The care, stimulation and nutrition of children from 0-2 in Malawi—Perspectives from caregivers; "Who’s holding the baby?"

IntroductionUniversal access to quality early childhood development and care is a fundamental part of Sustainable Development Goal 4.2.1. Research from diverse settings, including that in low and middle income countries, now demonstrates the positive impact that interventions to promote play, stimulation, early communication and responsiveness can have, not just on child development, but on long term gains in education and economic growth. International agencies have recently produced the Nurturing Care Framework for Early Child Development in order to promote this and to encourage countries to move the focus from child survival to child thrival. Research on the best methods of integration of these programmes into present care practices, particularly in African settings is still very limited.MethodsWe used qualitative methods to gain an understanding of care practices (play, developmental stimulation, early communication and responsive feeding) for children 0–2 years. We conducted 18 focus groups (FGDs), six PFGDs (Participatory Research focus groups), 18 in depth interviews (IDIs) and 20 observations with caregivers in rural and urban settings of Malawi. We used a topic guide, audio-recorded the FGDs and IDIS and transcribed them in Chichewa or Yao and then into English. We coded data using an inductive approach to thematic analysis. We placed the data within a framework with the emerging major and minor themes. We conducted quality assurance for translations and coding frameworks through cross comparison of data and used respondent validation to check our results.ResultsMalawian caregivers see children’s play as a consequence of good health and wellbeing, less an interaction that a parent undertakes to promote wellbeing and learning. Non-verbal communication and responsiveness with infants is clearly present and caregivers have many one-on-one interactions with young infants. Furthermore, many caregivers have good knowledge of feeding recommendations but cannot always follow these due to constraints on money. When children become mobile (toddlers), play is an activity done more often between children or with other caregivers such as siblings or grandparents.Community members consider that caring for children from 0–2 years is a woman’s domain. Despite this, both men and women acknowledge the importance of maternal wellbeing in enabling good care of children. The present socioeconomic situation of most families in our study means that income generation and food security come first. Many mothers spend most of their time managing the responsibilities of daily living and have limited time to dedicate to children’s play, responsiveness and communication with their children.DiscussionProgrammes promoted as part of the Nurturing Care Framework which provide advice on developmental stimulation, play, early communication and responsive feeding should ensure that topics within these programmes are culturally appropriate for the setting. Furthermore, programmes must not be an added burden to parents but be supportive to parents managing many responsibilities of daily living. Multi-sectorial approaches where both men and women are provided with knowledge but are also supported through programmes which address family finances, safe spaces for children whilst families are working, and family mental health and relationships may enable programmes to work more effectively.引言 优质幼儿发展与照护的全民可及性是可持续发展目标4.2.1的核心组成部分。现有来自不同场景（包括低收入和中等收入国家）的研究表明，针对游戏、发展性刺激、早期沟通与回应性照护的干预措施，不仅能促进儿童发展，还能为教育与经济增长带来长期收益。国际机构近期发布了《幼儿发展培育照护框架》（Nurturing Care Framework for Early Child Development），旨在推广相关实践，并推动各国将照护重心从儿童生存转向儿童茁壮成长。但针对将此类项目整合入现有照护实践的最优方法的研究仍十分有限，尤其是在非洲地区场景中。 方法 本研究采用质性研究方法，旨在理解0~2岁儿童的照护实践（包括游戏、发展性刺激、早期沟通与回应性喂养）。我们在马拉维（Malawi）的城乡场景中开展了18组焦点小组讨论（FGDs, Focus Group Discussions）、6组参与式研究焦点小组（PFGDs, Participatory Research Focus Groups）、18次深入访谈（IDIs, In-depth Interviews）以及20次照护者观察。研究采用话题指南开展访谈与讨论，对焦点小组讨论和深入访谈进行录音，先以奇契瓦语（Chichewa）或尧语（Yao）转录，再转译为英文。我们采用归纳式主题分析法对数据进行编码，将数据归入由浮现出的主要与次要主题构成的分析框架中。通过跨数据比对开展翻译与编码框架的质量控制，并采用受访者验证法对研究结果进行核验。 结果 马拉维照护者将儿童游戏视为儿童健康与福祉良好的结果，而非家长为促进儿童福祉与学习而开展的互动行为。照护者与婴儿间的非语言沟通与回应行为清晰可见，且会与年幼婴儿开展大量一对一互动。此外，多数照护者掌握喂养建议相关知识，但受经济约束往往无法严格执行。当儿童学会移动（即学步期幼儿）后，游戏更多发生于儿童之间，或是儿童与其他照护者（如兄弟姐妹或祖父母）之间。社区成员普遍认为，0~2岁儿童的照护是女性的职责范畴。尽管如此，男性与女性均认可，母亲的福祉是保障优质儿童照护的关键。本研究中多数家庭的当前社会经济状况表明，创收与粮食安全是首要任务。多数母亲将大部分时间用于处理日常生计事务，可用于陪伴儿童游戏、回应儿童需求及与儿童沟通的时间十分有限。 讨论 作为《幼儿发展培育照护框架》推广的项目，若旨在提供发展性刺激、游戏、早期沟通与回应性喂养相关指导，应确保项目内容契合当地文化场景。此外，此类项目不应给家长增添额外负担，而应向承担多项日常生计职责的家长提供支持。采用多部门协作模式，可为男性与女性普及相关知识，并通过针对性项目解决家庭经济问题、为务工家庭儿童提供安全活动空间，以及改善家庭心理健康与亲属关系，从而提升项目实施效果。