Enablers and barriers to scaling an ECD parenting program into primary health care services in rural Bangladesh

Early childhood development programs play a crucial role in fostering child development. However, scaling-up these programs in low- and middle-income countries poses significant challenges. We conducted a mixed-method study of an evidence-based early childhood parenting program integrated into the primary health care services (community clinics) across four districts in rural Bangladesh. The program caters to caregivers of children aged 6-36 months with mild-to-moderate malnutrition. The parenting program is delivered by government community health workers (CHWs) with small groups of mother-child dyads within the community clinic setting as part of their routine duties. Mothers-child dyads attend fortnightly sessions for one year. CHWs are trained and monitored by government supervisors with overall oversight provided by government health staff at the sub-district and district level. The aim of the study was to identify the strengths and weaknesses of the program and strategies for improvement. Quantitative data included data from clinic logbooks, observations of session quality (n=60), and in-person interviews with participating mothers (n=185) in sixty clinics and phone interviews with mothers (n=164) in a further eighty clinics. Qualitative data included in-depth interviews with CHWs (n=20), government inspectors (n=16), and managers (n=4), and focus group discussions with mothers (n=4 groups, n=30 mothers), and grandmothers (n=4 groups, n=28 grandmothers) across twelve clinics. Results indicated that the key enablers to program implementation included strong government ownership, high compliance in implementing the program by CHWs, adequate session quality, satisfactory session attendance, and positive attitudes towards the program by all stakeholders. Key barriers included low levels of supervision, insufficient advocacy messaging within the community, poor communication across health staff at the different levels, and challenges in providing play materials at scale. The findings are being used to inform revisions to the program to enhance implementation fidelity and sustainability within the health system.