Global research priorities to accelerate programming to improve early childhood development in the sustainable development era: a CHNRI exercise

Research priorities for cardiometabolic syndrome in humanitarian settings: A global consensus-based agenda

Non-communicable diseases (NCDs) are a leading cause of global morbidity and mortality. The burden of NCDs largely falls on low- and middle- income countries, where the majority of humanitarian crises fall. Already fragile health care systems in acute and protracted crisis settings struggle to meet the increasing needs of people living with NCDs. Cardio-Metabolic Syndrome (CMS), in particular, is of growing concern, with little evidence on effectively managing cardiovascular disease care in emergency settings. A strategy that begins with identifying clear research priorities to inform a collective and integrated CMS care in humanitarian preparedness and response is needed. This study aimed to generate consensus-based research priorities for the humanitarian sector targeting CMS care. This was done by adopting an adapted approach of the Child Health and Nutrition Research Initiative (CHNRI). Our findings highlight the need to prioritize models of care, including processes and outcomes, for people living with CMS and NCDs in humanitarian settings. They also highlight the importance of adopting integrated, multidisciplinary approaches that address research, interventions, and policies involving local and international stakeholders. Sustainable approaches that facilitate continuity of care and ensure integration within existing health care systems are needed to adequately address the growing global burden of CMS and NCDs. The ranked priority questions from this research priority setting exercise serve as guidance for advocacy and the deployment of funds for future research, interventions, and policies.

Building a research agenda on preventing and addressing sexual assault and intimate partner violence against trans people: a two-stage priority-setting exercise

BACKGROUND

Transgender (trans) people experience high rates of sexual assault (SA) and intimate partner violence (IPV) and seldom receive the care and supports they need post-victimization. However, there is little to no research that aids in the development or improvement of related interventions. We undertook a study to build a novel Canadian research agenda on SA/IPV against trans people to guide future work and address these profound gaps in knowledge.

METHODS

Guided by the Child Health and Nutrition Research Initiative (CHNRI) method for research priority-setting, we developed and circulated two consecutive surveys to a multi-stakeholder group of government decision makers; mental health, health and social service providers, researchers and trans communities, among others, who proposed research questions related to preventing and addressing SA/IPV against trans persons. The initial survey launched March 2021 garnered responses from 213 stakeholders. These items were cleaned and collated into 20 final questions that fell within seven thematic areas. The refined research questions were evaluated in August 2021 on predefined criteria for answerability, feasibility, impact and equity by 79 of 95 survey 1 respondents who agreed to participate in the second survey (response rate = 83.2%). The questions were ranked using a research priority score calculated by dividing the sum of all the answers for each question across the four criteria by the number of answers received.

RESULTS

All questions were highly rated on each individual criterion and each had an overall research priority score of above 80%, with the most highly ranked question falling within the theme, "improving quality and implementation of education and training: How can training (e.g., for university/college students, educators, nurses, physicians, social workers, police, lawyers, security guards) be improved to better support trans survivors of sexual assault and intimate partner violence?".

CONCLUSIONS

These questions form Canada's first research agenda on SA/IPV against trans people. Together, they reflect the insights of stakeholder groups who have been historically excluded from research priority-setting processes and will guide future and much-needed work on the topic. Actionable information on preventing and addressing SA/IPV against trans persons will help reduce negative outcomes associated with being victimized.

Addressing barriers to global multidisciplinary stakeholder inclusivity: Lessons from global orofacial cleft research priority setting

Background

Inclusivity in research priority setting is fundamental to capturing the opinion of all stakeholders in a research area. Globally, experienced healthcare workers often have deep insights that could impactfully shape future research, and a lack of their involvement in formal research and publications could mean that their voices are insufficiently represented. We aimed to modify the well-established Child Health and Nutrition Research Initiative (CHNRI) methodology to address barriers to inclusivity, which are particularly relevant in healthcare that requires highly multidisciplinary care.

Methods

This global research priority-setting exercise for orofacial clefts adapted the CHNRI methodology to include research experts, clinicians from multiple disciplines, and non-technical stakeholders (i.e. patients and parents and non-governmental organisations (NGOs)) on a global basis. A multidisciplinary international steering group proposed and discussed methodological changes to improve inclusivity, including survey edits, subgroups for research questions, a demographics section, translation in French and Spanish, phrasing adaptation, and alternative dissemination techniques.

Results

We received 412 responses and 1420 questions, spanning 78 different countries and 18 different specialties/groups. Challenges remain to improve representation of all groups, with the vast majority of answers (30%) being from surgeons and a comparatively small proportion from patient/parent groups (9%). This also includes managing responses in three languages, effective dissemination, and responses that were not worded as research questions.

Conclusions

This is one of the first CHNRI exercises to involve patients and parents, clinicians, and researchers in its first question submission stage, and the first ever to do so on a global scale. We describe our approach to addressing inclusivity challenges and report related demographic data to serve as a benchmark upon which we hope future CHNRI exercises will improve.

Neurological examination of healthy term infants at ages 6 and 10 weeks in Tshwane District

Background

Globally, there is a significant gap in detailed neurodevelopmental data for infants under 3 months, despite 6 weeks being identified a critical milestone for neuro-behavioural development. Normative values and optimal scores for healthy infants at 6 and 10 weeks postnatally are lacking in many settings. In South Africa, the statutory neurodevelopmental assessments at these ages exclude notable characteristics of central nervous system maturation and limit opportunities to collect data of early developmental progress.

Objectives

Our study aimed to assess developmental characteristics of healthy term infants aged 6 and 10 weeks using the Hammersmith Neonatal Neurological Examination (HNNE).

Method

A prospective longitudinal study was performed on 35 healthy term-born infants from low-risk pregnancies at 6 and 10 weeks' postnatal age in the Tshwane district. The statuses of infants' neurodevelopment in six domains were recorded using the HNNE. Optimality scores were derived from the raw scores of 34 items, using the 10th and 5th percentiles as cut-off points.

Results

Evidences of neurodevelopmental advancements, particularly in posture, muscle tone and visual behaviour between 6 and 10 weeks were illustrated, and total examination optimality scores of 29.5 in 91% and 31.5 in 94% of infants were recorded at 6 and 10 weeks, respectively.

Conclusion

This article provides data on the neurodevelopment characteristics of infants at and between 6- and 10-weeks post term ages.

Clinical Implications

The findings support the viewpoint to identify important milestone characteristics during early screening.

Effects of Two Early Parenting Programmes on Child Aggression and Risk for Violence in Brazil: a Randomised Controlled Trial

Violence is a major public health problem globally, with the highest rates in low- and middle-income countries (LMICs) in the Americas and southern Africa. Parenting programmes in high-income countries can diminish risk for violence, by reducing risk factors such as child aggression and harsh parenting, and increasing protective factors such as child cognitive development and school readiness. However, there is critical need to identify low-cost programmes with replicable benefits that work in real-world LMICs contexts. A three-arm, randomised, single-blind trial evaluated effects of two low-cost, group-based parenting programmes recommended for LMICs (ACT: Raising Safe Kids; DBS: dialogic book-sharing) on child aggression (primary outcome), child development, parenting, maltreatment, and stress. Participants were 369 children with medium-high levels of aggression (mean age 3.1 years at baseline) in poor households. Interventions were implemented in city health and education services in southern Brazil. Maternal reports, filmed observations, child tasks, and hair cortisol were assessed at baseline, 1-month post-intervention, and 8-month follow-up. Intention-to-treat analyses compared each of ACT and DBS with a control group. Three hundred sixty-eight (99.7%) participants completed follow-up assessments 8 months after the interventions. There was no effect of ACT (standardised mean difference, SMD 0.11, 95% CI - 0.05, 0.27) or DBS (SMD 0.05, 95% CI - 0.11, 0.21) on the primary outcome of child aggression. ACT reduced harsh parenting behaviour post-intervention (SMD - 0.23; 95% CI - 0.46, - 0.01), but not at follow-up. DBS improved book-sharing practices at both time points (e.g., maternal sensitivity at follow-up SMD 0.33; 95% CI 0.08, 0.57). There were no benefits of either programme for other parenting, child development, or stress outcomes. Two parenting programmes in Brazil had small effects on parenting practices but did not reduce child aggression or several other important risk/protective factors for violence. Effective early interventions that reduce violence in real-world LMIC settings are highly desirable but may be challenging to achieve.

Can home visits for early child development be implemented with sufficient coverage and quality at scale? Evidence from the SPRING program in India and Pakistan

Introduction

There is limited evidence from low and middle-income settings on the effectiveness of early child development interventions at scale. To bridge this knowledge-gap we implemented the SPRING home visiting program where we tested integrating home visits into an existing government program (Pakistan) and employing a new cadre of intervention workers (India). We report the findings of the process evaluation which aimed to understand implementation.

Methods and materials

We collected qualitative data on acceptability and barriers and facilitators for change through 24 in-depth interviews with mothers; eight focus group discussions with mothers, 12 with grandmothers, and 12 with fathers; and 12 focus group discussions and five in-depth interviews with the community-based agents and their supervisors.

Results

Implementation was sub-optimal in both settings. In Pakistan issues were low field-supervision coverage and poor visit quality related to issues scheduling supervision, a lack of skill development, high workloads and competing priorities. In India, issues were low visit coverage - in part due to employing new workers and an empowerment approach to visit scheduling. Coaching caregivers to improve their skills was sub-optimal in both sites, and is likely to have contributed to caregiver perceptions that the intervention content was not new and was focused on play activities rather than interaction and responsivity - which was a focus of the coaching. In both sites caregiver time pressures was a key reason for low uptake among families who received visits.

Discussion

Programs need feasible strategies to maximize quality, coverage and supervision including identifying and managing problems through monitoring and feedback loops. Where existing community-based agents are overstretched and system strengthening is unlikely, alternative implementation strategies should be considered such as group delivery. Core intervention ingredients such as coaching should be prioritized and supported during training and implementation. Given that time and resource constraints were a key barrier for families a greater focus on communication, responsivity and interaction during daily activities could have improved feasibility.

The impact of income-support interventions on life course risk factors and health outcomes during childhood: a systematic review in high income countries

BACKGROUND

In high income countries one in five children still lives in poverty, which is known to adversely shape the life course health trajectory of these children. However, much less is understood on whether social and fiscal policies have the capacity to reverse this damage, which intervention is likely to be most effective and when these interventions should be delivered to maximise their impact. This systematic review attempts to address these questions by looking at the impact of income-support interventions, delivered during the first 1,000 days of life, on cardiovascular, metabolic, respiratory and mental health outcomes.

METHODS

The review was restricted to experimental or quasi experimental studies conducted in high income countries. Studies were retrieved from multidisciplinary databases as well as health, economic, social sciences-specific literature browsers. All papers retrieved through the search strategy were double screened at title, abstract and full text stage. Relevant data of the selected studies were extracted and collected in tables, then summarised via narrative synthesis approach. Robustness of findings was assessed by tabulating impact by health outcome, type of intervention and study design.

RESULTS

Overall, 16 relevant papers were identified, including 15 quasi-experimental studies and one randomized control trial (RCT). Income-support interventions included were unconditional/conditional cash transfers, income tax credit and minimum wage salary policies. Most studies were conducted in United States and Canada. Overall, the evidence suggested limited effect on mental health indicators but a positive, albeit small, effect of most policies on birth weight outcomes. Despite this, according to few studies that tried to extrapolate the results into public health terms, the potential number of negative outcomes averted might be consistent.

CONCLUSIONS

Income-support interventions can positively affect some of the health outcomes of interest in this review, including birth weight and mental health. Given the large number of people targeted by these programs, one could infer that - despite small - the observed effect may be still relevant at population level. Nonetheless, the limited generalisability of the evidence gathered hampers firm conclusions. For the future, the breadth and scope of this literature need to be broadened to fully exploit the potential of these interventions and understand how their public health impact can be maximised.

World Health Organization Labour Care Guide Research Prioritization Group, Abalos E, Adanu R, Bernitz S, Binfa L, Dao B, Downe S, Hofmeyr JG, Homer CSE, Hundley V, GaladanciGogoi HA, Lavender T, Lissauer D, Lumbiganon P, Pattinson R, Qureshi Z, Stringer JSA, Pujar YV, Vogel JP, Yunis K, Nkurunziza T, De Mucio B, Gholbzouri K, Jayathilaka A, Aderoba AK, Pingray V, Althabe F, Betran AP, Bonet M, Bucagu M, Oladapo O, Souza JP. Global research priorities related to the World Health Organization Labour Care Guide: results of a global consultation

BACKGROUND

The World Health Organization (WHO) published the WHO Labour Care Guide (LCG) in 2020 to support the implementation of its 2018 recommendations on intrapartum care. The WHO LCG promotes evidence-based labour monitoring and stimulates shared decision-making between maternity care providers and labouring women. There is a need to identify critical questions that will contribute to defining the research agenda relating to implementation of the WHO LCG.

METHODS

This mixed-methods prioritization exercise, adapted from the Child Health and Nutrition Research Initiative (CHNRI) and James Lind Alliance (JLA) methods, combined a metrics-based design with a qualitative, consensus-building consultation in three phases. The exercise followed the reporting guideline for priority setting of health research (REPRISE). First, 30 stakeholders were invited to submit online ideas or questions (generation of research ideas). Then, 220 stakeholders were invited to score "research avenues" (i.e., broad research ideas that could be answered through a set of research questions) against six independent and equally weighted criteria (scoring of research avenues). Finally, a technical working group (TWG) of 20 purposively selected stakeholders reviewed the scoring, and refined and ranked the research avenues (consensus-building meeting).

RESULTS

Initially, 24 stakeholders submitted 89 research ideas or questions. A list of 10 consolidated research avenues was scored by 75/220 stakeholders. During the virtual consensus-building meeting, research avenues were refined, and the top three priorities agreed upon were: (1) optimize implementation strategies of WHO LCG, (2) improve understanding of the effect of WHO LCG on maternal and perinatal outcomes, and the process and experience of labour and childbirth care, and (3) assess the effect of the WHO LCG in special situations or settings. Research avenues related to the organization of care and resource utilization ranked lowest during both the scoring and consensus-building process.

CONCLUSION

This systematic and transparent process should encourage researchers, program implementers, and funders to support research aligned with the identified priorities related to WHO LCG. An international collaborative platform is recommended to implement prioritized research by using harmonized research tools, establishing a repository of research priorities studies, and scaling-up successful research results.

Sustainable Development Goals in Ireland: How Public Health Nurses Are Contributing Through Engagement in an Interagency Community Pediatric Clinic

Introduction

United Nations Sustainable Development Goals (SDGs) were adopted as a plan of action for people, planet, and prosperity by 2030. SDG 3 aims to ensure healthy lives and promote well-being for all ages, and other goals focus on reduction of inequality, abolition of poverty, decent work for all, and building effective, accountable, and inclusive institutions. A community pediatric clinic, Kidscope, was established in a vulnerable Irish community offering free developmental assessment and onward referral of children 0 to 6 years. The Kidscope model involves multiagency input with local public health nurses (PHNs) acting as fundamental partners in the provision of specialist early years support to vulnerable children and families. This study evaluates PHN involvement in Kidscope in the context of SDGs.

Objective

To record and understand PHN roles within Kidscope and to capture their contribution to achieving SDGs in a disadvantaged Irish community.

Methods

Qualitative stakeholder analysis and mapping design. Snowball sampling identified participants. Data collection involved scoping interviews, questionnaires, one-to-one interviews, and a focus group. A Stakeholder Matrix Table was developed in line with the guiding framework. Transcripts were thematically analyzed.

Results

PHNs are key stakeholders in Kidscope contributing to clinic development, delivery, and sustainability. Six themes were identified: lead referrers, in-clinic support, learning and education, child and family follow-up, specialist early years role, and partnership working. PHNs contribute to six SDGs through the Kidscope model.

Conclusion

PHNs are fundamental partners in achieving SDGs in a disadvantaged Irish community through ameliorating childhood developmental delay by intercepting the gap within Ireland's early intervention system and disrupting the impact exclusion to healthcare has on vulnerable children and their families. Findings underscore a shift from the current "cradle to grave" model of working toward a specialist early years PHN role.

Validity and Reliability of the Parental Health Literacy Questionnaire for Caregivers of Children Aged 0 to 3 Years in China

Caregivers' health literacy plays a vital role in the quality of parenting and significantly impacts children's physical and psychological health. However, the instruments to assess the health literacy of caregivers of children aged 0 to 3 years are lacking. This study aimed to evaluate the reliability and validity of the Chinese Parental Health Literacy Questionnaire (CPHLQ) in China. We conducted a cross-sectional study. Six hundred and thirty-four caregivers of children aged 0 to 3 years were recruited from Shandong, Yunnan, and Shaanxi Provinces, representing the eastern, central, and western regions of China, between November 2020 and January 2021. The reliability was evaluated by internal consistency reliability and split-half reliability. The construct validity was determined by confirmatory factor analysis. Social determinants of parental health literacy were assessed by multivariate linear regression model. Results showed that CPHLQ had satisfactory reliability and acceptable construct validity. Mothers compared to other types of caregivers, higher education levels, and nuclear or extended families compared to other family compositions were significantly associated with higher parental health literacy. The study further demonstrated that CPHLQ is a reliable and valid instrument to measure the health literacy of caregivers of children aged 0 to 3 years in the Chinese population. It can be used as an evaluation tool for intervention research, to inform policy-making and future health education interventions of improving caregivers' health literacy.

Translational Research on Caregiver Reading and Playing Behaviors: Evidence from an In Vivo Community-based Intervention throughout the COVID-19 Pandemic

This study provides a rigorous assessment of a community-based early child development (ECD) intervention to understand the drivers of caregivers' reading and playing practices in a low-resourced township in South Africa. Mentors visited 157 homes biweekly (2474 observations from 2019-21; children ages 0-5), completing surveys regarding caregiver behaviors and engagement. One hundred and fifty-seven caregivers (mostly Black, Zulu women) participated in the program during this time period and completed surveys biannually on their support system (modified version of the Multidimensional Scale of Perceived Support) and ECD beliefs (modified versions of the Parental Play Beliefs Scale and the Parent Opinion Survey). Longitudinal Hierarchical Linear Model revealed that several behaviors and beliefs significantly predicted positive parenting behaviors. Regression discontinuity plots suggest that positive parenting behaviors could continue and even improve following Covid-19 shutdowns, especially in homes with more intervention visits. This paper provides translational evidence on tangible ways interventions can engage caregivers in stimulating ECD behaviors.

Cost-effectiveness and economic returns of group-based parenting interventions to promote early childhood development: Results from a randomized controlled trial in rural Kenya

BACKGROUND

Early childhood development (ECD) programs can help address disadvantages for the 43% of children under 5 in low- and middle-income countries (LMICs) experiencing compromised development. However, very few studies from LMIC settings include information on their program's cost-effectiveness or potential returns to investment. We estimated the cost-effectiveness, benefit-cost ratios (BCRs), and returns on investment (ROIs) for 2 effective group-based delivery models of an ECD parenting intervention that utilized Kenya's network of local community health volunteers (CHVs).

METHODS AND FINDINGS

Between October 1 and November 12, 2018, 1,152 mothers with children aged 6 to 24 months were surveyed from 60 villages in rural western Kenya. After baseline, villages were randomly assigned to one of 3 intervention arms: a group-only delivery model with 16 fortnightly sessions, a mixed-delivery model combining 12 group sessions with 4 home visits, and a control group. At endline (August 5 to October 31, 2019), 1,070 children were retained and assessed for primary outcomes including cognitive and receptive language development (with the Bayley Scales of Infant Development, Third Edition) and socioemotional development (with the Wolke scale). Children in the 2 intervention arms showed better developmental outcomes than children in the control arm, although the group-only delivery model generally had larger effects on children. Total program costs included provider's implementation costs collected during the intervention period using financial reports from the local nongovernmental organization (NGO) implementer, as well as societal costs such as opportunity costs to mothers and delivery agents. We combined program impacts with these total costs to estimate incremental cost-effectiveness ratios (ICERs), as well as BCRs and the program's ROI for the government based on predictions of future lifetime wages and societal costs. Total costs per child were US$140 in the group-only arm and US$145 in the mixed-delivery arm. Because of higher intention-to-treat (ITT) impacts at marginally lower costs, the group-only model was the most cost-effective across all child outcomes. Focusing on child cognition in this arm, we estimated an ICER of a 0.37 standard deviation (SD) improvement in cognition per US$100 invested, a BCR of 15.5, and an ROI of 127%. A limitation of our study is that our estimated BCR and ROI necessarily make assumptions about the discount rate, income tax rates, and predictions of intervention impacts on future wages and schooling. We examine the sensitivity of our results to these assumptions.

CONCLUSIONS

To the best of our knowledge, this study is the first economic evaluation of an effective ECD parenting intervention targeted to young children in sub-Saharan Africa (SSA) and the first to adopt a societal perspective in calculating cost-effectiveness that accounts for opportunity costs to delivery agents and program participants. Our cost-effectiveness and benefit-cost estimates are higher than most of the limited number of prior studies from LMIC settings providing information about costs. Our results represent a strong case for scaling similar interventions in impoverished rural settings, and, under reasonable assumptions about the future, demonstrate that the private and social returns of such investments are likely to largely outweigh their costs.

TRIAL REGISTRATION

This trial is registered at ClinicalTrials.gov, NCT03548558, June 7, 2018. American Economic Association RCT Registry trial AEARCTR-0002913.

Early intervention for children with developmental disabilities in low and middle-income countries - the case for action

In the last two decades, the global community has made significant progress in saving the lives of children <5 y of age. However, these advances are failing to help all children to thrive, especially children with disabilities. Most early child development research has focussed on the impact of biological and psychosocial factors on the developing brain and the effect of early intervention on child development. Yet studies typically exclude children with disabilities, so relatively little is known about which interventions are effective for this high-risk group. In this article we provide an overview of child development and developmental disabilities. We describe family-centred care interventions that aim to provide optimal stimulation for development in a safe, stable and nurturing environment. We make the case for improving opportunities for children with developmental disabilities to achieve their full potential and thrive, including through inclusive early childhood development intervention. Finally, we call for the global research community to adopt a systematic approach for better evidence for and implementation of early interventions for children with developmental disabilities in low-resource settings.

Age-related patterns of early childhood development practices amongst rural families in Burkina Faso: findings from a nationwide survey of mothers of children aged 0-3 years

BACKGROUND

Around two thirds of children in Sub-Saharan Africa are at risk of not meeting their developmental potential. Scalable interventions, based on an understanding of local contexts, that promote nurturing care in children's early years are needed.

OBJECTIVES

To investigate age-related patterns of Early Childhood Development (ECD) practices amongst caretakers of children aged 0-3 years in rural households in Burkina Faso, in order to inform the design of a mass media campaign to be evaluated through a randomized controlled trial.

METHODS

A household survey using a structured questionnaire was used to collect data from 960 rural mothers of children aged 0-3 years in a regionally stratified random sample of 130 villages.

RESULTS

The mother was the main caretaker and engaged most in ECD-related activities at all ages (0-3 years). The father, grandmother and older children also engaged in ECD-related activities with older children (aged 1-3 years). Singing and playing occurred moderately frequently. Singing in the last three days: 36% at age 0-5 months increasing to 84% at age 3 years; playing in the last three days: 26% at age 0-5 months, increasing to 65% at age 3 years. Activities such as reading, counting, drawing, 'showing and naming' and 'chatting' were limited, particularly in the child's first year. Reasons for not engaging in these activities include lack of literacy, lack of books and toys or playthings and a belief that the child was too young.

CONCLUSION

Opportunities for learning, especially through verbal interactions, appeared to be limited during the developmentally crucial first three years, most notably in the first year of life. The challenge for ECD intervention development in Burkina Faso will be finding ways to promote more responsive interactions at an early age and finding ways of mobilizing other family members to become more engaged in stimulating activities in the child's early years.

Group-based parenting interventions to promote child development in rural Kenya: a multi-arm, cluster-randomised community effectiveness trial

Background

Early childhood development (ECD) programmes can help address early disadvantages for the 43% of children younger than 5 years in low-income and middle-income countries who have compromised development. We aimed to test the effectiveness of two group-based delivery models for an integrated ECD responsive stimulation and nutrition education intervention using Kenya’s network of community health volunteers.

Methods

We implemented a multi-arm, cluster-randomised community effectiveness trial in three rural subcounties across 60 villages (clusters) in western Kenya. Eligible participants were mothers or female primary caregivers aged 15 years or older with children aged 6–24 months at enrolment. If married or in established relationships, fathers or male caregivers aged 18 years or older were also eligible. Villages were randomly assigned (1:1:1) to one of three groups: group-only delivery with 16 fortnightly sessions; mixed delivery combining 12 group sessions with four home visits; and a comparison group. Villages in the intervention groups were randomly assigned (1:1) to invite or not invite fathers and male caregivers to participate. Households were surveyed at baseline and immediately post-intervention. Assessors were masked. Primary outcomes were child cognitive and language development (score on the Bayley Scales of Infant Development third edition), socioemotional development (score on the Wolke scale), and parental stimulation (Home Observation for Measurement of the Environment inventory). Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT03548558.

Findings

Between Oct 1 and Nov 12, 2018, 1152 mother–child dyads were enrolled and randomly assigned (n=376 group-only intervention, n=400 mixed-delivery intervention, n=376 comparison group). At the 11-month endline survey (Aug 5–Oct 31, 2019), 1070 households were assessed for the primary outcomes (n=346 group only, n=373 mixed delivery, n=351 comparison). Children in group-only villages had higher cognitive (effect size 0·52 SD [95% CI 0·21–0·83]), receptive language (0·42 SD [0·08–0·77]), and socioemotional scores (0·23 SD [0·03–0·44]) than children in comparison villages at endline. Children in mixed-delivery villages had higher cognitive (0·34 SD [0·05–0·62]) and socioemotional scores (0·22 SD [0·05–0·38]) than children in comparison villages; there was no difference in language scores. Parental stimulation also improved for group-only (0·80 SD [0·49–1·11]) and mixed-delivery villages (0·77 SD [0·49–1·05]) compared with the villages in the comparison group. Including fathers in the intervention had no measurable effect on any of the primary outcomes.

Interpretation

Parenting interventions delivered by trained community health volunteers in mother–child groups can effectively promote child development in low-resource settings and have great potential for scalability.