Table 1 presents sociodemographic characteristics of the research participants such as the number of children under 5 and number of adults in the household, primary caregiver, mother's education, and SES tertiles among the three intervention doses for the two sites. For Nepal, significant differences were found with respect to no. of children <5 years in the household (higher proportion in low dose), SES (higher proportion of poorest in medium dose), and maternal education (highest proportion of mothers with no formal education in medium dose). In Uganda, differences were found for no. of children 5 years and adults in the household (higher proportion in high dose), primary caregiver (lowest proportion of mothers identified as primary caregivers) and SES tertiles (higher proportion of poorest in high dose).
Child Development
In Nepal, children in the medium and high dose groups showed significantly higher mean scores in fine motor and cognitive domains (M=0.69, SD=1.29; M=0.79, SD=1.29), gross motor (M=0.48, SD=1.19; M=0.67, SD=1.19), language development (M=0.34, SD=1.44; M=0.50, SD=1.44) compared to the low dose group (M=0.27, SD=1.29; M=-0.13, SD=1.18; M=0.08, SD=1.43) respectively. Additionally, significant higher score was found between high and medium dose for gross motor only (p=0.017).
In Uganda, only children in the medium dose group showed significantly higher mean scores in all domains: fine motor and cognitive (M=0.25, SD=1.25), gross motor (M=0.07, SD=1.09), and language (-0.049, 1.21) compared to the low dose group (M=0.09, SD=1.17; M=-0.09, SD=1.16; M=-0.52, SD=1.29) respectively [Table 2]. Similarly, children in the medium dose scored higher than high dose for all domains except social.
Early learning and stimulation
The data suggested that, in both Nepal and Uganda, as the dose of stimulation activities increases from low to medium to high, the percentage of participants engaging in ≥ 4 stimulation activities also increases. In Nepal, there is an increase in engagement from 62% for the low dose to 64% for the medium dose and a more substantial increase to 75% for the high dose. In Uganda, there is a similar trend, with an increase from 64% for the low dose to 73% for the medium dose and a further increase to 77% for the high dose. The difference was significant for both high and medium dose when compared to low dose in both sites. When compared between high and medium dose, the proportion was significantly higher for high dose in Nepal for the high dose but not in Uganda.
Responsive feeding
For responsive feeding data from Nepal, 14.6% of caregivers in the low dose group, 17.1% in the medium dose group, and 27% in the high dose group reported practicing responsive feeding. There is a statistically significant difference between all groups (p<0.001), with the high-dose group having the highest percentage of caregivers practicing responsive feeding. In Uganda, there was a statistically significant difference between all groups (p<0.001), with the medium dose group (37.6%) having the highest percentage of caregivers practicing responsive feeding followed by low dose group (18.9%), and high dose group (9.5%).
Child discipline
For child discipline, in Nepal 69.9% of caregivers in the low dose group, 79.3% in the medium-dose group, and 64.3% in the high-dose group reported using at least one violent discipline practices (p<0.001). The data from Uganda showed that 80.5% of caregivers in the low-dose group, 76.3% in the medium dose group, and 68.2% in the high dose group reported using at least one violent discipline practice in the past month (p<0.001).
Caregiver mental well-being
Caregiver mental well-being varied across different doses in both Nepal and Uganda. While the high dose appeared to have a positive effect in Nepal, the results in Uganda are more mixed, with a slight increase in mental well-being for the medium dose but a decrease for the high dose. In Nepal, caregiver mental well-being showed no significant change between the low (75%) and medium doses (73%), but there was a notable increase with the high dose (83%). Conversely, in Uganda, there was a slightly higher proportion of caregivers with positive mental well-being than the low dose (75%) to the medium dose (77%). However, for the high dose, caregiver mental well-being score was lower (64%).
Experiences
This section provides qualitative evidence that describes the experiences of the caregivers and the implementation team based on the main themes. Adoption with sub-themes: i) change in mothers; ii) change in fathers; and iii) change in the GBG workforce
Change in mothers
The GBG model has had a positive impact on mothers, including teenage mothers, as indicated by the thematic analysis. The program's influence has been expressed in several ways, demonstrating its far-reaching effects:
Value of learning through play: Mothers across different doses have embraced the importance of learning through play. As one mother shared, “Ever since the program's inception, I've seen that, as mothers of children, we have learned to play with our children for them to become bright.” [Mother, FGD, Tororo, Medium dose, Uganda] This highlights the program's role in enhancing maternal understanding of caregiving roles and the significance of play in child development. Mothers from High dose in Amuria shared similar feelings in one of the FGDs,
“Yes, I learnt to ensure children well-being”; “Yes, I learnt to playfully parent for example getting some time to play with the children”; “Yes, I learnt that I should take good care of the pregnancy and even while breastfeeding my baby since all this reflects on the baby’s development and growth.”
We raised our children before the session also, but after participating in the sessions, now we know how to care for them more and how giving them time helps us in their development.” [Mother, High dose, Nepal]
Safe and stimulating environments:Mothers have recognised the value of using locally available materials to create stimulating and safe environments for their children. This shift empowers children to play freely and explore their creativity. Additionally, mothers have embraced cleanliness and safety in their homes, organising regular cleaning days to remove potential hazards. One of the mothers shared, "Ever since the program started, I have embarked on general cleanliness of my home, we organize one day in a week to clean our homes by removing all dangerous items that can hurt our children while playing like broken bottles and throw in pit latrine." [Mother, Tororo, Medium dose, Uganda]. Another mother from Nepal shared similar sentiments “Yes, I learnt to support early –learning opportunities for our children”[Mother, High dose, Nepal]
Building positive relationships: Positive relationships between mothers and their children have become integral to caregiving practices. Love, affection, and bonding have flourished, allowing children to be more open and comfortable. Mothers actively engage with their children, fostering healthier relationships. One mother highlighted that their children can now "Ever since the program inception, I seen that as mothers of children we have learned to play with our children for them to become bright, I have also learned how to make play materials for my children like toys and balls rather than buying play materials. This has made our children creative and can freely play with their colleagues at any time without inconveniencing me to buy play materials." [Mother, Tororo, Medium dose, Uganda]Another mother from High dose commented, "Yes, I feel a change in my child as a result of GBG program services. Yes, I learnt that I should show love to our children, through listening to their concerns."[Mother, Bundibugyo, High dose, Uganda]
“I used to shout that baby didn’t write and didn’t read at home and baby always used to play and I used to be angry before but after attending GBG, I learnt that we shouldn’t shout at them and allow them to do things they like.” [Mother, Medium dose, Nepal]
Collective responsibility: The program has emphasized that child-rearing is not the sole responsibility of mothers but a collective endeavor. Fathers have taken on more active roles in parenting. As one mother in Uganda noted “Fathers have started playing with children these days.” [Mother, Medium dose, Uganda]
“Yes, I learnt that whenever were resolving domestic conflicts, we should always be mindful of the children in order not to stress our children” [Mother, High dose, Uganda]
And another in Nepal said, “A child cannot grow by a single parent’s hardship only. It needs care from both father and mother for a better future.” [Mother, High dose, Nepal]
Change in fathers
The GBG model has brought about significant shifts in fathers' perspectives and roles in parenting and family life, particularly highlighting their understanding of the importance of their children's well-being.
Transforming child discipline:Fathers have departed from traditional corporal punishment and now emphasize constructive forms of discipline. Their focus has shifted to the importance of education. As one father shared, “I changed in the way I care for my children; I no longer beat them like I used to, and I try very hard to make sure my kids get an education.”[Father, Amuria, High dose, Uganda]
“I’ve learned about the positive ways of child discipline, that I do not need to always shout and beat the child for making him disciplined. Such practices should be spread in the community as well.” [Father, Medium dose, Nepal]
Active involvement in play: Fathers are actively engaging in playful parenting activities with their children, recognizing their role in child brain development. Playtime is viewed as an opportunity for children to explore and learn. Fathers have embraced endearing names for their children, enhancing their bonds. As one father emphasized, “I participated in playing with my children efficiently because it’s the time for child’s brain development, the child needs to be given time to play and engaged in activities that will support his brain development. I also learned that calling and naming children with insulative names distends the child’s love from you.”[Father, Amuria, High dose, Uganda]
“I am engaged in my business during the daytime, so I can’t give enough time at the day. But after closing my shop, I go home and play with my child for 2/3 hours. This gives me a sense of relaxation and also helps to create a bond between me and my child.” [Father, Medium dose, Nepal]
Improved communication and relationships: Fathers have adopted more meaningful interactions with their children. This shift fosters deeper bonds and understanding within the family. Fathers are not only more attentive but also provide constructive feedback. As one father expressed, , “The GBG intervention has increased unity in the community. Even women who had conflicts amongst themselves now days share the same lesson class because of GBG intervention.” [Father, Medium dose, Nepal]
Recognizing the significance of playful parenting: Fathers had come to realize the importance of playful parenting sessions and their impact on child well-being. These sessions offer opportunities for both children and parents to grow and connect. Another father emphasized, “The positive changes I have observed are the increased friendship between parents and their children. Parents and children freely interact, work together, and feed together. There is increased family unity, and men are more responsible compared to then.”[Father, Tororo, Medium dose, Uganda]
“Before, I used to go to work for the whole day and after returning, I used to have chit-chats with my friends. But these days, after returning to home, I play with my child and I have realized that my child now feels comfortable to share his things and express himself with me. Before, there was an environment of fear but now it’s not the case.” [Father, Medium dose, Nepal]
Monitoring child health through play: Through observing their children's reactions during play, fathers had become more aware of their children's health. Changes in children's behavior can signify their well-being or indicate potential health issues. This increased awareness was evident in fathers' interactions with their children. A father observed, “The program/ activities is good because you will realize that when the child is not playing it should be a sign that the baby is sick, and action has to be taken.”[Father, Omoro, Medium dose, Uganda]
Change in GBG workforce
The GBG program, designed to promote the holistic development of children in Uganda, has not only enriched the lives of parents and caregivers but has also affected the program's facilitators, mentors, and project officers both personally and professionally.
New knowledge: Embracing child development: GBGFs in Tororo (medium dose, Uganda) have received the tools and knowledge to effectively advocate for child development. They've discovered the significance of enabling children to play freely without constraints, creating an environment where children can play safely. This newfound knowledge has instilled hope and positivity in parents who may have lacked direction for their children's growth. As one GBGF shared, “GBG taught me how to allow children to play freely without limitations. The intervention prepares a conducive environment for children to play without hurting themselves. "Parents didn't have hope and dreams for their children, but after the intervention, more parents have built hope and positivity in their children.” [ GBGF, Tororo, Medium dose, Uganda]
“At the community level, the most neglected age group is children. But, after the implementation of this program at the community level, people, somehow are aware that, we need to take care of children at the early stage of their development.” [GBGF, High dose, Nepal]
New Knowledge: Creating a safe environment: GBGFs have also grasped the importance of establishing a safe and conducive environment for children to play and grow. This includes removing obstacles in play areas and providing shade and water for children. They've also gained insights into age-appropriate tasks for children. “I learned from the training was home environment, meaning when you are playing with your children at home, you should create a safe environment for children, for example, there should not be stones in the play environment of children. Another thing is that there should be shades in the compound where children can sit and play from, and there should be water for children to drink.”[TOT, Tororo, Medium dose, Uganda]
“Before they were untidy and they don’t use to manage the home environment (haphazardly placing sharp equipment like sickles etc.) but now they have improved cleanliness, cover the food in utensils, making children wear clean cloths and home environment and they send their children to schools.” [GBGF, High dose, Nepal]
Improved skills: Building relationships with families: The GBG program has not only empowered parents but has also transformed GBGFs. They've developed new skills, including public speaking, mobilization, guidance and counseling, and the confidence to approach families without fear. These skills enhance their ability to make a meaningful impact on the communities they serve. “I can now speak in public without any fear. Thanks to the training offered by GBG interventions. I can do mobilization; this skill of bringing people together was trained by GBG. I can conduct guidance and counseling.”[Father, Tororo, Medium dose, Uganda]
“The community now recognizes and relates me with their children. They also share the positive changes that I made to their children. Though it is all because of this program, but they identify me as the changemaker. I feel proud about this.”
Improved skills: Building relationships with children: GBG has not only been a catalyst for community change but also for parent-child dynamic among the project staff. GBGFs shared that their children now enjoy more open and affectionate relationships. As parents they create time to support their children with schoolwork, discuss issues, and be present in their lives in ways they might not have before. “My child is now very friendly and free with me, unlike in the past before GBG. In the past, the children were not my friends, but now, because of GBG, I relate well with them. I am now able to create time for my children, I even support them with school homework and discuss any other issues that affect them.”[Father, Omoro, Medium dose, Uganda]
“I am a mother myself. So, the things that I have learnt from this program, I first apply those things in my child and family. This has been a dual benefit for the children of my family and my community.” [GBGF, Medium dose, Nepal]
New knowledge: Promoting child rights: In Buliisa (High dose, Uganda), GBG facilitators have not only provided caregivers with skills for child nurturing but have also taught parents about children's rights and the importance of early education. The broader perspective and practical knowledge imparted by GBG have contributed to significant changes in their communities. “1st of all, I taught parents how to nurture their children, how they can extend love to their children by feeding them, giving them a conducive environment for playing, and giving them food that is rich in all food values. In my area Busiga before this project, parents used to send their children to school when they have grown up, but now what I can say, things have changed, and parents are sending their children to school even at a younger age.”[GBGF, Buliisa, High dose,Uganda]
“The child shares their learnings from ECD to home, so the parents have started sending their children to schools.”[GBGF, Medium dose, Nepal]
Fostering creativity: GBG facilitators have embraced creativity, crafting play materials for children and enhancing their playful experiences and learning opportunities. Their proficiency in music, dance, and drama skits has also seen significant improvement. “I developed skills of making play materials for children.”[TOT, Medium dose, Uganda]
“Material development training has helped a lot. We all enjoyed it very much. I didn’t know the importance of games and after this GBG, I knew that playing games with baby helps to develop their hand and legs. I have made many toys after that event.” [GBGF, High dose, Nepal]
Collective inspiration: GBGMs have recognized the power of the program, which extends beyond individual families to entire communities. Communities unite, draw inspiration from each other, and create a collective energy that fuels the project. “Definitely yes, this intervention has strengthened my family relationship. We happily and freely interact.”[TOT, Medium dose, Uganda]
“My mother-in-law is also happy after I share the learnings with her. My sister-in-law also
has a small baby. I happily share my learnings with her as well.” [GBGM, High dose, Nepal]
Even project officers, responsible for overseeing the program, had been touched by its positive results and success stories. They have not only felt inspired and motivated but also reflected on how they can apply the same principles and practices in their own families. “Yes, I am able to apply all I learn at my home; the intervention is child-centered and basically the most suitable for any parent to uphold.”[Project Officer, Medium dose, Uganda]
In conclusion, the GBG program has led to changes in parenting practices, family dynamics, and community involvement, resulting in more nurturing and attentive caregivers and healthier, happier children across diverse settings.Top of FormBottom of Form
Reach of the program
In Nepal, the high dose intervention reached 1,900 people in group sessions, while in Uganda, it reached a significantly larger group of 33,061 individuals. Similarly, the medium dose intervention in Nepal reached 2,415 people, while in Uganda, it reached 17,072 individuals. Uganda had more participants in both the high and medium dose interventions compared to Nepal.
Dose delivered: Group sessions
With respect to the dosage of group sessions, according to the data available from Nepal, 36% of the families attended the 80-100% of group sessions (4-5 sessions) in the medium dose while, 28% of the families in the high dose attended the same proportion of group sessions (8-10 sessions). In Uganda, for the medium dose intervention, 45.4% of caregivers attended 80–100% of the sessions, and 42% attended 50–79% of the sessions. Similarly, for the high dose intervention, 42.2% of caregivers attended 80–100% of the sessions, while 37.4% attended 50–79% of the sessions [Figure 4].
Dose delivered: Home visits
Percentage of targeted families receiving home visits: In Nepal, for the medium-dose group, 95% of the targeted families received home visits, while in the high dose group, this percentage increased to 98%. In Uganda, for the medium dose group, 50% of the targeted families received home visits, which is notably low coverage. In the high dose group in Uganda, the percentage of families receiving home visits was slightly lower at 72.3%.
Percentage of families receiving the full package of home visits: In Nepal, high percentages of caregivers in both the medium (94%) and high (92%) dose groups received the full package of home visits, indicating high coverage and adherence. In Uganda, there was a significant difference between the two dose groups. Only 35.6% of caregivers in the medium dose group received the full package, while this proportion slightly increased to 52.6% in the high dose group. However, these proportions are considerably lower compared to Nepal [Figure 5].
Quality of the dose delivered
In Nepal, the high dose program was well-delivered at a rate of 70%, with 26.4% needing improvement and 3.6% falling behind. For the medium dose program, 41.9% is well-delivered, 49.5% needs improvement, and 8.6% is falling behind. In Uganda, the high dose program was well-delivered at a rate of 78.1%, with 27.8% needing improvement and 5.6% falling behind. For the medium dose program, 66.7% was well-delivered, 27.8% needs improvement, and 5.6% is falling behind. On average, approximately 72.4% of the program is well-delivered, 27.8% needs improvement, and 5.6% is falling behind. This data suggests that, in general, a significant portion of the program in both countries in high doses was well-delivered [Figure 6].
Data for the quality of home visits was available only from Nepal. Analysis of the data from 186 households of caregivers indicated that more than half (59.1%) of the home visits were delivered well as per the guidelines; 29.0% needed improvement, followed by 11.8% that were seen falling behind.
Caregiver satisfaction
In both countries and across different intervention doses, a significant portion of caregivers are satisfied with the GBG program highlighting that the program has generally garnered a positive response from caregivers in both settings.
Feasibility of implementation
Experience with the implementation is presented with findings from the main theme Feasibility; sub-themes include: i) Facilitators ii) Challenges and iii) Recommendations.
Some of the enablers shared by participants are described below. In the realm of behavior change projects, recognition and rewards can serve as powerful motivators for the delivery personnel, which is what we see here.
Relevant content: Health workers acknowledge the program's alignment with their training. They understand the significance of play in promoting proper childhood growth, reinforcing the importance of GBG. “Absolutely yes, every project that has a positive impact on the lives of people will be recognized, and as health workers, this project came to reinforce what we had been taught at school about playing with our children for proper growth.” [GBGM, Tororo, Medium dose Uganda]
“At the community level, the most neglected age group is children. However, with the introduction of this program, there has been a noticeable increase in awareness among people about the importance of early-stage child development and the need for proper care.”
Community recognition: Community members, motivated by the program, express their support and eagerness to get involved. Their enthusiasm serves as a testament to the program's effectiveness. "Yes, the intervention has positively affected my motivation in a way that I am able to freely express myself to my supervisor. The majority of community members want to become involved, and this motivates me to keep up with the work." [Project Officer, Paya and Mudumba, Uganda]
“This project has contributed to establishing a foundation within the community for early child development awareness. To ensure the continuity of these learnings, ongoing support from the local government or other programmatic components of World Vision is essential.” [Project officer, Mahottari,Nepal]
Motivated by success stories: The ultimate reward is witnessing the transformation of families and communities. The stories of healthier children, more supportive husbands, and improved lives serve as profound motivators. "Absolutely yes. This is because parents, mothers, and caregivers have made testimonies that their children are now healthy and strong, their husbands are supportive, and that their lives have improved, and to me, this is more motivating." [GBGM,Buliisa, High dose, Uganda]
Professional development: Project officers, enriched with in-depth program knowledge, are among the champions of GBG. Their recognition and acquired skills enhance their dedication to the cause.
“Definitely. My work has been rewarded by the program through skilling me on the GBG model, MDAT, empowered World View, and Channels of Hope approaches that did not only help me at work but also enhanced my capacity as an individual to manage myself better.” [Project officer, Amuria, High dose, Uganda]
The journey of GBG offers rewards that go beyond tangible tokens. Participants understand that growth and improvement are integral to the process. "Yes, not really, I feel there is so much work to be done, I feel it’s the start, and there are so many unfortunate things that we didn’t do well like planning better, budgeting better, and implementing better. I feel there is still room for me to achieve satisfaction."
Valued by seniors: The GBG program values collaboration and feedback from stakeholders at all levels. Recognizing their pivotal role, the program listens to their insights and contributions. "There is no way the program would fail to listen to our feedback because as foot soldiers we are the ones to make the project successful, and because the program needs to succeed, they had to openly listen to our feedback for the betterment of the project."[Faith Leader, Imam Asamuk,Uganda]
The rewards of the GBG program encompass more than financial compensation. Recognition, acknowledgment, and opportunities for growth are potent motivators for everyone involved. From health workers to community members, project officers to mentors, GBG thrives thanks to the dedication of its stakeholders. The recognition received further fuels the drive for change, reaffirming the program's pivotal role in nurturing children through play-based learning and holistic development.
Various stakeholders involved in the GBG program faced distinct challenges during the implementation of the initiative. These challenges encompass a wide range of issues, from healthcare limitations to poverty-related obstacles and difficulties in communication and transportation.
Non-responsive communities: A key issue noted was the reluctance of fathers to actively participate in the program. Many fathers were not responsive to interventions, leaving the burden of childcare primarily on women. This gender imbalance created challenges in achieving comprehensive family involvement in the GBG program.
Another challenge is the non-responsiveness of the fathers to these interventions where they leave the women to do everything in their homes. [Health Worker, High dose, Uganda]
“In rural communities, a full-time commitment is a big challenge since they will be engaged in their daily work. Sometimes they rush to go during the sessions.” [GBGM, Medium dose, Nepal]
Culture, Poverty and parental challenges: Poverty was a common denominator among the challenges faced. Parents' impoverished circumstances negatively impacted their ability to provide for their children adequately. For instance, limited access to funds affected their capacity to afford clothing, medicines, food, and education.
Poverty is the major impediment to the successful implementation of the project ideas because poverty cannot allow us to implement and provide all that we need for our children. The major challenges that the parents or caregivers in Asamuk Sub County experience are a lack of knowledge about how to properly raise children and the high poverty levels among the parents, which have affected their ability to provide the necessary requirements for proper growth, such as a proper diet and health. [Faith Leader, SDA, Uganda]
The parents lack money to buy study and reading materials for the children. The single mothers and fathers raising the children by themselves with little or no support also affect the quality of their development of the children. [Faith Leader, SDA, Uganda]
High poverty levels within the community emerged as a significant obstacle. Parents' capacity to provide essential dietary values for their children was hindered by economic constraints. Climate change further impacted food production, making it even harder for parents to maintain balanced diets for their children. Additionally, limited parental awareness about their role in nurturing children added to the developmental challenges.
The high poverty levels in the community are the greatest challenge affecting parents' ability to provide the necessary dietary values for their children. The ability to grow enough food has been affected by the ever-changing climate, but ignorance by parents of what is expected of them also affects the development of children. For example, does it really need a project to be in place to sensitise parents to play with their children. [Health Worker, IDI, Uganda]
In the terai areas of Nepal, the cultural beliefs did not allow the women to participate in the gatherings. The lack of incentives was also a major concern. But with continuous effort and support from the project staffs, the attendance gradually began to rise.
“Initially in few communities of Terai region, cultural beliefs and norms impacted on participation of caregivers.” [Project officer, High dose, Nepal]
“They used to complain about snacks and they used to argue that they have been rearing and caring their children since many years and there is no benefit of attending the sessions.” [Project Officer, High dose, Nepal]
Communication and weather challenges: Obstacles related to communication and logistics were frequently encountered. Technical issues, like unclear radio signals, disrupted communication channels. Weather conditions, such as rain, caused substantial delays and interruptions in program activities.
Signals from the radio stations weren’t figuring out the frequency well, but later the signals were fixed. About the function, bad weather (rain) interfered with the program for nearly two hours, and testimonies and programs were shortened. [ECD focal person, Omoro]
There were instances when we could not conduct the sessions due to heavy rainfall and disturbed road conditions. Getting the people to gather at one place used to be a problem, especially during the rainy season as the mobile phones also did not work properly during heavy rainfall. Many times, the parents used to get angry and refused to attend the next session gathering. [GBGF, High dose, Nepal]
Signals from the radio stations weren’t figuring out the frequency well, but later the signals were fixed. About the function, bad weather (rain) interfered with the program for nearly two hours, and testimonies and programs were shortened. [ECD focal person, Omoro, Medium dose, Uganda]
There were instances when we could not conduct the sessions due to heavy rainfall and disturbed road conditions. Getting the people to gather at one place used to be a problem, especially during the rainy season as the mobile phones also did not work properly during heavy rainfall. Many times, the parents used to get angry and refused to attend the next session gathering. [GBGM, Buliisa, High dose, Uganda]
There were several challenges faced by the GBG team community mentors and coordinators. With respect to the intervention delivery team, their dedication is unquestionable, but without a clear path forward, their motivation wanes, impacting their effectiveness. The process of mentorship must be more clearly defined and recognized to ensure the individuals supporting the program feel valued and their efforts appreciated. As the GBG program continues to evolve, addressing these challenges will be essential to maintaining the enthusiasm and dedication of the implementation teams in similar communities.
Communication, commute, and coordination: Issues of high operational costs, absenteeism during learning sessions, difficulties in coordinating trainers, and inadequate phone access among trainers affected the program.
Secondly, I have witnessed absenteeism during learning sessions, some don’t turn due to several factors, and this has affected our program coverage. [GBGF, Tororo, Medium dose, Uganda]
I have a few challenges that have affected my work to a limited extent. But the most challenging is the high cost of movement from one TOT to the other. It’s difficult to move on foot from one place to another. [GBGF, Tororo, Medium dose, Uganda]
Thirdly, I find it difficult to coordinate the TOTs because some of them don’t have phones and become hard to contact. I also observed that during the rainy season, there is a low turnout since most mothers go to their gardens. 2 Some of the challenges I noticed were related to capacity gaps; some TOTs were not so knowledgeable about some topics. [GBGF, Tororo, Medium dose, Uganda]
The geographical challenges have been a hindrance in many programs and this is not a new case. But the positive influence from the neighborhood and society works positively in such community-based programs. [Project Officer, High dose, Nepal]
Unpaid Mentors: The commitment of the GBGMs to the cause is appreciable, but the lack of financial recognition leaves them feeling underappreciated. These volunteers, despite their dedication, sometimes see their efforts go unrewarded.
“As a mentor in the project, we were not so much considered because we were just doing it voluntarily. When they called for those visits, we were not paid anything, so we were not rewarded.” [GBGM, Buliisa]
For example, we have TOTs, and for TOTs, they are to conduct these sessions. In conducting these sessions, they were supposed to be paid such an amount, then a mentor to go and mentor a TOT. That one was really lacking; it was not specific that when you go to a mentor, you document, then you report, and maybe you could be paid for it. This wasn't there, and this affected my motivation negatively.” [GBGM, Medium dose, Uganda]]
Initially I agreed to work voluntarily for around 6 months. But because of the significant delay in the initiation of the program, I was in dilemma if I should continue or not. I could not attend my undergraduate exams as I could not prepare well because of the engagement in this program. [GBGM, High dose, Nepal]
Lack of role clarity: While the GBG program's objectives are crystal clear, there is a disconnect when it comes to the mentorship component. Mentors are unsure of their place within the project and how they fit into the program's design. The lack of clarity leaves mentors questioning their roles and value. The absence of specific guidelines for mentorship duties, documentation, and the potential for compensation leads to a feeling of ambiguity.
“Really, we were not motivated so much in a way that we didn't know how the program was designed because the mentors were not so much considered in the project, so we really don't know why.” [GBGM, Buliisa, High dose, Uganda]
At the start, there was a little bit of confusion because there wasn’t clarity, but then we had mentorship as part of the activities, which was dropped. There were challenges with reporting, the finance officers needed a lot of capacity development. Project field officers needed support in implementing the intervention. Along the way, after the GBG training, things started getting smoother, and there was clarity in the way things were done. [Project Officer, Izere Foundation, Uganda]
"The mentors were also the same from the training we attended. I feel that many of the mentors were not clear about their roles and responsibilities. They were often confused with the content." [GBGF, Medium dose, Nepal]
Program management: Challenges arose in the context of organizational internal systems, budgeting issues, and complicated reporting. Furthermore, service gaps existed in terms of financial compensation for staff, and an abrupt end to mentorship activities left stakeholders in a state of confusion.
I have faced challenges right from Organizational internal systems to working with partners and community level implementation, but what is important to note are the implementation challenges, which range from the late start-up of project activity implementation with a very short duration to accomplish all the deliverables to the high stakeholder expectations. [Project Coordinator, IDI]
I was not compensated enough as team leader, but the fault was in our budgeting. The project officers were getting the bear minimum, and it was too heavy on the project. We performed multiple roles towards the end of the project and was not compensated. [Project Officer, Izere Foundation, Uganda]
“We had to look at the GBG sessions, home visits and the renovation activities as well, at times it became hard to cover all the activities.” [Project Officer, High dose, Nepal]
These challenges collectively underline the multi-faceted nature of the obstacles faced in the GBG program. They reflect issues of healthcare, education, communication, transportation, and resource limitations. Recognizing and addressing these challenges is vital for the program's success and the well-being of the communities it serves.
Recommendations
The workforce shared key areas for improvement in the GBG parenting approach for the continuation of the program, training, supervision, and continuous quality improvement. Faith leaders called for increased supervision of program activities. They recognized the need for more training to better support families. Continuous learning is crucial, while VHTs emphasized that comprehensive training was hindered by limited time and extensive topics. They recommended more focused training for
-depth understanding. GBG facilitators stressed the importance of continuous training, and CVAs recognized the value of refresher sessions for teachers and caregivers to stay aligned with program goals. GBG mentors also proposed including local leaders and VHTs in reflection meetings to enhance community engagement. GBG program mentors urged intensified training efforts and expanding the number of beneficiaries for a more significant impact. VHTs recommended timely information sharing for smooth program execution and participatory field report review for improvements. Program officers advised clarifying mentorship processes by identifying mentors at sub-county or district levels.
Table: Quote for the recommendations theme
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Theme
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Quote
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Recognize dedicated caregivers
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They should consider the caregivers because these caregivers started attending these sessions from the beginning up to the end, and they were disappointed when we were at the parenting days. They thought they would receive some gifts, but they were not given any. So, I would like them to consider how to motivate these caregivers. [GBGM, KII, High dose, Uganda]
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Program continuity
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More time is needed to see more positive results in our community.” [GBGF, FGD, Medium dose, Uganda]
Continuity is essential to reach all community members, including those initially left out. [GBGF, FGDs, Buliisa, High dose]
The project should be rolled out to all the villages in the Area Programme so that all children and mothers’ benefit from the interventions for positive parenting. [VHT, FGD, Amuria, High dose, Uganda]
There should be sensitization of parents about the need to keep implementing the GBG program. [VHT, FGD, Bundibugyo, High dose, Uganda]
This project was done in 19 villages, so my recommendation is that they should scale up. [GBGM, Buliisa, High dose, KII, Uganda]
GBG program should be widened to cover wider areas and reach many people. [ECD Focal person, Omoro, Medium dose, KII, Uganda]
The program should continue; 'removing hands off the program after one year is like you leaving a one-year-old child to feed themselves. [PO, Izere Foundation, KII, Uganda]
With every session, the caregivers have started to show keen interest to
attend the session. [GBGF, Medium dose, Nepal]
The engagement of fathers and other family members too can be more effective as the
decision-making power does not rely only with women.” (GBGF, Medium dose, Uganda)
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Investment in training supervision
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We should invest more time in supervising program activities. [Faith leader, Omoro, Medium dose, KII, Uganda]
More training is needed to improve our ability to support families. [Mentor, Tororo, Medium dose, KII Uganda]
The trainings were not enough to provide quality services because the topics were so wide, yet the training time was limited thus affecting the ability of all the topics to be exhausted. [VHT, Amuria, High dose, FGD, Uganda]
Continuous training is essential for maintaining our effectiveness. [GBGF, Buliisa, High dose, FGD]
"They should conduct refresher sessions to help the teachers get more knowledge or remind them about what they were taught or maybe see if they are doing it the right way. [CVA, Amuria, High dose, FGD]
I request that the program conducts more training of TOTs and mentors and increases the number of beneficiaries. [GBGM, Tororo, Medium dose, KII, Uganda]
Reflectional meetings should be adjusted to include local leaders and the VHTs, which could solve the challenge of mobilization and sensitization. [GBGM, Buliisa, High dose, KII, Uganda]
We also had mentors who were at the same time facilitators, and we realized that this created a gap in the mentorship processes since they also had their own arms to facilitate. I would think that in the next phase, mentors should be identified from the sub-county or district level for overall supervision at field sites. [Project Coordinator, KII, Uganda]
Mentor and project officer used to come for supervision during session conduction and we used to share our challenges during their visits and during reflection meetings but only some challenges were addressed. (GBGF)
At times, it was hard and confusing to us regarding the content of the sessions. The refresher trainings have made things easier. Likewise, the continuous engagement of the caregivers in the sessions might be very beneficial for changing their behavior. (GBGF)
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Data Management Improvement
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They should improve on the system which they were using to receive our data. [GBGF, Buliisa, High dose, FGD, Uganda]
Timely informing of field-implementation plans to ensure smooth program execution. [VHT, Bundibugyo, High dose, FGD, Uganda]
Participatory review of field reports to identify areas for improvement and enhance program effectiveness. [VHT, Bundibugyo, High dose, FGD, Uganda]
There was not clarity about the implementation at field level. We were also confused about the sessions and dosage. I feel there has been a communication gap between the plan and implementation. [Project officer, Rautahat, Nepal)
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Commute assistance
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VHTs be facilitated with transport means such as bicycles or motorcycles to ease their movements from home to home and this will increase number of home visits conducted. [VHT, FGD, High dose, Uganda]
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Ownership from School Committee
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“We did receive the learning roots training and learnt about the playful engagement and learning to children but because of lack of teachers in the school, we need to teach other students as well.” [ECD teacher, Rautahat, Nepal]
"Our local government doesn’t focus to ECD classes and teachers. They only look after higher classes. As this is a project with limited period, the local government should take ownership in provision of materials and trainings to us." [ECD teacher, Mahottari, Nepal]
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Stakeholder involvement
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The program should bring on board more stakeholders and use different channels to communicate to its beneficiaries. [GBGM, Tororo, Medium dose, KII, Uganda]
We would also wish to be involved throughout the project, right from the beginning other than only in the end. [ECD Focal person, Omoro, Medium dose, KII, Uganda]
Let alone having engagements at the community level, I would say that the local government sector must be engaged since this is a sector which does supervision and monitoring of implementation, planning and decision-making, which includes budget allocation for local needs and priority areas. [Project coordinator, KII, Uganda]
Overall, everything is great. But, if the local ward representative had prioritized this program for the development of the community, it would have been much better. Sometimes, I felt the ward representative is ignoring this program. [GBGF, Medium dose, Nepal]
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VHT=Village Health Team, KII=Key Informant Interview, ECD=Early Childhood Development, CVA=Citizen Voice Action, FGD=Focus Group Discussion, GBGF=Go Baby Go Facilitator