At every stage of its work, PATH conducted formative assessments with caregivers and health providers to better understand their perspectives, realities, and needs while adapting or designing new tools and services.
Baseline interviews and focus groups with caregivers were first conducted in southern Mozambique in 2013–2015, when ECD programming was just starting. Early findings indicated that daily family routines were underutilized as opportunities for play and communication, and that caregivers rarely played with their children, leaving this task to siblings. In 2018, when the work transitioned to northern Mozambique, the team conducted in-depth interviews with 35 families in Monapo district to identify what needed to be adjusted in this new context. The data provided additional examples of daily activities where play could be integrated, and revealed that fathers in the north were expected to engage with their young children to a greater extent than fathers in the south and that disabilities in children were commonly attributed to witchcraft.
More systematic studies of caregiver experiences and perspectives in northern Mozambique were carried out by the Harvard School of Public Health in 2021 and during human-centered design of improved ECD solutions for health services in 2022. Caregiver experiences of health services were collected, and it was found that at least half of the caregivers came in touch with ECD interventions during health services. Furthermore, in both Kenya and Mozambique, caregiver perceptions of provider interpersonal communication were documented as part of human-centered design, since such communication is implicated in caregiver uptake of services.
Additionally, existing caregiver play and communication practices with young children were documented and caregiver reasons for engaging in play were identified in both countries; these were later used to re-design the play sessions in the waiting rooms.
Furthermore, every time new interventions were to be introduced, PATH conducted in-depth interviews or focus groups with caregivers to inform the design. For example, in-depth interviews with 25 postnatal care clients permitted PATH to identify scenarios to depict in the counseling cards used by MCH nurses to counsel on maternal depression. Similarly, interviews with caregivers of children with disabilities led to introduction of caregiver support groups and an agricultural production project run by our local partner, ADEMO, in Mozambique.
Formative assessments were also used by PATH to understand how health services worked and how the global Care for Child Development (CCD) package could be adapted to busy facility and community providers’ schedules. We observed how much time each consultation or household visit lasted, whether any counseling was provided, how and with what tools, and what data was recorded. We used what we learned to re-design counseling tools, training materials, and mentoring guides. For example, one of the innovations based on formative assessments was to develop integrated mentoring guides for facility and community touchpoints, as opposed to having ECD-focused tools. This helped improve the quality of the whole consultation or household visit, as opposed to just the ECD component. Another innovation was a playbox session in the waiting room, which addressed the problem of long waiting hours and lack of space for setting up permanent play corners.
After introducing the new or re-designed tools, PATH would go back to document their acceptability, feasibility, and initial impact, as perceived by the health providers. An example is an operational research study conducted in southern Mozambique, in 2018, to evaluate facility provider use and perceptions of developmental monitoring and counseling tools and protocols.
Regular analyses of data in primary care and specialist registers also helped understand common challenges experienced by providers and inform intervention design. For example, analyses of three months of physiotherapy data in two major hospitals of Maputo province in 2017 suggested under-detection of developmental risk factors such as birth asphyxia by MCH nurses and resulting late referrals to specialists. This has led to relevant updates in training for the nurses.
At a later stage, when PATH’s Living Labs team in Kenya was established, we increasingly began to use principles of human-centered design to not only understand the provider work context but also to co-create interventions with them. In Kenya, this has led to the co-design of the SOP for ECD, a tool that helps facility and community providers to make better use of the national Mother Child Health Handbook. In Mozambique, it allowed the team to identify opportunities for counseling in maternity wards, among other touchpoints. Additionally, we are currently using human-centered design to identify motivators and barriers in providers’ delivery of ECD services, including the contributing attitudes and actions of health facility directors and supervisors.
