Improving humanitarian health responses for children through nurturing care

Abstract

Children are disproportionately impacted by humanitarian disasters, which cause toxic stress. When a crisis overwhelms the capacity of health and social systems to meet the needs of a population, external crisis response teams working in a range of sectors may offer support to save lives and meet the affected populations' basic needs. Gaps have been identified in health sector interventions for children in humanitarian contexts, including lack of routine interventions to protect and promote early child development (ECD). To address this gap and improve the quality of humanitarian responses for girls and boys, the Global Health Cluster, Child Health Task Force, and the Inter-Agency Network for Education in Emergencies held a webinar series on Strengthening Nurturing Care in Humanitarian Response. It concluded that incorporating interventions to support nurturing care for ECD into health responses in acute phase emergencies is lifesaving. In crisis contexts, even simple interventions can be the difference between life and death, and when systematically applied, they can dramatically improve a child's life opportunities as well as national recovery and economic growth.

Highlights

• •Children are disproportionately affected by humanitarian disasters.
• •Humanitarian crises cause pervasive harm to children's physical and brain development.
• •Nurturing care is a simple, low-cost approach to support healthy child development.
• •Incorporating nurturing care into humanitarian health responses has both lifesaving and longer-term implications.

When a crisis overwhelms the existing capacity of health and social systems to meet the needs of a population, external crisis response teams may offer support. Traditionally, the humanitarian system is organised into sectors that respond to specific aspects of population needs in crisis contexts. These sectors include health; nutrition; water, sanitation, and hygiene; education; protection (including child protection); shelter; food security and livelihoods; social and behaviour change, and cash and voucher assistance; among others. From a health system perspective, this broad range of sectors can be seen to address acute and chronic health needs as well as the social determinants of health. With the increasing trend of protracted and compounded crises, including conflict, forced displacement, climate change, and epidemics, sectors have recognised a need to improve coordination with each other and to integrate activities for optimal outcomes matched to social, economic, and cultural factors. While needs assessments are now routinely undertaken in an intersectoral way, it remains challenging to implement interventions from multiple sectors in an integrated fashion. One of the most important areas for integration across sectors is in activities to support, protect, and treat children. Child health is heavily determined by social, structural, political, and economic factors. However significant gaps have been identified in health sector interventions for children in humanitarian settings, particularly in terms of health worker competencies in paediatrics, provision of integrated care, availability of appropriate medical equipment to support paediatric interventions in humanitarian contexts, and more generally, prioritisation of children's health and developmental needs during a crisis (Martinez Garcia et al., 2022).

Children are disproportionately affected by humanitarian disasters. More than one in six children live in a conflict zone (Denselow et al., 2022), and while children only make up 30% of the general population, they account for 40% of displaced people worldwide (UNHCR, 2023). In crisis contexts, the morbidity and mortality rates of children under 5 years are estimated to be up to twenty times that of children living in more stable settings (Nurturing care for children living in humanitarian settings, 2020). Children who survive crises may experience a range of challenges. These include lack of support to meet their basic needs, loss of a parent or caregiver, serious injury or illness, the injury or illness of a parent or caregiver, loss of their home and community, and upheaval of their lives (Kadir et al., 2018; Martinez Garcia & Sheehan, 2016). Humanitarian crises are therefore a form of toxic stress for girls and boys. Toxic stress refers to the excessive or prolonged activation of the stress response systems in the body and brain (Bucci et al., 2016). It has been shown to cause pervasive harm to children's physical and brain development, as well as measurable harm to health, development, morbidity, and mortality (Hughes et al., 2017). This has consequences for children and their rights. There is an array of available and often simple interventions to mitigate the harms caused by severe adversity and toxic stress, however these are not commonly implemented by health sector responses in humanitarian contexts. This is a lost opportunity to invest in the brain development of children and harness their cognitive capital for the future of nations (Noble et al., 2017).

Interventions to mitigate harm to children's health and development from toxic stress are inherently intersectoral in nature and are carried out by health workers as well as sectors addressing other basic needs and social concerns. In humanitarian settings, and particularly during the acute phase of crisis, toxic stress and early child development (ECD) are not routinely addressed in humanitarian health responses. This may be because the “invisible” harm that children suffer is not yet widely understood to be immediately life-threatening. Further, the effort to address toxic stress may be perceived to be highly specialized and/or resource intensive. While other sectors, including the nutrition, education, and protection sectors, are working to fill this gap to the extent possible within their sphere of focus, activities remain siloed with a notable and marked gap in health sector responses, most pronounced in the early period of a child's life from pregnancy up to three years of age. This time is not only the most critical for physical development of a child's organ systems, brain, and body, but it is also a period when children and caregivers are more likely to come into contact with health services. As such, humanitarian health actors have a responsibility to promote healthy child development and protect children's health.

In order to address this gap and improve the quality of humanitarian responses for children, the Global Health Cluster, Child Health Task Force, and the Inter-Agency Network for Education in Emergencies held a webinar series on Strengthening Nurturing Care in Humanitarian Response (Webinar series: Strengthening Nurturing Care in Humanitarian Response, 2023). The first webinar reviewed the scientific evidence on the harmful effects of toxic stress on child health, development, and survival, and how health actors can address this using Nurturing care for children living in humanitarian settings (Nurturing care for children living in humanitarian settings, 2020). The Nurturing Care Framework, launched in 2018, provides a framework and toolkit to support actors across contexts to develop and implement policies and interventions that promote early child development (Fig. 1: Components of Nurturing Care). (World Health Organization et al., 2018) In 2020, a thematic brief was launched to support adaptation of the Nurturing Care Framework to humanitarian settings. The second webinar reviewed examples of interventions to support ECD in health and nutrition responses in Myanmar, Syria, Colombia, Ethiopia and Afghanistan. Examples of adapted interventions included assessment of developmental milestones in nutrition and health services combined with provision of anticipatory guidance; activities to support child-caregiver attachment and stimulation of the child; parenting support activities; and the incorporation of caregiver mental health activities in child health programming. These activities resulted in improved programme functioning, with positive feedback from health workers as well as caregivers and communities, and improved outcomes for children and caregivers. The third webinar was a discussion with leaders across sectors on how to institutionalise nurturing care in health sector responses, including how to engage health actors. The take home message of the series was clear: incorporating interventions to support nurturing care for ECD into health responses in acute phase emergencies is lifesaving - a week from now, a month from now, and years from now.

Fig. 1.

Components of nurturing care (World Health Organization et al., 2018).

Source: World Health Organization, United Nations Children's Fund, World Bank Group. (2018). Nurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential. Geneva: World Health Organization. Licence: CC BY-NC-SA 3.0 IGO. Available at: https://nurturing-care.org/

Dialogue has started globally, but there is much to be done to institutionalise and normalise support for nurturing care in humanitarian health responses. Health workers at all levels should be trained in using the Nurturing Care Framework to support healthy early child development, so that when a crisis occurs, they are prepared to incorporate it into their response. Similarly, humanitarian health actors should be trained in early child development and using the Nurturing Care Framework in health responses before they are deployed to support a response. We invite humanitarian health actors including government and nongovernmental organisations, bilateral agencies, and research institutions to work with us to make humanitarian health responses more appropriate and relevant for children. We propose to start by collecting a series of case studies, lessons learned, tips, and training materials to support humanitarian health actors to systematically address all components of nurturing care in their programmes and to measure the impacts on child health and development outcomes in the short- and long-term. In crisis contexts, even simple interventions can be the difference between life and death, and when systematically applied, they can dramatically improve a child's life opportunities as well as national recovery and economic growth.

CRediT authorship contribution statement

Ayesha Kadir: Conceptualization, Writing – original draft. Linda Doull: Writing – review & editing. James McQuen Patterson: Writing – review & editing, Conceptualization. Mushtaq Khan: Writing – review & editing. Rachael Cummings: Writing – review & editing. Douglas James Noble: Writing – review & editing. Anshu Banerjee: Writing – review & editing.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.