from EVIDENCE to POLICY Learning what works for better programs and policies October 2017 BANGLADESH: Can child stimulation messages be added to an existing platform for delivering health and nutrition information? EARLY CHILDHOOD DEVELOPMENT Development institutions and governments agree on the need provide new mothers with child development information dur- to start early when it comes to children’s healthy development. ing their visits to community health clinics and during regular Early childhood is a critical time for both the brain and body, home visits by health workers and family welfare assistants. The and it’s important that children receive appropriate nutrition, World Bank’s Strategic Impact Evaluation Fund (SIEF) sup- health, stimulation and ported an evaluation to test the impact of adding this child socio-emotional support stimulation component to a national nutrition program. The in this period. But child evaluation found that almost all families that received the addi- development programs can tional services, including informational cards on child develop- be expensive and compli- ment and picture books, reported using them, and their chil- cated to deliver—especial- dren showed small to modest gains in cognitive, linguistic and ly when they include home physical development compared with children whose families visits to show caregivers were not offered the program. The results show that it is possi- how to stimulate healthy ble to supplement existing health and nutrition programs with development—and it’s still not clear how best to design and an additional component to improve children’s cognitive devel- deliver cost-effective programs in low-income areas. For exam- opment in the early years, before they start any formal school ple: Can information about best practices for keeping children program. However, almost 50 percent of households didn’t get healthy and stimulated successfully be delivered through estab- the materials as expected, underscoring the challenges of us- lished programs, like cash transfers or health services? What ing an already existing system of government community clin- sort of training and mentoring is needed for successful home ics and community outreach to deliver additional services. As visits and can these be made cost-effective? policymakers in Bangladesh and in other countries seek suc- The Government of Bangladesh is working with a variety cessful approaches for supporting healthy child development, of partners on initiatives to improve early childhood develop- this evaluation provides promising evidence that the health sec- ment and provide the country’s youngest citizens with a good tor can be used to improve young children’s development but start. Save the Children, an international non-governmental also a cautionary lesson in the challenges of broadening existing organization, designed and implemented a pilot program to health programs to include other components. Context Bangladesh has made considerable economic and social prog- for their age; stunting also often results in cognitive delays that ress in the past decade, and as poverty rates have fallen, health, can harm their ability to learn and reach their full potential. nutrition and education services have become increasingly ac- The government’s National Nutrition Services was launched cessible. But the country continues to have one of the world’s in 2011 to promote healthy nutrition for young children and largest populations of malnourished children, with 36.4 per- pregnant women and to better integrate services into health cent of children under age 5 showing signs of stunting, accord- and family planning activities. This program relies on routine ing to 2014 World Bank figures, a rate that is higher among home visits by community health assistants and family wel- the country’s rural poor. Stunted children aren’t just very small fare assistants, along with women’s visits to community health clinics, as platforms for delivering information on nutrition, health and family planning workers visited their homes. Health micronutrient supplements and deworming medications. Save clinic staff and these community workers were given extra the Children’s pilot sought to use this existing infrastructure training by Save the Children on how to incorporate the early to deliver additional messages on child stimulation—why it’s stimulation messages into their visits and events. By integrating important and how to do it—and give mothers special cards the program into the government’s existing community health and booklets on child development and picture books for the infrastructure, Save the Children hoped to create a low-cost children. The cards and booklets were illustrated so they could program that would be scalable nationwide. As designed, the easily be used by illiterate mothers. The plan was that women program would cost less than $7 per child. The program ran would receive the materials and verbal information on child from 2013 through 2015 and targeted mothers with children EARLY CHILDHOOD DEVELOPMENT stimulation when they visited clinics and when community under age three. Evaluation With support from the Strategic Impact Evaluation Fund, a ran- The research team used several tools to evaluate children’s domized control trial was built into Save the Children’s pilot pro- development, including the Bayley Scales of Infant and Toddler gram to understand the impacts on child development and mea- Development, specifically the subscales which assess cognitive sure the effectiveness of integrating the program into an existing and language skills. They used as the Wolke Behavioral Rating government service. The program was implemented in three ru- Scale, which assesses children’s socio-emotional development, ral subdivisions where the National Nutrition Services program and they used a modified version of the Home Observation for had already started: Satkania, in Chittagong region; Muladi, in the Environment tool (HOME) to measure the frequency and Barisal region; and Kulaura in Sylhet region. In these three areas, quality of early stimulation in the home. In addition, the team 78 community clinics and the households in their catchment collected monitoring data from a random set of service provid- areas were randomly assigned either to receive the Save the Chil- ers and households, including information on the delivery and dren program or to be the control group, which didn’t receive use of child development materials. anything apart from usual government services and the National Recommendations for program implementation Nutrition Services program. The research team conducted the baseline survey between November 2013 and January 2014, be- • Laminate child development cards so they can’t be easily damaged fore the clinics were randomized into the two groups. Endline • Make it possible for the child development card to be hung on a data was collected between September and December 2015. wall to reduce the chance it gets lost Results The program had positive impacts on the cognitive, Children in the treatment group showed better cognitive and linguistic and socio-emotional development of linguistic development at the end of the program period when children in families that were supposed to receive compared with children in families who were receiving only the materials and information on child stimulation the usual health and nutrition services. They also scored bet- and development. ter on measures of socio-emotional development and other be- havioral-related skills. The program impact was twice as good This policy note is based on Chinen, M. & Bos, J.M. (2016). Final Report for the Impact Evaluation of the Save the Children Early Childhood Stimulation Program in Bangladesh. Washington, DC: American Institutes for Research. when comparing families who actually received the materials to receive special counseling sessions on the importance of early and messages—about half of those eligible—with children in stimulation and how to provide it. However, only 53 percent of the control group. families recalled receiving one or more of the four materials—a development card, a booklet and two picture books—that were Children in families eligible for the program also had supposed to be handed out. In most cases, people reported that better physical development, perhaps because their they received the materials during routine health visits to com- families were more likely than families in the control munity clinics and to the immunization centers; 18.5 percent group to take advantage of the government’s reported that they received the materials during routine home nutrition support program. visits from community workers. Mothers and others caregivers also received far fewer counseling sessions on how to use the ma- Children in families that were supposed to receive the stimula- terials than the program expected: Save the Children intended tion messages showed anthropometric improvements in terms of that women with children would get at least three sessions, weight for age and also in terms of weight for height when com- whether in the home or clinic, while pregnant women would get pared with children in families that did not live in program areas. 15 over the course of the program. Forty-four percent of women In addition, there was a drop in the percent of children severely recalled having only one session, 41 percent said they had two underweight, wasted and severely wasted. and 12 percent said they received three. However, because the The changes weren’t expected because the program didn’t messages were being delivered as part of the regular activities of include a component to encourage better nutrition or health. But after the program, households in the treatment group were more likely to utilize services provided to families through the government’s National Nutrition Services program, which may be the reason behind their children’s better growth. This program uses health clinics and regular home visits by community health and family planning workers to promote and support nutrition services for pregnant women and young children. The Save the Children pilot program on child stimulation used the same clin- ics and community health workers—both groups received spe- cial training on the new messages and materials—and perhaps informing families about healthy child development strength- ened their use of the nutritional services. Families that had at least one of the four early stimulation materials were significantly health assistants and family planning assistants, it’s possible some more likely to have the growth monitoring card and more growth women received the stimulation information and didn’t identify monitoring check-ups, part of the National Nutrition Services it as a separate activity. program, than families in the treatment group that didn’t receive There was no statistically significant difference in the num- any of the materials. Moreover, households in the treatment group ber of visits women made to clinics or the number of visits they also were more likely than those in the control group to report received from community workers when compared with the that they fed their children eggs, fish, chicken, or meat. control group: about one visit over the prior six months to the health clinic, and one visit each from a health and a family plan- Community health workers, including those who ning assistant. But women did spend almost two minutes more handled family planning, were supposed to distribute per visit in the clinic and they were more likely to report that that the cards, booklets and picture books when they community workers they met spoke about early childhood de- made their routine home visits and when mothers velopment and how to use the materials they were handing out. visited health clinics, but almost 50 percent of eligible families didn’t remember receiving anything. The materials were widely used by households that received them. Parents were supposed to receive these materials during their visits to the local health clinic or during home visits by com- Households that received the program materials—whether spe- munity workers. During these visits, mothers were also expected cial cards with key messages or picture books—reported using the materials and about 95 percent said they used them three to The program was supposed to run for 20 months, but in seven days a week. Almost all mothers reported using the materi- practice it was implemented over a 12-month period, largely als, as did 30 percent of fathers and 15 percent of mothers-in-law, because of delays in getting various government permissions. according to what program participants reported. About half of This meant community workers had a shorter period of time in mothers also used the materials with their other children. And which to distribute materials and hold informational sessions; mothers continued to use the materials over the course of the and this also reduced the period in which women could be ex- program—at the endline survey, 90 percent of mothers said they pected to visit a health clinic. were still using the picture books and development cards. The other possible problem was that in more remote areas, families may infrequently visit clinics and there may be some who EARLY CHILDHOOD DEVELOPMENT Apart from the problem of getting all materials don’t regularly attend community meetings. So if they didn’t get distributed and ensuring women received the expected the materials during a routine home visit by a community health number of conversations with health workers on child worker, they were less likely to receive the information at all. development, the program faced other implementation issues that could have affected the impact. Conclusion Giving parents the tools they need during a critical window in development messages because a new program doesn’t need their children’s development can create real change in the lives to be created to deliver the information. However, wrapping of those who need it most and as the evidence underscores, a new program into an existing one can pose some problems, it’s also possible without creating large and expensive new pro- as this evaluation found, and it’s important to understand the grams from scratch. Meeting parents where they already are— challenges when devising such an approach. For example, it’s in this case, the health clinic or in their homes—and providing important to ensure those delivering the program have the ca- them supplementary information can go a long way in making pacity—not only knowledge, but time and incentive—to take sure that children have the tools early on to reach their full on additional responsibilities. potential. It can also be a cost-effective way to support child The Strategic Impact Evaluation Fund, part of the World Bank Group, supports and disseminates research evaluating the impact of development projects to help alleviate poverty. The goal is to collect and build empirical evidence that can help governments and development organizations design and implement the most appropriate and effective policies for better educational, health, and job opportunities for people in developing countries. For more information about who we are and what we do, go to: http://www.worldbank.org/sief. The Evidence to Policy note series is produced by SIEF with generous support from the British government’s Department for International Development and the London-based Children’s Investment Fund Foundation (CIFF). THE WORLD BANK, STRATEGIC IMPACT EVALUATION FUND 1818 H STREET, NW WASHINGTON, DC 20433 Series editor and writer: Aliza Marcus For more information on the evaluation contact SIEF researcher Marjorie Chinen at mchinen@grade.org.pe