Jamii ni Afya: Improving early child development through a digital CHV program in Zanzibar: evidence from a quasi-experimental study.

Background Nearly half of children under age five fail to reach their developmental potential in low- and middle-income countries (LMICs). These experiences in early life impact a child’s health, development, and economic productivity throughout their lifetime, making early childhood development (ECD) a critical investment area globally. Many countries are extending the role of community health programs to include a focus on ECD, showing promising results, positively impacting responsive caregiving, early learning, and overall safety in the home. In Zanzibar, implementation of a national, digitally supported community health program, Jamii ni Afya, promoted improvements in caregiving practices, the home environment, early childhood development, and child health and nutrition. This study presents findings from a quasi-experimental evaluation of Jamii ni Afya’s impact on child health, development, the home environment and parenting practices, comparing panels from a baseline (2019) and follow-up survey (2023) conducted after program implementation. Results After adjusting for key confounders, small but significant improvements were found in children's overall development scores as measured by the Caregiver Reported Early Childhood Developmental Index (CREDI) (Mean score difference 0.591, p < 0.001) as well as in all specific (motor, cognitive, linguistic, and socio-emotional) CREDI domains. Caregivers in the follow-up survey provided a more stimulating home environment, with increased availability of books (Adjusted OR 3.733 p < 0.001), homemade toys (Adjusted OR 1.643 p < .001), greater paternal engagement, play activities (Adjusted OR 11.148 p < .001)) and lower levels of harsh physical or verbal discipline (Adjusted OR 2.912 p < .001). Additionally, caregiver knowledge related to child health and nutrition improved. Changes in care-seeking behaviors, immunization rates, and nutritional status did not reach statistical significance, likely due to high baseline levels or limited sensitivity of these indicators. Overall, these results suggest Jamii ni Afya positively impacted child development outcomes and caregiver knowledge and behaviors, highlighting continued opportunities to enhance early childhood care in Zanzibar. Conclusions Implementation of a nationally scaled digitally supported community health program promoting health, nutrition and early childhood development in Zanzibar was associated with improvements in caregiver knowledge, practices, and child developmental outcomes. National ECD strategies should consider integrating digital solutions to expand scope, scale and impact on child health and development. Further studies should explore optimizing digital ECD delivery in community health and also conduct further analysis to evaluate the impact of the individual components of the nurturing care framework services (health, nutrition, early learning, responsive care, and safety and security) on health and ECD outcomes.