DISCUSSION
WASTED
This study shows that it is feasible to integrate an ECD care package at RHCs and subdistrict hospitals, as reflected by the enrollment rate and minimal attrition rate. Integration of similar interventions in primary care has also been found feasible and effective in many other settings, such as Jamaica, where parenting skills and early psychosocial interventions integrated at the primary care level resulted in improvement in child development and knowledge and practices of mothers.The behavioral stimulation intervention resulted in a lower proportion of children aged 12–24 months with developmental delays as compared to routine care. Similarly, various stimulation interventions in rural Pakistan, Bangladesh, and Uganda were also found to be effective in improving cognitive, language, and motor development.Our study found that mother education to promote home-prepared recipes and hygienic food preparation and storage led to significant improvement in child growth. However, this did not significantly decrease the proportion of stunted, underweight, or wasted children. A similar intervention in rural China on basic education of nutrition delivered through local health services led to better z-scores among children.The strengths of our study include a robust study design (i.e., cRCT); external assessors for data collection at baseline and endline who were blinded to arm allocation of clusters; samples with similar characteristics recruited in both arms; and minimal loss-to-follow-up rate in both arms. A major strength of the intervention package is its better replicability and scalability, as it was integrated into the existing public health care and the messages on child development (both cognitive and physical) were contextually adapted in a way that required minimal additional resources.Our study indicates that LMICs with reasonably functioning primary health care structures in place can adapt integrated ECD care interventions to address ECD delays. Our experience of successfully integrating ECD care into MCH at public-funded primary health care facilities is a significant step toward addressing the challenge of early development delays, mainly through staff skill enhancement and with almost no additional capital investment. Our experience suggests that integrated ECD care can be successfully sustained and scaled under routine health care circumstances. Our study implies that a countrywide scaling can possibly prevent global development delays in around one-quarter of children aged 12–24 months.Our experience of successfully integrating ECD care into MCH at public-funded primary health care facilities is a significant step toward addressing the challenge of early development delays.