Socioeconomic inequalities in early child development in children aged under 36 months in South Asia: A systematic review

BACKGROUND

In South Asia, 89 million children under 5 are at risk of not reaching their developmental potential. Household socioeconomic position (SEP) is a determinant of early child development (ECD). However, synthesised evidence for the association between ECD and SEP in young children in South Asia is not available. Therefore, this review synthesises evidence on the relationship of household SEP with ECD in children under 36 months of age in South Asia.

METHOD

PubMed, Cochrane Library, MEDLINE and Scopus were systematically searched to identify studies from South Asian countries that reported evidence on the association between SEP and ECD. Search terms included items related to motor, cognitive, language and socioemotional development. Study quality was assessed using the QualSyst tool, with three quality levels (high/medium/low), and a narrative review for each ECD outcome was constructed (PROSPERO registration: CRD42019131533).

RESULTS

Twelve of the 950 publications screened met the inclusion criteria (nine from India, two Nepal and one Bangladesh). The majority (n = 10, 83%) reported language development on its own or alongside another ECD outcome. Fewer articles assessed cognitive (n = 6, 50%), motor (n = 7, 58%) or socioemotional development (n = 3, 25%). Higher SEP was associated with better ECD for one third of the associations reported. One ECD outcome (socioemotional development) was negatively associated (with socioeconomic status) based on low quality evidence. Mother's education and family income were the major SEP constructs associated with ECD. One, four and seven studies were rated as having a low, medium and high risk of bias, respectively.

CONCLUSION

This review reveals the scarcity of evidence exploring associations between household SEP and ECD in children under 36 months in South Asia, especially outside of India. Enhancing evidence for associations between ECD and SEP is needed for evidence-based policy making to reduce developmental delays associated with a disadvantaged SEP in the South Asian region.

Stunting, maternal investment, and early child development in Serbian Roma children aged 36-59 months

Stunting has shown negative associations with poor child developmental indicators. However, in poor ethnic minority populations the evidence for associations of anthropometric growth indicators and child development is limited. This study examined associations between stunting, height for age z scores (HAZ) and other determinants, with Early Child Development (ECD) among children in poor Roma communities. Publicly available data from Multiple Indicator Cluster Surveys for Serbian Roma settlements were used to assess a cohort of 1075 Roma children aged 36-59 months. Indicators of child growth and nutrition included children?s HAZ scores and stunting. ECD assessed physical, learning/cognition, literacy/numeracy and socio-emotional developmental domains. Multiple regressions were used to assess the association between HAZ and stunting with ECD, controlling for maternal and child confounders. Sum score for ECD in Roma children was low, and 18% of children were stunted. After adjusting for potential confounders, HAZ and stunting revealed no significant associations with developmental outcomes. Instead, increasing maternal investment was positively associated with overall ECD score and higher scores in each of the individual developmental domains, except socio-emotional. In a low-resource setting, maternal investment appeared a good predictor of child development: it may buffer against the effects of poverty and stimulate child development.

Development, feasibility and acceptability of a gamified cognitive DEvelopmental assessment on an E-Platform (DEEP) in rural Indian pre-schoolers - a pilot study

Background: Assessment of cognitive development is essential to identify children with faltering developmental attainment and monitor the impact of interventions. A key barrier to achieving these goals is the lack of standardized, scalable tools to assess cognitive abilities.

Objective: This study aimed to develop a tablet-based gamified assessment of cognitive abilities of 3-year-old children which can be administered by non-specialist field workers.

Methods: Workshops among domain experts, literature search for established and gamified paradigms of cognitive assessments and rapid review of mobile games for 3-year-old children was done to conceptualize games for this study. Formative household visits (N = 20) informed the design and content of the games. A cross-sectional pilot study (N = 100) was done to assess feasibility of the tool and check if increasing levels of difficulty and the expected variability between children were evident in game metrics. In-depth interviews (N = 9) were conducted with mothers of participating children to assess its acceptability.

Results: Six cognitive domains were identified as being integral to learning – divided attention, response inhibition, reasoning, visual form perception and integration and memory. A narrative, musical soundtrack and positive reinforcement were incorporated into the tool to enhance participant engagement. Child performance determined level timers and difficulty levels in each game. Pilot data indicate that children differ in their performance profile on the tool as measured by the number of game levels played and their accuracy and completion time indicating that it might be possible to differentiate children based on these metrics. Qualitative data suggest high levels of acceptability of the tool amongst participants.

Conclusions: A DEvelopmental assessment on an E-Platform (DEEP) has been created comprising distinct games woven into a narrative, which assess six cognitive domains, and shows high levels of acceptability and generates metrics which may be used for validation against gold standard cognitive assessments.

Mechanisms linking height to early child development among infants and preschoolers in rural India

Stunting has been negatively associated with children's development. We examined the range of height by testing hypotheses: (a) height is positively associated with children's development, with associations moderated by inflammation and (b) home environments characterized by nurturance and early learning opportunities is positively associated with children's development over time and attenuate associations with height. Data included 513 infants (mean age 8.6 months) and 316 preschoolers (mean age 36.6 months) in rural India from a randomized controlled trial of multiple micronutrient powders (MNPs). Measures included height (height-for-age z-scores based on WHO standards), inflammation (C-reactive protein concentration >5 mg/L), nurturance (HOME Inventory), child development (Mullens Scales of Early Learning), and inhibitory control (preschoolers). Linear mixed effects models accounting for repeated measures, clustering, and confounders were used to assess associations between height and child development over time (infants: enrollment, 6 and 12 months; preschoolers: enrollment and 8 months). Moderating effects of inflammation and nurturance were tested with interaction terms. Among infants and preschoolers, height and nurturance were positively associated with all domains of child development over time, with the exception of inhibitory control. Among preschoolers, in the presence of inflammation, height was not associated with child development. Among infants, but not preschoolers, a nurturant home environment attenuated significant associations between height with fine motor and receptive language development. The mechanisms associated with children's development over time are multifactorial and include direct and indirect associations among nutrition, health, and the home environment, as supported by the Nurturing Care Framework.

More than poverty

Studies from both high and low-middle income (LAMI) countries have documented how being reared in poverty is linked to compromised child development. Links between poverty and development are mediated by the timing and extent of exposure to both risk factors nested under poverty and to protective influences which can attenuate the impact of risk. While children from high-, middle-, and low-income countries are exposed to similar types of developmental risks, children from low- and middle-income countries are exposed to a greater number, more varied and more intense risks. Given these contextual differences, cumulative risk models may provide a better fit than mediated models for understanding the nature of pathways linking economic insufficiency and developmental inequality in low- and middle-income countries, and for designing interventions to promote development of children from these countries. New evidence from a large scale UNICEF data set illustrates the application of a cumulative risk/protective perspective in low- and middle-income countries.

Introduction to the special section on pathways underlying the impact of economic inequality on children’s development

A special section of the International Journal of Behavioral Development devoted to the topic of pathways underlying the impact of economic inequality on children’s development.