Two years ago, Mary Kinney visited a remote region of Tanzania to assess newborn care facilities. Working for Save the Children, Kinney helps to scale Kangaroo Mother Care (KMC): an intervention in which low-birth-weight newborns nestle against their mother’s skin like a baby kangaroo in a pouch. This skin-to-skin contact has been shown to boost both the child’s chances of survival and future development.
When she arrived, Kinney received quite a shock. “It was so sad,” she said. “Room after room said KMC but they were empty”. Only one facility out of the 12 she visited had a functioning KMC ward. The project team had left, and the local staff they trained had been transferred elsewhere.
KMC has spread to over 30 countries and saved thousands of newborns’ lives. As shown in the Tanzanian region Kinney visited, however, a successful project with impressive results can still encounter serious problems when scaling up. And when interventions consist of high-touch elements like a parent’s contact and care, introducing them successfully to new communities requires changes to deep-rooted behaviours and cultures.
So how can early childhood practitioners make these shifts at scale, and ensure they’re sustainable?
Developing a message
Touch and caregiving are universally available, which means interventions like KMC have the potential to be replicated anywhere in the world. However, local cultural barriers can make that difficult.
For example, said Kinney, the context in sub-saharan Africa is very different to southeast Asia. In places like Pakistan and Afghanistan, women aren’t as likely to want to show skin. Meanwhile, in some settings in Africa, when a low-birth-weight baby is born the “expectation for survival is so limited” that families need convincing that they can make any difference, she added.
It’s therefore essential to build messages with local experts who know the context best, said Kinney. In Malawi, a broad-based behaviour change campaign took place which helped to shift social norms around the care of newborns. Using a wide variety of pre-tested messages, the Ministry of Health and Save the Children bombarded the population across multiple channels, from information in health facilities to mass media radio jingles.
In areas where messaging was most comprehensive, KMC mothers and pregnant women were significantly more likely to report changes in their thoughts about preterm babies, and higher support from family and the community.
The priorities and concerns of parents of low-birth-weight-newborns also differ in different contexts, said Anne-Marie Bergh from the University of Pretoria, and messages need to adapt accordingly.
In low-income contexts, practitioners tend to emphasise child survival: prolonged skin-to-skin contact regulates the newborn’s temperature, and breastfeeding protects the baby from infection.
For high-income countries, Bergh said, it’s easier to convince parents by focusing on bonding and attachment and the long-term benefits: KMC is linked to stronger cognitive development in babies compared to traditional neonatal care.
Learning together, by example
The challenge of changing behaviour at scale, particularly when it includes the high-touch and often emotional aspects involved in early childhood care and parenting, is not only faced by KMC programs.
“Regardless of the culture, the transition into parenthood is a pretty life changing experience,” said Ruti Levtov, Director of Research at Promundo.
Promundo helps to scale MenCare: an early childhood intervention encouraging fathers around the world to become more involved in caregiving, especially during the prenatal and postnatal stages.
MenCare uses a wide variety of interventions, from workshops and counselling to mass media campaigns. And the evidence suggests it’s been successful: in Rwanda, for example, men who participated in MenCare spent 60% more time a day on unpaid care in the home.
One of the most powerful aspects of MenCare in helping change behaviour is their peer-support groups for fathers, set up with community organisations and run by trained local facilitators.
In Rwanda, facilitators meet a dozen fathers in a local area, weekly for three to four months. In the sessions, fathers discuss issues and engage in participatory activities like role playing. Through this process, said Levtov, fathers come to an understanding about how they can contribute to their family and how they can behave differently. They then work through the skills to do that, such as how to hold a baby and how to improve their communication.
Learning by example, and alongside other members of the community, has also been essential in scaling KMC. What’s been particularly effective in changing people’s minds, said Bergh, are stories of mothers whose babies survived and thrived thanks to KMC. In Malawi, these women would attend events with their healthy babies, such as open days in the community, to promote the practice.
It’s not just parents who need convincing, though. Families need to be supported by healthcare workers who appreciate KMC’s importance, Bergh said. However, “it’s much more difficult to incorporate this intangible love and touch into training in a way that will stick,” she said.
The example of other healthcare professionals has been a useful tool. Respected nurses can be champions of the practice, she said, convincing others by helping babies thrive using KMC. This could be vital in high-income countries, where pushback from the professional community has been a significant roadblock in reaching scale.
As MenCare and KMC’s work shows, when scaling interventions which challenge traditional social and professional norms, trained and sensitised champions can be vital to promote the programs and to guide people through the changes they encompass.
Changing the system
If high-touch early childhood interventions are to scale widely and sustainably, though, they need more than individual buy-in: there needs to be wider support systems in place.
“Working with individuals is necessary but not sufficient,” explained Levtov. For MenCare to work effectively, the broader support systems around fathers, such as access to quality childcare and healthcare, need to improve, she said.
These broader systems can also be utilised to reach scale. In Chile, for example, MenCare has been incorporated into the national government’s early childhood program Chile Crece Contigo (“Chile Grows With You”), which now includes guidance and materials around engaging men in childcare and education.
As opposed to a five-year pilot — when a program parachutes into a community and does a randomised control trial — real change to long-established cultures and behaviours of parents and families needs a holistic health systems approach, said Kinney. “No one wants to say that,” she said, “because that’s not going to get a donor.”
Like MenCare, KMC is a package of interventions — from the initial skin-to-skin contact to follow-up services — and therefore “you need to work across the various facets of the health system,” said Kinney.
As was the case in remote Tanzania, unless ownership and leadership of a program by the local community is combined with systems change, high-touch programs like KMC and MenCare will not be sustainable over the long term.
Success at scale can require a careful combination of ingredients: messaging that has been adapted to local contexts; trained professionals and peers to lead by example; and systems change to ensure the required support is in place. “There’s no silver bullet in these things,” Kinney concluded. — Jack Graham
(Picture Credit: Unsplash)