Enablers and Barriers to Implementing Early Childhood Development Assessment and Nutrition Interventions in Community Settings: Qualitative Case Study From Sidama Regional State, Ethiopia

ABSTRACT

Despite improvements in children's nutritional status and a commitment to early childhood development (ECD) policy developments in Ethiopia, the risk of poor ECD outcomes remains alarming. This study aimed to identify enablers and barriers to the implementation of ECD assessment and provision of nutrition‐focused interventions in community settings. A qualitative case study was employed in Hawassa city and Dore Bafano district of Sidama region from November 2023 to February 2024. Fifteen key informant interviews (KIIs) and five focus group discussions (FGDs) were conducted with purposively selected key informants from the healthcare system and mothers of children under two years old, respectively. Pre‐tested interview and discussion guides were used for data collection and a narrative thematic analysis was applied at different levels of the socio‐ecological model (SEM). The existing ECD policy and strategy landscape, healthcare system, communication and trust built between the health Extension workers (HEWs) and the community, existence of different mothers groups and the HEWs positive attitudes were identified as enablers; however, gaps in ECD practical knowledge and community awareness, low commitment of HEWs and political leaders at multiple levels, as well as absence of training, facilities and standardized indicators of ECD were identified as barriers for the implementation of ECD assessment and provision of nutrition‐interventions in the community settings. ECD assessments and nutrition‐focused interventions can be integrated into the existing health extension program, with HEWs playing key roles. This requires raising awareness of ECD policies across all healthcare levels and providing targeted training for HEWs on ECD assessment and its targeted interventions. Building the capacity of all persons associated with health posts, and incorporating ECD indicators into HEWs' services and their supervision checklists will enhance the effectiveness and sustainability of ECD integration in the community, leading to improved child health and development outcomes. Additional research is required to develop a tailored, user‐friendly and time‐saving ECD assessment tool for use in the community by the HEWs to assess, classify and identify children at risk of developmental delay.

Summary

• Early childhood development (ECD) assessment and targeted nutrition interventions potentially can be integrated effectively in the community setting through the existing healthcare system.

• ECD policy and strategy landscape, the existing healthcare system, communication and trust built among Health Extension Workers (HEWs) and the community, existence of mothers' groups, and HEWs' positive attitudes towards ECD were enablers, while gaps in ECD practical knowledge, poor HEWs and leaders commitment, low community awareness, limited ECD training, facilities, and absence of standardized ECD indicators were barriers to ECD assessment and provision of targeted nutrition interventions in community settings.

• Understanding key enablers and barriers can support the design of evidence‐based, multi‐level strategies to mitigate implementation gaps and strengthen the integration, delivery, and sustainability of ECD assessments and provision of targeted nutrition interventions within the existing healthcare system.

• Capacitating health institutions and frontline health workers with ECD practical skills and facilities would benefit the integration of ECD interventions in community settings.

1. Background

Early childhood development (ECD), covering the period from pregnancy to 8 years old, is marked by rapid physical, cognitive, motor, language and socio‐emotional development, which makes it particularly responsive to environmental influences (American Academy of Pediatrics 2024; UNICEF 2024; WHO 2018). The World Health Organization's nurturing care framework (NCF) emphasizes that optimal brain development and the promotion of children's physical, cognitive, motor, language and socio‐emotional growth require a stimulating environment, proper or adequate nutrition, good health, responsive feeding, early learning and social interactions (Britto et al. 2017; UNICEF 2022; WHO 2018).

Nutrition interventions can affect ECD both directly and indirectly. During the first 1000 days, adequate nutrition has essential roles for proper brain development which in turn affects the child's behaviour by increasing their ability to explore their environment and interact with caregivers (Prado and Dewey 2014; Yousafzai et al. 2013). Well‐nourished children tend to be more active and seek more attention and responsiveness from their caregivers, while malnourished children may experience frequent illness, leading to irritability and less engaging responses from caregivers (Pelto et al. 1999; Yousafzai et al. 2013). Targeted and nutrition‐focused interventions for ECD have been shown to enhance both cognitive and motor development in young children. A study conducted with children in rural India demonstrated that providing caregivers with education on complementary and responsive feeding led to significant improvements in the children's dietary intake and overall growth, as well as their cognitive and motor skill development (Vazir et al. 2013).

A poor start in life can lead to poor health, development and inadequate learning, resulting in low adult earnings as well as social tensions (Black et al. 2017; Lu et al. 2016). However, despite the acknowledged far‐reaching benefits of ECD interventions, various studies conducted globally have shown that around 250 million children under the age of five in low and middle‐income countries are still facing the risk of failing to reach their full developmental potential due to poverty and stunting, as well as lacking access to transformative ECD interventions (Black et al. 2017; Lu et al. 2016).

ECD assessment is the process of gathering information about a child's cognitive, motor, language and socio‐emotional development skills for their age; such assessments are used to plan and implement targeted interventions (Department of Early Education (EEC) 2014). The assessment and provision of targeted interventions for ECD is a critical part of a high‐quality ECD program and by prioritizing it, the global community acknowledged the beneficial positive effect that ECD has on lifelong learning, health and well‐being, thereby contributing to the realization of sustainable development goals (SDGs) (UN‐SDGs) (UN 2018; UNICEF 2024).

ECD assessment, evaluation of developmental delay and provision of targeted interventions in the first 2 years of age is a crucial component of quality healthcare to optimize developmental outcomes for children, families and a nation at large. It also helps health workers to identify and address developmental delays, often defined as deviations from typical milestones in terms of delayed cognitive, language, motor and/or socio‐emotional development (Boggs et al. 2019; CDC 2024).

In Ethiopia, in spite of the improvements in children's nutritional status over time (EPHI and ICF 2021), the government has highlighted that the risk of poor ECD outcomes remains alarmingly high, impacting over half of children under the age of five (MOH 2020). Ethiopia's poor ECD outcomes are evident in global indicators like the Human Capital Index (HCI) and early learning assessments. The World Bank (2020) reports Ethiopia's HCI at 0.38 on the scale of 0–1, which is below the average for the sub‐Saharan region, indicating a child born in Ethiopia might only reach 38% of their developmental potential, primarily due to issues that include childhood stunting. Additionally, the report reveals that 90% of Ethiopian children are “learning poor,” lacking basic reading skills by the end of primary school and unable to comprehend simple text by age ten (World Bank 2021).

Considering the high risk of poor ECD outcomes and their long‐lasting consequences, the Ethiopian government has shown its commitment at the federal level to ECD through developing an ECD policy framework and strategy, which aimed to create a structured and coordinated approach to support the holistic development of young children (MOH 2020; UNICEF Ethiopia 2022). Early assessment, classification and provision of targeted interventions for ECD is set as one of the objectives on the ECD policy framework (UNICEF Ethiopia 2022), and based on this, developmental milestones have been incorporated in the modified 2021 version of the integrated management of newborn and childhood illness (IMNCI) manuals (FMOH, WHO 2021).

However, to our knowledge, the implementation of both ECD assessments and provision of targeted interventions for ECD remains inadequate in the community setting where majority of the children reside. The Health Extension Program (HEP) in Ethiopia, which has health extension workers (HEWs) as the main actors, is seen as an opportunity for scaling up different health and nutrition interventions in community settings, as it delivers services directly to families. However, in Ethiopia, where a large portion of the population lives in rural community settings, ensuring that all children receive proper ECD care remains a challenge (MOH 2020; UNICEF Ethiopia 2022).

Additionally, despite the widespread implementation of the growth monitoring program to track children's physical growth at community settings by the HEWs, assessment of ECD is often neglected. Furthermore, apart from a few ECD initiatives at the health institutions in cities like Addis Ababa (AACAMO 2022), to our knowledge, the implementation of ECD assessments and provision of targeted nutrition interventions at the community level in the study area remains limited and underexplored. Therefore, this study aimed to identify the enablers and barriers to ECD assessment and nutrition interventions in community settings of Sidama region, Ethiopia, providing insights that could inform more effective ECD program strategies to improve child development outcomes in the study area and similar settings.

2. Methods and Materials

2.1. Study Settings

The study was conducted in Hawassa Zuria Woreda (Dore Bafano district) and Hawassa City Administration, both located in the Sidama Regional State. The region is situated approximately 350 km south of the national capital, Addis Ababa, and has a population of approximately four million, with 95% living in rural areas. (Population Census Commission 2015). The study sites were intentionally chosen to encompass a range of insights from participants residing and working both in urban and rural settings (Figure 1).

Figure 1.

Map showing location of the study area (Yaekob Chiriko 2021).

2.2. Study Methdology

We employed a qualitative case study methodology from November 2023 to February 2024 to explore the enablers and barriers to ECD assessment and the provision of nutrition‐focused interventions, using diverse and in‐depth data collection methods (Patton 2002; Stake 1995). Guided by a constructionist epistemology, we approached the research with the understanding that knowledge and meaning are shaped through human interaction with the world and each other (Crotty et al. 2020; Koro‐Ljungberg et al. 2009).

2.3. Theoretical Framework

The Bronfenbrenner social‐ecological model (SEM) which is widely applied in health behaviour research was used as a suitable theoretical framework for the study (Bronfenbrenner 1977; Sudbery and Whittaker 2018). The SEM depicts through circles various layers of the environment, each influencing behaviour to varying degrees. The innermost circle usually signifies the individual's immediate environment, and moving outward the subsequent circles represent broader factors including interpersonal, community, institutional and policy level influences (Bronfenbrenner 1977).

2.4. Study Population

The sample size for the key informant interviews (KIIs) and focus group discussions (FGDs) was not defined before beginning the research; rather, the sample sizes for both KIIs and FGDs were determined as the study progressed, ensuring the saturation principle (Byrne 2001). HEWs, who are oriented and the closest healthcare providers to the community, assisted in the purposeful selection of FGD participants, mothers of children aged less than 2 years of age. Eight of these mothers were randomly selected and included in a single FGD, and totally, 40 mothers participated in five FGDs.

In addition to the FGD participants, a purposive sampling method was used to recruit KII participants with varying work experience and expertise to optimise variability. The KII participants were chosen from the healthcare system at different levels from the federal to the health posts, according to their willingness and ability to inform the study. A total of 15 individual KII participants were selected from health posts, woreda and zonal health offices, a regional health bureau and the federal Ministry of Health.

2.4.1. Inclusion and Exclusion Criteria

The KIIs enrolled adults 18 years of age or older who were willing to participate and who had at least 5 years of experience in the healthcare system. Mothers who had children under the age of 2 years, who were willing to participate in the study and who had spent at least 6 months in the study area were included in FGDs.

2.5. Data Collection Methods

We employed KII and FGD as data collection methods, which were flexible, iterative, and participatory. The KII data were collected first with the intention to get a deeper understanding on how the ECD policy framework and strategy commitments at the national level are being translated at the community level. The FGDs subsequently were conducted to understand mothers' knowledge, attitudes and practices about ECD.

Semi‐structured FGD and KII guides were developed based on insights from the literature (Cavallera et al. 2019; Ssewanyana et al. 2023) and preliminary discussions with different stakeholders. The FGD guide was developed first in English and later translated into the local language (Sidaamu Afoo) while interviewing, whereas the KII guide was initially prepared in English and translated into Amharic, the national language of the country. Both the KIIs and FGDs were tape recorded with minimal noise and were facilitated by the principal investigator (PI) and one trained note taker at the participant's workplace or nearest health post. Before the following data collection, the semi‐structured FGDs and KIIs were transcribed and reviewed by reading and discussion to capture emerging insights to be included in the interview and FGD guides.

2.5.1. Quality Assurance

The KII and FGD guides were pretested and amended as per the feedback. After each set of KIIs and FGDs, the PI reviewed the main findings and potential difficulties. Upon completion of each recording, the audio files were transferred to a secure, password‐protected PI's computer and verbatim transcription was made for every recording. The second author revised a section of the transcripts, ensuring that they were understandable without specific local knowledge. Uncertainties and ambiguities were discussed among the PI and the second author and reformulated to a common agreement. Due attention was given to careful participant selection, interview design, triangulation, and researcher reflection to minimize bias and enhance credibility.

2.5.2. Trustworthiness

To establish credibility and reliability of the research, both FGDs and KIIs were utilized. Data from these different sources were cross‐referenced by the PI to ensure consistency. Member checking was conducted by calling the KII interviewees and affirming from FGD participants during summarizing the notes at the end of each FGDs, and the manuscript was reviewed by the second and third authors. Additionally, debriefing was carried out by two independent qualitative researchers working at another US University.

2.5.3. The Researchers and Reflexivity

As health and nutrition professionals, our backgrounds might have influenced the study's design and interpretation of enablers and barriers to ECD assessment and nutrition interventions in the study area. To mitigate such potential biases, we engaged in reflexive practices, including team discussions to systematically examine how our expertise shaped data collection and analysis. Initially, for the FGDS, we planned using an Amharic‐translated English guide, but we prioritized cultural and linguistic aspects by using a local translator fluent in Sidaamu Afoo. Throughout data collection, the PIs' role involved conducting interviews, documenting memos, and cross‐verifying transcripts, while the multidisciplinary research team collaboratively refined interview guides, analysed data and contextualized findings.

2.5.4. Data Management and Analysis

A narrative thematic analysis was used to systematically identify factors that enable or hinder ECD assessment and provision of nutrition‐focused interventions at different levels of the SEM (Braun and Clarke 2023). The data analysis began during the data collection phase by using reflexive memo writing while reading the transcripts. We simultaneously examined individual data elements while considering their interconnectedness within the broader context to develop rich interpretations and emergent themes (Luttrell 2019; Wolgemuth et al. 2024). Data from KIIs were also triangulated with information gathered from the FGDs (Mathison 1988).

During the application of the narrative thematic analysis, we followed six steps for analysis. In the initial phase, all interviews were audio recorded. The second phase involved preparing and organizing data for analysis using verbatim transcripts which was done by nutrition graduates and translation to English was made by the PI. In the third phase, the transcriptions were reviewed for gaps and limitations. In the fourth step, evolving data and potential biases were evaluated. In the fifth step, all evolving data were coded and categorized. Finally, in the sixth phase, comparable categories were organized into distinct themes based on different levels of influences using the SEM.

2.6. Ethics Statement

The study was approved by the Ethical Review Committee of the College of Medicine and Health Sciences at Hawassa University (IRB/021/21). Support letters were obtained from Hawassa University, Sidama Regional State Health Bureau and local authorities. The study followed the essential requirements for working with human subjects. Informed and written consent was secured from all study participants, and they also gave permission for their voices be recorded. The team protected the confidentiality and anonymity of study participants' data throughout the entire study. Participation was entirely voluntary, and participants were reminded that they could choose not to disclose any information they felt uncomfortable sharing and could discontinue the interview or discussion at any time. All recorded data, transcriptions and translations were stored in a password‐protected computer. Informed consent was obtained from all subjects involved in the study.

3. Results

3.1. Socio‐Demographic and Economic Characteristics of Study Participants

A total of five focus group discussions (FGDs) were held among 40 mothers with mean age of 26.7 years. The majority of the mothers were housewives and had completed primary education (Table 1). Additionally, 15 KIIs were conducted among participants who had a mean work experience of 12.4 years (Table 2).

Table 1.

Characteristics of the FGD participants, n = 40.

Category	Value
	Number	Percentage
Sex
Female	40	100
Occupation
Housewife	30	75
Farmer	1	2.5
Merchant	5	12.5
Employed	4	10
Educational Status
Non‐formal	3	7.5
Primary (Grade: 1–8)	15	37.5
Secondary (Grade: 9–12)	12	30
College and above	10	25
Age in years (mean)	26.7

Table 2.

Characteristics of the KII participants, n = 15.

Category	Value
	Number	Percentage
Sex
Female	6	40
Highest level of Education
Diploma certificate	4	26.7
Bachelor's degree	6	40.0
Master's degree	5	33.3
Profession
HEWs	5	33.3
Health Officers	3	20.0
Nurses	3	20.0
Others (public health specialist, Nutritionist, ECD expert and Agriculture)	4	26.7
Occupation
Child health and nutrition experts	9	60.0
ECD expert	1	6.7
HEWs	5	33.3
Work experience in years (mean)	12.4
Age in years (mean)	35.5

3.2. Themes and Sub‐Themes

The themes were structured according to the SEM (Bronfenbrenner 1977), which delineates various levels of influence. Each theme is further broken down into sub‐themes that emerged directly from the data. Both the themes and sub‐themes are presented in Figure 2 and discussed in detail to illustrate how the data aligns with and supports the SEM framework.

Figure 2.

Socio‐ecological Model of the study adapted from Bronfenbrenner (1977).

3.3. Individual Level Influences

3.3.1. Knowledge, Attitudes and Practices of the Health Workers

The study revealed that knowledge, attitudes and practices of the HEWs were factors affecting ECD assessment and provision of nutrition‐focused interventions in the study area. The very practical concept of ECD assessment and its targeted nutrition interventions were unclear to most of the KII participants. Instead, most participants in the KII's choose to discuss and were more aware about the links between child physical growth and maternal and child nutrition. Despite their theoretical understanding, particularly in areas such as children's cognitive, motor and communication skill development, none of the KII participants had practical experience in conducting assessments or provision of nutrition‐focused interventions for ECD. One of the KII respondents noted that the lack of sufficient knowledge and practice serve as barriers arising from gaps in on‐the‐job training related to ECD assessment and targeted nutrition‐focused interventions.

…I have the basics of the ECD concept mainly from my graduate and postgraduate studies. I know maternal nutrition during pre‐pregnancy, pregnancy and child nutrition have an effect on childhood development. I know different interventions have been given to young children in the health institutions as well as in the community, however, in my professional experience in the health sector, I have never encountered or heard of any assessments or targeted interventions for ECD.

(KII, 12 years work experience, child health and nutrition expert)

Supporting the response from the child health and nutrition expert, an experienced KII interviewee highlighted her lack of practical knowledge and hands‐on skills needed to assess ECD. She further pointed out that she has never seen children being assessed for their cognitive, motor and language skills development.

I understand the effects that delayed early childhood development will have on the child. When a child experiences developmental delays during the critical early years, it can affect their brain development leading to long‐term challenges in their educational achievements, and career opportunities. Even if I am aware of this, I do not have the practical knowledge and experience about how to assess and provide targeted nutrition‐focused intervention for ECD. Even, I have never seen children being measured for their brain, motor and language skills development.

(KII, 13 years work experience, HEW)

The weight and mid‐upper arm circumferences (MUAC) are the most commonly used anthropometric measurements to monitor children's physical growth in the study area. However, none of the KII participants in the study area mentioned conducting cognitive, motor and language skills assessment nor did they indicate implementing nutrition‐focused interventions for ECD.

…the growth monitoring is the most commonly used practice we implement to check the child's physical growth. We usually measure weight and MUAC of a child. However, our HEWs do not measure and intervene for cognitive, motor and communication skills development. They also did not report anything in relation to these developmental parameters.

(KII, 11 years work experience, child health and nutrition expert)

Despite the gaps in practical knowledge and practice regarding the assessment and delivery of nutrition‐focused interventions for ECD, all KII participants expressed positive attitudes towards the purpose and necessity of ECD assessment. They also supported integrating nutrition‐focused interventions into the current healthcare system, viewing these as enabling factors. One participant elaborated on the importance of ECD assessment and the need for targeted nutrition interventions to support ECD.

…with no question, strengthening and mainstreaming of ECD in the existing health system at the community level is vital. If we didn't intervene childhood development delay at its early stage, it will have an effect at individual, community and country level. I myself need this ECD assessment for my children, I want to know my child's brain, motor and language skills development.

(KII, 13 years work experience monitoring and evaluation expert)

Another HEW emphasized the importance of ECD assessments and interventions for both mothers and children. She also expressed a keen interest in participating in ECD initiatives.

…inclusion of ECD assessment and intervention in the health system is important both for children and mothers. As we are the closest health workers working with mothers and children from pregnancy up to 2 years of age, we can follow the development status of the children and I hope we will be successful if we work on this.

(KII, 12 years work experience, HEW)

3.4. Commitment of HEWs

Most of the KII participants stated that the commitment level of the HEWs varies among individuals and is influenced by factors such as work load, prioritization of campaigns and emergency tasks, lack of incentives, and absence of refresher training. Thus, the commitment of HEWs to engage in ECD assessment and delivering targeted interventions was identified as one of the potential barriers for implementing ECD assessment and provision of nutrition‐focused interventions.

…these days we are busy with some emergency and campaign related health activities like vaccination and we are work loaded. Thus, sometimes, we lose morale in work place for development works. But, we still try the best working for the children.

(KII, 10 years work experience, HEW)

An experienced maternal and child health expert also discussed some factors that could influence dedication of the HEWs to their roles. Personal commitment can significantly affect the assessment and implementation of ECD programs, highlighting the importance of keeping health workers motivated to meet the needs of the communities they serve.

…usually health workers including the HEWs are committed to their work as per the oath's during their graduation. But, when the working environment is not conducive enough and when they did not get incentives for their effort, their commitment level will decline. In addition, sometimes when there is a dispute in the workplace, the commitment also declines.

(KII, 13 years work experience, maternal and child health expert)

Another HEW revealed how competing priorities like emergency response and campaign‐based health works impact the engagement of the HEWs in development activities.

Due to several reasons including lack of awareness and many emergency and campaign oriented health related activities like immunization, the commitment level of the HEWs is not sufficient for development related interventions like ECD.

(KII, 11 years work experience, HEW)

3.5. Interpersonal Influences

3.5.1. Communication and Trust

The study participants identified the presence of effective communication and trust built between the HEWs and the mothers, which was well demonstrated from implementation of different health interventions, as enabling factors for effective ECD assessment and provision of nutrition‐focused interventions.

…the HEWs are selected from the community and they get training from health science colleges to serve in the community where they are selected. They are part of the community, they speak the local language, know the culture and they know how to approach the mothers. Mothers usually respect and listen to what is being said by the HEWs.

(KII, 12 years work experience, HEWs supervisor)

A majority of the mothers who participated in the FGDs responded similarly.

We felt confident and close enough to the HEWs; the presence of the HEWs in the community made it easier for us to approach and ask for any advice.

(FGD 1)

The above point was emphasized as the HEWs are more reachable and aware of local problems, thus potentially helping implementation of the ECD assessment and interventions. Most mothers further mentioned the knowledge of the local language and culture by the HEWs and how it has made them feel that the health knowledge they received is more appropriate to their lives.

The HEWs are very close to us, they know our culture and language and if they bring any information and educate us about anything including child development, we feel confident and don't have any problem to listen, trust and act based on their advice.

(FGD 3)

3.6. Community Level Influences

3.6.1. Existence of Mothers' Groups

The existence of various maternal groups, such as the mothers' group and pregnant mothers' forum established by the HEWs, was recognized as one of the enabling factors by the study participants for the successful implementation of ECD assessment and nutrition‐focused intervention. All mothers in one of the FGDs identified the mothers' group as a valuable source of information for them.

…we usually get new health related information for ourselves and our children from the mothers' group meeting and we also get some information about what diet we have to take during our pregnancy from the pregnant mothers' forum where pregnant mothers sit together and discus about their pregnancy in the presence of the HEWs. We can do the same if they tell us about our children's brain and language skills development.

(FGD 2)

An experienced HEW focal person highlighted how the pregnant mothers' forum is instrumental in providing a path for the integration of ECD assessment and the delivery of nutrition‐focused interventions.

…. the pregnant mothers' forum can be considered a very important session for the mothers to create awareness about different health behavior including maternal and child health and nutrition, and childhood development. The HEWs can work on child development using this forums.

(KII, 12 years work experience, HEWs' focal)

3.7. Community Awareness

The majority of key informants and FGD participants highlighted that community awareness particularly among mothers regarding the monitoring of children's cognitive, motor, and communication development remains low. This knowledge gap affects the early identification of developmental delays, which was identified as a key barrier to effective child development assessments and the subsequent delivery of targeted nutrition interventions in community settings. The participants emphasized that without such awareness, caregivers often miss critical windows for early intervention, leading to delayed support for children at risk.

We usually get ample information from the HEWs regarding infant and young children feeding, personal and environmental hygiene and sanitation, vaccination, exclusive breast feeding and complementary feeding. However, we don't know when exactly our child should sit down, crawl, walk, manipulate certain activities, say “dada and baba”.

(FGD 4)

A HEW confirmed that the personal experience of the mothers and family, especially mothers‐in‐law, are usually the sources of information for mothers on how they should follow their children's development.

…we as a HEW provide the mothers with lots of information based on the HEW's packages. We educate mothers about child feeding, water, hygiene and sanitation, nutrition and others, however the mother‐in‐law and the mother's previous birth experience are their sources of information especially on how to determine, and follow their children's brain, language and motor skills development.

(KII, 11 years work experience, HEW)

3.8. Organizational Influence

3.8.1. Existence of the Healthcare System

The healthcare system ranging from the federal to the community‐based services level is recognized by the KIs as enabler for the integration of assessment and provision of nutrition‐focused intervention for ECD. An experienced HEW stated that the existing healthcare system at the community level is well positioned to enhance implementation of ECD assessment and provision of nutrition‐focused interventions.

…the existing health system that we have recently can enable the implementation of ECD interventions. The number of man power in the health system can be considered as an enabling factor for the implementation of ECD interventions. In addition, we don't need to add a new package on the existing HEWs package, rather we can easily integrate the assessment and intervention of ECD under the growth monitoring package, that way the HEWs can easily assess, classify development milestone and intervene accordingly.

(KII, 11 years work experience, HEW)

A HEWs linkage officer expressed his support for the idea that the existing healthcare system could improve the effectiveness of ECD assessments and interventions.

…the existing health care system is very conducive to reach the community and work on the children. There are 16 health extension packages that is being used as guideline by the HEWs, and based on it the HEWs basically work and report on different packages including; nutrition screening using mid upper arm circumference and weight, anti‐natal care, post‐natal care, water hygiene and sanitation, malaria, vaccination, maternal and child nutrition. However, for some reason our HEWs did not educate, work and report on activities related to ECD assessment and its targeted nutrition interventions.

(KII, 8 years work experience, HEWs linkage officer)

An agreement was put forth by a senior ECD focal person working at the federal level about the existing healthcare system as an enabling factor.

The existing health care system could be considered as an enabling factor to start and strengthen ECD assessment and nutrition interventions at the health institutions. We have seen a success story from Addis Ababa (the capital city of Ethiopia) where we implemented the ECD assessment and intervention by integrating it into the existing health care system at different touch points; under‐five unit, immunization, antenatal care, and nutrition screening.

(KII, 10 years work experience, ECD focal)

3.9. Facilities and Training for ECD

Despite the healthcare system being recognized as a key enabler for ECD assessment and provision of nutrition‐focused interventions, several factors were mentioned as barriers for effective implementation of ECD intervention. A senior HEW and her supervisor said the following:

….a very short‐term on‐job‐training can bring a change, even a small orientation can bring a change, however the absence of ECD training in our area is one of the challenges that hinders us from implementing ECD assessment and targeted interventions. I also haven't seen any checklist or awareness creating materials (visuals) that can aid us to teach the mothers on how to follow their child development based on the child age. We also don't have the tools and enough rooms for the children to stay and do the ECD assessment.

(KII, 13 years work experience, HEW)

In another context, all of the HEWs who participated in the current study attested that they don't have any education materials or checklists that aid them to work on activities related to ECD assessment and provision of nutrition‐focused interventions when they visit the households.

When we visit the households in the community, we just ask the mothers about their child's health and physical growth, we don't have any checklist or equipment which help us measure the brain and communication skills development of the children based on their age. We also don't have any pictorial education material to show the mothers and educate them about how to follow their children's early development status in terms of brain or communication skills development.

(KII, 12 years work experience, HEW)

A majority of KII respondents reported one important issue about the implementation of ECD assessments and nutrition‐focused interventions, which is the absence of ECD‐specific indicators in the reporting format and supervision checklist of the HEWs. The absence of these indicators prevents efficient monitoring and integration of the ECD‐related activities within routine health services, and thus restricts the ability to track and improve developmental and nutritional needs during early childhood.

…. to fully implement ECD assessment, and provide focused interventions, the activity progress must be monitored using indicators that can be measured. However, in our setting there are no indicators that can be used for monitoring and evaluation of the implementation of ECD assessment and interventions. But still, it is as simple as including one bullet point about developmental milestone into our supportive supervision checklist.

(KII, 13 years work experience, monitoring and evaluation officer)

Similar to the observations made by the monitoring and evaluation officer concerning the absence of the ECD indicators in the system, one of the HEWs said that the absence of established indicators has hindered their ability to effectively carry out activities related to ECD.

…we do several health related activities in the community based on the sixteen health extension packages and we report to the health centers accordingly, however, since we are not doing it and it is not included in our HEWs package as an indicator, we did not report any thing related to childhood development to the health center and woreda health office.

(KII, 13 years work experience HEW)

3.10. Commitment of Political Leaders

The commitment level of political leaders in the healthcare system was reported to be variable. At the higher level, the commitment given to early childhood development activities is very good, and this was manifested by the development and dissemination of a national ECD policy framework and ECD strategic plan. A senior ECD focal working at the national level said that;

…the commitment at the federal level is really great. They (the health leaders at the federal level) give due attention to ECD and are passionate about ECD. They all have the passion because this ECD thing affects everybody's house. All leaders who have children have their own “ahaa” moments when we tell them about ECD. Because of the fact ECD interventions are a low‐cost high‐impact intervention, almost all of the leaders at the top level of the health care system are committed to ECD and its interventions.

(KII, 10 years work experience, ECD focal)

Another KII respondent, however, said that the commitment of healthcare leaders at the middle and lower levels of the healthcare system is not sufficient.

…because of the competing health priorities, the health care leaders at the middle and lower level give more commitment and attention to emergency and lifesaving activities and due to this the attention given to development related activities like ECD assessment and provision of nutrition‐focused nutrition intervention is affected.

(KII, 12 years work experience, child health and nutrition expert)

3.11. Policy Level Influence

3.11.1. ECD Policy and Strategy

Ethiopia has established a comprehensive policy framework and strategy for ECD to tackle the various associated challenges (MOH 2020; UNICEF Ethiopia 2022). One of the study participants, an ECD focal at the national level, identified the existence of ECD policy and strategy as an enabling factor for its implementation.

The start‐up of ECD intervention at the federal level through initiation of policy and strategy development is very good. Even the ECD intervention is included in the regional health care system through the HEWs Integrated Community Case Management (ICCM) guidelines. We have seen a success story in the assessment and provision of nutrition‐focused interventions in Addis Ababa).

(KII, 10 years work experience ECD expert)

Although there is an ECD policy and strategy in place, the majority of the key informants were not familiar with any local guidelines or protocols that would assist them to initiate ECD assessments and deliver nutrition‐focused interventions.

…I didn't know that the ECD assessment is included in the Integrated Management of New‐Born and Child Illness (IMNCI) or Integrated Community Case Management (ICCM) guidelines. The HEWs did work lots of health activities based on the ICCM guideline, and they report the activities in to the health centers. However, none of the reports did mention about any assessment and intervention of ECD.

(KII, 8 years work experience, HEWs linkage officer)

4. Discussion

ECD interventions require a comprehensive, integrated, and sustained approach to effectively support children, especially those at heightened risk of developmental delays. Timely assessment and intervention during childhood are essential, as they facilitate the identification of developmental strengths and potential delays (Radner et al. 2018; Schiariti et al. 2021). The current study identified the enablers and barriers to ECD assessments and the delivery of nutrition‐focused interventions within the community, employing a qualitative case study approach rooted in the SEM (Bronfenbrenner 1977).

The ECD policy and strategy in the country, which is aligned with the WHO's nurturing care framework, was identified as crucial for facilitating the strengthening and integration of ECD assessments and interventions within community settings. By promoting a structured and coordinated approach, the ECD policy framework can support the holistic development of young children, ensuring that all aspects of ECD are effectively addressed and integrated into community‐based services (MOH 2020; Spier et al. 2023; UNICEF Ethiopia 2022).

The ECD policy specifies that the health sectors are responsible for offering ECD assessment, counselling to parents and caregivers on nutrition, play, communication, and child development. The policy framework seeks to integrate high‐quality, comprehensive ECD services across both community and facility settings, with a particular focus on providing targeted nutrition services (UNICEF Ethiopia 2022). In addition, the strategic plan for ECD aims to promote the early identification and treatment of children with developmental delays (MOH 2020). However, despite this policy and strategy commitment, the present study identifies a stark lack of initiatives aimed at ECD assessment and the delivery of nutrition‐focused interventions in the community setting.

Several enablers and barriers were also identified as factors affecting the implementation of ECD interventions in community settings. At the individual level, the study identified key barriers to the effective integration and strengthening of ECD services in the community. HEWs who are primarily responsible for promoting health through education, screening, prevention, and targeted clinical interventions (Caglia et al. 2014; MOH 2010), faced challenges due to their limited practical knowledge of ECD assessment and the delivery of targeted nutrition interventions.

Additionally, their commitment was often hindered by factors such as heavy workloads, competing responsibilities, lack of incentives, and insufficient opportunities for refresher training. These issues could contribute to the difficulties in providing effective ECD support in community settings. In line with the current study, despite the significant contributions of HEWs to improve child and maternal health by expanding coverage of high‐impact interventions, they still face limitations in skills and capacity when it comes to delivering other low‐cost but yet highly effective maternal and child interventions that can be implemented at the grassroots level (Zerfu et al. 2023).

Another study conducted in Addis Ababa revealed inadequate practice of assessing ECD milestones among healthcare providers at health institutions, with fewer than 1% (0.77%) of health workers demonstrating commitment to applying the Integrated Management of Childhood Illness (IMNCI) guidelines for the assessment and intervention of children with developmental delays (Tesfay et al. 2021). Studies have also demonstrated that training health workers in ECD greatly improves their knowledge, skills, attitudes and practices, empowering them to offer more effective ECD support and interventions (Pérez‐Escamilla et al. 2018; Sadoo et al. 2022; UNICEF 2012).

On the other hand, at the individual level, the commitment and positive attitude of HEWs towards implementing ECD assessment and providing targeted nutrition interventions at the community level through the existing health system are recognized as key enabling factors. Despite the challenges, HEWs demonstrated a strong willingness to support the integration of ECD assessment and nutrition interventions in the community. This finding is aligned with a study conducted in Kenya, which highlighted that strong health workers' motivation and commitment were crucial in successfully advancing the goals of integrated ECD programs (Ssewanyana et al. 2023).

At the interpersonal level, the communication and trust built between HEWs and the community were identified as one of the enabling factors for effective integration of the ECD assessment and interventions in the community. The HEWs understand the local dialect, culture, and even the ways of life within that particular community very well, and as a result, have good rapport with members of their respective communities. In addition, by working within the area where they live, these HEWs become trusted figures who are playing a vital role in improving the health and well‐being of the community (Koblinsky et al. 2010; Wilder 2008).

The existence of mothers' groups in the community is recognized as a good opportunity for effective integration of ECD assessment and provision of targeted nutrition interventions in the community. These groups offer a supportive network and serve as a valuable source of information ensuring that the key health messages are effectively communicated through different channels (Strange et al. 2016). The linkage between community members including mothers' groups and the primary healthcare system act as an effective and efficient way to exchange information (Intrahealth Ethiopia 2008; Yitbarek et al. 2019).

In contrast, at a community level, there are gaps among mothers about ways to assess children's development using some basic skills other than their indigenous knowledge. A study conducted in Brazil revealed that limited knowledge of the family about ECD was a barrier to home visiting ECD programs (Buccini et al. 2024). Mothers' prior experiences, along with information shared by other mothers and their mothers‐in‐law, have been identified as valuable sources for assessing their child's developmental status. Mothers‐in‐laws', who usually live with or close to the mother, are key family members who significantly influence the mothers by providing insights regarding the family health in general (Kea et al. 2018).

In the current study, based on their deep knowledge of community needs and the healthcare system's capabilities, the study participants stressed that the established existing healthcare system (Workie and Ramana 2013) and the network of community‐based healthcare services can effectively support timely identification and provision of nutrition‐focused interventions for children with developmental delays. The MOH 2021 IMNCI guidelines introduced the assessment of developmental milestones in health facilities among young infants to identify potential delays (FMOH, WHO 2021). However, the implementation of these guidelines remains low due to poor adherence among healthcare professionals (Tareke et al. 2024; Tesfay et al. 2021). In addition, the developmental milestones are not part of the Integrated Community Case Management (ICCM) guideline (FMOH 2018). The absence of clear, actionable guidance based on ECD policies in the ICCM hampers community health workers' ability to effectively implement ECD strategies and deliver essential services to young children, hindering progress in community‐based ECD initiatives.

Recognizing the importance of the existence of the healthcare system, barriers identified for effective ECD assessment and interventions in community settings were lack of training, shortage of facilities, absence of user‐friendly ECD assessment tools and checklists, and educational materials including pictures. Furthermore, the lack of ECD indicators in the community healthcare system not only hindered the capacity of HEWs to monitor and assess ECD‐focused interventions but also restricted their ability to integrate ECD initiatives into their routine community health services.

The current study adds to the existing knowledge by exploring multi‐level factors influencing ECD assessment and targeted nutrition interventions in community settings. Unlike most of the previous studies in Ethiopia that have focused mainly on nutritional status and its associated factors, this study incorporates perspectives about ECD related to the recently adopted conceptual framework for malnutrition (UNICEF 2021). The findings highlight the opportunity to integrate ECD into Ethiopia's existing Health Extension Program. With growing global recognition of the importance of early brain development and the future demand for knowledge‐based skills, ECD intervention for children is more critical than ever. Expanding ECD services through the health system at the community level would support equitable child development across the country and might help reduce urban migration pressures.

Although conducted in a single region, Sidama, the findings of this study are likely transferable to other rural and low‐resource settings across Ethiopia, a country of over 120 million people, the majority of whom live in rural areas. The findings can also be transferred to similar settings in LMICs globally where the barriers and enablers identified may reflect common challenges in implementing ECD and nutrition interventions. By contextualizing the findings within Ethiopia's Health Extension Program and aligning with policy recommendations such as nurturing care for ECD (WHO 2018) and the UNICEF Conceptual Framework for Malnutrition (UNICEF 2021), the study can potentially offer practical insights that can inform policy and program adaptation in comparable primary healthcare systems.

4.1. Strengths and Limitations of the Study

The application of the Socio Ecological Model (SEM) along with the qualitative case study assisted the study to identify the multi‐level factors influencing ECD assessment and provision of targeted nutrition intervention in the community setting. The study also involved a wide range of stakeholders within the health sector, ranging from the Kebele level to the Federal Ministry of Health.

Considering limitations, translating the FGD may have introduced biases such as loss of nuance in meaning and potential translator bias. The need for translation during the FGD may have increased the interview duration. Using the HEWs to select the FGD participants might also have introduced a selection bias. Another limitation was the exclusion of participants from other sectors involved with ECD, such as the Ministry of Education and the Ministry of Women, Children, and Youth. The focus on the health sector is justified; however, as the core of ECD assessment and nutrition intervention is largely driven by healthcare services; thus making the involvement of other ministries less central to the scope of this study.

4.2. Recommendations

Integrating ECD interventions into community settings can help identify developmental delays early and provide targeted support. While efforts to promote ECD and nutrition interventions exist in Ethiopia, addressing barriers is essential to improve the effectiveness and long‐term sustainability of ECD assessments and interventions within the community.

Advocating and creating awareness among the political leaders at the middle and lower level can bring change in the implementation of ECD intervention in the community settings. Strengthening and capacitating the healthcare system by incorporating ECD indicators, and empowering HEWs with the necessary training, resources and tools are essential to improve ECD assessment and provision of targeted interventions. Community engagement, especially through mothers' groups, is crucial for better dissemination of information and support for ECD and nutrition programs.

To enhance the sustainability and effectiveness of ECD service implementation in the community, the health and nutrition workforce must be strengthened by tackling systemic challenges such as health worker shortage and excessive workloads among HEWs through strategic expansion, practical training, structured supervision, and adequate resource allocation. The findings from this study can be used to guide the development of a set of multi‐level strategies to close existing implementation gaps and improve the adoption, implementation, and sustainability of ECD assessment and nutrition interventions in community settings.

Additional mixed‐methods research involving all stakeholders engaged in promoting ECD in the country is recommended to further investigate barriers and enablers for children in community settings. Developing and validating a user‐friendly and time‐efficient ECD assessment tool tailored to community settings can enable HEWs to effectively assess, classify and identify children at risk of developmental delays, and support the design of effective interventions.

5. Conclusions

Despite the presence of an ECD policy framework, implementation often falls short especially in the community settings. The findings of the current study identified several enablers that could facilitate the successful implementation of ECD assessments and nutrition interventions in community settings. These enablers include: the existence of a national ECD policy and strategy, a functional healthcare system that reaches out to the community, positive attitudes of health workers towards ECD initiatives, active involvement of community‐based groups such as mothers' groups, and the socio‐emotional connection between the HEWs and the community.

However, the study also identified several barriers that may hinder the effective delivery of ECD assessments and nutrition interventions. These include decreased HEWs' commitment, which is rooted in limited incentives, burnout and other competing priorities, inadequate community awareness of the importance of ECD, absence of ECD training along with lack of ECD manuals, guidelines, easily identifiable indicators, and locally tailored materials for community education. Furthermore, poor political commitment, which is allied with competing priorities and the tendency to give more attention to emergency and campaign work over development activities such as ECD initiatives, hinders the ECD assessment and provision of targeted interventions.

Author Contributions

Conceptualization: Hailu Hailemariam, Barbara J. Stoecker and Zelalem Tafese Wondimagegne. Methodology: Hailu Hailemariam, Barbara J. Stoecker and Zelalem Tafese Wondimagegne. Data analysis: Hailu Hailemariam and Zelalem Tafese Wondimagegne. Writing original draft manuscript: Hailu Hailemariam. Writing, review and editing: Hailu Hailemariam, Barbara J. Stoecker and Zelalem Tafese Wondimagegne. All authors have read and agreed to the published version of the manuscript.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data presented in this study will be available on reasonable request to the corresponding author.