Human resources and curricula content for early child development implementation: multicountry mixed methods evaluation

Using Implementation Research to Inform Scaling of Parenting Programs: Independently Conducted Case Studies from Zambia and Bhutan

Two case studies of parenting programs for parents of children 0 to 36 months of age, developed and implemented by Save the Children/Ministry of Health/Khesar Gyalpo University in Bhutan and UNICEF Zambia, were conducted by an independent research group. The focus was on how program delivery and scale-up were revised on the basis of feedback from implementation research. Feedback on workforce delivery quality was based on observations of deliveries using a monitoring form, as well as survey and interview data collected from the workforce. In-depth interviews with the resource team during the fourth year of implementation revealed how the feedback was used to address horizontal and vertical scaling. Delivery quality was improved in some cases by revising the delivery manual, offering refresher courses, and instituting regular monitoring. Scaling challenges in Zambia included slow progress with regard to reaching families in the two districts, which they addressed by trialing group sessions, and stemming workforce attrition. The challenges in Bhutan were low attendance and reducing the workload of providers. Vertical scaling challenges for both countries concerned maintaining demand through continuous advocacy at community and government levels to sustain financing and to show effectiveness in outcomes.

Scaling up a home-visiting program for child development in Brazil: a comparative case studies analysis

Background

In 2016, Brazil scaled up the Criança Feliz Program (PCF, from the acronym in Portuguese), making it one of the largest Early Childhood Development (ECD) programs worldwide. However, the PCF has not been able to achieve its intended impact. We aimed to identify barriers and facilitators to achieving the PCF implementation outcomes across the RE-AIM dimensions (Reach, Effectiveness or Efficacy, Adoption, Implementation and Maintenance) during the COVID-19 pandemic.

Methods

This comparative case study analysis selected five contrasting municipalities based on population size, region of the country, implementation model, and length of time implementing the PCF. We conducted 244 interviews with PCF municipal team (municipal managers, supervisors, home visitors), families, and cross-sectoral professionals. A rapid qualitative analysis was used to identify themes across RE-AIM dimensions.

Findings

Families' limited knowledge and trust in PCF goals were a barrier to its reach. While the perceived benefit of PCF on parenting skills and ECD enabled reach, the lack of referral protocols to address social needs, such as connecting food-insecure families to food resources, undermined effectiveness. Questions about whether the social assistance sector should be in charge of PCF challenged its adoption. Implementation barriers exacerbated by the COVID-19 pandemic included low salaries, temporary contracts, high turnover, infrequent supervision, lack of an effective monitoring system, and nonexistence or non-functioning multisectoral committees. The absence of institutionalized funding was a challenge for sustainability.

Interpretation

Complex intertwined system-level barriers may explain the unsuccessful implementation of PCF. These barriers must be addressed for Brazil to benefit from the enormous reach of the PCF and the evidence-based nurturing care principles it is based upon.

Funding

NIH/NICHD.

'Children awaken by playing': a qualitative exploration of caregivers' norms, beliefs and practices related to young children's learning and early childhood development in rural Burkina Faso

INTRODUCTION

Evidence suggests that responsive caregiving and early learning activities positively impact developmental outcomes, with positive effects throughout the life course. Early childhood development interventions should align with local values, beliefs and resources but there has been little research of caregiver beliefs and perspectives on development and learning, especially in sub-Saharan Africa. This qualitative study explored norms, beliefs, practices and aspirations around child development of caregivers of young children in rural Burkina Faso.

METHODS

We conducted 32 in-depth interviews with mothers and fathers of young children and 24 focus group discussions with mothers, fathers and grandmothers, which included trying behaviours and reporting on experiences. The research informed the development of Scaling Up Nurturing Care, a Radio Intervention to Stimulate Early Childhood Development (SUNRISE), an early child development radio intervention.

RESULTS

Caregivers described a process of 'awakening', through which children become aware of themselves and the world around them.Perceptions of the timing of awakening varied, but the ability to learn was thought to increase as children became older and more awake. Consequently, talking and playing with babies and younger children were perceived to have little developmental impact. Caregivers said children's interactions with them, alongside God-given intelligence, was believed to impact later behaviour and development. Caregivers felt their role in helping their children achieve later in life was to pay for education, save money, provide advice and be good role models. Interaction and learning activities were not specifically mentioned. Caregivers who trialled interaction and learning activities reported positive experiences for themselves and their child, but interactions were often caregiver led and directive and play was often physical. Key barriers to carrying out the behaviours were poverty and a lack of time.

CONCLUSIONS

Exploring early childhood beliefs and practices can reveal important sociocultural beliefs which, if incorporated into programme planning and implementation, could help achieve more impactful, acceptable and equitable programmes.

TRIAL REGISTRATION NUMBER

NCT05335395.

A Tale of Two Programs for Parents of Young Children: Independently-Conducted Case Studies of Workforce Contributions to Scale in Bhutan and Rwanda

Two case studies of parenting programs, aiming to improve parenting practices and child development outcomes, and implemented by Save the Children/Ministry of Health/Khesar Gyalpo University in Bhutan and Boston College/University of Rwanda/FXB in Rwanda, respectively called Prescription to Play and Sugira Muryango, were conducted by an independent research and learning group. Implementation research focused on the workforce, a crucial but little-studied element determining the success of programs going to scale. Mixed methods were used to examine their training, workload, challenges, and quality of delivery. Health assistants in Bhutan and volunteers in Rwanda were trained for 10-11 days using demonstrations, role plays, and manuals outlining activities to deliver to groups of parents (Bhutan) or during home visits (Rwanda). Workers' own assessments of their delivery quality, their confidence, and their motivations revealed that duty, confidence, and community respect were strong motivators. According to independent observations, the quality of their delivery was generally good, with an overall mean rating on 10 items of 2.36 (Bhutan) and 2.44 (Rwanda) out of 3. The facilitators of scaling for Bhutan included institutionalizing training and a knowledgeable workforce; the barrier was an overworked workforce. The facilitators of scaling for Rwanda included strong follow-up supervision; the barriers included high attrition among a volunteer workforce.

Pathways to scale up early childhood programs: A scoping review of Reach Up and Care for Child Development

Evidence-based early childhood development (ECD) programs that strengthen nurturing parenting skills and promote early stimulation, such as Reach Up (RU) and Care for Child Development (CCD), are critical investments for interrupting cycles of intergenerational poverty; however, the implementation impact of these programs varies greatly globally. Analyzing systematically the evidence on the implementation pathways based on contexts (i.e., external and internal influences on intervention implementation), implementation strategies (i.e., mechanisms used to promote program initiation, design, and delivery with existing systems), and implementation outcomes (i.e., related to the implementation goals) can increase the likelihood of implementation success. Our scoping review aimed to identify implementation pathways of RU and CCD programs in low- and middle-income countries. A search in English, Spanish, and Portuguese of grey literature and five databases of peer reviewed literature; from inception through July 16, 2022, yielded 2,267 publications. Using predetermined eligibility criteria, 75 records yielded implementation details for 33 programs across 23 low- and middle-income countries. Two reviewers independently extracted program data on context, implementation strategies, and implementation outcomes following a program theory. A thematic analysis identified 37 implementation strategies across six "building blocks of implementation": program emergence, intersectoriality, intervention characteristics, workforce, training, and monitoring systems. Implementation pathways across building blocks are highly influenced by contextual factors, such as infrastructure, social norms, and the target population's demand and interest, which may shape different implementation outcomes. Six 'building blocks' shaping implementation pathways of CCD and RU in LMICs were identified. The careful consideration of context and use of intentional evidence-based planning can enable the successful implementation of ECD nurturing care interventions. We recommend the use of the ECD Implementation Checklist for Enabling Program Scale Up to guide decision-making regarding context and implementation strategies to support implementation outcomes and subsequent ECD program success.

Early care and support for young children with developmental disabilities and their caregivers in Uganda: The Baby Ubuntu feasibility trial

Background

Early care and support provision for young children with developmental disabilities is frequently lacking, yet has potential to improve child and family outcomes, and is crucial for promoting access to healthcare and early education. We evaluated the feasibility, acceptability, early evidence of impact and provider costs of the Baby Ubuntu participatory, peer-facilitated, group program for young children with developmental disabilities and their caregivers in Uganda.

Materials and methods

A feasibility trial, with two parallel groups, compared Baby Ubuntu with standard care. Caregivers and children, aged 6-11 months with moderate-severe neurodevelopmental impairment, were recruited and followed for 12 months. Quantitative and qualitative methods captured information on feasibility (ability to recruit), acceptability (satisfactory attendance), preliminary evidence of impact (family quality of life) and provider costs.

Results

One hundred twenty-six infants (median developmental quotient, 28.7) were recruited and randomized (63 per arm) over 9 months, demonstrating feasibility; 101 (80%) completed the 12-month follow-up assessment (9 died, 12 were lost to follow up, 4 withdrew). Of 63 randomized to the intervention, 59 survived (93%); of these, 51 (86%) attended ≥6 modules meeting acceptability criteria, and 49 (83%) completed the 12 month follow-up assessment. Qualitatively, Baby Ubuntu was feasible and acceptable to caregivers and facilitators. Enabling factors included community sensitization by local champions, positive and caring attitudes of facilitators toward children with disability, peer support, and the participatory approach to learning. Among 101 (86%) surviving children seen at 12 months, mixed methods evaluation provided qualitative evidence of impact on family knowledge, skills, and attitudes, however impact on a scored family quality of life tool was inconclusive. Barriers included stigma and exclusion, poverty, and the need to manage expectations around the child's progress. Total provider cost for delivering the program per participant was USD 232.

Conclusion

A pilot feasibility trial of the Baby Ubuntu program found it to be feasible and acceptable to children, caregivers and healthcare workers in Uganda. A mixed methods evaluation provided rich programmatic learning including qualitative, but not quantitative, evidence of impact. The cost estimate represents a feasible intervention for this vulnerable group, encouraging financial sustainability at scale.

Clinical trial registration

[https://doi.org/10.1186/ISRCTN44380971], identifier [ISRCTN44380971].

Parental Practices and Environmental Differences among Infants Living in Upper-Middle and High-Income Countries: A Cross-Sectional Study

Parental practices and environmental factors can impact a child's development and, consequently, functionality. The objective is to assess the parental practices and environmental differences in healthy and at-risk infants at 3-6 months of age living in upper-middle (Brazil) and high-income (Italy) countries. A total group of 115 infants was identified and classified into four groups: healthy Italian infants (H_IT); Italian infants exposed to biological risk factors (R_IT); healthy Brazilian infants (H_BR); and Brazilian infants exposed to environmental risk factors (L_BR). The dependent variables were parental practices and environmental factors, which were assessed through a semi-structured interview and the "variety of stimulation dimension" from the Affordances in the Home Environment for Motor Development-Infant Scale (AHEMD-IS) questionnaire. Descriptive analyses, a multivariate analysis of variance (MANOVA), and correlation tests were applied. Regarding the environment and parental practices, the mother's age, maternal and paternal education, civil status, and variety of stimulation showed significant differences among the infants living in Brazil or in Italy. There were strong dissimilarities in parental practices and environmental factors among infants living in low/upper-middle and high-income countries. Since the home environment is the main stimulus for infant growth and development, our results are meaningful for providing knowledge about these two different cultures.

Early detection and intervention for young children with early developmental disabilities in Western Uganda: a mixed-methods evaluation

BACKGROUND

Early support for children with developmental disabilities is crucial but frequently unavailable in low-resource settings. We conducted a mixed-methods evaluation to assess the feasibility, acceptability, and impact of a programme of early detection and intervention for young children with developmental disabilities in Western Uganda.

METHODS

Early child development training for healthcare workers (HCWs) was implemented in three rural districts, and attendance was tracked. HCW knowledge and confidence were assessed pre-/post-intervention, and referral numbers tracked to evaluate impact. Facilitators were trained and mentored to deliver a participatory, group, early intervention programme (EIP) for young children with developmental disabilities and their families. Facilitators were tracked as they were identified, trained, and delivered the intervention, and attendance of families was tracked. Pre-/post-intervention assessments evaluated changes in family quality of life (PedsQL 2.0, Family Impact Module), and child nutritional outcomes. Focus group discussions with stakeholders also assessed feasibility, acceptability and impact.

RESULTS

Overall, 93 HCWs from 45 healthcare facilities received training. In the pre-/post-evaluation, median knowledge and confidence scores increased significantly (from 4.0 to 7.0 and from 2.7 to 4.7, respectively (p < 0.001)). HCWs reported feeling empowered to refer and offer care for families with a young child with disability. Referral rates increased significantly from 148 to 251 per annum (70%; p = 0.03). Eleven EIP facilitators were trained, and all delivered the intervention; 84 families were enrolled, of which 78% attended at least 6 out of 10 modules. Amongst those with paired pre-/post-intervention data (n = 48), total family quality of life scores increased significantly (21%, p < 0.001). Improvements were seen across all domains of quality of life, with the largest impacts on emotional functioning and social functioning (p < 0.001). The programme was acceptable to caregivers and facilitators. Caregivers reported improved knowledge, family relationships, hope, emotional wellbeing, and reduced self-stigma.

CONCLUSIONS

A programme of early detection and intervention for children with early developmental disabilities and their families was feasible and acceptable in a rural community-based Ugandan setting. HCW training positively impacted knowledge, confidence, attitudes, and referral rates. Families enrolled to the EIP reported significant improvements in quality of life. Important programmatic barriers identified included geographical spread, poverty, gender inequality, and stigma.

Teaching home-visitors to support responsive caregiving: A cluster randomized controlled trial of an online professional development program in Brazil

Background

Home-visiting programs are a common and effective public health approach to promoting parent and child well-being, including in low- and middle-income countries. The World Health Organization and UNICEF have identified responsive caregiving as one key component of the nurturing care children need to survive and thrive. Nonetheless, the importance of responsive caregiving and how to coach it is often overlooked in trainings for staff in home-visiting programs.

Methods

To determine whether it is possible to enhance home-visitors’ understanding of responsive caregiving and how to coach it, we conducted a cluster randomized controlled trial with 181 staff working in Brazil’s national home-visiting program. We used a computerized random number generator to randomly assign half of participants to take an online professional development course about responsive caregiving immediately and the other half to a waitlist. Individuals assessing outcome data were blind to group assignment.

Results

Compared to those in the control group (N = 90, both randomized and analyzed), participants assigned to take the course (N = 91, both randomized and analyzed) were more knowledgeable about responsivity (Cohen’s d = 0.64, 95% Confidence Interval (CI) = 0.34, 0.94) and its importance for children’s socioemotional (odds ratio (OR) = 1.88, 95% CI = 1.00, 3.50) and cognitive (OR = 2.57, 95% CI = 1.15, 5.71) development, better able to identify responsive parental behaviors in videotaped interactions (d = 1.86, 95% CI = 1.51, 2.21), and suggested more effective strategies for coaching parents on responsivity (d = 0.51, 95% CI = 0.21, 0.80) and tracking goal implementation (OR = 3.20, 95% CI = 1.28, 7.99). There were no significant changes in participants’ tendency to encourage goal setting and reflection, or their perspective-taking skills. Participants were very satisfied with the course content and mode of delivery and there was no drop-out from the program.

Conclusions

A short, online professional development program created moderate to large improvements in home-visitors’ knowledge and intended coaching practices. This suggests that such programs are feasible, even in low-income and rural areas, and provide a low-cost, scalable option for possibly maximizing the impact of home-visiting programs – particularly with regard to parental responsivity, and in turn, child outcomes.

Providing Services for Children With Developmental Difficulties, Delay or Disability — Early Diagnosis and Interventions at the Community Level

This paper describes two programs using the recommended tiered approach — World Health Organization’s (WHO) Nurturing Care Framework (NCF), viz., Early Childhood Champions (ECC) program and Child Development Aide (CDA) program delivered by Ummeed Child Development Center, a non-governmental organization in Mumbai. The ECC program builds capacity in community health workers (CHWs) employed by community based organizations in urban, semi-urban and rural areas to deliver the responsive caregiving and early learning components of WHO-NCF framework to all children (universal services) and those with or at risk for disabilities (targeted and indicated services). The CDA program trains CHWs to become disability workers in communities where rehabilitation services are scarce or nonexistent. ECC and CDA programs integrate ECD services into the existing work of established CHWs in the communities and have preliminary evidence of reach, effectiveness and acceptability. Till date, the 145 CHWs trained by the ECC program have reached 7073 children, of whom 835 (7.4%) have been identified with developmental delays. The ECC program meets the well-recognized need for training packages on responsive caregiving and early learning components of WHO NCF framework.

An Implementation Evaluation of A Group-Based Parenting Intervention to Promote Early Childhood Development in Rural Kenya

Early childhood development (ECD) parenting interventions can improve child developmental outcomes in low-resource settings, but information about their implementation lags far behind evidence of their effectiveness, hindering their generalizability. This study presents results from an implementation evaluation of Msingi Bora ("Good Foundation" in Swahili), a group-based responsive stimulation and nutrition education intervention recently tested in a cluster randomized controlled trial across 60 villages in rural western Kenya. Msingi Bora successfully improved child cognitive, receptive language, and socioemotional outcomes, as well as parenting practices. We conducted a mixed methods implementation evaluation of the Msingi Bora trial between April 2018 and November 2019 following the Consolidated Advice for Reporting ECD implementation research (CARE) guidelines. We collected qualitative and quantitative data on program inputs, outputs, and outcomes, with a view to examining how aspects of the program's implementation, such as program acceptance and delivery fidelity, related to observed program impacts on parents and children. We found that study areas had initially very low levels of familiarity or knowledge of ECD among parents, community delivery agents, and even supervisory staff from our partner non-governmental organization (NGO). We increased training and supervision in response, and provided a structured manual to enable local delivery agents to successfully lead the sessions. There was a high level of parental compliance, with median attendance of 13 out of 16 fortnightly sessions over 8 months. For delivery agents, all measures of delivery performance and fidelity increased with program experience. Older, more knowledable delivery agents were associated with larger impacts on parental stimulation and child outcomes, and delivery agents with higher fidelity scores were also related to improved parenting practices. We conclude that a group-based parenting intervention delivered by local delivery agents can improve multiple child and parent outcomes. An upfront investment in training local trainers and delivery agents, and regular supervision of delivery of a manualized program, appear key to our documented success. Our results represent a promising avenue for scaling similar interventions in low-resource rural settings to serve families in need of ECD programming. This trial is registered at ClinicalTrials.gov, NCT03548558, June 7, 2018. https://clinicaltrials.gov/ct2/show/NCT03548558.

Developmental Signs of Autism Spectrum Disorder in Iranian Pre-Schoolers

PURPOSE

Early identification and intervention is recommended for developmental disabilities such as autism spectrum disorders (ASD). Various screening tools are available, but most were developed in affluent English speaking countries.

DESIGN AND METHODS

In order to identify possible early signs of ASD within Iranian society, parents of 623 children in an age range from 3 to 7 years of age at risk of ASD, were interviewed about the signs that alerted their concerns. Also two screening instruments were developed and tested with the parents using items derived from the Gilliam Autism Rating Scale (GARS2). One focused on autistic behaviors and the second on developmental indicators.

RESULTS

Using both tools, 93% of the children who were identified as likely to have ASD based on a full GARS assessment were identified using the two screening tools.

PRACTICE IMPLICATIONS

These assessments might be used in initial screening for ASD by early year's personnel or public health professionals with Iranian parents of toddlers who have concerns about their child's development.

Scaling up of Brazil's Criança Feliz early childhood development program: an implementation science analysis

To address inequities that prevent socioeconomically vulnerable young children from reaching their full developmental potential, Brazil implemented Programa Criança Feliz (PCF) ("Happy Child" early childhood development program) in 2934 of its 5570 municipalities. A qualitative case study was carried out on the basis of in-depth interviews with 22 key informants, employing purposive sampling, from past or current national and state coordination teams. Thematic analysis followed the RE-AIM framework, and complex adaptive system constructs mapped how barriers and enablers influenced scale-up. One overarching theme related to PCF emergence, and 18 subthemes were identified within the RE-AIM. An enabling national political environment favored PCF emergence through a top-down approach that led to governance challenges. Changes in the enrollment criteria for families facilitated reach, and evidence-based methodology favored the designing of the home visits. However, operationalizing the intersectoral actions remains a barrier for effectiveness, while intrasectoral resistance across levels delayed adoption. WhatsApp facilitated networking, capacity building, and adoption. Rushed scale-up generated barriers for quality delivery and led to different implementation pathways across municipalities. Legal institutionalization is critical to assure permanent funding and maintenance. PCF has enhanced early childhood services in Brazil, but strong negative feedback loops need to be addressed for effective sustainability.