Feasibility and acceptability of integrating an early childhood development intervention into the health-facility setting in Siaya County: findings of a qualitative study

doi:10.21203/rs.3.rs-3347606/v1

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Research Article

Feasibility and acceptability of integrating an early childhood development intervention into the health-facility setting in Siaya County: findings of a qualitative study

https://doi.org/10.21203/rs.3.rs-3347606/v1

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Background

This paper explores the perceptions and experiences of stakeholders to understand the feasibility and acceptability of integrating early childhood development (ECD) intervention into the health system.

Method

Data were derived from an endline qualitative survey, which was part of a larger ECD study conducted in Siaya County, Kenya. Purposive sampling was used to select participants for the qualitative interviews. We conducted KIIs, focus group discussions (FGDs), and in-depth interviews (IDIs). Analyses were organized according to the preselected thematic areas.

Result

Political goodwill, proper coordination and support, and good linkages between the community and the health facility facilitated the implementation despite the challenges of a shortage of personnel and staff transfers. Integration of ECD intervention into the health system seems feasible in terms of its performance, service provision, information provided, and efficiency. In addition, stakeholders willingly supported the implementation of the intervention at different levels and capacities, which led to perceived acceptability. Furthermore, there was general satisfaction with the implementation due to perceived benefits that could potentially improve children’s developmental outcomes.

Conclusion

This study demonstrates the feasibility of integrating ECD interventions into the health system. Future interventions integrating ECD messages into nutrition and health programs can leverage key drivers identified through this study for smooth and effective integration.

early childhood development

feasibility

children

health facility

healthcare provider

Recent studies have shown that children who received nurturing care exhibited higher intellectual and linear growth compared to their peers who may not have received such services (1, 2). Early parenting interventions that enhance parent‒child interactions improve responsiveness in feeding and caring for infants and young children, increase attachment, improve communication, and encourage play activities, learning, book reading, positive discipline, and problem-solving (3). These parenting interventions may be delivered through home visits or community groups (4) or may be embedded within the health care system (5–7). The expansion of routine maternal and child health and nutrition services by integrating ECD services has been recommended to promote children’s optimal outcomes (8). Linking an ECD intervention to primary health care provides excellent coverage and compliance with child health visits, saving on additional staff costs, as it can be implemented by existing clinic staff. In addition, it requires no additional time for parents at the health facility and has no adverse effects on the nutrition or health status of the children (9).

Feasibility studies on the integration of ECD interventions into health systems are still rare in most developing countries. Most programs integrating ECD into either nutrition or health programs are not based on scientific evidence (6). Nonetheless, a few of these programs that have been evaluated have provided sufficient evidence on the feasibility of integrating ECD interventions into health and nutritional programs (6, 7, 10); these studies have been conducted outside Kenya, mainly in high-income settings. In addition, the existing evidence has revealed that integrated ECD messages have the potential to improve both health workers' and caregivers' knowledge of responsive caregiving, promoting early childhood development as well as satisfaction and retention in primary healthcare services (11–13). Several studies on early parenting and ECD programs targeting the youngest children have been conducted in Kenya (4, 14–16). However, most of these studies focus3focused more on the impact on child development and improving parenting knowledge and practices than on how they work, particularly their feasibility and acceptability. Of note, there is limited evidence on the feasibility of integrating ECD content into health and nutritional programs, especially in household and health delivery settings. The results presented in this paper are from the qualitative survey that evaluated the health system intervention for its feasibility and acceptability. In this paper, we explored the perceptions and experiences of different health stakeholders to understand the feasibility and acceptability of the integration of an ECD intervention into a real-world healthcare setting in Siaya County, Kenya.

Study design and participants

This was a qualitative study that formed part of a larger ECD study that sought to evaluate a healthcare system-integrated ECD intervention for its feasibility and effectiveness in terms of improving mother/caregiver ECD knowledge, attitudes, and practices, as well as child growth and developmental outcomes, conducted in Bondo subcounty in Kenya (17). This paper focused on the stakeholders' perceptions of the feasibility and acceptability of integrating ECD content into the health system at the end of the evaluation. ‘Stakeholders’ refers to a diverse group that includes caregivers, who were the end-users of the intervention; CHVs, who were the link between the community and the health facility, healthcare providers and the local health management team. Purposive sampling was employed to select participants for the study.

The ECD intervention

The Siaya ECD intervention involved training and mentoring health care providers (mainly nurses and clinical officers) and CHVs. The health care providers integrated ECD counseling and monitoring with light-touch nutrition counseling. In addition, caregivers and their children were exposed to playboxes during the health facility visits that also included ECD-related information. The playboxes were implemented in the waiting areas of the health facilities to take advantage of the lengthy wait times and make these spaces more child-friendly. The CHVs and the healthcare providers further taught caregivers how to engage in play with their children through responsive caregiving techniques and the use of homemade toys. The intervention was implemented for 27 months.

Data collection procedures

We developed open-ended interview guides for IDIs, FGDs, and KIIs. These guides were developed based on the study objectives, intervention procedures, and current health practices. The guides were developed in English but later translated to the local language (Dholuo) by a professional translator. The team then piloted the guides to check that the items were appropriate for the research question ahead but also that they were culturally appropriate and did not contravene the ethics requirement. A debrief session was conducted, and feedback from the pilot exercise was incorporated into the final tools. The caregivers who participated in the qualitative interviews were among those who received the intervention.

We conducted 36 IDIs with primary caregivers of children below the age of three, which is the intervention’s targeted age. We also conducted three FGDs with CHVs and three FGDs with secondary caregivers (fathers). In addition, we conducted 17 KIIs with the managers of the facilities, three with the subcounty health management team (SCHMT), and three with the project implementers from the PATH organization. The first and third authors conducted all the interviews in private locations within the health facilities for confidentiality and to avoid disruptions. Interviews were conducted in Dholuo or English, depending on what was preferred by the participant. Each IDI with primary caregivers lasted approximately 60 minutes, while the FGDs took 60 to 90 minutes. Participants were informed about the research procedures, including duration, well in advance of the commencement. All participants interviewed provided their informed consent. All the interviews and FGDs were conducted face to face and were audio-taped. To ensure the high quality of the data collected, we recruited and carefully trained a field team of college graduates to conduct the interviews. We also checked the transcripts for validity, and those that were flagged were sent back to the field team for verification.

Data management and analysis

The audio files were transcribed verbatim by a professional transcriber and validated by the research team by reading the transcripts and listening to the recording. Data analysis used the deductive approach, where information related to feasibility and acceptability was extracted based on the criteria in Table 1 and organized according to the preselected thematic areas. Participants’ perceptions and experiences of the performance of the intervention, services provided under the intervention, information provided to participants, and efficiency of the intervention were derived under feasibility. The performance of the intervention was determined in relation to how it met the needs of both users and providers. Service provision, on the other hand, was based on the five components of nurturing care (adequate nutrition, opportunities for early learning, good nutrition, safety and security, and responsive caregiving). In addition, we determined from the end-users’ and providers' perspectives whether the services were accessible, affordable, and of good quality. Information was defined in two aspects: 1) the ECD counseling messages on caregiving given to the caregivers by the CHVs and healthcare providers during the counseling sessions and 2) the information provided to the healthcare providers and CHVs during the training on nurturing care. Each of the participants, whether end-users (caregivers) or providers, reported their experiences in terms of how useful the messages were. The efficiency of the intervention was determined by how the users and providers perceived its fit within the existing infrastructure and the success of the intervention.

Support for the intervention, satisfaction with the implementation, perceived benefits of the intervention, and barriers and facilitators were considered key determinants of acceptability. Support entails the contributions the study participants made to ensure the success of the intervention. This specifically included material, financial support, supervisory support, and/or training. We also determined the level of acceptability of the intervention by examining the level of satisfaction of both the users and the providers of the intervention.

An analysis plan was developed and used as a point of reference during transcription, coding, and analysis. The transcripts were manually coded and analyzed thematically by reading through the scripts and noting significant statements and themes according to areas of concern. The similarities and contrasts within the data were identified by the research team, and the data that seemed to cluster together were sorted into categories and thus matched with the topics being addressed.

Table 1

Criteria for developing interview guides and analysis plan
Main criteria
How well will the ECD intervention work in the health system?
Performance: Does the intervention address any unmet needs of providers, and beneficiaries/community? How does it affect the system?
Information: Does the intervention provide caregivers, health service providers, and managers with useful information?
Efficiency: Does the ECD intervention make good use of available resources?
Service: Does the ECD intervention provide desirable and reliable service for those who need it? Is the intervention scalable?
Is the integration of ECD into the health system perceived as acceptable and useful?
Support: Do the health facility, subcounty, county management, and community health strategy support the ECD intervention?
Is the ECD intervention acceptable or useful for mothers?
Barriers: What are the barrier to the intervention, if any, from the point of view of management, provides, and caregivers? How can the barriers be overcome?
Facilitators: What are the factors that facilitate the intervention at the community, facility, and management levels?

The feasibility of the intervention

Performance of the intervention

Both users and providers mentioned that the intervention performed well in terms of addressing unmet needs. The majority of the caregivers reported that the intervention improved their childcare skills and provided them with opportunities to learn new information regarding child care and development. In addition, they learned how to support their children’s development through play and making play materials.

"We were taught how to care for our children; now we are able to identify what the children like and don’t like. We now make them toys with regard to what their interests are, and I can say our childcare knowledge has greatly improved." IDI with a primary caregiver, IDI

CHVs reported improved knowledge of childcare as a result of the new information. With additional training on nurturing care, the CHVs felt more equipped to carry out home visits effectively.

"We did not know that it is important to play with the child right from the womb to three years. So our knowledge of childcare has improved as a result of our participation in the trainings, and we feel more equipped to conduct home visits better." FGD with a CHV

Services provided under the intervention

Nurturing care services related to adequate nutrition, opportunities for early learning, good health, safety, security, and responsive caregiving. Regarding adequate nutrition, nutritional advice on exclusive breastfeeding for the first six months, complementary feeding, and continued breastfeeding were mentioned by most healthcare providers. In addition, the provision of vitamin C and the referral of extreme cases of malnutrition were also reported.

"I encourage mothers to practice exclusive breastfeeding for 6 months without giving anything. I talked to them about complementary feeding at 6 months to introduce them to other food items and ensure that the feeds were balanced. We also give vitamin C supplements and refer severe cases to the main hospital." KII with a healthcare provider.

Some caregivers mentioned that they received advice from the CHVs and healthcare providers to exclusively breastfeed their children for at least six months and continue breastfeeding for at least two years of the child’s age with careful introduction of other foods in the child’s diet.

"My 2-year-old child is still breastfeeding based on the information and guidelines that we were given at the facility by the CHV and the nurse. Had it not been for this information, I would have stopped him long ago. They also taught us the importance of exclusive breastfeeding for at least six months, which I practiced.IDI with a primary caregiver

For opportunities for early learning and responsive caregiving, some caregivers mentioned that they were taught that children should be engaged in play, supported in identifying objects in the house, and taught the names of different family members. Furthermore, the caregivers reported having been taught by the CHVs how to play and communicate with their children. In addition, they were also provided with toys whenever they visited the health facilities. In addition, they were encouraged to provide their children with adequate playtime.

"The CHV has taught me how to play and make play material for my child. She has also taught me the importance of clinic sessions and vaccinations and reminded me about clinic vaccination days. FGD with a CHV

Fathers also mentioned that they supported their children’s physical and social development by giving them time to play and providing them with play items. They provided opportunities for early learning for their children by talking to them, playing with them, and calling the names of objects as they played with them.

"We provide play materials according to the age of the child. This enhances their brain development. Additionally, materials of different colors and shapes make the brain develop rapidly."FGD with a secondary caregiver

Healthcare providers reported that caregivers received health talks on providing opportunities for early learning right from the time of conception. In addition, they mentioned that they provided playbox sessions for the children within the health facility and further advised caregivers to continue practicing the same at home using play items made from locally available materials.

"We teach mothers that they should start interacting with their unborn children. In a nutshell, we teach them the importance of child stimulation, communication, and play. We also conduct playbox sessions with the caregivers," –KII with a healthcare provider.

Regarding good health, primary caregivers reported receiving curative services whenever they sought such services for their children. They also reported that their children received their immunizations as scheduled. In addition, they reported having received information from the CHVs on how to promote their children’s health by ensuring that the environment where they play is safe and clean.

"We receive services like treatment. When children are sick, they are tested and given medicine at the facility. They also receive the vaccination and maybe mosquito nets. Most importantly, we enjoy health services offered to children below five years of age freely and without any pay." IDI with a primary caregiver

The CHVs reported that they advised pregnant mothers to visit the Maternal and Child Health (MCH) department within the nearest health facility for check-ups and plan for their delivery on time. Immediately after delivery, they ensure that they follow immunization schedules.

"We teach the pregnant mothers to attend clinics, and once the child is born, they should get all the immunizations and attend the facility at any given time the child falls sick." FGD with a CHV

Information provided to participants

Caregivers attributed the positive social and physical development of their children to the nutrition and play information that they received from CHVs during clinic visits. They added that play may be used to assess the health status of children. Moreover, they mentioned that, according to the information they received from the nurses, play helps children socialize well with other children.

"We were taught by the CHVs that play helps in the development of children’s brains, and play also helps in determining whether the child is sick or not, because when they are sick they do not play. Additionally, the nurses told us that play also helps the child socialize with other children." – IDI with a primary caregiver.

A secondary caregiver (father) reported having learned from the CHVs the importance of supporting my wife when she is pregnant, as it helps the unborn child grow well. He added that he had been enlightened about involving children in play activities as well as playing with them.

"I have learned that I should involve my children in activities like playing football and that I should provide adequate playtime for them and a place where they can play freely. The CHVs also taught us the importance of supporting my wife when she is pregnant, as this helps the child grow well." FGD with a secondary caregiver.

Some healthcare providers reported that the number of home visits has increased because the CHVs now have much information that they can talk about with the caregivers. The healthcare providers noted that the ECD training that CHVs received enhanced their knowledge, as they can now help caregivers choose age-appropriate play items during the play box sessions and even give them health talks based on the knowledge they acquired from the training.

"Home visits have improved since CHVs now have a lot of information to give to caregivers. Now they even include the importance of playing with the child and their hygiene".KII with a healthcare provider.

The efficiency of the intervention

On efficiency, the community was also perceived as having welcomed the program since it fits well with the existing system. Some caregivers mentioned that they welcomed the idea and were happy with it.

"The community has welcomed the program because the program has offered an avenue for our children to grow and develop wholesomely. We have all welcomed it. All of us are happy with it." IDI with a primary caregiver

Various respondents viewed the intervention as having been successful in its implementation. Some caregivers felt that the intervention made it possible for the health care workers to monitor their children better and to quickly determine if a child was sick or not.

"The beneficiaries of this project—those who have engaged in and benefited from its activities—truly embrace the program. They know the benefits that come with this new program in terms of promoting the growth and development of young children. IDI with a primary caregiver

Being able to identify delayed milestones by just going through the chart in the mother-child booklet during the health talk was very satisfying to healthcare providers, as they could relate this to their daily activities. Through the intervention, the healthcare providers were also able to discover cases that needed attention and were even able to make referrals when an impairment was discovered through play activities that the caregivers were encouraged to do at home.

"It has improved the relationship between parents and children. They have the information that playing with a child helps a lot and the importance of interacting with a child. Again, we realized that the mother-child booklet was important in helping identify delays in children, something we did not know before. This is very satisfying.KII with a healthcare provider

Acceptability of the intervention

Support for the intervention

Many of the caregivers reported having donated homemade play items to the facility so that children who visited it could play and grow well. Some caregivers mentioned that they allowed their children to interact with other children and helped with teaching other caregivers during health talks, which some CHVs thought promoted utilization (acceptability) of the intervention among the users and supported their work as CHVs.

I brought materials and even encouraged other mothers to bring in their children. Similarly, we could support the CHVs with the development of play materials and help pass messages to other caregivers during health talks – IDI with a primary caregiver.

Most healthcare providers mentioned that the CHVs helped in making the play materials and taught the caregivers how to make play materials. Furthermore, many of the healthcare providers mentioned that CHVs helped greatly in the establishment of the play corners, and the same CHVs ensured that toys were there in the facility.

Most of the play materials at the facility were made by the CHVs; mothers were asked to only make toys for their children at home. Therefore, what normally happens is that children use the play materials made by the CHVs at the facility and the materials made by their caregivers back at home. KII with a healthcare provider.

Some policy implementers mentioned that the major support provided by the county and subcounty officials during the implementation of the intervention included capacity building, support supervision, and mentorship. In addition, they offered on-the-job training for the nurses who were not trained, which they did alongside the implementers.

"They come to supervise what I do, and if they see there is something I am not good at, they advise and support me well. They also trained my colleagues who missed the training." KII with a healthcare provider.

Satisfaction with the implementation of the intervention

Many of the caregivers interviewed reported liking the messages they received at the facility about the development of their children. They also appreciated that the intervention had a positive impact on child upbringing, particularly when they compared their youngest children under the intervention with their other older children.

"The caregivers appreciate the information we give them since it is basic, especially about breastfeeding and how to hold the baby during breastfeeding. They take it positively and open up to us to inquire more about what to do when a child gets into any condition."KII with a healthcare provider.

Some healthcare providers mentioned that they received positive feedback from the community that seemed to suggest that they were satisfied with the intervention's delivery. A few healthcare providers added that the CHVs were also motivated to implement the intervention, as their work was made easier by the intervention.

"We also got positive reports from CHVs confirming that the intervention is well received in the wider community. The CHVs have told me that they are now motivated as they have additional information to give to the caregivers in the community.KII with a healthcare provider

Perceived benefits of the intervention

Initially, children were afraid of going to the facility to receive health services. This is because they were afraid of injections, which was their only activity. The caregivers mentioned that through the intervention, children’s attitudes changed due to the introduction of play. They no longer associate hospitals with pain, as before. In addition, the caregivers felt that it was useful for children to have something to do while they waited to be seen by the healthcare provider. With the rollout of the intervention, one caregiver reported that the children engaged in play as the caregiver supported them, and this gave them peace of mind.

"When my children come here when they are sick, they get a sigh of relief when they get a chance to play with these toys, and they are happy. Sometimes when we come here and he sees a nice toy, he will want that toy, and you know we cannot leave with a toy, so this motivates me to make him something like that, and that is a good thing”.IDI with a primary caregiver.

The healthcare workers stated that play box sessions and health talks given at the facility have played a major role in helping children 0–3 years to develop optimally between 0–3 years. They observed that children in the program were more active and recorded optimal growth and development compared to those who were not beneficiaries. The healthcare workers also reported an increased number of referrals due to enhanced home visits. In addition, children at risk of developmental delays are now identified early and referred for appropriate assistance.

We have seen the development of children, especially those below the age of three, improve. Currently, there are increased referrals of children under 5 years compared to the initial days before the intervention. KII with a healthcare provider.

The CHVs equally benefited from the intervention. They reported that they were now able to pick age-appropriate play items for children who visited the facility because of the knowledge they gathered from training and mentorship. The CHVs further reported that they acquired much knowledge and skills while conducting duties of nurturing care in their respective communities.

"I learned that a child can be communicated with while still in the womb by both caregivers, and playing with them makes them active once they join nursery school."FGD with a CHV.

At the facility, healthcare providers reported that they could now identify delayed milestones early by just going through the child's chart. It enriched their routine services with knowledge they did not have before and made them better parents to their children too.

"The training I received from this program has expanded my knowledge of responsive childcare, a concept I never knew before the intervention. I have gained from this intervention as a caregiver; I am now a better parent to my children at home." KII with a healthcare provider.

A health manager mentioned that the healthcare providers learned many new things about responsive care, stimulation, and the general development of children. The new information was not taught during preservice. The sentiments were shared by another manager, who mentioned that the attitude of the healthcare providers has changed and that they now love children more. This was attributed to the counseling sessions by the CHVs and healthcare providers.

"They thought learning starts at preschool, and now they know that a child starts learning in the womb." KII with a health manager.

The county and subcounty health systems also benefited from this intervention. One of the health managers noted that the intervention had brought significant changes in health management, with additional health services being provided other than traditional immunization.

"ECD nurturing care has brought many changes in the management and the general support for the healthcare provision of children below three years. Initially, we would see children brought in for immunization within the facilities and in the clinics. All their mothers knew that they were supposed to be taken to the facility for vaccines and thereafter taken back home. This has since changed. Our healthcare providers have made these sessions productive—more interactive and more educational."KII with a health manager.

Male involvement was not a project-specific target. However, it was a measure of how well the intervention was accepted by the male caregivers. Health managers noted that the involvement of male caregivers in nurturing care was still a problem. Even though there was still poor male involvement in providing nurturing care for children, some improvement was recognized.

"There is a big gap in regard to the involvement of male caregivers in childcare, despite training them (fathers) and having CHVs talk to them. I do not know what we can do to change them. All the same, I can say there is a change in male involvement in childcare, but we are not yet there." KII with a health manager.

Barriers and facilitators

Barriers

Caregivers reported a general shortage of personnel, which they thought made it difficult for them to receive the services efficiently. The fact that only one nurse managed the play box session and another provided other services was regarded as a large impediment to the effective implementation of the intervention.

"The play boxes are not manned because the few available nurses/CHVs are busy attending to other children and their mothers. This, I think, affected how we received the counseling on child development."IDI with a primary caregiver.

The project implementers interviewed also echoed the lack of personnel mentioned by the caregivers as an institutional barrier. This, they mentioned, made it difficult to get healthcare providers to attend scheduled training, particularly in cases where it was not possible to get someone else to stand in for them when they were away from work. They added that the staff available in some facilities was already overwhelmed and therefore could not conduct counseling or follow-up on how the caregivers and children had missed their appointments.

Facilities with inadequate staff cannot run this program effectively. They are overwhelmed by the work and hence cannot do counseling, reach out to caregivers one-on-one, or do follow-ups for children/caregivers who have missed an appointment. I have been to some facilities where one healthcare provider is manning outpatient, ANC, and PNC all at the same time—it is crazy. KII with the project implementer.

The transfer of staff from one facility to another was mentioned by the implementing staff as having a negative effect not only on the delivery of the intervention but also on the continuity of the program. The transfer of a trained mentor outside the project area was seen as a big blow to the project.

The high rate of staff turnover remains a major problem in the area. You find that after training healthcare providers on the program, you end up losing half of them in a transfer one month later—very bitter indeed. The transfers derail the smooth transfer of information to caregivers and community members a great deal. KII with a project implementer.

Additional workload to the already overwhelmed staff was mentioned as a barrier. The program implementer mentioned that, whereas ECD counseling should take place on a one-to-one basis, the high workload of healthcare providers may not allow this to happen. They added that sometimes the number of patients seeking other services is too large for the healthcare worker to notice important details during counseling.

"The workload will make you not be able to engage the caregiver so much and integrate the ECD so well. Sometimes you can miss out on a delay in a child since you are so busy with other health-related issues. There are also times when I find it very difficult to offer counseling due to the many other patients looking for healthcare services.KII with a project implementer.

CHVs mentioned poor male involvement as another major barrier to the implementation of the intervention at the community level. The CHVs complained that male caregivers were missing from most of the childcare activities

"It is very difficult to find male caregivers, and when you find them, it is very hard for them to discuss with you. Most of the time, when they see us, they take those as women's responsibilities. Again, when they accompany the mother to the clinic, it is difficult to convince them to get into health talks." FGD with a CHV.

Facilitators

The strong link between the facilities and the community was perceived as a key enabler of the delivery of this intervention by the project implementers. CHVs and healthcare providers were perceived as the driving forces behind the success of the intervention.

"I was lucky enough to have a high-spirited team of CHVs and healthcare providers who, after start-up training, work tirelessly at the community and household levels to educate and induct caregivers into integrating nurturing care into their childcare practices."KII with the project implementer.

Health cards made it easy for the CHVs and the healthcare provider to implement the intervention. The cards provided every detail of the messages and made them easy for the caregivers to understand.

"I think with tools such as counseling cards, even CHVs have come to like what they are doing. It is a motivating factor. Previously, CHVs used to visit households barehanded, only with some sketchy information they acquired in a seminar. However, now the counseling cards make the home visits very easy for the CHVs." KII with a health manager.

Proper coordination and capacity building among various stakeholders ensured that all stakeholders were on board; those who were not formally trained were sensitized through other platforms. The healthcare workers reported that this resulted in increased awareness of the intervention.

Proper coordination and capacity building of the health work force are truly healthy in the implementation. In addition, health workers who were not formally trained received on-board training. KII with a healthcare provider.

Political goodwill from the county leadership propelled the implementation of the intervention. The county governor supported the intervention and even sensitized the members of the county assembly to do the same.

"The intervention has goodwill from the MoH, and it is also enjoying political goodwill in the county. Our governor is in support of the intervention; MCAs have been sensitized, and they are positive about it—a very rare phenomenon in the political world. I think they embrace it because they have seen the changes nurturing care brings to the region about promoting child growth and development." KII with a health manager.

In addition, support supervision by the implementing organization was mentioned as having been very instrumental to the implementation of the intervention at the subcounty or county level.

"It hardly takes two months without them organizing support supervision, whereby a team from the county and subcounty offices and the implementing partner go down to the house level to check how the intervention is rolling out."KII with a health manager.

The study set out to determine the feasibility and acceptability of the integration of ECD intervention into mainstream health care services. For feasibility, the study focused on understanding how well the intervention worked in terms of its performance within the health system during the 27 months of implementation. The study also explored the services provided under the intervention, which were derived from the nurturing care framework and included adequate nutrition, good health, the opportunity for early learning, and responsive caregiving. Furthermore, we explored the information provided to both the end users, who were mainly caregivers, and the providers of the intervention, which also included CHVs. Under feasibility, we also explored how efficient the intervention was in terms of how the caregivers perceived its fit with the existing infrastructure. Finally, for acceptability, we explored how different stakeholders supported the intervention, how satisfied they were with the implementation, what they perceived as the benefits of the intervention, barriers that could have hindered the implementation, and factors that facilitated the implementation of the intervention.

Overall, our results revealed that, generally, the participants interviewed perceived the ECD intervention to have been well integrated into the health system. Furthermore, participants reported that they found the intervention to be useful in terms of service delivery, the knowledge provided during training, and the messages given to the caregivers during counseling sessions.

Previous studies evaluating early childhood development programs integrated into primary health care in low-income settings have found that they are effective, efficient, and feasible in promoting ECD outcomes (7, 13, 18). The performance of an intervention is determined by how successful it has been in meeting the needs of both the providers and the beneficiaries of that intervention (19). Both users and providers of healthcare services indicated that counseling on early infant nutrition, information on how to develop materials, opportunities for early learning and responsive caregiving, and good health of the children were important for infants’ overall development in line with the nurturing care framework (20). Earlier studies have reported that these services are critical to enhancing children’s developmental outcomes (8, 21–23). Furthermore, participants’ reports indicate that these services were accessible and affordable and were of good quality. The provision of health services that are of quality, accessible, and affordable to all users is the hallmark of health service provision. Paying out-of-pocket for health services is, for example, associated with low access to primary healthcare (24). However, quality, accessibility and affordability do not necessarily mean user satisfaction (25). Even though there was general agreement that the services were of good quality and accessible to all, healthcare providers in public facilities should consider reducing long waiting times, which are often associated with low user satisfaction (26). In contrast, this study revealed that such waiting times in the MCH may be reduced by the introduction of play activities.

Several facilitators that enabled the integration of the intervention into the health system were also reported. Key facilitators reported included a strong link between facility and community (a robust community strategy), the availability of health cards and mother-child booklets, proper coordination and capacity building by implementers, and political goodwill. These facilitators have been documented in the literature to support the delivery of the intervention, most of which are studies from high-income communities (27–31). For example, at the community level, CHVs have a ‘catalyst’ role in the delivery of the intervention, while at the health facility, healthcare providers are key pillars to its successful implementation (32). The role of CHVs in supporting community health activities has increasingly been demonstrated. Their enthusiasm to support health care programs within their communities together with the financial motivation (where they receive an allowance) make them willing to take on new roles in the communities. Studies have shown that CHVs can ably deliver community-based health services in resource-limited settings (33). Our findings indicate that both users and providers were satisfied with the implementation of the intervention and reported benefits from it. They also reported having provided various types of support for the intervention. Satisfaction with the implementation of an intervention benefits users and providers, and the level of support is a key indicator of the acceptability of an intervention (19). In contrast, the findings reveal key systemic and human resource barriers that were encountered during the implementation of the ECD intervention. The most notable ones were the shortage of personnel, staff transfers, and highly competing tasks that had negative impacts on the implementation. Challenges such as a shortage of personnel and poor infrastructure have been reported in the Kenyan health system (34, 35). For smooth integration of early childhood services, key policy makers could consider increasing the number of healthcare providers as well as improving health facility infrastructure.

The strength of this study is that the participants were diverse with regard to their levels of participation and examined the perspectives of both the providers and beneficiaries of the intervention. This diverse inclusion enabled the collection of rich insights into the intervention delivery process within the health system that will inform improvement going forward. The use of a variety of qualitative methods, such as key informant interviews, focus group discussions, and in-depth interviews, enabled the collection of rich and detailed information on the aspects of interest.

We acknowledge a few limitations. First, we used self-reported data, which are subject to social desirability bias, and as such, some participants may have exaggerated their positive opinions and perspectives toward the intervention to please the interviewer. We believe that this limitation may have been minimized by the interviews being conducted by researchers who were not involved in the implementation of the intervention and by using a variety of qualitative methods to collect the same information from different participants. Another limitation is that the transferability of the findings to other counties may be limited by the unique situation in Siaya County. Every county has its own priority area of focus. For example, the intervention was implemented with the political goodwill of the county’s governor and the First Lady of the county, who was the matron. This goodwill was a driving force behind the implementation of this intervention. Political goodwill may be lacking in other countries, which may affect implementation.

Overall, the findings indicate that integrating ECD messages into the health system is viable in terms of its performance, service provision, information offered, and efficiency in service delivery, despite some obstacles and limitations. Effective integration can be attributed to key facilitating factors or drivers of acceptability that should be leveraged for optimum benefits going forward. Notably, the adoption of the intervention among users and providers was greatly influenced by the perceived benefits and satisfaction with the way it was delivered. Key drivers identified through this study can be used by future interventions incorporating ECD into nutrition and health programs to ensure seamless and successful integration.

Ethics approvals and consent to participate

Ethics approvals were obtained from the Ethics Review Board of Amref Health Africa. Informed consent was obtained from all the participants before the interviews. As part of the consenting process, the study purpose and procedures were explained to the study participants, and they were made aware that they could end the interviews at any point in time or skip any question they were not comfortable with. Participants were also provided with the PI’s contact information in case they had any questions regarding the study or wanted to obtain further information.

Authors’ Contributions

SO, PKW, KO, MN, and EKM contributed to the study conception and design. Material preparation and analysis were performed by SO, PKW, KO, MN and D O. Data collection was performed by SO and KO. The draft of the manuscript was written by SO, PKW, KO, MN BO, CO and DS. EKM secured funding and provided overall oversight of the project activities. All authors read and approved the manuscript.

Acknowledgment

We would like to acknowledge and thank the County Government of Siaya as well as all study subjects for their support of this study.

Funding

This research received funding from ELMA Philanthropies and a subgrant from the Conrad Hilton Foundation through PATH.

Conflict of interest

No potential conflict of interest was reported by the author(s).

Availability of data and materials

The datasets used in the analysis during the current study are available from the corresponding author on request.

Ethics Approval and Consent to Participate

The study was approved by the Institutional Review Board of Amref Health Africa and was registered at ISRCTN Registry number ISRCTN11561283. All participants signed an informed consent

Consent for Publication

Not applicable

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Feasibility and acceptability of integrating an early childhood development intervention into the health-facility setting in Siaya County: findings of a qualitative study

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Abstract

Background

Method

Result

Conclusion

Background

Methods

Study design and participants

The ECD intervention

Data collection procedures

Data management and analysis

Results

The feasibility of the intervention

Performance of the intervention

Services provided under the intervention

Information provided to participants

The efficiency of the intervention

Acceptability of the intervention

Support for the intervention

Satisfaction with the implementation of the intervention

Perceived benefits of the intervention

Barriers and facilitators

Barriers

Facilitators

Discussion

Conclusion

Declarations

References

Supplementary Files

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