Four lessons from using a growth measurement tool for early childhood development in Indonesia

Stunting, defined as having a substantial below-average height for one’s age, indicates a significant risk to a child's physical and developmental potential. Affecting 21.6 percent of Indonesian children, stunting can impair learning, hinder cognitive and physical growth, and negatively impact overall well-being. A study by Fink and Rockers (2014) has linked stunting to delayed school enrollment and reduced educational attainment and performance. Addressing stunting is crucial for increasing children’s development and future economic potential, making it a priority for the Indonesian government. The government aims to reduce stunting prevalence to 14 percent by 2024, but achieving this target has been challenging.

To explore practical and effective strategies for addressing stunting in Indonesia, J-PAL Southeast Asia (SEA) collaborated with J-PAL invited researchers and coauthors to initiate a study evaluating the potential impact of home-based growth charts on children’s growth and development in East Nusa Tenggara, Indonesia. With support from J-PAL SEA, the study is led by invited researchers Peter Rockers (Boston University) and Gumilang Aryo Sahadewo (Gadjah Mada University), alongside coauthors Günther Fink (Swiss TPH, University of Basel), Milda Irhamni (University of Indonesia), and Doug Parkerson (Innovations for Poverty Action).

Growth charts help caregivers monitor their child's growth with essential nutrition messages and a height measurement section featuring color-coded zones for age-appropriate height. Previously, a similar study in Zambia showed that these positively impacted children’s development across cognitive, motor, language, and social-emotional domains.

The research team used the Global Scales for Early Development (GSED), a children’s development measurement tool newly developed by the World Health Organization (WHO) in early 2023. The GSED allows a comprehensive assessment of young children's development up to 36 months of age, assessing cognitive, socio-emotional, language, and motor skills across diverse communities and cultures. It provides a developmental score (D-score), a new standard unit for measuring development. The GSED aims to deliver a reliable and valid population-level measurement of early childhood development and seeks to serve as a globally applicable tool comparable to existing stunting measures, such as Height-for-Age Z-scores and Weight-for-Age Z-scores. Having been tested in  Bangladesh, Pakistan, and Tanzania, our study is one of the first, if not the first, to use GSED in Indonesia, offering a unique opportunity to gather valuable insights specific to this context.

In July 2024, the J-PAL SEA team conducted field visits in East Manggarai, East Nusa Tenggara, to implement the GSED tools as part of the project’s end-line survey. These visits revealed critical learnings on the opportunities and challenges of using the tools to interact with children.

1. Build trust with children during the assessment

A key challenge when assessing young children is their unfamiliarity with the assessor—a new adult in their environment—which can affect their level of comfort and engagement. To help children feel safe and at ease, assessors were encouraged to introduce themselves early and interact directly with the child. While incentives like stickers or snacks are not part of the study protocol, if offered voluntarily by the assessor, they should be given carefully and only at the end of the assessment to avoid influencing the child’s responses and performance.
 

Using existing GSED props can also help make children more comfortable participating in the assessment. For instance, if a child is too shy to engage verbally in the language and communication section of the assessment, assessors can start with a different section, such as physical tasks or activities involving toys (e.g., blocks, cars, or balls). Beginning with fun, interactive tasks can help break the ice and create a more relaxed environment.

Positive reinforcements also play an essential role for children during the assessment. Most children respond positively to verbal praise or simple gestures like clapping or high-fives. These encouragements boost a child’s confidence and foster a connection with the assessor. The timing of the assessment is also crucial. While we may not have the luxury of time to schedule assessments, it is recommended that assessors consider the child's routine and seek caregiver input to avoid scheduling during nap time and minimize disruptions. 

2. Develop clear and adaptable field protocols

Children’s responses during assessments can vary widely based on factors like their personality, health, and current mood—making it challenging to maintain consistency. While the WHO provides a user manual, developing an additional field protocol tailored to the specific study conditions was essential. For instance, it can be challenging to determine if a child cannot perform a task or is simply tired. Therefore, defining clear guidelines for recognizing a child’s engagement level and deciding on the next steps helps ensure standardization. Having protocols for handling unexpected issues—such as a child becoming uncomfortable, hungry, fussy, or distracted—is also advisable to ensure that assessors respond consistently. 

Additionally, time limits for each task should be set, and a course of action should be established when a child is unresponsive. Given that GSED assessments can take several hours, having specific rules for rescheduling or revisits is essential. We determined a reasonable number of revisits to balance time efficiency with the child’s comfort. Establishing the criteria prevents unnecessary discomfort for all involved—the assessor, the caregiver, and the child.

In our experience, caregivers often provided subtle assistance during assessments, such as signaling, pointing, or whispering. Additionally, the novelty of GSED activities in local settings often attracted crowds, including siblings, cousins, neighbors, and other family members. This created a distracting and sometimes uncomfortable environment for both the child and the assessor, often prolonging sessions or causing the child to disengage, leading to incomplete assessments.

We established clear caregiver involvement and crowd control guidelines to address these challenges. Initially, caregivers’ participation was limited to offering comfort or encouragement, which was consistent with the original GSED protocol by the WHO. However, the challenges in the field required adaptations, particularly addressing the language barrier between assessors and children. To facilitate assessments, caregivers could assist with translations—such as interpreting tasks into the local language or relaying the child’s responses—provided the task’s guidelines remained unchanged. For instance, in tasks that require children to identify primary colors, the Manggarai language does not distinguish between "green" and "blue," treating them as the same color. In such cases, clarification from the caregiver is necessary.

3. Incorporate local contexts in child assessments

Our observations in the field have shown that children’s responses can be heavily shaped by their local environment and daily experiences. For instance, when asked, “What do you do when you're feeling cold?” children in East Nusa Tenggara often reply, “Drink coffee,” reflecting the standard practice seen in their households. Although this may not match our typical expectations, it accurately represents the child’s lived experience, as confirmed by their caregivers. To provide some context, many villages in East Nusa Tenggara are coffee-producing communities. As a result, drinking coffee is a widespread cultural practice that is introduced to children at an early age. In this sense, coffee serves a similar purpose to tea on a cold day for warmth. Therefore, it is essential to consider the cultural context when interpreting children's responses. Conducting pilot tests and field practices can help identify necessary adjustments, making the assessment process more culturally sensitive and appropriate.

4. Ensure assessors’ skills are standardized 

Standardizing assessors’ skills in using GSED presented a significant challenge, as not all assessors are naturally adept at engaging with or handling toddlers. This was further compounded by the extensive nature of GSED measures, which require assessors to be attentive, adaptable, and precise during assessments. To address this, training sessions, field practices, and pilot tests were essential to equip assessors with the necessary skills and simulate real-world conditions. In addition to these efforts, we found it crucial to provide close supervision during field implementation to ensure adherence to established standards and protocols. Therefore, monitoring mechanisms, such as spot-checks, back-checks, and high-frequency checks, were necessary to maintain data accuracy and consistency. These mechanisms also served as a feedback loop to identify irregularities in the data or deviations from our protocols, allowing for timely interventions and targeted retraining to standardize assessors’ skills further.

Looking ahead

Assessing early childhood development allows for timely identification and intervention for developmental delays. GSED provides a promising approach by standardizing the evaluation of child development across diverse cultural contexts. This standardization is highly relevant, given the growing global interest in early childhood development. However, our fieldwork in Indonesia shows that implementing tools like the GSED requires careful adaptation to local contexts and the unique challenges of assessing young children. Following this activity, J-PAL invited researchers Peter Rockers and Gumilang Aryo Sahadewo, alongside coauthors Günther Fink, Milda Irhamni, and Doug Parkerson, are currently analyzing the data collected to inform future policies and interventions to reduce stunting and improve early childhood outcomes nationwide.