Researcher Q&A following Thrive in Conversation: Enablers and barriers to scaling parenting programmes – a comparison of Bhutan and Zambia

A recent Thrive in Conversation webinar on enablers and barriers to horizontal and vertical scaling covered research on two ‘playful parenting’ programmes: Prescription to Play (C4CD+) in Bhutan and Caring for the Child’s Healthy Growth and Development (CCD) in Zambia. Here, two of the webinar panellists – Carina Omoeva, Senior Director for Research and Evaluation at FHI 360, and Frances Aboud, Professor Emerita, Department of Psychology, McGill University, Canada – answer questions from the audience.

Q: Was it mothers who were mostly involved in both countries, or other caregivers?

A:While both programmes emphasised the importance of father engagement in parenting sessions, the overwhelming majority of caregivers attending sessions and receiving home visits were mothers. Our observation data showed that in over 90% of sessions, only the primary caregiver (presumed to be the mother) was in attendance. 

Q: Are there differences in the involvement of different caregivers in the sessions, for example mothers versus fathers or other caregivers?

A: We know that there is an immense cultural element to this. Caregiving, especially for newborns and young children, is often seen as the sole domain of mothers, and it takes a lot of work for programmes to gradually chip away at these norms. Aside from this, a huge factor is that the fathers are often simply not present during the daytime hours, off at work outside the home, so scheduling sessions around their presence was a challenge recognised by the programmes and their frontline providers.

In Bhutan, across a sample of 180 group sessions we observed, only 11% of primary caregivers (mothers) attended with their male partner. In Zambia, across 182 home visits observed, only 8% had a male caregiver present. And across the 60 group sessions observed (these were only introduced in the final year of our study in Zambia), 98% of mothers attended without their partner. 

Our observations also showed that fathers tend to take a back seat in group sessions, in which the majority of attendees are women. Similarly, there is often an initial reluctance to engage in the home visits, when the content is perceived as geared predominantly towards the women. It is important therefore to develop content and messaging specifically for men, and to create male-friendly spaces where they can be shared and reinforced. 

Q: What was the reason behind 44% attendance for at least one session in Bhutan?

A: There are likely multiple reasons. When we asked caregivers in a survey why they chose not to attend, the overwhelming majority (90%) stated that they did not know about the sessions. Then, when we asked caregivers why they did not return, if they attended just one session (out of nine offered), they stated that “not having the time” was a factor. In addition, in interviews, the frontline providers leading group sessions noted the challenges of having adequate space for the sessions, as well as session duration – which went up to 90 minutes in the initial programme design. Save the Children later revised the sessions to last just 45 minutes, to improve attendance, and our observations showed that sessions ranged from 20 to 75 minutes, depending on the provider. 

Q: Could you provide more details on ‘community norms and engagement’? Are there any specific differences between Bhutan and Zambia?

A: Caregivers in both countries initially emphasised the provision of nutrition and healthcare as the critically important domains of child development. Caregivers in Bhutan also placed emphasis on peer interaction. Over time, we observed in focus group discussions that caregivers started recognising that the provision of play and communication was important for mental development. Norms against father engagement were very strong in Zambia, as they were in Rwanda – caregivers shared that community members could insult and humiliate fathers seen taking their child to a health clinic. Both programmes sought to change these norms through deliberate engagement strategies, with variable success.

Q: Is there any experience globally where mothers lead groups themselves (similar to self-help groups)?

A: Yes, many organisations (especially NGOs such as ChildFund and BRAC) use mother volunteers to lead parenting groups. As with any volunteers, they require more extensive training and support, as well as instructional manuals or materials clearly outlining key messages and describing specific play and stimulation activities for children of different ages. In Zambia, we met a mother in the community who stepped up to become a Community-Based Volunteer precisely because of her experience with and appreciation of the programme.

Q: What level of government (national, regional or district) needs to be involved at different levels of the programme or research?

A: Ideally, all levels should be involved from the start – that is, if you are trying to take a programme to scale. Government coordinating bodies on early childhood development are essential counterparts in ensuring that the path from pilot to scale is realistic and well thought through. Similarly, at the district level, and any local level, success or failure often depends on the engagement of health officials – and not just passive awareness, but engagement, inquiry, and ownership. Building this relationship takes time – as we saw in Bhutan, this took time and effort – but ultimately, it is essential for long-term success.

More recently, there has been increasing acknowledgement of the fact that scaling up should not start at the point of programme completion (see, for example, resources at the Global Community of Practice on Scaling) – but rather, at the point of initial discussion with government stakeholders about what the challenges are, and how to address them at scale with available solutions. And only then building a process from the ground up to scale them.

Q: This sounds like an ambitious programme of services innovation. I’d be interested in understanding how many years you thought were necessary to achieve organisational maturity in Zambia i.e. where the workforce and the organisation supporting them had achieved ‘threshold maturity’?

A: There is no question that these are lengthy processes, that require long-term planning and commitment, as well as continuity of institutional knowledge from programme to programme. The Scaling Community of Practice recommends a time span of at least 10-15 years for successful scaling – but that of course depends on local context and capacity, as well as any external disrupting factors. 

Q: In fragile contexts such as Afghanistan, standalone early childhood development programmes often struggle with funding continuity and long-term sustainability. Integrating early childhood development within existing health and nutrition platforms is therefore essential for effective scale-up. I would appreciate hearing experiences and lessons learned from scaling early childhood development in similar contexts.

A:There is a vibrant community of practice on early childhood development that can be accessed via ECDAN, where you should be able to connect with programme teams that do exactly that. Many early childhood development programmes – for example the UNICEF Care for Child Healthy Growth and Development in Zambia –find that their most direct pathway to caregivers is through existing health and nutrition programmes. This is true in the pilot phase but even more so at scale. The challenge is to ensure that the parenting and early childhood development messages get through to caregivers, and don’t get drowned out by immunisation and nutrition messages – those are of course essential, but not sufficient for whole child development. We recommended some adjustments that will help ensure that the play and communication content is equally recognised in importance by caregivers. The Bhutan programme tacked on the group parenting sessions to the monthly immunisation and growth monitoring visits in the hopes of increasing attendance.

Q: Considering the data on parenting session outcomes, what would be the recommended optimal number of sessions to ensure meaningful behaviour change while remaining feasible in a fragile context?

A: That is such a great question. Across the programmes we looked at as part of this study, it was a challenge to ensure that all caregivers attend a single session, let alone complete the full programme. The latest review of implementation features from low- and middle-income countries (not necessarily fragile contexts) was published by MN Ahun in the 2024 Annals of the New York Academy of Sciences. There is not one answer because the optimal number of sessions may be determined by the modality (home visits, group sessions, or some of both), frequency, and level of structure/demonstration as part of the session. The length of the curriculum should also depend on whether the responsive stimulating practices of parents are new to caregivers in a particular context. If this is the case, a best guess is that to achieve impact, programmes should include nine to 12 sessions focused on three Nurturing Care Framework practices related to play, talk and nutrition. However, as noted, not all sessions will be attended by all caregivers, and actual exposure for most will be dramatically shorter. What is that critical level of exposure, and how to reach it, is an important question requiring more evidence.