Community-based interventions to enhance early childhood development in fragile contexts: evidence from the West Bank

1 Introduction

The early years of children's lives represent a time when an abundance of growth is taking place. These early years provide many possibilities for children to develop in positive ways due to their brains rapidly developing and being able to adapt quickly to new experiences (Black et al., 2017; Draper et al., 2024). The most critical portion of this developmental window is the “first 1,000 days” that begins at conception and ends on the child's second birthday. This timeframe has significant impact on how the foundation for a child's future cognitive development, language development, socio-emotional development and self-regulation will be shaped by what they receive regarding nutrition, responsive caregivers, secure environments, opportunities for communication and play and protection from stress and potential harm (Britto et al., 2017; World Health Organization, United Nations Children's Fund and World Bank, 2018).

Globally, children grow in environments that include high levels of poverty and malnutrition, a lack of opportunities to be stimulated, as well as an unsafe environment for growing, all of which increase the chances of not achieving their developmental potential (Black et al., 2017; Lu et al., 2016). The risks are not isolated to one area of development but cross into each other in biological, relational, at-home, and at-community systems. When there is no stable source of nurturing care, adverse experiences during early childhood may interfere with the normal process of growth and increase the chance that a person will have continued difficulty in areas such as learning, health, or emotional regulation (Nores et al., 2024; Black et al., 2017). Conversely, investing in early years by providing support to caregivers, creating responsive interactions with caregivers, and monitoring child development can create a safer and healthier home environment that promotes positive developmental pathways (Jeong et al., 2021, 2018).

The Nurturing Care Framework can help explain the pathways described above. Five interconnected areas are identified as critical to supporting children's ability to both survive and develop: Good Health, Adequate Nutrition, Responsive Caregiver, Early Learning Opportunities, and Safety/Security (World Health Organization, United Nations Children's Fund and World Bank, 2018). This framework is particularly relevant in fragile and low-resource settings because children's development is shaped not only by individual caregiving practices, but also by the broader social and economic conditions that influence household food security, caregiver wellbeing, access to services, and the availability of safe learning environments (Britto et al., 2017; World Bank Group, 2016, 2024; Zou et al., 2024).

Socioeconomic vulnerability has a profound impact on understanding early childhood development in the West Bank. Conflict, travel restriction, economic instability, food insecurity, and limits to access to health care, nutrition, protection and early childhood services are all factors that many families experience in their daily lives (Palestinian Central Bureau of Statistics (PCBS), and UNICEF, 2021, World Bank Group, 2024). The above-mentioned conditions have multiple pathways with which they can affect child development: restricted household income can limit household's ability to purchase diverse foods and play/learning resources; caregiver stress due to socioeconomic issues can decrease emotional availability and responsiveness; and lack of proper service delivery systems can delay early identification and referral for developmental problems. Therefore, socioeconomic variables should not be viewed only as baseline characteristics, but as contextual determinants as they may shape both caregiving practices and children's developmental outcomes.

Within this context, integrated early childhood development and nutrition interventions have gained increasing attention. Evidence from low– and middle-income countries indicates that parenting interventions, stimulation activities, nutrition counseling, and home-based coaching can improve caregiver knowledge, responsive caregiving, and child developmental outcomes, particularly when delivered through community or primary health care platforms (Chang et al., 2015; Dulal et al., 2021; Muhoozi et al., 2018; Yousafzai et al., 2014). Community health workers are especially important in underserved contexts because they can reach families in their homes, reinforce key messages, identify risks early, and link families to available services.

World Vision's Go Baby Go (GBG) parenting model operationalizes nurturing care principles through caregiver education, play-based early stimulation, responsive caregiving, nutrition messages, and the creation of safe and supportive home environments (World Vision International, 2018, 2022, 2024). GBG-informed interventions have been used in vulnerable and humanitarian settings and have shown improvements in caregiver engagement, playful parenting, and early developmental outcomes (Sargsyan et al., 2023, 2024).

In a refugee setting in Rwanda, the Care and Comfort for Children (3C) project implemented using the GBG model reported significantly higher caregiver engagement in early learning and stimulation activities and more positive responsive caregiving behaviors compared with control groups (Sargsyan et al., 2023). Similarly, evaluations of GBG-informed playful parenting programs implemented in vulnerable communities in Nepal and Uganda documented improvements in caregiver responsiveness, secure attachment–promoting behaviors, and early developmental indicators among young children (Sargsyan et al., 2024). Additional evidence from South Asia demonstrates gains in caregiver confidence, nurturing care practices, and child developmental outcomes following GBG-based interventions, supporting the applicability of the model across low-resource and fragile contexts (Caldera et al., 2020; Sargsyan et al., 2023, 2024).

In the present study, the GBG model provided the core intervention framework, with additional emphasis on developmental screening, home follow-up, and clinic-based ECD corners. Although the intervention is conceptually situated within the 1^st 1,000 days, the enrolled children were infants aged 0–4 months at baseline and were followed during the 1^st year of life.

While it appears from the literature that there has been considerable interest in the 1^st 1,000 days of child development globally, to date, no studies have examined the impact of community delivered Nurturing Care through CHWs in West Bank. Most of what exists related to nutrition, parenting, caregiver wellbeing, or developmental screening is usually studied separately rather than examining them collectively (how they work together) in fragile, resource-challenged environments. Thus, the aim of this current study was to examine if a CHW-delivered, GBG-informed Nurturing Care program would be positively correlated with improved maternal knowledge about their infant's needs, enhanced responsive caregiving behaviors, increased stimulation of their infant while at home, enhanced supervisory behaviors by caregivers toward their infant, and better developmental screening outcomes for their infant. Additionally, this study aims to provide data-driven evidence for policy makers, public health practitioners working at all levels of healthcare systems, and non-profit entities who are looking for ways to develop and implement scalable and culturally relevant strategies to support Early Child Development programs in difficult-to-reach populations.

2 Methods

2.1 Study design and setting

We employed a quasi-experimental pre–post design to evaluate changes in maternal knowledge, caregiving practices, home learning environment, child supervision, and developmental screening outcomes following the intervention. The study was implemented in 30 vulnerable West Bank communities selected through World Vision vulnerability mapping. Communities were located across three geographic areas: South (n = 13), Central (n = 9), and North (n = 8), with sample size allocation within each area determined proportionally based on the estimated number of eligible participants. This strategy ensured balanced representation of communities according to population size and strengthened the representativeness of the sample within the intervention context. These communities were selected because they represented contexts characterized by socioeconomic vulnerability, access restrictions, limited availability of formal ECD services, and heightened need for community-based support.

2.2 Participants and eligibility

We enrolled a total of 449 mother–infant dyads. Infants were aged 0–4 months at baseline, allowing the intervention to begin during a critical developmental window and continue through much of the 1^st year of life. A proportional sampling strategy was applied to reflect the distribution of eligible dyads across the selected areas. Mothers were eligible if they resided in one of the selected communities, had an infant within the target age range at baseline, were willing to participate in group and home-based activities, and provided informed consent.

The study focused on mothers because, in the target communities and within the operational design of the primary health care and parenting sessions, mothers were the primary caregivers most consistently involved in infant feeding, daily care, health visits, and early stimulation activities. Working with mothers therefore provided a feasible and contextually appropriate entry point for assessing caregiver knowledge and practices. However, fathers, grandparents, and other caregivers may also play an important role in influencing early child development. Their limited inclusion in this study was mainly related to practical and contextual factors. Many intervention activities were conducted during daytime hours, when fathers were often at work, and the sessions were delivered by female community health workers. In several of the selected conservative communities, cultural norms made it more acceptable for female CHWs to interact primarily with mothers and female caregivers. Grandparents were intentionally engaged when they were living in the same household and actively involved in childcare; however, they were not systematically included in wider community-based sessions. This is acknowledged as an important area for future research. Future interventions should explore culturally appropriate strategies to engage fathers, grandparents, and other caregivers, such as offering sessions outside working hours, organizing separate sessions for fathers facilitated by male staff, involving extended family members in home visits, and designing family-centered approaches that strengthen the broader caregiving environment.

2.3 Intervention

The intervention was grounded in World Vision's GBG parenting model and aligned with the Nurturing Care Framework. It was implemented by trained community health workers (CHWs) over approximately 11 months starting in March 2024, and was completed between December 2024 and January 2025. The model combined structured group learning, practical demonstrations, home-based coaching, developmental screening and referral in addition, the model strengthened the capacity of primary health care providers by building their skills and supporting clinics through the establishment of Early Childhood Development (ECD) corners. These ECD corners were child-friendly spaces where mothers could safely breastfeed, access educational materials, and use age-appropriate toys with their children. These spaces are also equipped with standardized tools for assessing children's development, facilitating early screening, counseling, and referring within the primary health care system. This dual approach, empowering caregivers while reinforcing the health system, created a sustainable platform for promoting early childhood development at the community level.

The intervention began with training CHWs as the key personnel responsible for delivering the intervention. The CHWs were trained by certified trainers and were selected based on specific criteria, including community acceptance, prior experience working in a community-based setting and previously involved in implementing a project similar in nature. These factors were critical to ensure that the intervention was being implemented by individuals whom the community trusted and who were able to engage mothers effectively.

The CHW's underwent a 7-day training program to develop adequate levels of competence and quality in delivering the intervention. The training program was divided into two distinct phases.

Phase 1: Overview of the GBG Integrated Nurturing Care Model.

The first phase of the training program focused on the Go Baby Go (GBG) integrated nurturing care model (Palestinian Central Bureau of Statistics (PCBS), and UNICEF, 2021). Phase 1 training lasted 5 days and addressed the core elements of the intervention which include: Infant and Young Child Feeding (IYCF), Early Childhood Development (ECD), Responsive Caregiving, Early Stimulation, and Caregiver Support.

Phase 2: Refresher Training.

Refresher training for 2 days occurred 6 months post initiation of the intervention. The primary objective of the refresher training was to enhance CHWs core competencies, resolve any implementation challenges, and maintain adherence to the established intervention protocols. The refresher training also served to improve the quality and consistency of the intervention delivered by each CHW.

Following the completion of all training modules and competency assessments, CHWs were assessed for final competency and readiness to implement the intervention. For the entire duration of the implementation, CHWs worked under the direct supervision of primary health care nurses. The supervision ensured continuous support and guidance to the CHWs, in addition to maintaining the quality and integrity of the intervention model.

Additionally, all CHWs received training on child safeguarding principles and signed the project safeguarding protocol prior to intervention delivery.

The intervention included:

• Monthly group parenting sessions

Monthly group sessions focused on responsive caregiving, play, and early stimulation were delivered to caregivers to strengthen their understanding of early child development and promote positive, nurturing interactions at home. The sessions incorporated a behavioral change communication (BCC) approach at the household level, emphasizing modeling, guided practice, and reflection on daily caregiving behaviors. Each session included interactive learning activities such as storytelling, pictorial demonstrations, drawing, singing, and role-playing to make the learning process engaging and relevant. These participatory methods encouraged caregivers to internalize key messages, practice positive interactions, and foster joyful and developmentally supportive environments for their children. The monthly group sessions were conducted at the primary health care centers, with approximately 10 caregivers per group. The sessions were facilitated by the trained community health workers from each community and supervised by the clinic nurse.

• Home visits, developmental screening, and caregiver coaching

Home visits were conducted monthly by trained CHWs to reinforce key messages from group sessions, assess child development and caregiving behaviors, and provide tailored household-level support. During these visits, CHWs used the EDUS Developmental Behavioral Scales–Palestine (DBS-P) to screen children's developmental progress (Pistoljevic and Dzanko, 2020). For children identified as not developmentally on track, individualized stimulation plans were developed, and caregivers received hands-on guidance to support developmental progress through daily routines and play. For children identified as developmentally on track, caregivers received reinforcement and positive feedback to sustain appropriate nurturing and stimulation practices. CHWs received routine technical supervision from trained supervisors, and children with persistent or severe developmental concerns were referred to appropriate primary health or specialized services in accordance with established referral pathways.

Both group sessions and home visits were documented using a standardized tracking form developed for monitoring and quality assurance purposes. The form captured session attendance, key content delivered, child developmental screening activities, caregiver follow-up actions, and referrals when applicable, enabling routine supervision and verification of intervention fidelity.

• Peer support and structured counseling sessions

Peer support sessions were organized at primary health clinics, providing caregivers with opportunities to share experiences, receive psychosocial encouragement, and discuss challenges related to caregiving, early learning, and responsive parenting. They were held in groups of approximately 10 participants, facilitated by the community health workers.

• ECD-friendly corners

To enhance the quality of caregiver–child interactions within clinic settings, ECD-friendly corners were established in health centers. These child-friendly spaces offered toys, learning materials, and stimulation tools that created a joyful and interactive environment for mothers and children during visits. To support sustainability and consistent developmental monitoring, both CHWs and clinics were equipped with the necessary tools and didactic materials to support ongoing DBS-P screening (Tables 1, 2).

Table 1. Summary of intervention components, delivery methods, and monitoring tools.

Table 2. Sessions and key topics covered during the intervention.

2.4 Measures

Maternal knowledge of early childhood development, brain development, and responsive caregiving was assessed using a standardized 23-item questionnaire developed by World Vision International. The tool was selected because it directly reflects the intervention's behavior change objectives and captures caregiver understanding of early learning, stimulation, responsive interaction, stress, safety, and developmental needs. The questionnaire has demonstrated acceptable internal consistency across programmatic applications and has been used in low- and middle-income settings to assess changes in caregiver knowledge before and after parenting interventions (World Vision International, 2019). This tool was administered twice: at baseline and endline.

Caregiving practices and home learning environment were assessed using structured items adapted from UNICEF Multiple Indicator Cluster Survey modules applied in the Palestinian context (Palestinian Central Bureau of Statistics (PCBS), and UNICEF, 2021). These items captured caregiver engagement in reading, storytelling, singing, playing, going out with the child, as well as availability of children's books and play materials, and child supervision practices. These measures were chosen because they correspond closely to the responsive caregiving, early learning, and safety domains of the Nurturing Care Framework (World Health Organization and United Nations Children's Fund, 2021).

Child developmental outcomes were monitored using the EDUS Developmental Behavioral Scales-Palestine (DBS-P), a developmental screening and monitoring tool validated for use in West Bank and available in Arabic (Pistoljevic and Dzanko, 2020,a). The DBS-P assesses age-appropriate developmental expectations across cognitive, language/communication, motor, socio-emotional, and self-help/independence domains. Depending on age, children were screened using the 1–3-, 3–6-, 6–9-, and 9–12-month forms. Children classified as requiring retesting or as delayed received targeted follow-up and, where needed, referral to primary health or specialized services.

The selection of these instruments was guided by three considerations: alignment with the Nurturing Care Framework and the GBG intervention theory of change; feasibility for use by trained CHWs in community and primary health care settings; and relevance to the West Bank context. Together, the tools captured the expected pathway from improved caregiver knowledge to improved caregiving behavior, safer and more stimulating home environments, and age-appropriate developmental progress.

2.5 Data collection and quality assurance

Baseline data on mothers' knowledge and practices were collected before implementation and endline data were collected after approximately 11 months of intervention exposure. However, EDUS Developmental Behavioral Scales–Palestine (DBS-P) data were collected at specific developmental milestones, depending on the child's age.

Data were collected by trained CHWs who underwent a 5-days training program. This training consisted of both theoretical and practical components. CHWs were given the opportunity to become familiar with data collection techniques and questionnaire administration. This step was essential for ensuring accurate, consistent, and thorough knowledge of the tools and materials before implementation began.

Data were collected digitally using the Field Task application integrated with the SMAP server, allowing real-time validation, field monitoring, and correction of inconsistencies. In addition, standardized tracking and monitoring forms were developed, and CHWs were required to submit them to supervisors for review. Supervisors monitored completeness and provided feedback to maintain data quality and intervention fidelity.

2.6 Ethical considerations

Ethical approval was obtained from the Institutional Review Board of Al-Quds University (REF.4/24) on 15 February 2024. The study was conducted in accordance with local ethical requirements and the principles of the Declaration of Helsinki. Informed consent was obtained digitally from all participating mothers through the digitized questionnaire, which included an introductory statement describing the study's objectives, procedures, expected duration, and confidentiality safeguards. Only participants who provided electronic consent were enrolled in the study.

Personal identifiers were separated from study data, and only anonymized and de-identified data were used for analysis.

2.7 Statistical analysis

Data were analyzed using IBM SPSS Statistics, version 28. Descriptive statistics were used to summarize participant characteristics and outcome distributions.

Paired-samples t-tests were used for normally distributed continuous measures, including total maternal knowledge scores. Wilcoxon signed-rank tests were used for ordinal pre-post measures, including frequency of caregiver engagement in early stimulation activities and availability of books and play materials.

McNemar tests were used for paired dichotomous indicators, and McNemar-Bowker tests were used for multi-category nominal outcomes such as child supervision practices. Statistical significance was set at p < 0.05. Effect sizes were interpreted using Cohen's guidelines where applicable (Cohen, 1988).

3 Results

3.1 Participant characteristics

The majority of the enrolled mothers were aged 21–39 years (89%), while 9% were younger than 20 years and 2% were aged 40 years or older. Educational attainment varied: 45% had a university degree, 40% had completed high school, and 15% had secondary education or less. Household economic capacity also varied, with 57% reporting sufficient income for food and other essential needs, 40% reporting partial sufficiency, and 3% reporting significant difficulty securing adequate food. These characteristics indicate that the sample included families exposed to varying levels of socioeconomic vulnerability, an important contextual factor for interpreting caregiving and developmental outcomes (Table 3).

Table 3. Baseline sociodemographic characteristics of participating mothers and households.

3.2 Maternal knowledge of early childhood development

Maternal knowledge scores improved significantly from pre-intervention to post-intervention (M_pre = 11.24, SD = 4.15; M_post = 21.25, SD = 2.13; [t (448) = −43.29, p < 0.001, d = 2.05, 95% CI (−10.38, −9.48)]. Across all 23 knowledge items, correct responses increased significantly, all p < 0.001, based on McNemar tests. The largest gains were observed in items addressing brain growth (+ 66.8 percentage points), the developmental impact of stress and violence (+ 63.7 percentage points), and the concept of crying as communication (+ 59.3 percentage points). These results indicate a marked improvement in maternal understanding of holistic child development, including physical, cognitive, and socio-emotional domains.

3.3 Home learning environment and caregiver engagement

The home learning environment improved substantially. A Wilcoxon signed-rank test showed a significant increase in the number of children's books or picture books available at home (Z = −15.03, p < 0.001, r = 0.71). Before the intervention, 38.3% of households had no books and 21.4% had three or more. After the intervention, only 6.0% had no books, while 66.8% reported having three or more books available. Overall, 64.4% of households showed improvement, indicating a strong positive shift toward richer home learning environments (Table 4).

Table 4. Pre-post changes in home availability of children's books.

Maternal engagement in five stimulation activities reading, storytelling, singing, going out, and playing with the child was measured using ordinal frequency scales. Wilcoxon signed-rank tests indicated statistically significant improvements across all five domains, all p < 0.001. Access to at least two types of play materials also increased from 170 children (37.9%) before the intervention to 362 children (80.6%) after the intervention (Table 5).

Table 5. Pre-post changes in mothers' engagement in five stimulation activities.

3.4 Child supervision and safety practices

Child supervision practices improved significantly. Before the intervention, 109 mothers (24.3%) reported leaving their child alone or under the care of another child younger than 10 years for 1 or more days during the previous week, 296 (65.9%) reported that they did not do so, and 44 (9.8%) were unsure. After the intervention, the proportion reporting unsafe supervision decreased to 98 (21.8%), the proportion consistently supervising increased to 347 (77.3%), and uncertainty declined to 4 (0.9%). The McNemar-Bowker test indicated a statistically significant change in supervision practices across assessments, χ² (3, N = 449) = 40.70, p < 0.001. These findings indicate improvement in safety-related caregiving practices following the intervention.

3.5 Child developmental outcomes

Child developmental outcomes were assessed using the DBS-P at age-appropriate intervals. In total, 449 children were screened, with most children completing two screenings (n = 296), 139 completing one screening, and 15 completing three screenings. Overall, 777 DBS-P screenings were conducted across four age-specific intervals. Across age groups, 86%−93% of children were classified as typically developing. Children who were classified as requiring retest or delayed received additional follow-up and caregiver coaching. Among children identified as delayed and successfully followed up (n = 57), 49 (86%) moved into the typical developmental range upon retest (Tables 6, 7).

Table 6. DBS-P results across age groups.

Table 7. Frequency and percentage of children classified as typically developing, retest, or delayed across developmental domains and age groups.

Collectively, the results show substantial improvements in caregiver knowledge, home stimulation, supervision practices, and developmental follow-up. These changes suggest that community-based delivery can strengthen multiple nurturing care domains simultaneously in fragile and resource-constrained contexts.

4 Discussion

4.1 Summary of main findings

This study evaluated a CHW-delivered, GBG-informed nurturing care intervention implemented in vulnerable West Bank communities. The findings show significant improvements in maternal knowledge, responsive caregiving practices, availability of learning and play materials, safe supervision, and developmental follow-up outcomes. The high proportion of children classified as developmentally on track across age-specific DBS-P intervals, together with the improvement observed among children initially classified as delayed, suggests that early identification combined with caregiver coaching may contribute to developmental recovery or catch-up during infancy.

These findings are consistent with the Nurturing Care Framework, which emphasizes that early childhood development is shaped by interconnected domains of good health, adequate nutrition, responsive caregiving, opportunities for early learning, and safety and security (World Health Organization, United Nations Children's Fund and World Bank, 2018; Britto et al., 2017; Daelmans et al., 2021). In this study, the strongest improvements were observed in domains most directly targeted by the intervention: caregiver knowledge, early stimulation, home learning resources, safety-related practices, and developmental monitoring.

4.2 Maternal knowledge, responsive caregiving, and early learning

The large increase in mothers' understanding suggests that when caregivers are presented with a series of group sessions that include both theoretical information about early childhood brain development as well as practical strategies for interacting with their children, they will be able to translate this new knowledge into an improved ability to provide a nurturing environment. These findings are also consistent with other research from around the world that shows that parenting interventions implemented during the 1^st 3 years of life enhance caregiver's knowledge, caregiver behavior and child developmental outcomes (Yousafzai et al., 2014; Jeong et al., 2018, 2021). The interactive nature of these groups (storytelling, singing, role-playing, demonstrations, etc.) likely contributed to the transition of knowledge into practice.

Maternal knowledge is especially important for understanding how much change occurs as caregiver knowledge is an intermediary for parenting programs to have an effect on child development. Caregivers need knowledge to help them be able to identify their child's needs and interact with their child in ways that will meet those needs. It is the combination of caregivers receiving this knowledge repeatedly over time and being given opportunities to apply that knowledge in practical and culturally appropriate ways during daily routines, that may provide caregivers with the confidence and skills necessary to support all aspects of children's development including cognitively, linguistically, physically and emotionally (Wang et al., 2022; Yousafzai et al., 2014; Jeong et al., 2021).

Behavioral improvements can be seen through a greater amount of time spent on reading, storytelling, singing, play and spending time outside with the child. These behaviors are keyways to show how you are being a responsive caregiver and creating early learning experiences for your child as stated in the Nurturing Care Framework. Other studies using similar methodologies to this one have reported findings showing relationships between responsive caregiving, enriching a child's environment of early learning, and an improvement in developmental progress (Wang et al., 2022). This study found that the increases in both toys/play materials and children's books suggest that caregivers not only learned new things, but they were able to make real changes in their own homes.

This is an indicator of how the intervention has altered the actions and the physical environment of the caregivers. The added opportunity through books and toys may have provided additional avenues for early stimulation, communication, and caregiver-child interaction. These are critical in vulnerable and under-resourced contexts, as these children will likely be exposed to fewer formal early education systems and their home environments become the primary mechanism for early development. Other research on integrated parenting and stimulation programs indicates that increasing caregiver's engagement with their child and the home environment provides children with more positive developmental paths (Muhoozi et al., 2018; Jeong et al., 2018; Yousafzai et al., 2014).

4.3 Developmental screening, follow-up, and child outcomes

The developmental findings highlight the value of combining parenting support with systematic screening and follow-up. Screening alone is insufficient if families do not receive guidance on how to respond to developmental concerns. In this intervention, CHWs used DBS-P screening results to provide individualized stimulation plans, reinforce positive practices, and refer children when persistent concerns were identified. The finding that 86% of successfully followed-up children initially classified as delayed moved into the typical developmental range is consistent with evidence that early coaching and caregiver involvement can improve outcomes among children at developmental risk (Ward et al., 2020).

These findings are especially important because early childhood is characterized by a significant amount of developmental “plasticity.” That is, when developmental challenges in young children are identified early on, and their parents/ primary caregivers receive training/coaching as to how best to promote their child's development, there is an increased likelihood that these children will be able to adapt and possibly move toward more typical patterns of development. Early intervention literature also supports the use of family-centered strategies such as caregiver coaching, which enhance families' ability to support their child's growth and development and therefore reduce the potential for ongoing developmental delays/disabilities (Ward et al., 2020) The fact that so many children were able to progress from a delayed classification to the typical range suggests that early identification coupled with the implementation of individually developed stimulation plans; multiple contacts in the home environment; and family-based interventions are all likely contributing factors.

The results also reinforce the importance of integrating developmental monitoring into community and primary health care platforms. In many fragile settings, specialized developmental services are scarce or difficult to access. A CHW-supported screening and coaching model can therefore serve as an early entry point for identifying concerns, supporting caregivers, and referring children when needed. This is consistent with the Nurturing Care Framework's emphasis on responsive services and enabling environments, rather than relying only on caregiver behavior change at the household level (World Health Organization, United Nations Children's Fund and World Bank, 2018; Britto et al., 2017).

4.4 Socioeconomic vulnerability and interpretation of findings

Socioeconomic vulnerability can shape child development through household material resources, caregiver stress, food security, availability of toys and books, transportation barriers, and access to health and ECD services. In this study, the participating communities were selected because they were vulnerable, and household economic capacity varied substantially. Although the intervention improved caregiver knowledge and practices, structural constraints may continue to limit the degree to which families can consistently provide diverse diets, learning materials, safe play spaces, and access to specialized services.

This interpretation is supported by evidence showing that poverty and limited household resources are strongly associated with disparities in early childhood development, particularly through reduced access to nutritious foods, health care, safe housing, toys, books, and stimulating learning opportunities (Black et al., 2017; Lu et al., 2020; Allel et al., 2021). In the West Bank context, these constraints may be further intensified by movement restrictions, economic instability, and limited availability of formal ECD services. Therefore, the observed improvements should be understood as meaningful changes within a constrained environment, rather than as evidence that caregiver-focused interventions alone can overcome structural adversity.

The results of this study are therefore best viewed from a perspective that focuses on how caregivers' social environment impacts their children's development. Interventions designed to focus on the caregiver may build knowledge, self-confidence in caregiving, and increase daily interaction; however, these types of interventions alone will not eliminate the socio-economic barriers that limit opportunities for child development. Understanding this difference will be helpful when developing policies and programs, particularly those involving integrated parenting and early childhood education (ECD) programs, which will require broader-based approaches to address issues associated with poverty, food security, maternal wellbeing, accessibility to basic health care services and available safe community space. The value of using the Nurturing Care Framework in fragile settings such as the West Bank lies in its emphasis on both the behavior of the caregiver and the ability of the environment to support or hinder development.

The improvement in supervision practices also needs to be interpreted within this broader ecological context. Safer supervision may not directly produce developmental gains in the same way as stimulation or responsive interaction, but it may create the conditions that allow children to explore, play, and interact safely. Previous literature suggests that safety and security are enabling conditions for early learning and responsive caregiving, particularly in settings where environmental risks may limit children's opportunities for exploration and play (Britto et al., 2017; Scherer et al., 2019; Wang et al., 2022).

4.5 Community health worker delivery and program implications

The intervention's CHW-delivered model is a key programmatic contribution. CHWs were able to deliver repeated messages, conduct home visits, support developmental screening, and provide practical coaching in communities where formal ECD services are limited. This delivery platform may be particularly relevant in settings where primary health care staff face heavy workloads and cannot provide extended individualized developmental counseling during routine visits. By linking household coaching with clinic-based ECD corners and nurse supervision, the model created a bridge between families and the primary health care system.

The findings align with evidence from community and primary health care-based ECD interventions in other low- and middle-income settings (Chang et al., 2015; Yousafzai et al., 2014). They also support the relevance of GBG-informed approaches in vulnerable and humanitarian contexts, where repeated caregiver engagement and playful parenting activities have been associated with improvements in nurturing care practices and developmental outcomes (Sargsyan et al., 2023, 2024). For non-profit organizations and public health systems, the results suggest that scalable ECD strategies should combine structured curricula, CHW capacity-building, supportive supervision, digital monitoring, and referral pathways.

The CHW model may be especially valuable because it combines accessibility with continuity. Repeated contact through group sessions and home visits allowed CHWs to reinforce key messages, observe caregiving practices, provide tailored feedback, and support follow-up for children identified as requiring additional attention. Similar community-based parenting and stimulation interventions have demonstrated that non-specialist or community-based workers can support improvements in caregiver practices and child development when they are trained, supervised, and supported through structured intervention materials (Yousafzai et al., 2014; Chang et al., 2015; Jeong et al., 2018).

The integration of ECD corners within primary health care clinics also has important implications for sustainability. These spaces helped embed early stimulation, caregiver counseling, and developmental screening within routine health service platforms. This approach is consistent with global recommendations to integrate nurturing care into health and community systems, particularly in settings where standalone ECD services are limited (World Health Organization, United Nations Children's Fund and World Bank, 2018; Daelmans et al., 2021).

4.6 Alignment with the nurturing care framework

Overall, the findings provide empirical support for the Nurturing Care Framework in a fragile West Bank context. The intervention addressed several framework domains simultaneously: responsive caregiving through caregiver coaching and interaction-based sessions; early learning through reading, storytelling, singing, play, and access to books and play materials; safety and security through improved supervision practices; and good health through developmental screening, follow-up, and referral pathways.

The research indicates that CHW provided interventions can increase caregiver capability, support caregiver application of their knowledge in practical terms and improve the conditions of caregivers' homes. This is relevant as it supports the Nurturing Care Framework's assertion that the process of child development involves an interaction among a variety of factors including caregiver knowledge, caregiver emotional availability, household and other resource levels available to children, safe physical environments and access to supportive services (Britto et al., 2017; Daelmans et al., 2021; World Health Organization, United Nations Children's Fund and World Bank, 2018).

Therefore, this research provides context-specific evidence from Palestine which has been hindered by conflict, socio-economic disadvantage and restricted access to services which limit early childhood development potential. The data indicate that community-based CHW delivered interventions may represent a viable and contextually applicable method for supporting early childhood development. Furthermore, the data highlights the necessity for system wide investment in addressing the structural factors which affect caregiving and the resulting outcomes for child development.

5 Limitations

In this study, a control group was not included due to both ethical and practical considerations. Intentionally identifying children at risk and withholding interventions solely for comparison purposes would have raised substantial ethical concerns, particularly given that early childhood is a critical window for brain development, during which delays in intervention can have long-term negative effects on wellbeing and developmental outcomes. In addition, implementing a non-intervention group could have jeopardized the trust-based relationships established with participating communities and caregivers, potentially compromising their willingness to engage in current and future programs. Future studies should therefore explore the use of matched comparison or stepped-wedge designs to strengthen causal inference while maintaining ethical integrity and community trust.

The study focused primarily on mothers because they were the main caregivers and most consistent participants in the intervention; future research should include fathers and other caregivers to better understand whole-family influences on early development. Follow-up was limited to the 1st year of life; longer-term tracking is needed to assess whether developmental gains are sustained into preschool and school-readiness stages.

6 Conclusion

This study provides robust evidence that integrating responsive caregiving and early stimulation components within existing community-based health and nutrition programs can significantly enhance maternal knowledge, engagement, supervision practices, and therefore their children's early childhood development in resource limited settings. Mothers demonstrated improved understanding of early child development, greater involvement in daily learning activities, and increased provision of safe and stimulating environments. These behavioral and environmental improvements are likely to contribute to better developmental trajectories for young children. Scaling up such integrated approaches within primary health care systems may yield sustainable improvements in child development and family wellbeing across vulnerable communities in the West Bank, in addition, serve as an example for other low-resource communities in the world.

This approach not only proved feasible and effective but also established a sustainable platform for institutionalizing ECD within the public health system. It offers a pragmatic model that can be adopted and scaled nationally bridging gaps in workforce capacity, reducing inequities in access to early childhood services, and strengthening the continuum of care from households to health facilities.

From a policy perspective, integrating community-based ECD interventions into existing primary care structures supports the implementation of the Palestinian National ECD Strategy and contributes to broader efforts toward universal health coverage and child rights realization. Sustained investment in CHW capacity-building, supervision, and intersectoral coordination will be essential to ensure the long-term impact and resilience of this approach.

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Footnotes

Edited by: Silvia Perzolli, University of Trento, Italy

Reviewed by: Soraya Maart, University of Cape Town, South Africa

Rebecca Barbieri, University of Trento, Italy