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The contribution of grandmother involvement to child growth and development: an observational study in rural Pakistan
  1. Esther O Chung1,2,
  2. Ashley Hagaman2,3,4,
  3. Katherine LeMasters1,2,
  4. Nafeesa Andrabi2,5,
  5. Victoria Baranov6,
  6. Lisa M Bates7,
  7. John A Gallis8,9,
  8. Karen O'Donnell8,10,
  9. Atif Rahman11,
  10. Siham Sikander12,13,
  11. Elizabeth L Turner8,9,
  12. Joanna Maselko1,2
  1. 1Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  2. 2Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  3. 3Department of Social and Behavioral Sciences, Yale University, New Haven, Connecticut, USA
  4. 4Center for Methods in Implementation and Prevention Science, Yale University, New Haven, CT, United States
  5. 5Department of Sociology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  6. 6Department of Economics, The University of Melbourne, Melbourne, Victoria, Australia
  7. 7Department of Epidemiology, Columbia University, New York, New York, USA
  8. 8Duke Global Health Institute, Duke University, Durham, North Carolina, USA
  9. 9Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
  10. 10Center for Child and Family Health, Durham, North Carolina, USA
  11. 11Department of Primary Care and Mental Health, University of Liverpool, Liverpool, Merseyside, UK
  12. 12Human Development Foundation Pakistan, Islamabad, Pakistan
  13. 13Health Services Academy, Islamabad, Pakistan
  1. Correspondence to Esther O Chung; echung{at}


Introduction Early childhood interventions primarily focus on the mother–child relationship, but grandmothers are often critical in childcare in low-resource settings. Prior research is mixed on how grandmother involvement influences child outcomes and there is a paucity of research on grandmother caregiving in low-income and middle-income countries. We examined the role of grandmother involvement on child growth and development in the first 2 years of life cross sectionally and longitudinally in rural Pakistan.

Methods We used data from the Bachpan Cohort, a longitudinal birth cohort in rural Pakistan. Maternally reported grandmother involvement in daily instrumental and non-instrumental caregiving was collected at 3 and 12 months. A summed score was created and categorised into non-involved, low and high. Outcomes included 12-month and 24-month child growth, 12-month Bayley Scales of Infant and Toddler Development and 24-month Ages and Stages Questionnaire—Socioemotional. We used multivariable generalised linear models to estimate mean differences (MD) at 12 months (n=727) and 24 months (n=712). Inverse probability weighting was used to account for missingness and sampling.

Results In our sample, 68% of children lived with a grandmother, and most grandmothers were involved in caregiving. Greater 3-month grandmother involvement was positively associated with 12-month weight z-scores; however, greater involvement was associated with lower 24-month weight z-scores. High 12-month grandmother involvement was associated with improved 12-month cognitive (MD=0.38, 95% CI −0.01 to 0.76), fine motor skills (MD=0.45, 95% CI 0.08 to 0.83) and 24-month socioemotional development (MD=−17.83, 95% CI −31.47 to –4.19). No meaningful associations were found for length z-scores or language development.

Conclusion In rural Pakistan, grandmothers provide caregiving that influences early child development. Our findings highlight the complex relationship between grandmother involvement and child weight, and suggest that grandmothers may positively promote early child cognitive, fine motor and socioemotional development. Understanding how grandmother involvement affects child outcomes in early life is necessary to inform caregiving interventions.

  • child health
  • nutrition
  • public Health
  • Cohort study

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  • Handling editor Stephanie M Topp

  • Contributors EOC conceptualised the research question, analysed the data, interpreted results, drafted the initial manuscript and reviewed and revised the manuscript. AH, KL, NA and JM assisted in the analytic study design, interpretations of results and reviewed and revised the manuscript. KO, AH, SS and JM developed the grandmother involvement measure. VB, LMB, JG, KO, AR, SS, ELT and JM designed the Bachpan cohort study, contributed to the interpretation of results and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

  • Funding The Bachpan cohort study was supported by NICHD (R01 HD075875) and NIMH (U19MH95687). The authors are grateful to the Carolina Population Center for training support (T32HD007168) and for general support (P2C HD050924).

  • Disclaimer The funders had no role in study design, data collection, analysis, interpretation of results or writing of the report. The authors had access to all the data and had full responsibility to submit for publication.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by institutional review boards at the Human Development Research Foundation, the University of North Carolina at Chapel Hill and Duke University. Written informed consent (or witnessed consent, if the participant was illiterate) was obtained from mothers before study participation.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request from the senior author, Joanna Maselko. Data are not publicly available due to ongoing data collection; however, data will be released when the Bachpan cohort study is completed.