Formative research on parenting practices and community support for early childhood development among caregivers in Telangana

INTRODUCTION

Early Childhood Development refers to the overall development of a child from conception up to 8 years of age across various domains such as physical, emotional, social and cognitive development. These domains are easily affected by the caregivers’ physical, psychosocial and neurobiological relationship with the child and the environment in which the child is brought up. There is lack of awareness among the community about the various simple early learning methods which can hasten the pace of development.¹ 25% children below 6 years in developing countries are exposed to poverty, unhygienic living conditions, unsafe home environment and many other factors which could hamper their development.² This often leads to poor health during adulthood further leading to loss of economic productivity.³

Early years of life are the ones where there is considerable scope for growth. The Sustainable Development Goals have incorporated ECD as a goal to achieve by 2030.⁴ Engaging children in early stimulation, play and communication activities from birth will help ensure all round development of the child, reduced risk of developmental delays, and better career opportunities in adulthood. Children attain their full developmental potential only when they are being encouraged and supported by the caregivers and family.⁵ The relationship among the family members with each other also contributes majorly for a child friendly home environment.⁶ Hence, empowering caregivers and family members by providing information through frontline workers regarding ECD and early stimulation practices will lead to improved child development.⁶ The challenging task is to engage with mothers and their children of different age groups in a single meeting.⁷ Despite implementation of programs in a suitable manner, their uptake by the community is still questionable owing to lack of knowledge and awareness regarding concepts and actionable ECD messages as an important reason. The level of penetration of print media, electronic media or telecommunication is an important factor to be assessed for sharing the messages with the community.¹ It is also critical to know the level of trust the community has on its frontline workers for receiving information related to health care or any other programs. This study was conducted to understand knowledge, attitudes and practices regarding parenting among caregivers of children below 5 years of age in Telangana, to identify gaps and explore pathways for informing behaviour change strategies to improve caregiving practices in local context.

METHODS

A cross sectional study was conducted using mixed methods in two randomly selected mandals (administrative block) of TS during the months of May and June 2022. Kaghaznagar mandal from Kumaram Bheem Asifabad district has a predominantly rural population while Golconda is a semi-urban mandal in the state capital Hyderabad. KAP survey of caregivers of children aged 0-5 years was conducted along with in depth interviews (IDIs) of Anganwadi workers (AWWs) and Accredited Social Health Activists (ASHAs) regarding their role in ECD. Focus group discussions (FGDs) were also conducted, one each with grandmothers and fathers to understand their perspectives in child rearing.

Sample size

For the KAP survey, a total sample size of 240 respondents was computed (120 for each mandal), assuming 50% participants had adequate knowledge, considering 95% confidence interval, 10% absolute precision and adjusting for 20% non-response rate. We stratified the sample in each mandal based on age groups of children. i.e., 30; 0-1 years-old, 30; 1-3 years-old, and 40; 3-5 years-old. From each mandal, 5 Anganwadi centres were selected randomly and both AWW and ASHA linked to the centre were interviewed. Participants in each category were selected by simple random sampling using the register obtained from the Anganwadi teacher. Participants for FGD with grandmothers were selected depending upon their availability at home as most of them worked in their farmlands. However, FGD for fathers was planned on a Sunday as it would be easy for them to participate actively in the discussion. A semi-structured questionnaire was developed, translated into Telugu (local language), pilot tested and modified before the KAP survey. The questionnaire was divided into various domains like socio-demographic details of primary and secondary caregivers, profile of children, KAP regarding ECD practices, information about Mother and Child Protection (MCP) Card, antenatal care, mothers meeting, house visits, mother’s attitude, father’s role in parenting, support from other family members, safety and security and sources of information. We had a mix of single choice, multiple choice, and Likert scale questions. The questionnaire was administered by trained junior research staff. FGD guide was developed in local language to gather information from fathers and grandmothers regarding their involvement in the upbringing of child, the rapport they develop with the child via play and communication, their understanding of child needs etc. IDI guide was developed in local language to capture service delivery, community engagement and knowledge about ECD from the frontline workers. FGDs for fathers (1 FGD with 10 participants) and grandmothers (1 FGD with 10 grandmothers), and IDIs for FLWs (10 AWWs and 8 ASHAs) were conducted by research staff in local language which were then transcribed and translated into English. Each FGD lasted for about 60-90 minutes, and IDI lasted for about 45 minutes. The data was analysed based on pre-defined themes and indicators. Quantitative data was analysed with the help of statistical software (STATA 14.0). The results (frequencies and percentages) were presented in the form of tables and graphs using appropriate data visualization tools. For qualitative data, a thematic analysis of key issues was undertaken using an iterative process of both a-priori codes and emerging new themes, in line with good practices for qualitative data analysis. The quantitative and qualitative information was triangulated to arrive at a comprehensive understanding.

RESULTS

Total 218 caregivers responded to the KAP survey, nearly 62% from nuclear families; 33.5% had only one child while the rest had 2 or more children. More than 55% participants in Kaghaznagar (rural) lived in semi-pucca houses compared to only 19.3% in Golconda. 26.2% and 25.2% mothers completed secondary education and graduation and above; these were 21.4% and 25% in fathers. Other caregivers surveyed were predominantly grandmothers, 79.1% of whom were illiterate.

Caregivers knowledge, attitudes and practices regarding ECD

More than 80% caregivers across age groups responded that most of the brain development occurs during pregnancy and first 3 years after birth. More than 97% of participants agreed that play, games and activities like singing or story telling were important for their child’s learning and physical development. But nearly 15 to 25% caregivers did not know that such simple activities could make their children more intelligent and such children had better chances of higher paid jobs as adults compared to others; this proportion was higher among parents of 3-5 years-old children. Almost all agreed that safe household, sanitation and good nutrition are contributors for improving child growth. On asking what should be done to improve child’s intelligence and emotional development, less than 50% mentioned that telling stories, being sensitive to the child, playing and protecting the child were necessary (Figure 1).

This was reiterated in the FGD where all fathers agreed that playing and communication activities help in improving children's health, encourages good behavior and develops mind; while play also reduces stress. All fathers believed that children should be treated with love and affection. “They will be good they will be healthy it is necessary to play for some time, it’s good for the body, good mind a little free from stress”-FGD1-Father7. Comparing responses for caregivers of different age groups, the positive responses in knowledge and attitude questions across all variables for cognitive and emotional development were higher for 0-1 year old than 1-3 years-old and 3-5 years-old group. But talking with the child and telling stories was slightly higher for 3-5 years-old age group. Reading and telling stories to the child are the least practiced activities (<50%) among caregivers of all age groups (Table 1). Fewer parents of children 3-5 years-old actively engaged with them while doing household chores, as the children may be old enough to play on their own. These parents were more engaged in reading, story-telling, and outdoor play activities as their 3-5 years-old children had grown to understand and participate. There is a significant reduction in practice of singing songs for older children.

More than 75% of mothers and around 70% grandmothers were involved in routine caregiving activities like feeding, bathing/washing and putting the child to sleep. Only around 50% fathers reported feeding or bathing (Figure 2).

Fathers were least engaged in primary caring of 0-1 years-old group. Most fathers were not aware of specific nutritional needs of their children as they felt mostly it was the mother’s responsibility. They felt it is the primary role of mothers to take care of children, which was affected if the mother was working. “Nowadays what happens is both mother and father are working. When we are asked to watch over the child we can’t take care for too long”- FGD1-Father10. Fathers are more involved in play activities, taking the child on lap or putting them to sleep. They also reported more participation in taking their child to the doctor for healthcare or routine immunization. Most fathers engaged with their children after returning from work. They played activities like ball games, singing or dancing as they felt it made their mind fresh and helped them bond with their children. They also watched children’s programs on mobile or TV with their children. “We spend two to three hours with our children. We can’t spend much time with the kids in the morning because we are working”- FGD1-Father4. Nearly 99% of participants felt that fathers should be involved in caregiving for the child. On asked why father’s participation was important, most common responses were “For the good of family”, “Both parents are required for child to grow” and “Fear of father”. Some fathers felt that children begin to understand only from the age of five years. “Only after five years the child understands what he is doing. Now two to three years children don’t understand what they are doing. When they turn 5 years old, they start to understand”- FGD1_Father2. All caregivers agreed that maintaining discipline was necessary for child development. However, majority resorted to shouting or hitting to discipline their child (60 to 70%). While nearly 50% of caregivers reported ‘being firm’ as a rules-based method, very few resorted to denying privileges such as favourite food or TV programs across all age groups.

As seen from the results of the FGD, fathers agreed on using harsh methods of discipline. They felt it may improve their children’s behaviour. But most fathers also felt that fighting, arguing or using harsh words in front of children will have a negative impact on children. “They should be scared of our sight (presence) itself, from the very start they should be scared of us, they should behave well when we go home. When we talk, we talk with affection, but they should fear us and fear outsiders and tell them that their daddy is dangerous and that they should behave well if daddy is around” FGD1-Father4. “What will we do without scolding. If they don’t listen, we have to hit them. How else will they have fear if we don’t hit them. They have to be afraid, right?” FGD2-Grandmother4. All fathers agreed that children were addicted to video devices and required them while eating. They felt it has increased during COVID lockdown and has worsened their children's behaviour and may lead to other problems later. Only one father believed that use of mobile phones improved child's knowledge. “During the lockdown phone has spoiled the children. The situation is very bad, we should take them out and buy outside food, if not they will get angry. In my house we don’t give phone at all, No not my kids, sir I am telling you about my brother’s child. The child got used to phone so much that now. She has to wear spectacles and can't see without them. We should give them the phone but just for five to ten minutes and if they don’t understand we should act like children and take them out. Now what I do is when they don’t eat and cry, I take them outside, feed them ice cream, spend some time and then we come back home, they are also happy, we are also happy” FGD1-Father4.

Sources of information regarding ECD

To understand various communication channels through which beneficiaries receive information and how they perceive such information, participants were asked the following questions regarding three popular Health related programs (KCR Kit, Poshan Abhiyaan, Kanti Velugu) and three Development schemes (Haritha Haaram, Mission Bhagiratha and Rythu Bandhu).^8-13

Anganwadi workers were found to be the primary source of information for both Health and social welfare schemes. A significant percentage of participants responded with ‘Others’ option which included ‘Hospitals’ for Health related programs and ‘Village Sarpanch’ and Family for Social welfare schemes. They felt they could understand messages shared by Anganwadi workers better compared to other information sources. They also reported TV and family members as information sources that could be understood easily. 92% respondents trusted health related information provided by Anganwadi workers (50% for social welfare schemes) followed by Family members, TV and Village Sarpanch. Very few participants relied on Social media platforms like YouTube and WhatsApp for information.

Information provided by frontline workers

Most mothers reported attending monthly mothers meetings at Anganwadi centre (57% to 70%), but only 45% said they attended regularly. Similarly, nearly 76 to 79% reported being visited by ASHA or AWW respectively during their pregnancy. While nutrition, pregnancy care and immunization were the most common topics discussed by ASHA and AWW during antenatal visits, topics like sanitation, early stimulation and learning, raising the child were hardly discussed (35%, 25%, 40% respectively). Frontline workers were not found to have received any training specifically on ECD or early stimulation activities. Most Anganwadi teachers were aware of early childhood care and developmental milestones as they were trained in assessing development of pre-school children who attended their centres. They mostly concentrated on Nutrition and Health related messages during community-based events, while early stimulation activities and responsive caregiving were not discussed in detail. “Most topics are taken on growth or on pre-school activities. SAM/MAM, pre-school activities so there are already regular videos madam so mostly we are asked to refer them and do things carefully and to cover ECCE well but mostly topics are about that, topics like growth because mostly that is where there are problems”. Aww1-R. Most AWWs understood the importance of early stimulation and advised some activities to parents like singing, talking, dancing, playing with household objects or taking children out to show animals. Few AWWs explained the effect of early stimulation activities on brain and motor development. “Identifying their development from birth itself that means looking at us when we call in the first month, identify the mother in the second month, hearing in the third month means looking at us when we make sounds” Aww5-R. ASHAs were completely unaware of ECD as their roles were mainly related to community mobilisation for pregnancy related care and immunisation of children and pregnant women. Some ASHAs understood play and communication activities but did not relate it to child development.

DISCUSSION

The thirty year follow up of the Jamaican Early Childhood Stimulation intervention reported nearly 40% increased earnings among adults who had received early stimulation through play and communication as children.^14-16 In our study, nearly 80% of caregivers agreed that major portion of brain development is completed by the age of 3 years, but many were unaware that simple activities such as talking or playing with their children improved their intelligence and increased their productivity as adults. Positive responses were higher among parents of 0-1 and 1-3 years children when compared to 3-5 years children, which was likely due to the introduction of the National nutrition program Poshan Abhiyaan in the year 2018 which focused on cross-sectoral intervention during the first 1000 days of a child’s life.¹⁷ While it has been shown that responsive caregiving activities such as listening to the child, responding through touch, talk and play improve communication, emotional and cognitive competence in children, positive responses for telling stories, being sensitive to the child, playing and protecting the child were 50% or less for all age groups. Caregivers did not associate such routine activities with their child’s cognitive or emotional development (Figure 1).¹⁸ Comparing responses for different age groups, the positive response across all variables for cognitive and emotional development declined from infant care (0-1 Years) to 1-3 years group. This may be due to reduced home visits by AWWs and ASHAs after 1 year of age.¹⁹ The positive responses for talking with the child and telling stories again slightly increased after 3 years, which may be a result of the child attending preschool at the Anganwadi centre.²⁰

Activities to develop language and communication such as reading and telling stories are not often practiced (Table 1). The higher never/rarely/sometime proportion for various daily activities to promote stimulation and play among 0-1 year age groups compared to 1-3 years age group reiterates that parents increasingly stimulate their children only when they begin to respond to sounds and actions. This lag in initiating stimulation activities may lead to developmental delays in the child.^16,20 Mothers were more involved in daily routine activities such as feeding, bathing, and putting children to sleep followed by grandmothers (other primary caregivers) (Figure 2). While it has been proven that fathers’ involvement in child rearing results in higher self-esteem and better school performance, fathers were mostly engaging children in play activities. Most fathers were not aware of specific nutritional needs of their children as they felt mostly it was the mother’s responsibility.²¹ They felt it is the primary role of mothers to take care of children, which was affected if the mother was also working. Good disciplining practices help children to organize their thoughts and emotions, develop socially appropriate behaviour and grow into emotionally mature adults.^21,22 While all caregivers agreed that discipline was necessary for child development, most employed harsh methods such as hitting or shouting, despite acknowledging that they can have negative effects on their child.

Sources of information

Ever since Anganwadi centres were first established in the 1960s, Anganwadi teachers have been found to play a very important role in guiding local communities towards better education and nutrition practices.²³ Villages with trained frontline health workers have seen a marked improvement in the health of families, especially children.²⁴ It appears that most local communities rely on AWWs not just for health and nutrition related information (KCR Kit, Poshan Abhiyaan, Kanti Velugu) but also other social welfare programs such as Haritha Haaram, Mission Bhagiratha and Rythu Bandhu (Table 4). They were also considered as most trustworthy sources for accurate information (Table 4). Also, nearly 80% of pregnant women were visited by AWWs and ASHAs during their pregnancy. This is crucial as it reiterates the importance of appropriate training for AWWs to improve knowledge of beneficiaries.²⁵ Social media platforms like WhatsApp and YouTube were not considered by beneficiaries as accurate or trustworthy sources of information. However, many caregivers reported that they received more information from their family members and from village leaders like Sarpanches. So improving the knowledge of all family members and village leaders is also essential for supporting caregivers in improving childcare practices. It was also found that topics like early learning and stimulation for children were rarely discussed at caregiver meetings. This may be because many FLWs mentioned that they were not given specific training on responsive caregiving or early learning and stimulation. AWWs were aware of early learning concepts while ASHAs were completely uninformed regarding Early Childhood Development and Nurturing Care despite availability of Mother and Child Protection card.²⁶ Hence, FLWs need to be trained specifically to provide timely information on age appropriate early learning and stimulation activities.

CONCLUSION

Caregivers need to be trained and empowered to initiate play and stimulation activities from an earlier age as it has cascading and accelerating impact on the child’s development. Engagement of all family members for the early stimulation of children from each age group is essential for motivating and empowering caregivers. The lag in initiation of early stimulation activities is a missed opportunity and may lead to delays in developmental milestones. This may also lead to lag in identification and timely management of such delays. Frontline workers need to be trained on assessment and documentation of developmental milestones for the children below 6 years of age. IEC materials like videos or audio messages can act as a powerful tool when disseminated by AWWs as they have a greater uptake by the community. More emphasis needs to be laid on early learning and stimulation activities for children of all age groups.

ACKNOWLEDGEMENTS

Authors would like to thank the Aga Khan Foundation for funding this study and providing on-field support. Authors would like to thank the department of women development and child welfare, Government of Telangana State for extending support through the ICDS department to ensure smooth coordination with the Anganwadi centres. Authors also acknowledge the field staff, Child Development Project officers, data collectors and district officials for their efforts.

Funding: Study was funded by Aga Khan Foundation

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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