Date of Award


Document Type

Open Access Dissertation


Health Promotion, Education and Behavior

First Advisor

James F Thrasher


Appropriate nutrition and psychosocial stimulation during the first three years of life can have long-lasting effects on a child's health and development. However, not all children in the world receive adequate nutrition and psychosocial stimulation during this period. There has been enormous interest in developing the evidence on the most effective ways of implementing and assessing early childhood development (ECD) promotion interventions in resource poor settings. Despite the interest, the integration of ECD interventions into pre-existing public health programs, and assessment of these interventions in extended family, rural household environment have not been addressed.

The dissertation research presented here was carried out in rural Pakistan, where child malnutrition and mortality are high, and where a primary care outreach program comprising more than 100,000 community health workers (called Lady Health Workers or LHWs) is in place. This research involved two studies: 1. a qualitative study that explored the factors that contribute to the successful integration of a comprehensive ECD intervention into a large-scale community health worker program; 2. a quantitative community survey that aimed to adapt and validate the Infant and Toddler version of the Home Observation for Measurement of the Environment (IT-HOME) inventory, which was expanded to address childcare that extended family members provide (HOME+).

Findings from qualitative interviews with LHWs (n=12) and mothers (n=18) suggest that the commitment of LHWs to work, their willingness to learn and take on additional roles, and acknowledgement of LHW work by the mothers are all favorable for implementation. Contextual factors that impede implementation included changes in LHW job responsibilities without her knowledge and involvement, and the lack of support from staff of the healthcare facilities. For mothers, the support provided by the family and the LHW facilitates the integration of new activities into their daily lives while lack of involvement by the family hampers this integration. These results indicate that the professional and domestic environments of LHWs and mothers are dynamic and, as such, should be addressed on an ongoing basis, as a new program moves through various phases of implementation and integration. This attention to the details of implementation is important for effective program delivery to achieve the overall goals of CHW programs, including child health and development.

Findings from community survey (n=153) revealed that a large proportion (70%) of the study sample lived in households that included extended family members. Subscale and total scores were higher in extended families as compared to nuclear families and this difference was consistently significant when HOME+ was used. Households whose index child was older (i.e., > 1 year) scored significantly higher than households with younger children on the "responsivity" dimension of HOME+, whereas no difference was found while using HOME. Compared for mother's education, children of highly educated mothers scored significantly higher than children of less educated mothers on "acceptance" dimension when HOME+ was used, while the difference was not significant while using HOME. Aside from these differences, the correlates of both HOME and HOME+ were mostly similar.

In extended families, higher subscale and total scores using HOME+ compared to HOME are suggestive of a richer environment that may favor ECD. Additional caregivers may be particularly important as the child grows older. That these caregivers may significantly impact ECD may help explain the inconsistent relationship found between HOME and ECD outcomes in prior research in countries where households are organized around extended families. Future studies should consider the HOME+ instrument to assess the developmental consequences of living in extended family systems.

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