An exploration of nurturing care environments: Micro, meso and macro systems

Abstract

Over recent decades, child health approaches have expanded from focusing solely on reducing mortality to a broader framework emphasizing both survival and thriving. Early efforts by organizations like UNICEF addressed immediate child health needs, prioritizing basic healthcare and immunizations. This approach evolved in the 1980s and 1990s to include holistic child development, influenced by the 1989 Convention on the Rights of the Child, which recognized cognitive, emotional, and social well-being alongside physical health. The inclusion of child development in the MDGs and SDGs reinforced this integrated approach. By 2017, the Multigenerational Life Course Framework encapsulated this perspective, highlighting the role of caregivers, families, and communities in supporting child development through nurturing care inputs, such as health, nutrition, safety, responsive caregiving, and early stimulation and learning. This dissertation is grounded in the Multigenerational Life Course Framework, which emphasizes the importance of both nurturing care inputs and enabling environments in promoting child development. It examines caregiver, household and community resources within this framework, analyzing their interactions across multiple levels of influence—macro, meso, and micro—as described in Bronfenbrenner’s ecological systems theory (1979). Specifically, the dissertation investigates how caregiver, household, and community resources affect caregivers' ability to deliver nurturing care in low- and middle-income countries (LMICs), focusing on the broader cultural, social, and economic contexts that shape these environments. The research is structured into three papers. Paper 1 examines the role of women’s empowerment in caregiving practices in rural Pakistan. The study found positive associations between women’s bodily autonomy and household decision-making power and their responsiveness as caregivers. Qualitative insights revealed that cultural norms around gender roles often limited women’s autonomy, and that caregiving responsibilities are often shared among family members, suggesting that parenting programs in similar settings should include other family members to support caregiving roles effectively. Paper 2 focuses on a nationally implemented parenting program in Brazil, evaluating how program outcomes on caregiver knowledge of child stimulation are influenced by caregiver characteristics, such as education and household resources. The findings suggest that customizing program dosage to align with caregiver characteristics may enhance program performance. Paper 3 assesses the availability of community resources, such as healthcare and nutrition services, across Brazilian municipalities and their association with early childhood development (ECD) outcomes. Results showed that access to quality exams and early home visits positively impacted child development at 3 years old, underlining the role of multisectoral public services in resource-limited settings. Overall, the dissertation highlights the interconnectedness of nurturing care, caregiving practices, and broader societal contexts. It calls for interventions that address both direct care and enabling environments to improve ECD outcomes, emphasizing the need for multisectoral collaboration that aligns with cultural and social contexts. Recommendations include developing culturally appropriate measures of women’s empowerment, adopting flexible program designs to accommodate caregiver variability, and enhancing primary care services and multisectoral collaboration to support early childhood development (ECD). This research underscores the importance of an integrated approach to child health that not only supports survival but also fosters children’s holistic development within their broader social and cultural ecosystems.