis was to identify common themes that emerged across the different participant groups, and to uncover similarities and differences in their experiences. We therefore used a systematic comparative analysis approach across the different participant groups to explore the themes. The data were analyzed using the Framework Method process outlined by Gale and colleagues (2013). The Framework Method was useful as the research team was multi-disciplinary in nature, and not all members had experience of qualitative data analysis. The research team worked collaboratively in the analysis and interpretation of the data. All the interviews were transcribed verbatim and concurrently translated into English.
Using an abductive approach (Thompson, 2022) which offered flexibility in coding, we coded the data using pre-defined codes that consisted of ideas, concepts, behaviors and interactions in order to classify all the data and make them easier to organize and retrieve. Additional codes were developed based on observed patterns for those data that did not fit under the pre-defined codes.
We combined consensus and split coding methods at different stages of the analysis (Richards & Hemphill, 2018). In the early stages, an independent researcher coded all the transcripts. The same transcripts were then coded by two members of the research team (PM and MW) who ensured coder consistency in application of the codes before they finalized the codebook. They compared the transcripts on a one-to-one basis and reviewed the journal. In some cases, multiple codes were assigned to text during the coding process which enabled the research team to understand the data in multiple ways. The amount of text to which codes were assigned varied from a single phrase to an entire paragraph – this was especially in the case where the participants restated a similar idea in various ways or provided examples. Disagreements in the coding were dealt with through discussions and debate on the material being coded until a consensus was reached. During the later stages of analysis, the research team convened a two-day data review meeting away from the interruptions of the office environment to discuss emerging themes and codes and get a sense of the emerging data. Members of the research team independently coded transcripts that had been assigned to them. After coding the first few transcripts, the research team met to compare the labels they had applied and agreed on a set of codes to apply to all subsequent transcripts.
A list of key ideas was then developed by grouping the codes into categories to explain the findings guided by an explanatory framework which was informed by the derived data. After coding, patterns of meaning (themes) were identified and connections were made to facilitate a systematic comparison (Gale et al., 2013). The themes were compared to the dataset to ensure that they were accurate representations of the data. At the final stage, a matrix was developed, and the data were summarized from each transcript by category (charting). The chart included interesting or illustrative quotations that facilitated recognition of patterns in the data by any member of the research team and enabled description of the data using the participants’ own subjective frames and expressions. Supplemental checks of the data were made by confirming with seven participants who were involved in the KIIs that the data resonated with their experiences and those of community members.
Apart from being a practical way to reduce and interpret the data, one advantage of the Framework Method is that it enabled all members of the research team to engage with the data and offer their perspectives during the analysis process without having to read all the transcripts. Another advantage is that as it is not aligned with a particular epistemological viewpoint or theoretical approach, it can be adapted for use in a combination of inductive and deductive analysis methods.
Results
Most of the quotes that were used in the results section reflected the patterns in the data. In some cases, we included discrepant examples to illustrate the divergence of views around a particular issue. The selected quotes were also distributed across participants in order to provide a representative dataset. For each quote, we have provided contextual information indicating which specific community health units the participants were from.
The themes identified from the data were categorized under four main headings to align with the aims of the study: (i) Varied understanding of ECD informed by personal experiences; (ii) Care practices in the context of traditional and religious beliefs; (iii) User, stakeholder and service provider needs for incorporating parental support for nurturing care into the BFCI; and, (iv) Opportunities for and existing gaps in program implementation. The first main heading provided information on the study context in relation to ECD knowledge, attitudes and practices. The sub-themes under the second main heading included cultural factors that influence child development and nurturing care practices. Under the third main heading, the sub-themes included household, community and societal needs; and strategies and recommendations for incorporating parental support for nurturing care into the BFCI. Under the fourth main heading, themes were concerned with potential facilitators and barriers to program implementation.
Varied Understanding of ECD Informed by Personal Experiences
It was important to obtain an understanding of the characteristics of the study context, including awareness of existing knowledge, attitudes and practices around ECD and early stimulation. Understanding this enabled us to determine what knowledge and attitudes caregivers had about ECD, and the practices they engaged in at the time of the study. In addition, this information also enabled us to establish existing gaps which provided the basis for considerations of what to include in a training package on CCD within the Kenyan context in order to effectively integrate support for nurturing care.
The concept of ECD had different connotations for various participants. As shown in Table 4, primary caregivers seemed to have a broad understanding of ECD but focused more on physical growth, appropriate feeding and good health. Some mothers equated child development with achievement of milestones like walking and talking (see IDI, mother). On the other hand, fathers were less involved and their understanding of ECD was in terms of a child’s ability to communicate different needs (see IDI, father). CHVs had similar understanding as primary caregivers and believed that nurturing care covered aspects of children’s physical growth from conception to delivery, and appropriate care (see FGD, CHVs). They recognized the importance of ECD for later development as they noted that children who received optimal care were likely to do well when they got to school (see IDI, CHV). One of the policy implementer’s perspective reflected a needs-based approach to ECD, emphasizing the critical developmental milestones of children under five years of age (see KII, Policy Implementer).
Table 4
Knowledge, attitudes and practices on ECD
Concepts (sub-themes) | Illustrative quotes | |
|---|---|---|
Understanding of what ECD encompasses | Users (primary caregivers/ mothers, fathers and grandparents) | “We are told when a child reaches around 6 months s/he starts to sit down; when s/he reaches 9 months, s/he starts to stand; and then after there, s/he starts to grow teeth; …then 9 months to 12 months, s/he will start standing properly and start walking slowly and then when it reaches 1 year to about 1 and a half, that is when s/he walks properly … s/he starts speaking one word until when s/he will speak properly.” IDI, mother, Simotwet |
“Most of the time through crying you will know the child has a problem, if not hunger, she/he is very full or she/he is…, as a parent you will have the responsibility of asking yourself what it is the child needs through crying.” IDI, father, Tugumoi | ||
Service providers | “I can say ECD is raising the child from when she/he is born and to continue until she/he reaches 5 years.” FGD, CHVs | |
“I believe that from when a mother is pregnant until she delivers and adheres to the instructions which we or the doctor gave …. When the child is born, she should adhere as recommended. The child is to be breastfed for 6 months and given a balanced diet for 2 years while breastfeeding. When s/he reaches 5 years you will see their importance to the growth of a child.” FGD, CHVs | ||
“I think it is good because these children if they grow in a proper way and they receive good upbringing, even in school they get to know. You can see the child grows very fast. The growth of those children who have received proper upbringing is okay… proper way and even brains… you can see they grasp things; they grasp things well because diseases are not frequent.” IDI, CHV, Solian | ||
Stakeholders | “Okay … for early childhood development as we all understand that these are children who are still under-fives and under-fives are children who are supposed to attend clinic services. Most of them go to school to play and learn a few things.” KII, Policy implementer | |
Benefits of play | Users (primary caregivers/ mothers, fathers and grandparents) | “There are those that can play with the child in a bad way but as a parent I will play with them such that they will be active. They might become stupid if I don’t play with them.” “Playing with them, teaching her/him if it is a sheep you tell her/him this is called this, show her/him this is called this, this is a particular thing, like that. She/he will know this is this and this.” “They (siblings) help when you have a lot of chores, they hold the baby, they cuddle them, and they can also feed them.” FGD, mothers, Shauri |
“Play helps the children to grow intellectually, to develop muscles and the bones. It will make the child to grow properly, even the mind develops, she/he will think properly when playing and also it helps her/him in the proper circulation of blood…. …I smile at her/him like this, I show her with hand gestures, jumping, soothing her like this, throwing her up and making her sleep like this. You show the child that you are happy during playing, during singing, during dancing. The child will know that it is time for dancing, you show her/him like this, during clapping, you show her/him with the hands.” IDI, Mother, Simotwet | ||
“Something else I have taught myself, when a child is playing, as a parent, you are supposed to be playing together. You teach the child, you play together, and the child will be happy and will think positively about you … when you arrive home, the children run to you. You will also have a good relationship between you and the children. When the children see you, they will know that this is their father…because it is good you talk with the child and it follows, I mean, it becomes possible to… discipline them.” FGD, fathers, Arama | ||
Service providers | “I think you also take time to play with your children, at least to play with the child, you can introduce games, that is when the child will start to play also.” FGD, CHVs | |
“…is to talk to the children, to take them to church, to buy for them balls so that they play with, so that they develop well.” KII, ECD center provider, Torongo | ||
Stakeholders | “Of course, for children apart from the play items… they need to play more especially at that young stage, instead of giving them a lot of activities like go to school and learn so many things that is not of interest for them at that moment. They can be given enough time to play, play with the toys, even play with the mud, whichever at least to exercise their brain at that young age.” KII, Policy implementer | |
Opinions about adults interacting with children | Users (primary caregivers/ mothers, fathers and grandparents) | “When we play, we don’t say that we are really playing a real game that has been played since… If the child runs up to where are, you run also, and the child chases you. Yes, it is a game like that. It does not have to be a game where we kick a ball. As soon as you see the child running towards you, you know that you begin running. And when you start running, the child starts laughing and you will have played with the child that time.” FGD, fathers, Shauri |
“I think it is not good because there are some games where children get thrown up in the air and someone might not catch the child, and they drop on the ground by mistake. The child might get hurt or they can pass out.” FGD, mothers, Shauri | ||
Service providers | “Of late there is a worry about the interaction of children with other people. There are areas that have liquor dens and children can be abused there because the father is not around, and the child might be taken by someone. Sometime back, there were concerns over the incidences you hear about people committing funny things to children. Almost three years ago I heard once or twice a small child had been raped.” KII, ECD center provider, Shauri | |
Stakeholders | “I would recommend, especially at the household level that household members be educated on the small…activities that they can do with their children to grow and also to be given that knowledge on some of those things they can do to their children to trigger growth at household level.” KII, policy implementer | |
Importance of communication with young children | Users (primary caregivers/ mothers, fathers and grandparents) | “You must talk to a child that is still small, even if he does not understand … you also show him any signs, you tell him, until eventually this child grows to understand everything.” FGD, fathers, Arama |
“It is important, it is important as a parent to speak with my child, so that it is possible to teach them things that, many things because there are things that may be there, even if I teach how a cow is cared for or how work is done, so it is important I talk to the child so that I can teach-teach things slowly.” FGD, fathers, Arama | ||
“For a child from 1-3 years, you talk with her/him, you speak to her/him words, s/he will start knowing because at least she/he is starting to utter one word. You tell her/him …cow, goat, things that s/he can see, you communicate with her/him “that is a cow,” “that is a goat,” “that is a cat.” S/he will be able to communicate well.” IDI, mother, Simotwet | ||
Service providers | “…There are some parents who are ever busy, so they don’t have time to raise the child. Most of the time the child will come here when they don’t know how to talk, and they will start to talk because s/he has interacted with others. There is improvement in that child, and he/she will start to talk if he/she was not talking.” KII, ECD teacher, Timboroa | |
Importance of learning through play | Users (primary caregivers/ mothers, fathers and grandparents) | “I teach them about God and singing. I also teach them the alphabet i.e. (A, B, C, D). They rehearse. We also pray. When you are with them, you teach them such stuff. Every evening, the children I stay with tell me to go and sing with them in the sitting room. Our main activity there is to sing, jump and pray. I pray for them in Swahili since children nowadays are speaking in Swahili.” FGD, grandmothers, Makutano |
Stakeholders | “An example of what we want to do is that we want to introduce play in schools and when these children play, they are able to socialize. We are again bringing the music and movement from a long time ago, remember those people used to drum, sing, recite which nowadays is not there. Through that, these children learn socialize, they learn to express themselves.” KII, Policy implementer | |
Primary caregivers, mostly mothers, recognized the importance of play and actively engaged their children in various play-based activities. Their approach to play was shaped by available resources, cultural norms and daily routines. Caregivers used play as teachable moments incorporating physical activities (throwing objects, clapping, dancing); cognitive stimulation (singing songs, counting numbers, storytelling, naming objects) (see FGD, mothers); and social interaction (singing songs, structured ‘serve and return’ tasks like passing balls). Some of the play activities reported seemed to be incidental or occurring naturally as they took place during routine day-to-day activities (see IDI, mother).
While mothers acknowledged the importance of play, some reported limited time due to household and other responsibilities. House helps and older siblings often stepped in to bridge the gap, ensuring children receive consistent engagement (see FGD, mothers). Some of the primary caregivers (see IDI, mother), CHVs (see FGD, CHVs) and ECD center providers (see KII, ECD center provider) generally recognized the importance of adults playing with young children as it fostered bonding, stimulation, and skills development. Conversely, some respondents including mothers (see FGD, mothers) and ECD center providers (see KII, ECD center provider) expressed concerns about certain risks such as accidental injuries and child protection issues associated with adult involvement in play. Fathers involved in the FGDs reported that they engaged in physical play, pretend play, storytelling and verbal and non-verbal interactions. Unlike mothers, fathers emphasized disciplinary communication, using play as a teachable moment for behavioral guidance. Similar to mothers, fathers postulated that engaging in play activities with the child fostered bonding and improved their relationship (see FGD, fathers).
Grandmothers played a critical role in early motor development, assisting children in learning how to walk by holding their hands and massaging their legs. Grandmothers also reported that they provided toys, and structured activities such as beating drums, singing songs and teaching the alphabet and religious messages (see FGD, grandmothers). Their caregiving approach blended traditional practices with interactive learning.
One of the ECD center providers indicated that children exposed to consistent verbal interactions in childcare facilities showed improved vocabulary and communication skills. The structured environment provided opportunities for peer interaction, which further supported language acquisition (see KII, ECD teacher). Grandmothers and policy implementers highlighted the critical role of play in early learning (see KII, policy implementer).
Although participants expressed diverse understanding of ECD and early stimulation, their interpretations were largely shaped by personal caregiving experiences and interactions with CHVs. Despite the variation, common threads emerged across respondents, reflecting a shared appreciation for nurturing care during early childhood. Assessing current levels of ECD knowledge, attitudes and practices among participants provided a good starting point for identifying key gaps in information and behavior. These are critical considerations in the incorporation of nurturing care into the BFCI.
Care Practices in the Context of Traditional and Religious Beliefs
We sought to establish contextual and cultural influences on child development and nurturing care practices and the extent to which participants perceived those practices as promoting nurturing care. Contextual influences refer to the environmental and economic conditions while cultural factors encompass shared practices, values and beliefs.
Several traditional beliefs and practices reported by participants were found to influence the care of young children, with implications for incorporating parental support for nurturing care into the BFCI (Table 5). These beliefs spanned various domains including adult-child interactions, infant feeding, the use of traditional medicines and general caregiving. Some reflected deeply rooted gender norms that prescribed differential treatment of boys and girls. While a number of these practices were potentially beneficial or culturally symbolic, others posed risks to child wellbeing. Several beliefs were invoked to explain events that lacked a clear or scientific cause, highlighting the importance of contextual understanding when designing culturally responsive interventions.
Table 5
Traditional beliefs and practices
Concepts (sub-themes) | Illustrative quotes | |
|---|---|---|
Use of traditional concoctions | Users (primary caregivers/ mothers, fathers and grandparents) | “When grandmothers of small children come to visit a child and see their health is not good, they say that the child needs to be given medicine …old medicine, that is traditional medicine. They go to the forest to look for the medicine for the child so that he/she gets good health.” FGD, fathers, Arama |
“You know mostly; mostly for grandmothers it is herbs and milk because they know that us we can easily feed the child when he/she is still small.” IDI, grandmother, Simotwet | ||
Service providers | “Culture affects the lives of children. …There are people who use traditional medicine from the time the child is young. When the child vomits there is medicine the child is supposed to be given. When a mother gives birth … they give the child ash. This ash is not what the doctor prescribed; it is traditional. You don’t know if the child will react to the ash. If you give the child and the reaction is positive, then the ashes are considered okay. If there is a negative reaction, you will give him/her more.” KII, ECD teacher, Timboroa | |
“The culture over here is children under six months must be given traditional medicine and it is very hard to tell them to stop. While they are told that the child is supposed to be breastfed for six months, they say that the child must be given herbal medicine.” KII, ECD center provider, Simotwet | ||
“Yes, so these grandmothers will make sure that these young kids are given some herbs. They believe that they help in their growth, of which we discourage but we cannot force them. We are trying to encourage them and tell them the importance of not initiating these herbs as early as that.” KII, CHEW, Kiptuno | ||
‘Bad’ eye | Users (primary caregivers/ mothers, fathers and grandparents) | “You may find the child crying overnight, and you are told the child is crying because someone who is not good came and looked at him with a ‘bad eye.’ … it is better for the child to stays indoors; the child should not be brought outside.” FGD, fathers, Arama |
Service providers | “You find some people saying someone with a ‘bad eye’ has looked at my child. Maybe someone made a visit and the child became sick, so there will be questions and domestic squabbles. …they believe that someone might have bewitched their child.” KII, healthcare provider | |
Gender socialization | Service providers | “…when their children are small, some parents do not want to wrap them, if they are boys. They say that male children are not wrapped. … a parent leaves the child to mess himself as she does not want to wrap the child.” KII, ECD provider, Timboroa |
Perceptions on gendered roles | Users (primary caregivers/ mothers, fathers and grandparents) | “When the child is young, under 3 years, there is nothing much we can contribute. Mostly it is the woman who does that work. We men are not at home the whole day, and most of the time we come back in the evening. That is when you can spend some time with the child. When you arrive, you hold her/him, let’s say when the mother has gone to prepare food. However, most of the time we do not have time with the child. If the mother tells you that the child needs some items or that their health is not good, that’s when you think of how you can help. Most of the time, when the child is okay, we do not consider it our responsibility when the child is at that age.” IDI, father, Toniok |
Service providers | “I think maybe they usually think a child belongs to the mother, so it is the responsibility of the mother to take care…” KII, ECD Teacher, Makutano | |
“Yes, most of them because if it is the father that is at home he thinks that the mother is supposed to go with the child. The mother is supposed to go because it is her child.” KII, ECD teacher, Simotwet | ||
Stakeholders | “You find that culture especially in this community where we come from, majority of the people in Koibatek …are Kalenjins. Kalenjins have their own culture. When we talk about supporting the mother to the health facility, they don’t believe in that. They know whoever is supposed to be with the mother especially when expectant or even when carrying this baby is the mother in-law or the sister in-law…” KII, Policy implementer | |
Religious and health-related beliefs | Users (primary caregivers/ mothers, fathers and grandparents) | “There is an immunization that is harming children. That is what is being rumored. Some children are getting sick after being immunized. Some children are unable to speak after immunization. The children just keep quiet after immunization. They refuse to talk.” FGD, grandmothers, Makutano |
Service providers | “There are some parents who say, like Wakorino, they say their children are not supposed, they are not supposed to go to some hospitals. Religion affects the lives of children. There are some parents who say they don’t go to hospital. So those who don’t go to hospital, the parents don’t allow their children to take drugs or be given any immunization… … That church doesn’t want anything to do with treatment. When the woman is pregnant, she doesn’t go to the clinic. So, from conception this child has a problem.” KII, ECD teacher, Timboroa | |
“Another tradition apart from herbal medicine most of them believe in names. That if a child does not want a name, the child will get sick.” KII, ECD center provider, Simotwet | ||
“Maybe disabilities, maybe they think if a child cannot stand up or maybe…, they even give the traditional medicine, they don’t believe the hospital one, some of them.” KII, ECD center provider, Torongo | ||
“Let’s say for example a child is not supposed to take milk and eat meat.” KII, ECD teacher, Arama | ||
Stakeholders | “What can happen, maybe the child … is used to her/his mother’s milk, so if s/he drinks another different one, maybe a (health) problem will occur.” KII, Policy implementer | |
Some of the grandmothers in the FGDs believed that administering traditional herbs and medicines alongside breastfeeding during the first six months was essential for a child’s growth and development (see IDI, grandmother). This belief by grandmothers was echoed by some of the fathers (see FGD, fathers) and CHEWs (see KII, CHEW). One of the ECD teachers noted that due to cultural norms, the use of traditional medicine commenced at a young age (see KII, ECD teacher). In addition, an ECD center provider acknowledged that this practice was deeply entrenched and difficult to change (see KII, ECD center provider).
Other beliefs reflected local interpretations of childhood illness and behavior. For example, some fathers linked persistent night-time crying to a child being looked at by someone with a ‘bad’ eye or ill intent (see FGD, fathers), a belief also reported by healthcare providers as part of local explanations for bewitchment (see KII, healthcare provider).
Gender-related socialization norms were also evident. Some community members believed that wrapping infant boys could hinder genital development (see KII, ECD center provider). Others perceived health clinics as spaces for women, discouraging male involvement in health facility visits (see KII, ECD teacher). and framed caregiving as the sole responsibility of mothers especially for younger children (see IDI, father; KII, ECD teacher). A policy implementer noted that it remained common for pregnant women to be accompanied to health facilities by female relatives, reinforcing traditional gender roles (see KII, policy implementer). Collectively, these beliefs posed significant barriers to male participation in childcare.
Religious and health-related beliefs significantly influenced caregiving decisions within the community. Some parents, for instance, withheld their children from school, refused medical treatment during illness (see KII, ECD teacher), or declined immunizations – actions often rooted in religious teachings. In such cases, ECD center providers sometimes intervened by taking children to health facilities for immunization without parental consent, later attributing the action to government directives to avoid conflict. Similarly, some pregnant women refrained from attending antenatal clinics based on religious prohibitions (see KII, ECD teacher). Beliefs also shaped the care of children with disabilities, with some parents relying exclusively on traditional medicine due to mistrust of hospitals (see KII, ECD center provider).
A number of myths and misconceptions rooted in health and religious beliefs were reported by community members, influencing the care of young children. For example, some grandmothers believed that immunizations were harmful and should be avoided (see FGD, grandmothers). A policy implementer noted a widespread belief that children could suffer adverse effects from consuming breast milk expressed by women who were not their biological mothers (see KII, policy implementer). Other misconceptions included prohibitions against feeding children milk or meat (see KII, ECD teacher); and the notion that children became ill if given a name they “did not like” (see KII, ECD center provider). These deeply held beliefs underscore the need for culturally sensitive messaging and dialogue that acknowledges community perspectives while promoting evidence-based caregiving practices.
User, Stakeholder and Service Provider Needs for Incorporating Parental Support for Nurturing Care into the BFCI
Participants were asked about their needs in relation to incorporating parenting support for nurturing care into the BFCI. Needs included the requirements of what they perceived should be in place to enable them to efficiently provide support for integration. The needs were framed at the household, community and societal levels. Participants also suggested some strategies and made recommendations on how to incorporate parental support for nurturing care into the BFCI. Some illustrative quotes are provided in Table 6.
Table 6
Household, community and societal needs
Concepts (sub-themes) | Illustrative quotes | |
|---|---|---|
Household level needs | Users (primary caregivers/ mothers, fathers and grandparents) | “The problem is that it could be at that time you have delivered and as a mother you could be that you don’t have food to eat properly, even you the mother you starve… so the child will not get milk properly and then again maybe the child has reached 6 months and you the mother don’t have enough food to wean the child and there is no balanced diet…” IDI, mother, Simotwet |
“…this mother needs to be taken care of, given food so that she has milk. A mother must be taken care of by the father so that when the mother is happy, even her milk lets down properly and she will be able to breastfeed the child…. If she goes to the farm and comes back without being fed, that is what will be a problem. We as men we must take care of the mother and then after taking care of the mother, the mother will be able to take care of the child.” FGD, fathers, Tugumoi | ||
“…there is this situation, let me say a small one, sometimes we find a parent, a mother can be lacking milk and the Ministry of Health is telling us a child should not be given anything, so there sometimes is a challenge because you cannot force milk to come out if the mother does not have.” IDI, father, Toniok | ||
“Some can sleep and then in the morning they leave without checking on her/his children, especially these youths. They leave children, their work is to impregnate women and they cannot even think that this mother needs to be taken care of, given food so that she has milk, milk in the mother. A mother has to be taken care of by the father so that when the mother is happy even her milk lets down properly and she will be able to breastfeed the child but being left like that and then she goes to the farm and comes back without being fed, that is what will be a problem again. We as men we must take care of the mother…. …more training could be increased through CHVs and health extension officers, in regards to more teachings concerning care giving. And also, I think they should also emphasize the issues of family planning also so that we are able to get few children that we can take care of well, we should not have many children that we cannot take care of.” FGD, fathers, Tugumoi | ||
“Sometimes, you aren’t financially stable. You cannot afford some types of food for the child. You may not have a milking cow. You therefore have to buy milk. You buy 2 cups of milk. 2 cups of milk are not enough to prepare tea and for the child’s consumption. The child can stay for a week without milk… … Look at my hands, the hands are infected. I can’t do anything. Even digging is a challenge. I have sought treatment for these hands but they haven’t recovered. I therefore face a lot of challenges in life.” FGD, grandmothers, Makutano | ||
Community level needs | Service providers | “At the moment children under five years are supposed to be monitored from 0-5 yrs. However, after they finish immunization, their caregivers don’t bring them to the facility for monitoring as they believe they are done. This is an area which we need to focus on because that’s an area where we can identify children who are not doing well in terms of their nutrition and health. We can then intervene.” KII, healthcare provider |
“Yes, so these grandmothers will make sure that these young kids are given some herbs. They believe that they help in their growth, of which we discourage but we cannot force them. We are trying to encourage them and tell them the importance of not initiating these herbs as early as that.” KII, CHEW, Kiptuno | ||
“The fear is mostly HIV. That is what they are mostly afraid of. You know there are some people who don’t want to go get tested but that is unless you don’t go to the clinic because those who go to the clinic, those who give birth when they have it they must know it at the hospital and there are those who are negligent and they refuse.” KII, ECD teacher, Timboroa | ||
“Men need to be sensitized, to know that upbringing of a child does not depend on one person; it depends on all people so that she/he grows and be healthy.” KII, ECD center provider, Toniok | ||
Stakeholders | “So one of the opinions that I can give is maybe the relatives to be educated on how important it is to give support to the mothers especially during that period of nursing the babies…” KII, policy implementer | |
“…if you find a disability you are able to report it early, that is for the teachers. And again also teachers should be trained on handling these young kids.” KII, policy implementer | ||
Societal level needs | Service providers | I believe linkages with the different stakeholders that provide other services let’s say Ministry of Health, Ministry of Birth and Registration will help them to manage the needs…So I would wish sensitization is done at the location or at the community level so that those caregivers who do not take their children to health campaigns can be reached” KII, ECD representative |
Stakeholders | “Well with good policies we expect that they would give direction on how a child should be cared for in order to develop well, particularly if they are implemented to the letter. I want to take for you for example through the policy on breastfeeding. There is … the Breast Milk and Substitute Act which bars … advertisements of milk substitutes apart from breast milk within a facility. So, if for example staff are made aware of that particular policy and they implement it, then we are very sure that children will be exclusively breastfed, and a child will be breastfed up to 2 years ….We expect a positive impact on the growth of this child.” KII, policy maker | |
“One, there is need to invest in personnel. Once we get more personnel, I believe that issues of ECD will be handled better….So the other thing is the resources, once the resources are available in terms of money, I know actually we can do better.” KII, policy maker | ||
“…and each and every partner needs to play their roles. Maybe the government, the county government, central government and everybody even the education sector, agriculture sector, health sector, they need to come up and own that particular policy and implement it. You know the problem is Kenya we have got a lot of policies, but we don’t implement them.” KII, policy maker | ||
“…the various players need to have a common implementation so that we don’t get education implementing issues of ECD differently, we get health implementing issues of ECD differently, we get agriculture implementing issues of ECD differently, we get the department of children not even aware of what health is doing. So, all the players need to be brought together and be educated on this particular policy so that during the implementation, everybody knows his/her role at different stages because it is not all of us who will implement at the same level…” KII, ECD official | ||
Fathers participating in the FGDs emphasized the importance of promoting caregiver health and nutrition as a key enabler of the provision of nurturing care (see FGD, fathers). Poor caregiver wellbeing was seen to directly impair their ability to provide responsive and consistent care to young children. Some mothers and fathers alike noted that breastfeeding women were especially vulnerable to early cessation of exclusive breastfeeding when they lacked adequate support at home or believed that they had insufficient milk supply (see IDI, mother; IDI, father). As reported by one of the participants involved in the IDIs, some breastfeeding mothers lacked adequate food, often due to poverty, and the burden of competing responsibilities such as household chores and childcare left them fatigued and unable to rest (see IDI, mother). These circumstances contributed to poor child nutrition, reduced quality of care, poor hygiene and failure to meet young children’s basic needs. In such contexts, caregivers often prioritized immediate survival over developmental stimulation, making it difficult to support incorporation of nurturing care into the BFCI. Fathers, particularly new ones, highlighted the need for practical knowledge on how to care for their families and ensure household wellbeing – an area identified as critical in supporting children’s holistic development (see FGD, fathers).
At the community level, the absence of a strong social support system was identified as a significant barrier to providing optimal care for young children (see KII, Policy implementer). This gap was particularly evident where grandmothers – who lamented that "no one cares for another person’s child”- were left with the sole responsibility of raising their grandchildren. Due to their advanced age and, in some cases, poor health, many of these caregivers struggled to meet the demands of nurturing care (see FGD, grandmothers). These constraints limited their ability to support the integration of nurturing care for young children into the BFCI. Strengthening community support structures would therefore be essential to reducing caregiving burdens and enabling multigenerational households to better integrate nurturing care.
CHVs, ECD teachers and healthcare providers emphasized the need for caregivers attending regular antenatal visits and ensuring their children received timely immunizations and growth monitoring. These practices were considered essential for the early identification of health and nutrition concerns among young children (see KII, healthcare provider). However, challenges such as fear of mandatory HIV testing deterred some caregivers from seeking antenatal care (see KII, ECD teacher). Additionally, one ECD center provider noted the need to actively engage men in child-rearing responsibilities to support children’s holistic development (see KII, ECD center provider). A policy implementer highlighted the persistent exclusion of children with disabilities, whose needs were often overlooked in both community structures and service delivery (see KII, policy implementer). One of the things that was pointed out was the need to incorporate cultural considerations in health messaging as in some cases, traditional beliefs contradicted biomedical messages which made adherence difficult for community members (see KII, CHEW).
Policy makers underscored the importance of having robust policy frameworks to guide the incorporation of parental support for nurturing care into early childhood programming. They emphasized that effective implementation of these policies would promote optimal child growth and development. Developing a clear implementation plan was seen as essential to translating policy intent into actionable steps – illustrating, for example, how nurturing care components could be embedded into the BFCI. Reference was made to the Breast Milk and Substitutes Act which prohibits the promotion of breastmilk substitutes in healthcare facilities, as a model for aligning policy with practice. Financial investment was flagged as a critical enabler, with policy makers calling for partnerships with relevant stakeholders to support resource mobilization. Human resource capacity was also noted as a priority, with adequate staffing essential to sustaining ECD-focused initiatives (see KII, policy maker). A representative from an ECD organization and an ECD official both highlighted the need for a multisectoral approach that fosters collaboration and builds a shard understanding among diverse actors to ensure coherent and efficient implementation of ECD strategies (see KII, ECD representative; KII, ECD official).
Opportunities for and Existing Gaps in Program Implementation
The fourth area in which information was generated was in relation to opportunities for and existing gaps in implementation of the BFCI plus CCD intervention (Table 7). Opportunities were considered in relation to facilitating factors while gaps were looked at in terms of challenges.
Table 7
Opportunities for and existing gaps in incorporating ECD into the BFCI
Concepts (sub-themes) | Illustrative quotes | |
|---|---|---|
Complementary community health strategy | Stakeholders | “…I still believe that issues of ECD can be implemented very well through the community units because the CHVs are people who are based at the household level. So once you build their capacity, then you expect that thing to be rolled as you have told them.” KII, Policy implementer |
Existing ECD-related services and programs | Users (primary caregivers/ mothers, fathers and grandparents) | “Also we have been urged to make sure that children sleep under a treated mosquito net so as to prevent malaria. You also observe cleanliness of food and even of the body.” FGD, mothers, Solian |
“…they came to teach about how to protect the child using supanet. Because sometimes mosquitoes mostly affect expectant mothers and children under five years old, they are at risk of malaria.” FGD, fathers, Arama | ||
“I was taught about the rights of the child that, first, the child should be satisfied and then, he/she should get good clothes, and, and say where the child stays when he/she sleeps everything should be okay. He should have clothes, I mean like blankets, the things for covering oneself, they should be okay.” FGD, fathers, Arama | ||
“My work caring for grandchildren is… to talk to the parents, that is, my own children… As we have been taught that we should not let them be fed things which they shouldn’t be when they are still young, below the age of 6 months. After that, we need to ensure that they have been fed foods that are proper.” IDI, grandmother, Kiptuno | ||
Service providers | “Now me being a community health worker, I volunteer …my time even twice in a week visiting women in the villages. So, I chose to go to different areas checking on women especially those who are pregnant. I talk to them so that they can go to the clinic early and then complete. They continue going until they finish, 4 times and onwards and I monitor. About food, sometimes you get one who does not want to eat a certain food. You tell her that she has to eat it so that the child can get good nutrition. I also sometimes monitor when they give birth … and I tell them to be close to where they will deliver, not at home… When they deliver I visit them also to see if they are positioning the baby well for breastfeeding. I also check that she eats food that can help her so that the child can get enough milk and exclusively breastfeed … for 6 months.” IDI, CHV, Solian | |
“And also most of the time we do give them, we teach them about their developmental milestones; how they should be assessing their children even at home, the way they should be going, how many meals their child should receive according to the age.” KII, CHEW, Toniok | ||
“…it allows us to do growth monitoring by weighing the child…” KII, CHEW, Kiptuno | ||
Stakeholders | “So some of the mothers have bought the idea and you see them bringing their children even when you visit their homes you find those educated on the issue of variety of foods, you find some of them they have planted kitchen gardens.” KII, Policy implementer | |
“…facilitating factors so far is like, there is this ‘Malezi Bora’ (good upbringing) activity, that when it is going on like now this is the month of May, Malezi Bora activity is going on. So during ‘Malezi Bora’, the county government gives us support in terms of supervision. We go supervise the ECD center during this Malezi Bora activity, when they are given the supplements, supplementation of vitamin A and also deworming services.” KII, Policy implementer | ||
Existing relevant policies and guidelines | Stakeholders | “…as a sub-County we have benefited from the BFCI. We have the BFCI policy which … takes into consideration the issue of child feeding up to 1000 days, the importance of child development and, it articulates the issue of breastfeeding and weaning …we have the immunization policy that recommends that children complete their immunization which should be done correctly. … the MIYCN policy is also another one …which takes care of the under-fives…” KII, Policy implementer |
“I also wish to recommend that the county and the national government have a steering working group that oversees the implementation of the issues of ECD for these children 0-36 months. In this way, we will not have duplication of roles at the county and national levels. There should be a steering group which …could be meeting quarterly to evaluate the implementation.” KII, Policy implementer | ||
Ongoing support | Service providers | “When they came to us for the first time, they were able to even set up for us projects and to bring women together. We formed groups and those groups are continuing up to now. Those women are still together, they are doing merry-go-round. Some have even started a project of rearing chicken for themselves, and others are keeping beehives which benefit us a lot” FGD, CHVs |
Stakeholders | “Actually, I can say it really contributes a lot because we cannot say when we educate the mother here everything will be done as said by the health worker in the facility. That is why if we take the BFCI which is going to the community, it will roll out effectively such that the community is empowered on how to take care of the babies optimally. These mothers can get support because at times we say in the hospital, okay, breastfeed exclusively for 6 months but when the mother reaches home, they say other things because at home there are many other influencers; people who change these mothers, in spite of them being knowledgeable. So what is now going to happen is if the community is empowered on how to take care of the babies optimally, then the mother will get enough support and then this child will get optimal nutrition.” KII, Policy implementer | |
Multi-sectoral coordination | Users (primary caregivers/ mothers, fathers and grandparents) | “I have heard from radio stations that children should take millet. Several varieties of flour should be mixed. You can mix millet and maize then you grind them. Prepare ugali using the mixed flour. Give that ugali to the child in the evening and in the morning. According to the information, ugali is very beneficial to children. The radio was saying that flour gives the body energy.” FGD, grandmothers, Makutano |
Service providers | “We try to urge parents on the importance of breastfeeding mother’s milk, we tell them the importance of that food, the mother’s milk so that they should not introduce the other one before 6months. And we also try to tell mothers how to look for food to produce good milk for the child.” KII, ECD center provider, Torongo | |
“There are times we use the ‘chest’ (colloquial translation of ‘force’) … because the parent will come here and tell me the child will not be immunized. As the child is with me, I try to save the child’s life so that he/she is not affected by the parent’s decision.” KII, ECD teacher, Timboroa | ||
“There is another program we were taught, of using technology… So we taught these, we registered, they used to get messages through their phones and then they follow up on growth of their children through messages that they receive” FGD, CHVs | ||
Poor adherence to monitoring visits | Stakeholders | “…after 6 months, that is, exclusive breastfeeding, whatever happens after weaning there is no follow up and the same also with the mothers. You see, we encourage mothers to bring their children for weighing up to 5 years but when a child has finished the 9-month immunization, you can only meet with that mother when she is coming for her ANC services or you can meet that particular mother when she brings that child for the 18-month measles jab…So actually there exists a big gap …from …12 months to 36 they are not given any priority because they believe that after the immunization at 9 months, the child now is safe…” KII, Policy implementer |
Workload as a barrier | Stakeholders | “One of the challenges is inadequacy of personnel. Actually, now currently what we have is fewer personnel in the field and this has impacted negatively on even health care delivery.” KII, Policy implementer |
Limited male involvement as a barrier | Users (primary caregivers/ mothers, fathers and grandparents) | “It is just the lack of support from the father.” FGD, mothers, Shauri |
Service providers | “Men just have that attitude that clinic is for women.” KII, ECD center provider, Simotwet | |
Stakeholders | “Another thing is alcoholism, alcoholism is another problem, men really drink, drink and drink and they forget about the family. And so you know, when somebody is not doing what is expected, then of course one thing will have to go wrong especially the health of the children because men are the providers, men are the decision makers in the house.” KII, Policy implementer | |
Lack of stimulating materials at health facilities | Service providers | “At the facility level or even at school, we need those children’s activities, maybe like with toys…So you come to our facility at the district hospital, there is nothing like that, it is only the doctor. The child is sick, and when the child cries, the only thing the doctor will tell the mother is ‘calm the child down, give them the breast.’” IDI, Policy implementer |
Suggestions for improving service delivery | Service providers | “…so that CHVs improve their work is to give them motivation… if there is something they can be given, they should be given so that they have the energy and the heart to work more than how they are working now.” IDI, CHV, Tugumoi |
“…like the time of clinics to make sure that this child has gone for vaccination, we follow up as my colleague has said that we follow up in the houses to see that the child has received the immunization that was required.” FGD, CHVs | ||
“Maybe we can do home visits so that we find out exactly where the problem lies because before you identify where the problem is.” KII, CHEW, Kiptuno | ||
Strategies for improving male involvement | Service providers | “In a group like in the unit we have male CHVs. We go to public action days with the men so that male caregivers can see truly this thing is not for women only.…” FGD, CHVs |
“…there are men who usually come also, we involve a few in the mother-to-mother groups and the women whose husbands don’t help them at home, they also help each other to the extent at least the man who is not helping his family, he will see advantage of helping.” FGD, CHVs | ||
“The action that I can take is to approach these fathers, when I am doing household visitation I meet them, I try to teach them slowly the importance of participating in good nutrition in the family.” IDI, CHV, Tugumoi | ||
“I think maybe if they can be brought to the training and be told that being with the child is not only for the mothers, it is for all of them…if they could be taught and be told that the child belongs to both of them…and they should not leave the responsibility to one person… it is also their responsibility to take care of the child.” KII, ECD teacher, Makutano | ||
One of the most critical facilitators for incorporating parental support for nurturing care into the BFCI was the community’s openness to new interventions that promised tangible benefits. As one policy implementer noted, “the community was receptive and was willing to accept anything that would benefit them” (KII, policy implementer). This receptiveness was further strengthened by the existing community health strategy and the presence of functional community units staffed by capable CHVs (Table 7: see KII, policy implementer). These CHVs played a pivotal role in delivering key messages during home visits including the importance of timely immunization, early initiation of breastfeeding, and exclusive breastfeeding up to six months, contributing to consistent caregiver engagement in nurturing care practices. To motivate CHVs further, one of the recommendations that was made during an IDI was to consider how to improve their work situation (see IDI, CHV).
The provision of ECD-related services was identified a key facilitator for integrating parenting support for nurturing care into the BFCI. For instance, one CHEW reported sharing information with caregivers about the developmental milestones and the role of play in promoting healthy child development (see KII, CHEW). The nutrition-related services that mothers received from CHVs included demonstrations on breastfeeding positioning, preparation of child-friendly meals like porridge, and guidance on age-appropriate feeding practices (see IDI, CHV). A policy implementer also noted that mothers had received information on home-based vegetable gardening to support dietary diversity (see KII, Policy implementer). In terms of childcare, CHVs conducted home visits to monitor children’s height, weight, health and general growth; they also guided mothers on grooming and other caregiving routines (see KII, CHEW). Additionally, CHVs actively encouraged caregivers to attend regular check-ups and growth monitoring, reinforcing the linkages between routine care and developmental outcomes.
In the FGDs, both primary caregivers and fathers confirmed that CHVs had taught them key practices for maintaining child health including immunization, the use of insecticide-treated mosquito nets, proper hygiene and sanitation (e.g. safe latrine use and critical times for handwashing) and timely health-seeking behavior (see FGD, mothers; FGD, fathers). Caregivers viewed this information as empowering and vital for supporting the health dimensions of nurturing care. Fathers also highlighted the importance of safeguarding children’s rights and ensuring their security (see FGD, fathers). The consistency of health messages across CHVs and other service providers reinforced caregivers’ knowledge, enhancing their understanding of how to support holistic child development. One grandmother, reflecting on her caregiving role, noted that she considered advising parents an integral part of her responsibility (see IDI, grandmother).
Policy makers and implementers reported concerted efforts to educate mothers on key health topics such as vitamin A supplementation, deworming, hygiene and sanitation. The sub-county health department also engaged pregnant and new mothers in discussions about developmental milestones and how to monitor children’s progress (see KII, policy implementer).
CHVs noted that their participation in the earlier BFCI programming had provided a strong foundation for expanding their role to include incorporating parental support for nurturing care. Notably, the groups that were set up through the earlier intervention remained active (see FGD, CHVs). CHVs observed improvements in caregivers’ knowledge and skills, particularly around childcare and breastfeeding practices, as evidence of prior impact. Building on this momentum, both CHVs and policy implementers expressed confidence that integrating nurturing care into the BFCI would foster supportive community networks that promote early child development (see KII, policy implementer).
Other stakeholders and organizations also played a role in delivering ECD-related services with coordination among these actors enabling a more integrated and multi-sectoral approach to incorporating parenting support for nurturing care into the BFCI. For instance, one ECD center provider reported engaging mothers on the importance of breastfeeding during the first six months, and complementary feeding thereafter (see KII, ECD center provider). in addition, an existing child health program disseminated mobile phone messages on child growth and development to enrolled caregivers (see FGD, CHVs). There was a lively discussion by grandmothers who described receiving child development messages via radio broadcasts (see FGD, grandmothers). These platforms are useful for reinforcing parenting practices. These diverse communication avenues also served as important sources of information and consistent reminders for caregivers, enhancing the uptake of nurturing care practices within the BFCI framework.
Policy implementers highlighted several existing policies relevant to early child development including the BFCI and the MIYCN policies, which directly target children under five years of age (see KII, policy implementer). The ‘Malezi Bora’ (which means ‘proper nurturing’) program was also cited as a key facilitator to the integration of nurturing care into the BFCI, as it has enhanced accessibility of health services for pregnant women and young children (see KII, policy implementer). Whilst these policies provided an enabling framework, policy implementers underscored the need for clear implementation guidelines to translate policy intent into action. They recommended the formation of a county-level steering committee to oversee and coordinate the implementation of nurturing care activities, ensuring alignment across sectors and promoting consistent delivery of integrated ECD support (see KII, policy implementer).
One of the key barriers to integration of nurturing care into the BFCI was loss to follow-up, as many mothers exited the monitoring program once their children attained the age of six months (see KII, policy implementer). This pattern suggested that caregivers placed limited value on continued clinic visits for up to 36 months, despite the developmental importance of this age range. To address this, a CHEW reported accompanying healthcare workers on home visits to deliver home care and provide tailored health education to caregivers who were reluctant to attend clinics (see KII, CHEW). These visits served not only to fill service gaps but also to build trust and open dialogue with resistant families, creating a foundation for encouraging parental engagement in nurturing care. In situations where caregivers intentionally missed immunization appointments, CHVs and ECD center providers reported collaborating with local authorities to safeguard public health and prevent setbacks in community immunization coverage (Table 7; see FGD, CHVs; KII, ECD teacher). Immunization was considered one of the most important aspects of nurturing care which needed to be in place to promote integration.
Another reported barrier to incorporating ECD counselling into routine health facility visits was the perceived reluctance among healthcare service providers to engage in these discussions with primary caregivers. According to a policy implementer, this hesitation appeared to stem from providers feeling overwhelmed by existing workloads and unwillingness to take on additional responsibilities (see KII, policy implementer). A related concern was a general lack of motivation among healthcare providers to promote parental support for nurturing care within facility settings. This was evident in the absence of play materials or child-friendly spaces that could be used to engage children during waiting periods (see KII, policy implementer).
Participants reported that limited male involvement in supporting young children’s growth and development remained a significant challenge. According to some mothers, many fathers were disengaged from productive work and failed to provide adequate financial support for their families (see FGD, mothers). Others noted that fathers often refused to accompany their wives to health facilities, perceiving this as solely the responsibility of mothers (see KII, ECD center provider). In cases where men did accompany their partners, they were described as waiting outside the clinic rather than participating in the visit. A policy implementer observed a broader trend of men abdicating their traditional roles as household providers and decision makers, attributing this shift tin part to alcoholism which compromised their ability to support their families (see KII, policy implementer). The limited male involvement in childcare activities was seen as a hindrance to enlisting their support for incorporation of nurturing care into the BFCI. To deal with this issue, CHVs reported on the different strategies that they used to increase male involvement so that men could also provide support for nurturing care. During home visits, fathers were also targeted for sensitization on the importance of them playing an active role in childcare, good nutrition and health for the family (see IDI, CHV). Another CHV mentioned that she encouraged men to participate in the public meetings held regularly (see FGD, CHVs). CHVs also reported that they asked men who did not get involved at home to participate in mother-to-mother support groups so that they could appreciate the importance of their engagement with their families (see FGD, CHVs). In addition, CHVs liaised with healthcare providers to sensitize men on the need to ensure that their families were well provided for, as once basic needs were catered for, then caregivers would be able to support children’s need for nurturing care. ECD center providers reported that male partners could be consistently trained, sensitized and counseled through seminars to sensitize them on the importance of their involvement in child growth and development (see KII, ECD teacher). They could also be encouraged to take care of the health of their wives from pregnancy onwards.
Discussion
This feasibility study was part of a follow-up study of an earlier BFCI intervention and was conducted to provide a better understanding of the local contexts and cultural factors that influence development; user, stakeholder and service provider needs for incorporating parental support for nurturing care into the BFCI; and, to explore opportunities for and existing gaps in program implementation. Qualitative interviews among users, stakeholders and service providers provided extensive information on their understanding regarding ECD, beliefs around caregiving, needs at the different levels and potential barriers and facilitators.
Knowledge, Attitudes and Practices on ECD and Early Stimulation
That caregivers considered ECD to encompass aspects of child growth, hygiene, feeding, and health demonstrated that they were aware that it comprised several domains. However, the missing components from the caregivers’ understanding was that of early learning and stimulation and children’s developmental progression. Knowledge deficits in the milestones that children should be able to achieve under different developmental categories have also been reported in a previous study in South Africa among caregivers of children under the age of six years (Meintjes & Van Belkum, 2013). As with the current study, health workers were considered an important and trusted source of information on and support for ECD as they seemed to have a greater understanding of nurturing care (Meintjes & Van Belkum, 2013). Caregivers spend a lot of time with their young children and are therefore important in providing support for incorporating nurturing care (World Health Organization et al., 2018) into the BFCI. They are also able to contribute to children’s desired developmental outcomes through timely identification of developmental delays (UNICEF et al., 2019). However, they can only do so if they are equipped with the necessary knowledge on nurturing care (Alghamdi et al., 2023); a process which can be facilitated through CHVs. Interventions in which caregivers are expected to play a major role should build on their existing knowledge to facilitate their understanding of its importance and ultimately, future success. When caregivers feel that their importance is recognized, they are likely to take ownership of such interventions, which further facilitates sustainability (Iwelunmor et al., 2016).
Fathers reported a limited understanding of ECD, as they perceived it in terms of child behavior like crying and playing. Given that there are particular periods of early development when certain types of behavior are most helpful, it is critical to extend fathers’ understanding of nurturing care. To the extent possible, fathers should also be involved in nurturing care activities to support the role that mothers play. This is particularly with regards to their engagement (direct interactions), availability (presence and accessibility), and responsibility (material provision) (Garcia et al., 2022; Lamb et al., 1987) which have an impact on child outcomes.
Fathers reported that they mainly engaged in outdoor play activities with their children, a finding which is corroborated by others who found that fathers tend to be more involved in “rough and tumble” play (e.g. Spetter, 2019). On the other hand, primary caregivers who were mostly mothers, commonly reported engaging in indoor activities and those which promoted independence in carrying out activities of daily living among children. As incorporating parental support for nurturing care into the BFCI is facilitated by interactions between children and their parents, the role of both parents remains very important.
Different participants had varying connotations of ECD. Primary caregivers focused on child growth, hygiene, feeding, and health, while fathers emphasized communication of needs through crying. CHVs highlighted the importance of nurturing care from conception to delivery and proper feeding practices. These findings imply the need for a comprehensive approach while focussing on those areas where there seemed to be limited understanding. A comprehensive understanding of ECD can significantly contribute to integrating support for nurturing care and ensuring that children receive optimal care for their healthy development.
Contextual and Cultural Influences on Child Development and Nurturing Care Practices
The role of cultural beliefs that we identified seemed to be in influencing the differential treatment of children according to their gender, understanding events with an unknown cause as well as shaping gender roles in the early care of children. Grandmothers were mostly the purveyors of cultural beliefs such as the use of traditional herbs by breastfeeding mothers to promote their children’s growth and development. As grandmothers exert a lot of influence in decisions around the care of young children (Pulgaron et al., 2016), they provide an effective pathway for changing practices that may be detrimental to young children’s health and dispelling myths and misconceptions around parenting. Religious beliefs also seemed to have a strong influence on caregivers’ healthcare seeking behaviors particularly in relation to medical treatment when children were unwell and use of preventative services such as immunization. Similar to our findings, beliefs which have been reported in other studies prescribed expected behavior according to gender (Nsamenang, 1987) and encouraged ‘hiding’ away a breastfeeding mother from the ‘evil eye’ (Kavle et al., 2019). It could be that, as has been mentioned in previous studies (Cabrera et al., 2007), mothers are expected to assume responsibility of primary caregiving in the early years. As has been alluded to in a study among participants in a rural area in Burkina Faso (Hollowell et al., 2019), the clear separation of caregiving tasks and material provision could be informed by gendered divisions of household roles and labor. With regards to healthcare seeking behaviors, a systematic review of barriers to improve childhood health and survival noted that misconceptions about childhood immunization which may arise from religious beliefs were a major hindrance to effective utilization of immunization services (Bangura et al., 2020). Finding ways to dialogue with participants on positive traditional practices that can be sustained, such as the reliance on multiple caregivers for the care of young children, and recognition of the critical role of elders and traditional healers, are important in incorporating parental support for nurturing care into the BFCI. Further, the use of a community-initiated mechanism such as mother-to-mother groups which were sustained from the earlier intervention could form a suitable forum for discussions on how to deal with myths and misconceptions which are detrimental to ECD practices. Understanding and addressing cultural beliefs and practices, including respecting traditional practices while at the same time promoting beneficial ones, are crucial for the successful integration of ECD into the BFCI.
In order to enhance integration, it is essential to empower caregivers, families and communities so that they are able to make use of existing services, demand more and better services and improve their nurturing care activities (UNICEF et al., 2019). Involvement of caregivers in discussions around what they believe would work for them and giving them opportunities to provide recommendations for improvement of certain aspects as was done in the study reported here is one way of empowering them. In addition, providing them with the necessary knowledge and resources such as training on proper health and early stimulation practices could lead to improvements in their children’s outcomes. Such a process would also enable them to eliminate harmful cultural practices and maintain those that are considered beneficial to promoting nurturing care.
User, Stakeholder and Service Provider Needs for Incorporating Parental Support for Nurturing Care into the BFCI
The FGDs and KIIs revealed that users, stakeholders and service providers had multidimensional needs which were important considerations. The needs reported by multiple participants highlighted the importance of being sensitive to the needs of participants living in disadvantaged settings before requiring them to support the implementation of a specific program. For instance, children need access to quality care, and this is compromised when a caregiver does not have good health. Given that there are likely to be multiple caregivers in a child’s life, the assumption is that alternate caregivers would step in to provide care when the mother was not able to. In the case of the study context, alternate caregivers included grandmothers who themselves needed support thus rendering them unable to plug the caregiving gap. Other studies have reported similar findings (Baker & Silverstein, 2008; Barman & Sahoo, 2024). The finding that children with disabilities remained ignored suggested the need for inclusive programs in which children are not left out based on their physical conditions or health status. This would link in very closely with the recommendation of the Lancet 2016 ECD Series on inclusive policies and initiatives for children with disabilities to maximize returns from early interventions (Black et al., 2017). Integration of nurturing care into the BFCI is likely to benefit those who are most vulnerable, and children with disabilities are among those who stand to benefit the most. The creation of a supportive and more inclusive environment for all children is likely to support their optimal development.
Opportunities for and Existing Gaps in Program Implementation
There were generally positive feelings about the program as CHVs believed that it would amplify the effects of the earlier intervention. CHVs also believed that integrating nurturing care into the BFCI would result in greater knowledge of and support for ECD within the community. CHVs facilitated the incorporation of nurturing care activities into the BFCI as they seemed to understand the importance of holistic development of children. Identifying what is accessible within the community would go a long way in facilitating tailoring targeted messages for impact.
The most important facilitative factor that was mentioned was the existence of a robust community health strategy which could be used to reach out to families with the relevant messages on a regular basis (Ministry of Health Kenya, 2007). The wide range of services provided by different players illustrated that there are several related departments (such as health, education and agriculture) that need to work together to ensure smooth integration for the holistic development of a child. Some of these services were targeted at mothers, while others were targeted directly at the child. It is imperative that the different services are provided in a manner such that there are no duplicative roles, and that each service provides an additive advantage (Kirk, 2018). Identifying supportive frameworks as was done in the study reported here is an important consideration to make when planning integrated interventions as these are critical determinants of success or failure. In addition, establishing how well existing platforms work in supporting integrated interventions is a good starting point for identifying how they could be used more effectively (Ndayizigiye et al., 2022). Finding a feasible route for delivery that builds on existing systems and costs, rather than adding new infrastructure (DiGirolamo et al., 2014) is therefore an important consideration in incorporating parental support for nurturing care into the BFCI. The existing community health strategy can lead to more efficient and effective delivery of community services.
Noteworthy is that the limited male involvement was cited as a major barrier to incorporating parental support for nurturing care to enhance children's optimal growth and development. And yet, as has been mentioned earlier, successful integration will only happen if all those who come into contact with young children provide full support for the various activities. Encouraging greater male involvement and that of other family members in child-rearing activities can enhance the nurturing care provided to children.
Some of the gaps that were revealed through the interviews with policy makers illustrated that children at some specific ages may not be receiving optimum care and attention. For instance, after nine months, parents may lose out on the benefits of regular growth monitoring for their children because they stop visiting the clinics. Although we could posit that mothers may not really understand the importance of regular growth monitoring hence the cessation of facility visits after the last immunization, it is worthwhile to seek a better understanding of why this is the case. In addition, there is need to identify strategies to encourage mothers to maintain clinic visits until the age of five years (and this is recommended within the Kenyan health system) to support better planning of services. Other gaps are in regard to the provision of services which may be less than optimal as service providers may not be up to date with the latest information. These gaps suggest that educational campaigns could be used to increase knowledge about the benefits of growth monitoring beyond immunization visits. Routine health encounters provide opportunities for healthcare providers to encourage incorporation of parental support for nurturing care into the BFCI. Further, growth monitoring should encompass age-appropriate counselling as these visits could serve as a platform to support interventions and services that incorporate nurturing care (UNICEF et al., 2019).
Policy makers were not able to identify any ECD-related policies that had been formulated within the country. The only policies that they mentioned being available were those related to infant feeding and health care. As recommended by policy makers, it is important that efforts are made to develop policies directly related to nurturing care as this would help highlight the importance of the ECD sector. In line with this, Neuman & Okeng’o (2019) pointed out the need for well-designed, adequately funded and contextually appropriate policies for young children in order to realize the promise of ECD. Given that ECD was devolved in Kenya through the 2010 Constitution, (Government of Kenya, 2010), the responsibility of budgeting for and implementing ECD programs shifted to the county (subnational) level. There is therefore an opportunity for different counties to develop their own ECD policies which would provide guidelines for incorporating parental support for nurturing care through implementation of actions to promote the holistic growth and development of young children. Some counties have already made progress in these efforts.
Participants at the user, service provider and stakeholder levels offered several insightful recommendations on how to incorporate parental support for nurturing care into the BFCI. The recommendations focused on ensuring the inclusion of children with disabilities, conducting community outreaches, providing family counselling programs and encouraging greater male involvement. These recommendations illustrated that participants were aware of the need to deal with their unmet needs, while at the same time, were willing to provide ‘home grown’ solutions, which could be harnessed to improve support for early child development in rural Kenya. The opportunities and gaps highlighted illustrate the importance of a comprehensive and culturally sensitive approach to integrating ECD into existing health and nutrition programs like the BFCI.
Strengths and Limitations of the Study
One strength of the current study is the inclusion of a wide range of participants who were able to provide different perspectives. Capitalizing on relationships that we had already formed in the community through the earlier BFCI intervention reduced the resources required to mobilize this range of study participants. Moreover, the qualitative design enabled us to capture in-depth information on participants’ perceptions of their role in promoting the incorporation of parental support for nurturing care into the BFCI. The inclusion of primary caregivers as major participants is both a strength and a limitation. On the one hand, primary caregivers are a reliable source of information on nurturing care practices and their influences, as they spend a significant part of the day with young children. However, it is also possible that primary caregivers may have wanted to present themselves in the best possible light due to social desirability, which may influence the accuracy of the information reported. The previous delivery of the BFCI intervention by our team may have compounded this further because participants may have focused on reporting behaviors consistent with those that the BFCI promotes. The limitations notwithstanding, the study makes a unique contribution to the literature on considerations to be made in incorporating parental support for nurturing care into existing national nutrition programs such as the BFCI.
Conclusion and Future Directions
Overall, our findings suggested that whereas users, service providers and stakeholders did not have all the necessary information on how to incorporate parental support for nurturing care into the BFCI, there were opportunities to increase their level of knowledge. Moreover, even though users such as mothers engaged in some activities with the children, they did not seem to understand their role in stimulating young children’s development through these activities. The needs mentioned did not seem to be a hindrance to incorporating parental support for nurturing care as the different groups of participants themselves were able to suggest solutions. Consideration needs to be made of the cultural traditions and beliefs that may impact the acceptability of an integrated intervention to improve nurturing care as well as the involvement of fathers. With regards to incorporating nurturing care into the BFCI, the presence of a robust community strategy linking relevant departments and coordinated from the national level would provide a good platform for enhancing the sustainability of such a program. Future programs could consider incorporation of messages on positive parenting. Champion caregivers could also be engaged as models of incorporating parental support for nurturing care into the BFCI supported by community support groups to ensure inclusion of caregivers other than mothers into the program. In conclusion, integrating ECD into BFCI has the potential to create a more comprehensive approach to child health and development, benefiting young children, caregivers, and the community.
Acknowledgements
The successful outcome of this project was made possible through the support and guidance from many individuals and teams. The research team thanks all the study participants for their contribution to the success of the study. We also acknowledge the support of staff from the Nutrition and Child Health Departments within the Ministry of Health at the sub-county, county and national levels for their guidance and input during the implementation of the project. We are also grateful for the guidance we received from the PATH team with regards to the implementation of the CCD package. This study was supported through funding from the British Academy.
Compliance with Ethical Standards
Conflict of Interest
The authors declare no competing interests.
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