Discussion
Our study also demonstrated that the effectiveness of a responsive parenting program integrated with nutrition intervention significantly affected the development of children under 2 years of age and promoted a conducive home environment and mother-to-child interactions. The optimum growth and development of children under three may break the cycle of inequality and vulnerability and lay the foundation for achieving sustainable development goals (We co-created and implemented a responsive parenting and nutrition program delivered through community networks that included Government Anganwadi Centers for 24 months. The findings emphasized that community engagement, a theory-driven conceptual framework, and formative research are needed to design and implement complex interventions effectively. A paper by Bentley and colleagues also stressed a need to contextualize a program through an inclusive process and sustained stakeholder engagement to improve the quality of delivery (Our program’s key highlight was sustained community engagement. A ‘Balsakhi,’ meaning the friend of a child in the local language, delivered the entire intervention. Despite the well-conceptualized intervention, which draws upon the community’s strengths and is contextually appropriate, we faced challenges in intervention delivery by the community volunteers in the initial stages. Quality of service delivery was a primary concern, and data revealed coverage gaps, including community volunteers’ low motivation and engagement. Thus, we redesigned the implementation approach to motivate and engage service providers to deliver the intervention with fidelity. We appointed a community supervisor for handholding and mentoring community volunteers. Supervisors accompanied the community volunteers in at least 25% of the home visits. The implementation data revealed that the coverage improved over time and significantly improved the quality of intervention delivery. We presented the data in a separate paper, (Our program included fortnightly home visits along with monthly group sessions. Our trial’s frequency of contact with caregivers was similar to earlier studies from India (Our data showed a positive and statistically significant impact on the home environment and mother–child interaction. Mothers from the intervention group showed improved knowledge and skills for responsive parenting. Our study substantiates the findings of a systematic review that parenting interventions improve parenting knowledge, skills, parent–child interactions, and home environment are the critical pathways to bringing positive change in child development (The intervention had a maximum effect on Cognitive development, followed by language, motor, and socio-emotional development. Our results were comparable to the systematic review by Jeong and colleagues, which included 102 studies from 33 countries, concluding that parenting interventions in the first 3 years of life improve a child’s cognitive, language, motor, and socioemotional development and reduce behavioral problems (We observed that these effects on child developmental outcomes increased over time. Assessing the impact of the duration of the intervention on child development outcomes was not the primary objective of this trial; however, our data highlighted that the intervention given for a longer duration, that is 24 months, shows more benefits than an intervention delivered over 12 months. A systematic review published in 2021 reported a lack of evidence on the effect of variable program duration on child development outcomes (One of the limitations of our study is that we should have included nutrition supplementation. However, to avoid duplication of services offered at the Anganwadi Centers under the current ICDS program of India, we linked the beneficiaries to the Anganwadi Centers for nutritional supplementation. In previous studies, direct nutrition supplementation within a parenting intervention has shown significant benefits for 24 months of child age (Our program has several strengths. Despite the strong evidence from neurosciences and economics regarding the benefit of the intervention in the early years, most parenting interventions for cognitive and behavioral development are targeted at older children, at preschoolers (In addition to the evidence of the combined effect of nutrition and responsive parenting programs on child development, our study has provided program and delivery level guidance to positively influence interventions’ quality, engagement, and sustainability. The needs-based approach we employed guides the rapid re-design of delivery mechanisms, which was associated with acceptance by the community and led to a shift in responsibility and accountability at a local level (The strength of our innovation is that it aligns with the recommendation of 2013 National Early Childhood Education and Care Policy of the Government of India, enhancing the potential for sustainable scaling. Our innovation was designed to address scalability and replicability, to establish self-sustaining village-level units that serve as models for neighboring communities, and to foster expansion. To ensure the sustainability and expansion of our program, we prioritized community engagement and ownership, engaging local stakeholders, parents, and community leaders in the design and implementation of our intervention. We optimized resource utilization by leveraging locally local assets and investing in capacity building, thereby reducing reliance on external funding. A robust monitoring and evaluation system built around shared accountability, ensures continuous assessment. Regular review of effectiveness and impact of the program enables data-driven adjustments to meet evolving needs. This comprehensive approach ensures our program’s lasting impact and continued expansion of the innovation, benefiting a wider population of children, their families and communities.To conclude, our study emphasized the importance of developing a conceptual framework integrating a theoretical model with formative research for designing and redesigning a complex intervention. The study provides an evidence-based, responsive curriculum, with implementation strategies grounded in social learning theory that enhance caregivers’ knowledge and skills for promoting early child development. Due to the pragmatic nature of the study, our intervention also has the potential to integrate within the existing Integrated Child Development Program in India.