As a community health worker (CHW), Elizabeth Otieno cares for all the children in her community. During household visits, she checks for malaria, pneumonia, malnutrition, and other threats to a child’s health. But Elizabeth knows that a child’s well-being is about so much more than their health status. For decades, the global concern “was whether a child survives their first five years of life,” Elizabeth says. “Now, we also focus on their well-being–are they reaching developmental milestones? Are they encouraged to play and explore their environment? Do caregivers respond to their needs? Do they feel safe and secure? These are all the things a child needs to thrive.”
What Elizabeth is referring to is nurturing care for early childhood development. This approach brings together 5 interrelated conditions children need to survive and thrive–good health, adequate nutrition, safety and security, responsive caregiving, and opportunities for learning. In the past, early childhood development interventions around the world focused on school-aged children. But now evidence demonstrates that the health system is the best way to reach children in their first 3 years of life, a critical stage of brain development. When CHWs, health facilities, and communities work together, the health system can achieve much more than improving the physical health of the child–it can also promote positive development that will have a lasting impact on their lives.
Since our founding, Lwala has been committed to the holistic development of children–ensuring they survive and thrive. In 2020, Lwala began to pilot the delivery of nurturing care through CHWs and health facilities in North Kamagambo, with a population of 25,000 people. In addition to health and nutrition services, now CHWs and health facilities provide caregivers with information on how to practice responsive caregiving and provide opportunities for early learning. They also focus on the safety and security of the child, help caregivers enroll in health insurance, and ensure children are registered and have birth certificates.
A key venue for this work is CHW-led parenting sessions. Last month, Elizabeth hosted one of these sessions with about two dozen caregivers. She recapped their last session, which focused on breastfeeding practices and children’s nutrition–families have been trained to monitor their child’s nutritional status at home by using a color-coded measuring tape to track upper-middle arm circumference. After the recap, she launched into the day’s topic–play-based learning. During the parenting session, two additional CHWs managed a play area filled with children. One CHW encouraged the younger children to play with toys, while the second CHW engaged older children in singing and dancing.
“Why is play important?” Elizabeth asked the caregivers. “It helps children interact with others and with their environment, strengthens the imagination, makes a child sharp, and enables them to learn new things. It also tells a caregiver if the child is well or sick.” Elizabeth then demonstrated how to make toys like balls and shakers from household materials, and she gave caregivers the opportunity to ask questions. A mother named Hellen shared what she had learned about nurturing care and the importance of play: “Now I engage my daughter while doing household chores. For example, while I am cooking, I give her a container and a spoon so that she can pretend that she is also cooking.”
Through these parenting sessions and household visits by CHWs, we reach 90% of caregivers in North Kamagambo, nearly 4,000 each month, with nurturing care information. In our midline survey of the pilot, we saw a 60% increase in caregivers who are engaging in storytelling, a 146% increase in counting and drawing with children, and a 106% increase in reading books together.
Lwala’s 10 partner facilities are also incorporating nurturing care for early childhood development into routine services. When a mother comes for antenatal and postnatal care, or when a parent brings a child for well visits and immunizations, health workers are trained to talk about nurturing care. They counsel caregivers on breastfeeding, provide information on age-appropriate play and responsive caregiving, assess developmental milestones, and refer children with developmental delays. This work has helped boost health indicators: in North Kamagambo, the childhood immunization rate is 100%, and 98% of lactating mothers begin breastfeeding after delivery.
It’s also improved birth certificate registration for children and enrollment in health insurance–caregivers are more likely to access quality and affordable health care for themselves and their children when they are enrolled in the National Health Insurance Fund and Linda Mama, Kenya’s free health insurance for pregnant women. 92% of caregivers now participate in Linda Mama, which surpassed our target of 60% participation.
Florence Ochoo, a nurse at Minyenya health center, is one of the biggest champions for nurturing care. “I am a mother of a 3.5 year old girl,” she says. “When Lwala was training us on nurturing care, I applied everything I learned to my young daughter. I’ve seen her develop well and achieve all her milestones.” When asked about a story that has stayed with her, Florence recounts a mother who brought in her 2 year old child who was not yet walking. Florence recognized a physical developmental delay and referred the child to physical therapy at Rongo Subcounty Hospital. After a few sessions, the mother was so happy with her baby’s improvements that she came back to thank Florence.
“We ask parents to compare their child’s brain to a path,” she says. “If a path is not given appropriate care, it will become overgrown and hard to walk through. When cared for, however, it will be clear enough to walk from one level to another.”
- Florence Ochoo, nurse at Minyenya health center
To reach more children across Kenya, Lwala collaborates with government to integrate nurturing care into existing health systems and policies. As a relatively new approach that cuts across sectors–health, education, gender, and child protection services to name a few–nurturing care requires strategic coordination. In Rongo Subcounty, Lwala has helped to establish a Multisectoral Coordination Team, which brings together various government departments and implementing partners to collaborate on delivering early childhood development services for children.
At the national level, Lwala is working with the Ministry of Health and partners to develop the National Integrated Early Childhood Development Policy and the National CHW Curriculum on Nurturing Care. At every step of the process, Lwala has been a strong voice for CHWs–we helped define the role of CHWs in delivering nurturing care, and we’ve applied learnings from our pilot to policy development.
Lwala’s vision is that every child receives nurturing care–that they are healthy, well nourished, and protected, and that they have every opportunity to learn and grow. When CHWs, communities, health facilities, and policymakers work together, this vision is within reach.