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 Table of Contents  
Year : 2022  |  Volume : 2  |  Issue : 2  |  Page : 73-78

Last-mile delivery of early childhood development services: The role of community health workers in dadra nagar-haveli district

1 Developmental Pediatrics Unit, Ummeed Child Development Center, Mumbai, Maharashtra, India
2 Early Childhood Development and Disabilities Unit, Ummeed Child Development Center, Mumbai, Maharashtra, India

Date of Submission18-Feb-2022
Date of Decision23-Apr-2022
Date of Acceptance28-Apr-2022
Date of Web Publication30-May-2022

Correspondence Address:
Dr. Fernaz Dotivala
Ummeed Child Development Center, 1-B, Mantri Pride Building, NM Joshi Marg, Near Aurthur Road Junction, Subhash Nagar, Lower Parel, East, Mumbai - 400 011, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ipcares.ipcares_52_22

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Background: India has the dual challenge of a high prevalence of developmental delay and disabilities in early childhood and a paradoxical underutilization of available intervention services due to limited accessibility and acceptability by their families. Early Childhood Development (ECD) services delivered by community health workers (CHWs) ensure its last-mile delivery to every household. IIts acceptability is improved by including evidence-based, culturally, and contextually sensitive approaches as is done in the International Guide for Monitoring Child Development (IGMCD). The IGMCD is a tool that monitors and supports the development of children under 3 years of age and also enables provision of early intervention services when required. The IGMCD, recognizes caregiver strengths and priorities and helps to build a rapport between caregivers and providers. Clinical Description: We describe six children and their families from Velugam, Dadra-Nagar Haveli district, who received ECD services from CHWs who used the IGMCD package. These cases highlight how the CHWs used the IGMCD package to identify developmental delays, health and psychosocial risk factors to development and provide strategies to caregivers to support their children's development. Management: The CHW used individualized strategies to promote responsive caregiving and enhance opportunities for early learning. In addition, the IGMCD package reinforces health, nutrition, and ECD-directed messages that are provided at the Anganwadi centers. Conclusion: Children and families in underserved communities can receive comprehensive ECD services through CHWs who are trained to deliver the IGMCD.

Keywords: Community health worker, developmental monitoring, early childhood development, International Guide for Monitoring Child Development

How to cite this article:
Dotivala F, Edwards N, Khuje P, Lobo L, Marathe A, Srinivasan R. Last-mile delivery of early childhood development services: The role of community health workers in dadra nagar-haveli district. Indian Pediatr Case Rep 2022;2:73-8

How to cite this URL:
Dotivala F, Edwards N, Khuje P, Lobo L, Marathe A, Srinivasan R. Last-mile delivery of early childhood development services: The role of community health workers in dadra nagar-haveli district. Indian Pediatr Case Rep [serial online] 2022 [cited 2023 Feb 3];2:73-8. Available from: http://www.ipcares.org/text.asp?2022/2/2/73/346260

Early childhood development (ECD) includes cognitive, physical, language, socioemotional, and motor development of children until 8 years of age.[1] The World Health Organization (WHO) and other partners launched the Nurturing Care Framework (NCF) with various levels of support according to developmental status: “universal” for typically developing children, “targeted” for those at high risk of delay, and “indicated” for children with Developmental Difficulties (DD).[2] Caregivers, service providers, and policymakers from sectors like health and education are key stakeholders in ECD and play an important role in helping children access services in keeping with their needs.

The high prevalence of DD in children in India warrants ECD-directed services that are free or inexpensive, easily accessible, and acceptable.[3] Existing programs such as the Rashtriya Bal Swasthya Karyakram and Integrated Child Development Services have successfully addressed health-related concerns of children with special needs. However, they face multiple challenges in the provision of services. These include restricted access, disproportionately fewer number of District Early Intervention Centers (DEIC) – every district in India does not have an operational DEIC yet, shortage of trained multi-disciplinary personnel, and decreased utilization due to the lack of awareness or issues emerging from the necessity of multiple visits.[4] Since this scenario is common in many lower- and middle-income countries (LMICs), working models to overcome these barriers that have been proposed and successfully implemented, include integration of service delivery with primary health care and “developmental monitoring” of young children by community health workers (CHWs).[5] This evidence-based, culturally sensitive strategy is different from conventional “developmental screening,” which focuses primarily on identifying children at risk of DD, by virtue of “failing” a developmental screening test. In contrast, the process of monitoring helps to track and support the development of all children, extending beyond finding an aberration, and empowering caregivers by building their nurturing skills.[6],[7]

The International Guide for Monitoring Child Development

(IGMCD) is a developmental monitoring tool that has been standardized and validated in Indian children under 3 years of age. It comprises three key components: (1) monitoring (2) supporting and (3) providing early intervention. The “monitoring component” helps in tracking child development in seven domains (gross motor [GM], fine motor [FM], expressive language [EL], receptive language [RL], relating, play, and self-help [SH] skills), understanding the caregiving environment at home, and identifying the presence of protective and risk factors related to health and psychosocial factors that positively and negatively affect ECD, respectively. Typically developing children are expected to attain all milestones in the age interval that corresponds to their completed age [Figure 1]. A delay is inferred if the child does not attain one or more of the given milestones on or before the interval corresponding to their completed age.
Figure 1: The developmental domains, questions, examples of age ranges, and milestones of the International Guide for Monitoring Child Development

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The “supporting component” enables a trained CHW to provide learning opportunities that are developmentally and culturally appropriate. These are by giving supportive messages that emphasize noticing and building on the strengths and interests of the child, and being responsive to them.[8] Thus, it includes two components of NCF: responsive caregiving and providing opportunities for early learning.[2] The “early intervention” component simplifies the WHO International Classification of Functioning, Disability, and Health framework to apply family-centered and community-based early intervention for children with DDs.[8]

Our organization trains CHW employed by community-based organizations (CBOs) to use the IGMCD package. We partner with CBO working on maternal and child health and education in marginalized communities with limited resources and a high prevalence of factors detrimental to ECD, i.e., poverty, low parental literacy, anemia, malnutrition, and social problems such as alcoholism. Every CHW is educated till high school, has prior experience of working with children and families, and belongs to the community which they serve.[9]

We present six cases that highlight the importance of psychosocial stressors in ECD and have been managed by CHWs employed by the CBO. Both CHWs are from Velugam, Dadra-Nagar Haveli district. This village has 894 children under the age of 6 years (2011 census). The literacy rate is 54.95%, and most adults are daily wage laborers on farmlands.[10] Health care and the supplemental nutritional needs of this population are met by the primary health center. A DEIC situated 20 km away, is the nearest facility providing early intervention to children with DD. Since a visit to the center means missing a day's work, it proves to be a major deterrent for most families. No other ECD promotive services were available to the community before the introduction of the IGMCD package. The CHWs who have been trained to use the IGMCD package monitor the development of all the children under the age of 3 years in the community. The local anganwadis provide them with the list of households with children under the age of 3 years. Children identified with developmental delay receive weekly visits, whereas typically developing children are monitored on a monthly basis. We aim to sensitize our readers to the positive impact that even a simple strategy provided by trained CHWs can have in an under-resourced community.

  Clinical Description Top

Each summary and [Table 1] include brief details of the child and family: delays identified on IGMCD, health and psychosocial stressors, intervention initiated by the CHW at home, and changes that were observed in the developmental status and home environment after 6 months.
Table 1: Case-wise comparison of provision of the International Guide for Monitoring Child Development package and changes observed 6 months after initiation

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Family 1

The GM domain was primarily affected in this 2-month-old girl. The CHW recognized that though motivated, the caregivers were overburdened by farm and domestic work, and child-rearing responsibilities of the other children. The IGMCD support component was used to provide simple strategies like keeping an eye on her while the mother was doing her work and providing stimuli like colorful homemade toys to get her to reach out and grasp them.

Family 2

This 10-month-old (corrected age used) boy who had been born preterm and belonged to an extremely poor background displayed delays in GM and EL. The CHW recognized risks such as the remote location of their house and food scarcity. She also recognized the caregiver's willingness to support the infant's development and connected her with the Accredited Social Health Activist worker for the provision of nutritional support. The IGMCD support component was used to suggest simple strategies to promote development (e.g., the use of everyday opportunities and homemade toys to increase interaction with the infant).

Family 3

This 13-month-old girl was identified with delays in EL, FM, and play as well as the presence of malnutrition. The CHW recognized and reinforced the caregiver's commitment to her daughter's growth and development, including her efforts to obtain nutritional aid from the Anganwadi worker. She also noted risks within the home environment such as limited opportunities for exploration and learning. The CHW taught the caregiver to make sound-producing toys that the child liked and used them to teach her words [Figure 2]. Although the child showed improvement, she was lost to follow-up when the family relocated to another village.
Figure 2: A community health worker demonstrating strategies from the IGMCD support card to the caregiver. IGMCD: International Guide for Monitoring Child Development

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Family 4

The 16-month-old girl had a delay in EL. The CHW recognized several risk factors that were adversely affecting her development such as malnutrition, gender discrimination, marital discord revolving around the absence of a son, and repeated pregnancies in the attempt to get one. The caregivers had not sought medical attention for the child despite noticing her language delay and had stopped sending her to the Anganwadi after a younger sibling was born. The CHW collaborated with the Anganwadi worker and the dual efforts of both succeeded in motivating the caregivers to resend PJ to the Anganwadi. The CHW taught the child's aunt to notice and capitalize on the child's interest in books by making books at home and using it to help the child recognize and name pictures. The CHW also encouraged the aunt to model the use of words everytime the child used gestures. An attempt was also made to gently and gradually alter the parents' attitudes.

Family 5

This 27-month-old boy displayed a significant delay in EL. The CHW recognized that although his mother refused to acknowledge his delays (believing that he would eventually start speaking like other family members), she nonetheless prioritized his learning. Instead of challenging her beliefs, the CHW invested her efforts in building a rapport with the mother by suggesting activities that the mother considered useful and demonstrating the effect of using simple words such as “de” during daily interactions with her son. A major breakthrough was made when the mother confided her concerns regarding the poor scholastic performance of her elder child and sought the CHW's assistance in tackling that as well.

Family 6

This 3-year-old boy was particularly challenging due to his family circumstances. His parents had abandoned him and resided in a different city. The child was being reared by his elderly grandparents in the village. The child had been diagnosed with cerebral palsy at the district hospital at 9 months of age (the neurological sequelae of significant neonatal events). He also had malnutrition. Although they tried to look after him as best as they could and tried to feed him, they were unable to take him to the DEIC for intervention due to financial constraints, problems with commuting, and their own struggles with alcohol abuse. The CHW demonstrated strategies to provide developmental stimulation at home and improve nutrition [Figure 3].
Figure 3: The IGMCD Support Card. IGMCD: International Guide for Monitoring Child Development

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  Discussion Top

We know that home-based parenting interventions based on responsive caregiving practices and delivered by trained CHWs positively impact cognitive, motor, and language outcomes for children in many LMICs.[11] However, relatively little is known about factors that can sustain these gains. It is likely standardized delivery of an evidence-based, accessible, and acceptable ECD service will contribute to the sustainability and scalability of these positive outcomes. The IGMCD package is ranked highly for accuracy and feasibility of use.[12] By using open-ended questions, the CHW can discern which standardized milestones have been attained. Additional probing questions are used to elicit more information when needed. The tool elicits critical information related to caregiving practices at home, as well as risk and protective factors that can significantly influence ECD related to their interlinkages with health and psychosocial dimensions. Descriptors such as “strengths” and “areas needing extra support” are used instead of stigmatizing terms such as “pass” or “fail” while sharing results with caregivers. When a delay is identified, the identified risk factors are addressed, the delayed domain is supported, monitoring is repeated during follow-up, and community-based early intervention is added, as warranted. The rapport that gets established between the caregivers and CHWs enable them to discuss strategies to overcome factors that have been identified as detrimental to ECD with the family, in a nonconfrontational manner. Monitoring enables longitudinal follow-up and support of a child's and family's well-being and progress. This helps to build trust among caregivers. In addition to developmental monitoring and building responsive caregiving practices, the IGMCD package is used to reinforce the health, nutrition support, and ECD-directed messages that are being provided at the Anganwadi centers.

A standardized training program equips providers to learn about prevention, early identification, and planning of individualized intervention, which ensures consistent quality.[6] The IGMCD package is freely available for use once the users are trained. Clinicians from over 30 LMICs have been trained and 13 countries have national-level trainers.[13] The IGMCD package has been included in the preservice training of health providers and the national child health monitoring system in Azerbaijan and Turkmenistan. In India and Guatemala, not-for-profit organizations like ours have incorporated it into community home visit programs.[6] A randomized controlled implementation trial is currently exploring the effectiveness of the IGMCD package in rural settings in these two countries.[14]

Our case series demonstrates that the delivery of IGMCD by trained CHWs has a positive impact on the community, especially in vulnerable populations. With standardized training support, the CHWs were able to use IGMCD to reliably identify developmental difficulties and offer services and support in keeping with the locally available resources and family circumstances. The CHWs in our case series benefited from posttraining support to administer the IGMCD as recommended. This may have to be built into the training time for CBOs considering the use of the package in their communities. Truly, a comprehensive package such as the IGMCD presents an immense opportunity to take ECD services to the last mile in our country, where significant disparity in access to health-care services exists.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. Improving early childhood development: WHO guideline. Available from: https://www.who.int/publications/i/item/97892400020986. [Last accessed on 2022 Apr 20].  Back to cited text no. 1
World Health Organization, United Nations Children's Fund, World Bank Group. Nurturing care for early childhood development: A framework for helping children survive and thrive to transform health and human potential. Available from: https://apps.who.int/iris/bitstream/handle/10665/272603/9789241514064-eng.pdf. [Last accessed on 2022 Apr 19].  Back to cited text no. 2
Global Research on Developmental Disabilities Collaborators. Developmental disabilities among children younger than 5 years in 195 countries and territories, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Glob Health 2018;6:e1100-21.  Back to cited text no. 3
Kar A, Radhakrishnan B, Girase T, Ujagare D,Patil A. Community-based screening and early intervention for birth defects and developmental disabilities: Lessons from the RBSK programme in India. Disability, CBR and inclusive development. 2020;31:30-46.  Back to cited text no. 4
Kohli-Lynch M, Ponce Hardy V, Bernal Salazar R, et al. Human resources and curricula content for early child development implementation: Multicountry mixed methods evaluation. BMJ Open 2020;10:e032134.  Back to cited text no. 5
Ertem IO. The international guide for monitoring child development: Enabling individualised interventions. Early Child Matters 2017;126:83-7.  Back to cited text no. 6
Mukherjee SB, Aneja S, Sharma S, Kapoor D. Early childhood development: A paradigm shift from developmental screening and surveillance to parent intervention programs. Indian Pediatr. 2021;58:64-8.  Back to cited text no. 7
Ozturk Ertem I, Krishnamurthy V, Mulaudzi MC, et al. Validation of the International Guide for Monitoring Child Development demonstrates good sensitivity and specificity in four diverse countries. Acta Paediatr 2019;108:1074-86.  Back to cited text no. 8
Srinivasan R, Marathe A, Krishnamurthy V. Providing services for children with developmental difficulties, delay or disability – Early diagnosis and interventions at the community level. Indian Pediatr.2021;58:69-72.  Back to cited text no. 9
Census Info India 2011. Population size, 0-6 years (Number). Available from: https://censusindia.gov.in/2011census/censusinfodashboard/index.html [Last accessed on 2022 Apr 04].  Back to cited text no. 10
Zhang L, Ssewanyana D, Martin MC, et al. Supporting child development through parenting interventions in low- to middle-income countries: An updated systematic review. Front Public Health 2021;9:671988.  Back to cited text no. 11
Boggs D, Milner KM, Chandna J, et al. Rating early child development outcome measurement tools for routine health programme use. Arch Dis Child 2019;104:22-33.  Back to cited text no. 12
Ozalp Akin E, Mustafayev R, Pekcici EB, Ertem I, et al. Applicability of a tool for comprehensive pediatric assessments: The expanded guide for monitoring child development. J Pediatr Congenit Dis 2021;7:1-7.  Back to cited text no. 13
Raut A, Mustafayev R, Srinivasan R, et al. Hybrid type 1 effectiveness/implementation trial of the International Guide for Monitoring Child Development: Protocol for a cluster-randomised controlled trial. BMJ Paediatr Open 2021;5:e001254.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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