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Maternal depression affects one in four women in sub-Saharan Africa, yet evidence on effective and scalable interventions is limited. Our objective was to evaluate the effect of a community health worker (CHW) delivered home visit responsive stimulation, health and nutrition intervention, and conditional cash transfers (CCTs) for antenatal care and child growth monitoring attendance on maternal depressive symptoms. We conducted a cluster-randomized controlled trial in 12 villages in rural Ifakara, Tanzania (September 2017 to May 2019). Study villages were randomly assigned to one of three arms: (1) CHW, (2) CHW + CCT and (3) Control. Pregnant women and mothers with a child

Many young children in low- and middle-income countries (LMICs) face heightened risk for experiencing environmental adversity, which is linked with poorer developmental outcomes. Children's stress physiology can shed light on why children are differentially susceptible to adversity. However, no known studies have examined whether links between adversity and children's development are moderated by children's stress physiology in LMICs. The present study revealed significant interactive effects of hair cortisol concentrations, an index of chronic physiological stress regulation, and family wealth on preschoolers' cognitive skills in rural Pakistan. In a sample of 535 4-year-old children (n = 342 girls), we found significant associations between family wealth and direct assessments of verbal intelligence, pre-academic skills, and executive functions only in girls with lower hair cortisol concentrations. Specifically, girls with lower cortisol concentrations displayed greater cognitive skills if they came from relatively wealthier families, but lower cognitive skills if they came from very poor families. There were no significant associations among boys. Results provide evidence of biological sensitivity to context among young girls in a LMIC, perhaps reflecting, in part, sex differences in daily experiences of environmental adversity.

Background The combination of poverty, HIV and depression in the perinatal period represents a major public health challenge in many Southern African countries. In some areas, up to a third of HIV-positive women experience perinatal depression. Perinatal depression is associated with negative effects on parenting and key domains of child development including cognitive, behavioural and growth, especially in socio-economically disadvantaged communities. Several studies have documented the benefits of psychological interventions for perinatal depression in low- and middle-income countries, but none have evaluated an integrated psychological and parenting intervention for HIV-positive women using task-sharing. This randomised controlled trial aims to evaluate the effect of a home-based intervention, combining a psychological treatment for depression and a parenting programme for perinatally depressed HIV-positive women. Methods This study is a cluster randomised controlled trial, consisting of 48–60 geospatial clusters. A total of 528 pregnant HIV-positive women aged ≥ 16 years who meet the criteria for depression on the Edinburgh Postnatal Depression Scale (EPDS, score ≥ 9)) are recruited from antenatal clinics in rural KwaZulu-Natal, South Africa. The geospatial clusters are randomised on an allocation ratio of 1:1 to either the intervention or Enhanced Standard of Care (ESoC). The intervention group receives 10 home-based counselling sessions by a lay counsellor (4 antenatal and 6 postnatal sessions) and a booster session at 16 months. The intervention combines behavioural activation for depression with a parenting programme, adapted from the UNICEF/WHO Care for Child Development programme. The ESoC group receives two antenatal and two postnatal counselling support and advice telephone calls. In addition, measures have been taken to enhance the routine standard of care. The co-primary outcomes are child cognitive development at 24 months assessed on the cognitive subscale of the Bayley Scales of Infant Development-Third Edition and maternal depression at 12 months measured by the EPDS. Analysis The primary analysis will be a modified intention-to-treat analysis. The primary outcomes will be analysed using mixed-effects linear regression. Discussion If this treatment is successful, policymakers could use this model of mental healthcare delivered by lay counsellors within HIV treatment programmes to provide more comprehensive services for families affected by HIV. Trial registration ISRCTN registry #11284870 (14/11/2017) and SANCTR DOH-27-102020-9097 (17/11/2017).

Background Parents are the primary caregivers of young children. Responsive parent–child relationships and parental support for learning during the earliest years of life are crucial for promoting early child development (ECD). We conducted a global systematic review and meta-analysis to evaluate the effectiveness of parenting interventions on ECD and parenting outcomes. Methods and findings We searched MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and Global Health Library for peer-reviewed, published articles from database inception until November 15, 2020. We included randomized controlled trials (RCTs) of parenting interventions delivered during the first 3 years of life that evaluated at least 1 ECD outcome. At least 2 reviewers independently screened, extracted data, and assessed study quality from eligible studies. ECD outcomes included cognitive, language, motor, and socioemotional development, behavior problems, and attachment. Parenting outcomes included parenting knowledge, parenting practices, parent–child interactions, and parental depressive symptoms. We calculated intervention effect sizes as the standardized mean difference (SMD) and estimated pooled effect sizes for each outcome separately using robust variance estimation meta-analytic approaches. We used random-effects meta-regression models to assess potential effect modification by country-income level, child age, intervention content, duration, delivery, setting, and study quality. This review was registered with PROSPERO (CRD42018092458 and CRD42018092461). Of the 11,920 articles identified, we included 111 articles representing 102 unique RCTs. Pooled effect sizes indicated positive benefits of parenting interventions on child cognitive development (SMD = 0.32, 95% CI [confidence interval]: 0.23, 0.40, P < 0.001), language development (SMD = 0.28, 95% CI: 0.18 to 0.37, P < 0.001), motor development (SMD = 0.24, 95% CI: 0.15 to 0.32, P < 0.001), socioemotional development (SMD = 0.19, 95% CI: 0.10 to 0.28, P < 0.001), and attachment (SMD = 0.29, 95% CI: 0.18 to 0.40, P < 0.001) and reductions in behavior problems (SMD = −0.13, 95% CI: −0.18 to −0.08, P < 0.001). Positive benefits were also found on parenting knowledge (SMD = 0.56, 95% CI: 0.33 to 0.79, P < 0.001), parenting practices (SMD = 0.33, 95% CI: 0.22 to 0.44, P < 0.001), and parent–child interactions (SMD = 0.39, 95% CI: 0.24 to 0.53, P < 0.001). However, there was no significant reduction in parental depressive symptoms (SMD = −0.07, 95% CI: −0.16 to 0.02, P = 0.08). Subgroup analyses revealed significantly greater effects on child cognitive, language, and motor development, and parenting practices in low- and middle-income countries compared to high-income countries; and significantly greater effects on child cognitive development, parenting knowledge, parenting practices, and parent–child interactions for programs that focused on responsive caregiving compared to those that did not. On the other hand, there was no clear evidence of effect modification by child age, intervention duration, delivery, setting, or study risk of bias. Study limitations include considerable unexplained heterogeneity, inadequate reporting of intervention content and implementation, and varying quality of evidence in terms of the conduct of trials and robustness of outcome measures used across studies. Conclusions Parenting interventions for children during the first 3 years of life are effective for improving ECD outcomes and enhancing parenting outcomes across low-, middle-, and high-income countries. Increasing implementation of effective and high-quality parenting interventions is needed globally and at scale in order to support parents and enable young children to achieve their full developmental potential., In a systematic review and meta-analysis, Joshua Jeong and colleagues study the effectiveness of parenting interventions in children 3 years and younger in promoting early childhood development and parenting outcomes., Author summary Why was this study done? Parenting interventions have been underscored as a key strategy for improving early child development (ECD) outcomes. Although there are several existing reviews regarding the effectiveness of parenting interventions for improving ECD outcomes, prior reviews have focused narrowly on select types of parenting interventions, evaluated impacts on single ECD domain outcomes, included studies in either only high-income countries (HICs) or low- and middle-income countries (LMICs), and have not adequately explored treatment heterogeneity and potential moderators. What did the researchers do and find? We conducted a systematic review and meta-analysis of 102 randomized controlled trials of parenting interventions for children during the first 3 years of life that were implemented across a total of 33 countries. We found that parenting interventions improved early child cognitive, language, motor, socioemotional development, and attachment and reduced behavior problems. Parenting interventions additionally improved parenting knowledge, parenting practices, and parent–child interactions. However, they did not significantly reduce parental depressive symptoms. We found that parenting interventions had significantly greater effects on child cognitive, language, and motor development and parenting practices in LMICs than HICs (e.g., effect on cognitive development was 3 times greater in LMICs versus HICs). Parenting interventions that included content on responsive caregiving had significantly greater effects on child cognitive development, parenting knowledge, parenting practices, and parent–child interactions than interventions that did not include content on responsive caregiving (e.g., effect on parenting practices was nearly 4 times greater for interventions with responsive caregiving content versus those without responsive caregiving content). We uncovered substantial variation in program content and implementation characteristics across studies and considerable heterogeneity in pooled effect size estimates across nearly all evaluated outcomes. What do these findings mean? To the best of our knowledge, this is the largest and most comprehensive global systematic review and meta-analysis that demonstrates the effectiveness of parenting interventions during the first 3 years of life on a wide range of ECD and parent-level outcomes. Parenting programs are needed globally to enhance parent–child relationships and promote the healthy development of children during the earliest years of life. Future research should unpack the observed variability in program components and implementation features used across parenting interventions and examine their associations with outcomes to inform improved delivery, effectiveness, and scale of parenting interventions for ECD.

IntroductionEvidence on the effect of community health worker (CHW) interventions and conditional cash transfers (CCTs) on child growth and development in sub-Saharan Africa remains sparse.MethodsWe conducted a single-blind, cluster-randomized controlled trial of an integrated home-visiting health, nutrition, and responsive stimulation intervention alone and in combination with CCTs to promote antenatal and child clinic attendance from 2017 to 2019 in rural Morogoro region, Tanzania. Pregnant women and caregivers with a child ResultsThe CHW and CHW+CCT interventions had beneficial effects on child cognitive development as compared to control (standardized mean difference (SMD): 0.15; 95% confidence interval (CI): 0.05, 0.24) and SMD: 0.18; 95% CI: 0.07, 0.28, respectively). The CHW+CCT intervention also had positive effects on language (SMD: 0.08; 95% CI: 0.01, 0.15) and motor development (SMD: 0.16; 95% CI: 0.03, 0.28). Both CHW and CHW+CCT interventions had no effect on HAZ in the primary analysis; however, there were statistically significant positive effects in multivariable analyses. The CHW+CCT group (mean difference: 3.0 visits; 95% CI: 2.1-4.0) and the CHW group (mean difference: 1.5 visits; 95% CI: 0.6-2.5) attended greater number of child health and growth monitoring clinic visits as compared to the control group.ConclusionIntegrated CHW home-visiting interventions can improve child cognitive development and may have positive effects on linear growth. Combining CHWs with CCTs may provide additional benefits on clinic visit attendance and selected child development outcomes.Trial registration numberISRCTN10323949Key Questions BoxWhat is already known?Community health worker interventions that integrate health, nutrition and responsive stimulation components can improve child development but evidence from sub-Saharan Africa is limited.Conditional cash transfers can increase healthcare utilization but effects on child development and growth remain unclear.What are the new findings?An integrated home-visiting community health worker intervention benefited child cognitive development and may have improved child linear growth in rural Tanzania.Combining conditional cash transfers with the community health worker intervention increased child clinic visit attendance as intended and improved child cognitive, motor, and language development and may have improved child linear growth as compared to control.What do the new findings imply?Community health workers can improve child development and possibly child growth outcomes; however, additional research is needed to determine the intensity and frequency of visits to optimize impact as well as the direct and indirect mechanisms through which community health worker interventions work.Conditional cash transfers may provide additional benefits on clinic attendance and selected development domains as compared to community health workers alone; however, additional research is needed to directly compare integrated supply-side and demand-side strategies to promote child growth and development.

Limited information is available on the association between depression and viral suppression among people living with HIV (PLH) in sub-Saharan Africa. We conducted a prospective cohort study of 3996 adults initiating antiretroviral therapy (ART) in Dar es Salaam, Tanzania. Log-binomial models were used to assess the association between depression and the risk of an unsuppressed viral load (> 400 copies/mL) after 6 months of ART. Women who had depression at both initiation and after 6 months of treatment had 1.94 times (95% CI 1.22, 3.09; z = 2.78, p

IntroductionFamilies living in extreme poverty require interventions to support early-childhood development (ECD) due to broad risks. This longitudinal cluster randomised trial examines the effectiveness of Sugira Muryango (SM), a home-visiting intervention linked to Rwanda’s social protection system to promote ECD and reduce violence compared with usual care (UC).MethodsFamilies with children aged 6–36 months were recruited in 284 geographical clusters across three districts. Cluster-level randomisation (allocated 1:1 SM:UC) was used to prevent diffusion. SM was hypothesised to improve child development, reduce violence and increase father engagement. Developmental outcomes were assessed using the Ages and Stages Questionnaire (ASQ-3) and the Malawi Development Assessment Tool (MDAT) and anthropometric assessments of growth. Violence was assessed using questions from UNICEF Multiple Indicators Cluster Survey (MICS) and Rwanda Demographic and Health Surveys (DHS). Father engagement was assessed using the Home Observation for Measurement of the Environment. Blinded enumerators conducted interviews and developmental assessments.ResultsA total of 541 SM families and 508 UC families were enrolled and included in the analyses. Study attrition (2.0% children; 9.6% caregivers) was addressed by hot deck imputation. Children in SM families improved more on gross motor (d=0.162, 95% CI 0.065 to 0.260), communication (d=0.081, 95% CI 0.005 to 0.156), problem solving (d=0.101, 95% CI 0.002 to 0.179) and personal-social development (d=0.096, 95% CI −0.015 to 0.177) on the ASQ-3. SM families showed increased father engagement (OR=1.592, 95% CI 1.069 to 2.368), decreased harsh discipline (incidence rate ratio, IRR=0.741, 95% CI 0.657 to 0.835) and intimate partner violence (IRR=0.616, 95% CI:0.458 to 0.828). There were no intervention-related improvements on MDAT or child growth.ConclusionSocial protection programmes provide a means to deliver ECD intervention.Trial registration numberNCT02510313.

BACKGROUND AND OBJECTIVES: Previous research has demonstrated associations between maternal experience of intimate partner violence (IPV) and a range of adverse outcomes among women and their young children. However, few studies have examined the associations between maternal experience of IPV and early child development (ECD) outcomes in low- and middle-income countries (LMIC). Our objectives in this study were to examine the association between IPV victimization and ECD and assess whether the association was mediated by maternal and paternal stimulation. METHODS: We combined cross-sectional data from the Demographic and Health Surveys for 15 202 households representing mothers and fathers of children aged 36 to 59 months in 11 LMIC. We used multivariable linear regression models to estimate the association between IPV victimization in the year preceding the survey and ECD, which we measured using the Early Child Development Index. We used path analysis to determine if the association between IPV victimization and ECD was mediated through maternal and paternal stimulation. RESULTS: After adjusting for sociodemographic variables, IPV victimization was negatively associated with ECD (β = −.11; 95% confidence interval = −.15 to −.07). Path analysis indicated that the direct association between IPV victimization and ECD was partially and independently mediated through maternal and paternal stimulation. CONCLUSIONS: Interventions that include components to prevent IPV may be effective for improving ECD in LMIC.

Background Sugira Muryango is a father-engaged early child development and violence-prevention home-visiting programme delivered by trained lay workers. This cluster-randomised trial evaluates whether families living in extreme poverty (Ubudehe 1, the poorest category in the Government of Rwanda’s wealth ranking) who receive Sugira Muryango in combination with a government-provided social protection programme demonstrate greater responsive, positive caregiving, nutrition, care seeking, hygiene, and father involvement compared with control families receiving usual care (UC). Methods Using detailed maps, we grouped closely spaced villages into 284 geographic clusters stratified by the type of social protection programmes operating in the village clusters; 198 clusters met all enrolment criteria. Sugira Muryango was delivered to n = 541 families in 100 treatment clusters with children aged 6–36 months living in extreme poverty. We assessed changes in outcomes in intervention and n = 508 UC control families using structured surveys and observation. Analyses were intent to treat using mixed models to accommodate clustering. Results Families receiving Sugira Muryango improved on core outcomes of parent-child relationships assessed using the Home Observation for Measurement of the Environment (Cohen’s d = 0.87, 95% CI: 0.74, 0.99) and the Observation of Mother-Child Interaction (Cohen’s d = 0.29, 95% CI: 0.17, 0.41). We also saw reductions in harsh discipline on items from the UNICEF MICS (OR = 0.30: 95% CI: 0.19, 0.47) and in violent victimisation of female caregivers by their partners (OR = 0.49, 95% CI: 0.24, 1.00) compared with UC. Moreover, children in families receiving SM had a 0.45 higher increase in food groups consumed in the past 24 h (Cohen’s d = 0.35, 95% CI: 0.22, 0.47), increased care seeking for diarrhoea (OR = 4.43, 95% CI: 1.95, 10.10) and fever (OR = 3.28, 95% CI: 1.82, 5.89), and improved hygiene behaviours such as proper treatment of water (OR = 3.39, 95% CI: 2.16, 5.30) compared with UC. Finally, Sugira Muryango was associated with decreased caregiver depression and anxiety (OR = 0.58, 95% CI: 0.38, 0.88). Conclusions Sugira Muryango led to improvements in caregiver behaviours linked to child development and health as well as reductions in violence. Trial registration ClinicalTrials.gov number NCT02510313.

We summarize the state of the field of implementation research and practice for early child development and propose recommendations. First, conclusions are drawn regarding what is generally known about the implementation of early childhood development programs, based on papers and discussions leading to a published series on the topic. Second, recommendations for short-term activities emphasize the use of newly published guidelines for reporting data collection methods and results for implementation processes; knowledge of the guidelines and a menu of measures allows for planning ahead. Additional recommendations include careful documentation of early-stage implementation, such as adapting a program to a different context and assessing feasibility, as well as the process of sustaining and scaling up a program. Using existing implementation information by building on and improving past programs and translating them into policy are recommended. Longer term goals are to identify implementation characteristics of effective programs and determinants of these characteristics.

Meta-analyses of interventions such as parenting, stimulation, and early childhood education have reported consistent medium-to-high effect sizes on early childhood development (ECD) and early learning outcomes. However, few effective interventions promoting ECD have achieved scale. In order to increase the access to effective or high-quality services, greater focus on implementation research of interventions promoting ECD is necessary. In this paper, we describe the development of reporting guidelines for implementation research of nurturing care interventions designed to promote ECD following an expert consensus-building process. The goal of these guidelines is to support a transparent and standard reporting of implementation evidence on nurturing care interventions designed to promote early childhood development.

Children in low- and middle-income countries are at high risk of cognitive deficits due to environmental deprivation that compromises brain development. Despite the high prevalence of unrealized cognitive potential, very little is known about neural correlates of cognition in this population. We assessed resting EEG power and cognitive ability in 105 highly disadvantaged 48-month-old children in rural Pakistan. An increase in EEG power in gamma frequency bands (21–30 Hz and 31–45 Hz) was associated with better executive function. For girls, EEG gamma power also related to higher verbal IQ. This study identifies EEG gamma power as a neural marker of cognitive function in disadvantaged children in low- and middle-income countries. Elevated gamma power may be a particularly important protective factor for girls, who may experience greater deprivation due to gender inequality. Keywords: EEG, Low- and middle-income countries, Poverty, Executive function, Cognitive development, Sex differences

Many global settings lack indigenous measures of child development, making the adaptation of available instruments necessary. The aim of this study was to reliably adapt the core subtests of the We...

Background Given the significance of early language for later academic achievement, language development can be an important outcome measure in evaluation of early childhood intervention programmes. Language development may be challenging to assess in settings where trained personnel are hard to find; therefore, maternal report can be a reliable alternative measure. Aim The aim of this study was to adapt a maternal report measure, the MacArthur Communicative Development Inventory II-Short Form, in the Sindhi language and to examine its psychometric properties as a measure of language outcome in 2-year-old children in rural Pakistan. Methods A three-phase process was followed to produce a Sindhi adaptation of the tool comprising 100 words. The first phase was a review of the original 258 words through a focus group discussion with a team familiar with the context; the second phase was testing 258 words to compile a 100-word list of easy, moderate and difficult words. The third phase was a pilot of the 100-word list followed by administration in a larger intervention study population. Results On administration with 1381 children, concurrent validity with the Bayley Scale of Infant Development III using the Pearson's correlation test showed a moderate association for comprehension (r = 0.45, p = 0.01, n = 1381) and good association for expression (r = 0.51, p = 0.01, n = 1381). Internal consistency was high with alphas of 0.98 for comprehension items and 0.96 for expression items. Conclusion The authors conclude that the Sindhi adaptation of the MacArthur Communicative Development Inventory followed a feasible and rigorous methodology to create a reliable and sensitive tool to assess young children's language development for use in a child assessment battery for early childhood health, nutrition and development studies.

Background: Approximately 250 million children under the age of five in low and middle-income countries (LMICs) will not achieve their developmental potential due to poverty and stunting alone. Investments in programming to improve early childhood development (ECD) have the potential to disrupt the cycle of poverty and therefore should be prioritised. Support for ECD has increased in recent years. Nevertheless, donors and policies continue to neglect ECD, in part from lack of evidence to guide policy makers and donors about where they should focus policies and programmes. Identification and investment in research is needed to overcome these constraints and in order to achieve high quality implementation of programmes to improve ECD. Methods: The Child Health and Nutrition Research Initiative (CHNRI) priority setting methodology was applied in order to assess research priorities for improving ECD. A group of 348 global and local experts in ECD-related research were identified and invited to generate research questions. This resulted in 406 research questions which were categorised and refined by study investigators into 54 research questions across six thematic goals which were evaluated using five criteria: answerability, effectiveness, feasibility, impact, and effect on equity. Research options were ranked by their final research priority score multiplied by 100. Results: The top three research priority options from the LMIC experts came from the third thematic goal of improving the impact of interventions, whereas the top three research priority options from high-income country experts came from different goals: improving the integration of interventions, increasing the understanding of health economics and social protection strategies, and improving the impact of interventions. Conclusion: The results of this process highlight that priorities for future research should focus on the need for services and support to parents to provide nurturing care, and the training of health workers and non-specialists in implementation of interventions to improve ECD. Three of the six thematic goals of the present priority setting centred on interventions (ie, improving impact, implementation of interventions and improving the integration of interventions). In order to achieve higher coverage through sustainable interventions to improve ECD with equitable reach, interventions should be integrated and not be sector driven.

Background: Maternal depression affects a high proportion of women during the antenatal and postnatal period in low- and middle-income countries. While maternal depression is recognized as a significant risk for poor early child development that warrants interventions, the effects of chronic maternal depression on children’s development are less understood. Objective: To determine the association of chronicity of maternal depressive symptoms and early child development in a rural population in southern Pakistan. Materials and Methods: This study employs data from the “Pakistan Early Child Development Scale-Up Trial,” a randomized controlled study that evaluated the integration of responsive stimulation and nutrition interventions in a community health service. In the present analysis, linear regression was used to test the effects of chronicity of high maternal depressive symptoms on children’s early development (n = 1205 mother-infant dyads). Children’s development was assessed using the Bayley Scales of Infant and Toddler Development at 24 months of age. Maternal depressive symptoms were assessed at baseline and every 6 months using the Self-Reporting Questionnaire. Results: No significant associations were observed between chronic maternal depressive symptoms and child cognitive, language, or motor development after adjusting for parental characteristics, the caregiving environment and socioeconomic variables. A negative significant association between chronicity of high maternal depressive symptoms and child socio-emotional development (β coefficient −2.57, 95% CI: −5.14; −0.04) was observed after adjusting for the selected variables. Conclusions: The results suggest that interventions designed to promote early child development should also integrate repeat screening for depression and longer-term psychosocial support for mothers.

ObjectiveTo determine the magnitude of relationships of early life factors with child development in low/middle-income countries (LMICs).DesignMeta-analyses of standardised mean differences (SMDs) estimated from published and unpublished data.Data sourcesWe searched Medline, bibliographies of key articles and reviews, and grey literature to identify studies from LMICs that collected data on early life exposures and child development. The most recent search was done on 4 November 2014. We then invited the first authors of the publications and investigators of unpublished studies to participate in the study.Eligibility criteria for selecting studiesStudies that assessed at least one domain of child development in at least 100 children under 7 years of age and collected at least one early life factor of interest were included in the study.AnalysesLinear regression models were used to assess SMDs in child development by parental and child factors within each study. We then produced pooled estimates across studies using random effects meta-analyses.ResultsWe retrieved data from 21 studies including 20 882 children across 13 LMICs, to assess the associations of exposure to 14 major risk factors with child development. Children of mothers with secondary schooling had 0.14 SD (95% CI 0.05 to 0.25) higher cognitive scores compared with children whose mothers had primary education. Preterm birth was associated with 0.14 SD (–0.24 to –0.05) and 0.23 SD (–0.42 to –0.03) reductions in cognitive and motor scores, respectively. Maternal short stature, anaemia in infancy and lack of access to clean water and sanitation had significant negative associations with cognitive and motor development with effects ranging from −0.18 to −0.10 SDs.ConclusionsDifferential parental, environmental and nutritional factors contribute to disparities in child development across LMICs. Targeting these factors from prepregnancy through childhood may improve health and development of children.

ObjectiveTo compare early motor and language development of children DesignCross-sectional study.SettingWe analysed differences in motor and language skills across study sites in Cambodia, Chile, Ghana, Guatemala, Lebanon, Pakistan, the Philippines and the USA.Main outcome measureCognitive and language development assessed with the Caregiver Reported Early Development Instruments (CREDI) tool.Results4649 children aged 0–35 months (mean age=18 months) were analysed. On average, children in sites with a low Human Development Index (HDI) had 0.54 SD (95% CI –0.63 to –0.44) lower CREDI motor scores and 0.73 SD (95% CI –0.82 to –0.64) lower language scores than children growing up in high HDI sites. On average, each unit increase in national log income per capita was associated with a 0.77-month (95% CI –0.93 to 0.60) reduction in the age of motor milestone attainment and a reduction in the age of language milestone attainment of 0.55 months (95% CI –0.79 to –0.30). These observed developmental differences were not universal: no developmental differences across sites with highly heterogeneous socioeconomic contexts were found among children growing up in households with highly educated caregivers providing stimulating early environments.ConclusionDevelopmental gaps in settings with low HDI are substantial on average, but appear to be largely attributable to differences in family-level socioeconomic status and caregiving practices. Programmes targeting the most vulnerable subpopulations will be essential to reduce early life disparities and improve long-run outcomes.

Background Child health, nutrition, and responsive stimulation interventions have been developed to improve child survival, growth and development outcomes in low- and middle-income countries. Nevertheless, research on integrated implementation approaches to deliver and promote uptake of these interventions is needed, particularly in sub-Saharan Africa. Methods/design We will conduct a cluster-randomized controlled trial of a supply-side community health worker (CHW) delivered child health, nutrition, and responsive stimulation intervention alone and in combination with a demand-side conditional cash transfer (CCT) intervention to promote antenatal care and child growth monitoring attendance in rural Morogoro region, Tanzania. Twelve village clusters will be randomly assigned to one of the three trial arms: (1) CHW, (2) CHW + CCT, or (3) Control. Mothers (or another primary caregiver) residing in study villages are eligible for trial enrollment if they are currently pregnant or have a child

The UN Sustainable Development Goals provide a historic opportunity to implement interventions, at scale, to promote early childhood development. Although the evidence base for the importance of early childhood development has grown, the research is distributed across sectors, populations, and settings, with diversity noted in both scope and focus. We provide a comprehensive updated analysis of early childhood development interventions across the five sectors of health, nutrition, education, child protection, and social protection. Our review concludes that to make interventions successful, smart, and sustainable, they need to be implemented as multi-sectoral intervention packages anchored in nurturing care. The recommendations emphasise that intervention packages should be applied at developmentally appropriate times during the life course, target multiple risks, and build on existing delivery platforms for feasibility of scale-up. While interventions will continue to improve with the growth of developmental science, the evidence now strongly suggests that parents, caregivers, and families need to be supported in providing nurturing care and protection in order for young children to achieve their developmental potential.

This study contributes to the understanding of how early parenting interventions implemented in low- and middle-income countries during the first 2 years of children's lives are sustained longitudinally to promote cognitive skills in preschoolers. We employed path analytic procedures to examine 2 family processes-the quality of home stimulation and maternal scaffolding behaviors-as underlying mechanisms through which a responsive stimulation intervention uniquely predicted children's verbal intelligence, performance intelligence, and executive functioning. The sample included 1,302 highly disadvantaged children and their mothers living in rural Pakistan, who from birth participated in a 2-year, community-based, cluster-randomized, controlled trial designed to promote sensitive and responsive caregiving. Family processes were assessed at 2 developmental time points using parent reports, ratings of home environments, and observed parent-child interactions. Cognitive skills at age 4 were assessed using standardized tests. Controlling for socioeconomic risk (e.g., wealth, maternal education, food insecurity) and individual factors (e.g., gender, growth status), the quality of current home stimulation as well as both earlier and concurrent measures of maternal scaffolding independently mediated the intervention effects on cognitive skills at age 4. In addition, the intervention had a significant direct effect on executive functioning and performance intelligence over and above significant family processes and other covariates. We highlight implications for future program design and evaluation studies. (PsycINFO Database Record

Poor nutrition (substandard diet quantity and/or quality resulting in under- or overnutrition) and the lack of early learning opportunities contribute to the loss of developmental potential and life-long health and economic disparities among millions of children aged

The Bayley's Scales of Infant and Toddler Development-Third Edition (Bayley-III) were used to measure the development of 24-month-old children (N = 1,452) in the Interactions of Malnutrition and Enteric Infections: Consequences for Child Health and Development (MAL-ED) study (an international, multisite study on many aspects of child development). This study examined the factor structure and measurement equivalence/invariance of Bayley-III scores across 7 international research sites located in Bangladesh, Brazil, India, Nepal, Pakistan, Peru, and South Africa. Exploratory and confirmatory factor analyses were used to identify the factor structure of Bayley-III scores. Subsequently, reliability analyses and item response theory analyses were applied, and invariance was examined using multiple-indicator, multiple-cause modeling. The findings supported the validity, but not invariance, of Bayley-III language scores at all seven sites and of the cognitive and motor scores at six sites. These findings provide support for the use of scores for research purposes, but mean comparison between sites is not recommended. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

A pre-post design with 6–13-month follow-up assessed the feasibility and acceptability of a home-visiting intervention to promote early childhood development, improve parenting and shared decision-making, and reduce violence in impoverished Rwandan households. Twenty vulnerable families with a child 36-months or younger enrolled in Sugira Muryango. Measures of parenting, home environment, family-violence, decision-making, and health-status were administered at pre/post and follow-up. Families reported high satisfaction post-intervention. OMCI scores improved for 4.8% of mother-child dyads at post-intervention and 19.0% at follow-up, while 9.5% of dyads showed declines at both times. HOME Inventory scores improved for 9.5% and 14.3% of dyads at post-intervention and follow-up respectively and declined for 4.8% and 0.0%. Indicators for equal decision-making and child dietary-diversity improved at post-intervention and follow-up. Fewer mothers believed physical punishment was necessary at follow-up. Sugira Muryango shows promise for improving parenting, beliefs about harsh punishment, child nutritional status, and shared decision-making among vulnerable families.

CONTEXT: Early childhood stimulation interventions positively impact early child development (ECD) outcomes in low- and middle-income countries. However, trials have less comprehensively evaluated the effects of such parenting programs on caregivers’ skills and capacities. OBJECTIVE: We conducted a systematic review and meta-analysis to assess the effectiveness of stimulation interventions on improving parenting outcomes. DATA SOURCES: Six electronic bibliographic databases. STUDY SELECTION: Inclusion criteria included randomized controlled trials of stimulation interventions designed to improve ECD outcomes during the first 2 years of life that measured any maternal or parenting-related outcome after the start of the intervention. DATA EXTRACTION: Two independent reviewers extracted data by using a structured form. RESULTS: Fifteen studies representing 13 unique randomized controlled trials met the inclusion criteria. Pooled standardized mean differences (SMDs) based on random-effects models revealed medium-to-large benefits of stimulation interventions for improving the home caregiving environment (n = 10; SMD = 0.57; 95% confidence interval [CI], 0.37 to 0.77), mother-child interactions (n = 3; SMD = 0.44; 95% CI, 0.14 to 0.74), and maternal knowledge of ECD (n = 6; SMD = 0.91; 95% CI, 0.51 to 1.31). No significant difference was seen for maternal depressive symptoms (n = 9; SMD = −0.10; 95% CI, −0.23 to −0.03). LIMITATIONS: Limitations include heterogeneity across interventions, lack of standardized measures, and different time points of assessments across studies. CONCLUSIONS: Early childhood stimulation interventions improve several distinct aspects of maternal parenting. Improvements in parenting capacities may serve as key mechanisms by which these programs benefit ECD outcomes.

Research in early childhood development (ECD) has established the need for scaling-up multisectoral interventions for nurturing care to promote ECD, for improved socioeconomic outcomes for sustainable societies. However, key elements and processes for implementation and scale-up of such interventions are not well understood. This special series on implementation research and practice for ECD brings together evidence to inform effectiveness, quality, and scale in nurturing care programs; identifies knowledge gaps; and proposes further directions for research and practice. This paper frames the dimensions and components fundamental to the understanding of implementation processes for nurturing care interventions, factors for improving implementation of interventions, and strategies to scale by embedding interventions in delivery systems. We discuss emerging issues in implementation research for ECD, including (1) the role of context in adaptation and implementation, (2) standardized reporting of implementation research, (3) the importance of feasibility studies to inform scale-up and capacity building, (4) fidelity and program quality improvement, and (5) intervention integration into existing systems. Effective implementation of nurturing care interventions is at the heart of achieving positive developmental outcomes for young children. It is pivotal to adapt and implement these interventions based on evidence for high impact, especially in low-resource settings.

Background The United Nation’s Sustainable Development Goals encompass lifelong learning from birth to youth to adulthood (Goal 4) and economic opportunities for young people (Goal 8). The targets include improving access to quality early childhood care and education (ECCE) as well as learning and training opportunities for adolescents and youth. Cross-generational models for young children and youth may offer opportunities to address the interconnections between goals and targets for the next generation. We investigated whether an ECCE programme for young children (3.5–6.5 years) delivered by female youth (18–24 years) in rural Pakistan would be effective on children’s school readiness. Methods In partnership with the National Commission for Human Development in Pakistan, we implemented the ‘Youth Leaders for Early Childhood Assuring Children are Prepared for School’ (LEAPS) programme to train female youth to deliver ECCE. The effectiveness of the LEAPS programme on children’s school readiness was evaluated in a cluster-randomised controlled trial. We randomly allocated five clusters (villages) to receive the intervention (n = 170 children) and five clusters to control (n = 170 children). Children’s school readiness was assessed after nine months of intervention exposure using the International Development and Early Learning Assessment tool. Analyses was by intention-to-treat. The trial is registered with ClinicalTrials.gov, number NCT02645162. Findings At endline, the intervention group had significantly higher school readiness scores (n = 166, mean percentage score 59.4, 95% CI 52.7 to 66.2) compared with the control group (n = 168, mean percentage score 45.5, 95% CI 38.8 to 52.3). The effect size (Cohen’s d) was 0.3. Conclusion Trained female youth delivered an ECCE programme that was effective in benefitting young children’s school readiness. The cross-generational model is a promising approach to support early child development; however, further evaluation of the model is needed to assess the specific benefits to youth including their skills and economic development.

Background Parents are the primary providers of nurturing care for young children’s healthy early development. However, the literature on parenting in early childhood, especially in low- and middle-income countries, has primarily focused on mothers. In this study, we investigate how parents make meaning of fathers’ parenting roles with regards to their young children’s early health and development in rural Pakistan. Methods Data were collected between January and March 2017 through in-depth interviews with fathers (N = 33) and their partners (N = 32); as well as separate focus group discussions with fathers (N = 7) and mothers (N = 7). Data were analyzed using thematic content analysis. Results Parents described a distinct division of roles between fathers and mothers; and also several shared caregiving roles of fathers and mothers. Specifically, parents highlighted aspects of fathers’ coparenting and several common ways by which fathers supported their partners. We found that these gendered divisions in parenting roles were strongly embedded within a complex network of interacting factors across the individual, family, and sociocultural contexts of the study community. Conclusions Our findings suggest a more family-centered conceptualization of fatherhood during early childhood that encompasses both fathers’ direct engagement with their young children and their indirect contributions through coparenting, while recognizing a variety of contextual systems that shape paternal parenting. Future parenting interventions that reflect the lived experiences of both fathers and mothers as parents and partners may further enhance the nurturing care environments that are critical for promoting healthy early child development.

Policy and program implementers require evidence on whether integrated psychosocial stimulation and nutrition interventions can be effectively delivered at-scale, how, and at what cost? To address some of these issues, a comprehensive evaluation of implementation was designed for a trial in Pakistan that integrated psychosocial stimulation and nutrition interventions in a community health service. The first objective was to describe, analyze, and assess the quality and accuracy of the implementation of the interventions. The second objective was to identify barriers and facilitators for uptake of interventions. A mixed-methods evaluation of implementation processes was conducted. Interventions were accepted by the community and health providers and there was evidence for behavior change uptake of the care for early childhood care recommendations. The new interventions did not dilute delivery of routine services. However, fidelity and quality required supportive supervision and active use of monitoring data, which would require attention in scale-up.

BACKGROUND AND OBJECTIVE: Few studies have examined the relationship between paternal stimulation and children’s growth and development, particularly in low- and middle-income countries (LMICs). This study aimed to estimate the prevalence of paternal stimulation and to assess whether paternal stimulation was associated with early child growth and development. METHODS: Data from the Multiple Indicator Cluster Surveys rounds 4 and 5 were combined across 38 LMICs. The sample comprised 87 286 children aged 3 and 4 years. Paternal stimulation was measured by the number of play and learning activities (up to 6) a father engaged in with his child over the past 3 days. Linear regression models were used to estimate standardized mean differences in height-for-age z-scores and Early Childhood Development Index (ECDI) z-scores across 3 levels of paternal stimulation, after controlling for other caregivers’ stimulation and demographic covariates. RESULTS: A total of 47.8% of fathers did not engage in any stimulation activities, whereas 6.4% of fathers engaged in 5 or 6 stimulation activities. Children whose fathers were moderately engaged in stimulation (1–4 activities) showed ECDI scores that were 0.09 SD (95% confidence interval [CI]: –0.12 to –0.06) lower than children whose fathers were highly engaged; children whose fathers were unengaged showed ECDI scores that were 0.14 SD lower (95% CI: –0.17 to –0.12). Neither moderate paternal stimulation nor lack of paternal stimulation was associated with height-for-age z-scores, relative to high stimulation. CONCLUSION Increasing paternal engagement in stimulation is likely to improve early child development in LMICs.

Developmental potential is the ability to think, learn, remember, relate, and articulate ideas appropriate to age and level of maturity, and an estimated 39 percent of the world’s children under age five years do not attain this potential (Grantham-McGregor and others 2007).The main reason for giving prominent attention to mental development from conception through the first 24 months of life is that early unfavorable conditions can impair the normal development of the brain. The impairment is often incremental and unnoticed until schooling begins. The most striking example of impairment is the gradual deletion of unused brain synapses. The lack of use may be due to the absence of stimulation in the family environment or lack of available energy for brain activity. Regenerating those lost synapses may occur at an older age but with additional costs. For example, children who do not acquire a good vocabulary in the early years will have difficulty learning how to read; children who do not acquire simple problem-solving strategies in the first 24 months will have difficulty understanding math concepts; children who do not develop secure emotional attachments to adults will have difficulty coping with stresses and challenges throughout life. The plasticity of the brain diminishes with age, but greater plasticity in the very early years suggests that brain development has a greater chance of being modified by protective interventions than by interventions later in life (Werker and Hensch 2015).A second reason for attending to early mental development is that individuals, communities, and societies are healthier and more productive if they have mature mental skills. More educated adults are healthier and wealthier than less educated adults. Educated mothers have healthier children and are more likely to recognize symptoms of illness, follow medical advice, feed their children nutritious foods, and keep their homes clean (Boyle and others 2006; Cleland and van Ginneken 1988). Educated husbands are less likely to condone or use violence to resolve domestic conflicts (Abraham and others 2006). Follow-up data of adults who participated in early psychosocial stimulation programs demonstrate some of these long-term benefits (Gertler and others 2014).This chapter discusses mental development from birth to age 24 months in low- and middle-income countries (LMICs). We include recent literature published since the 2011 child development series in The Lancet. Although we focus on cognitive and language domains, we touch on socioemotional, fine motor, and gross motor development. First, a description of how these domains are measured provides an operational definition of the term mental development. Second, conditions that derail early child development are examined. These conditions arise during the prenatal period and continue throughout the next 24 months; they include psychosocial stimulation, prenatal and postnatal nutrition, the physical environment, and maternal mental health. Finally, the results of several systematic reviews and meta-analyses are presented to show the effects of stimulation and nutrition, along with disease-related interventions to promote mental development. Maternal interventions related to nutrition and mental health are also reviewed. A framework of critical components to include in programs is outlined.

The Strengths and Difficulties Questionnaire (SDQ) is widely-used to measure symptoms of common childhood behavioral problems that may lead to mental health difficulties. In a sample of 1,302 highly-disadvantaged mothers and their preschoolers, we evaluated the factor structure and reliability of the parent-report version of the SDQ in rural Pakistan. Confirmatory factor analyses suggested that the original structure of the SDQ was not appropriate for our data. We created conceptually- and empirically-coherent measures of children's externalizing behavior problems and prosocial skills. Child and family correlates of social-emotional behaviors were similar to those found in other countries, supporting the validity of our new composites. Girls and children with more siblings had fewer externalizing behavior problems and more prosocial behaviors at four years. Further, maternal depressive symptoms and food insecurity were uniquely linked to more externalizing behavior problems at four years. In contrast, maternal education, home environment quality, and social-emotional skills at two years were associated with more prosocial behaviors at four years.

Interventions to improve nutritional status of young children in low‐ and middle‐income countries (LMIC) may have the added benefit of improving their mental and motor development. This meta‐analysis updates and goes beyond previous ones by answering two important questions: (1) do prenatal and postnatal nutritional inputs improve mental development, and (2) are effects on mental development associated with two theoretically interesting mediators namely physical growth and motor development? The meta‐analysis of articles on Medline, PsycINFO, Global Health and Embase was limited to randomized trials in LMICs, with mental development of children from birth to age two years as an outcome. The initial yield of 2689 studies was reduced to 33; 12 received a global quality rating of strong. Of the 10 prenatal and 23 postnatal nutrition interventions, the majority used zinc, iron/folic acid, vitamin A or multiple micronutrients, with a few evaluating macronutrients. The weighted mean effect size, Cohen's d (95% CI) for prenatal and postnatal nutrition interventions on mental development was 0.042 (−0.0084, 0.092) and 0.076 (0.019, 0.13), respectively. Postnatal supplements consisting of macronutrients yielded an effect size d (95% CI) of 0.14 (0.0067, 0.27), multiple micronutrients 0.082 (−0.012, 0.18) and single micronutrients 0.058 (−0.0015, 0.12). Motor development, but not growth status, effect sizes were significantly associated with mental development in postnatal interventions. In summary, nutrition interventions had small effects on mental development. Future studies might have greater effect if they addressed macronutrient deficiencies combined with child stimulation and hygiene and sanitation interventions.

The aim of the present study was to explore the nature, extent and probable causes of nutritional deficiencies among children with disabilities living in Dharavi, a slum in Mumbai, India. A cross-sectional study was conducted to investigate whether the nutritional status of children with disabilities, aged 2–6 years (n 141), was worse than that of non-disabled sibling controls (n 122) and neighbour controls (n 162). Data on food patterns, anthropometry, micronutrient status and feeding difficulties reported by parents were collected. The mean weight for age of the children with disabilities (−2·44 (sd 1·39) Z scores; n 120) was significantly lower (PZ scores; n 109) and neighbour (−1·83 (sd 1·290) Z scores; n 162) control groups. The children with disabilities had significantly lower (Pn 134) compared with siblings (102 (sd 18) g/l; n 103) and neighbours (99 (sd 18) g/l; n 153). Relative risk (RR) analysis indicated that the disabled children with feeding difficulties were significantly more likely (P

OBJECTIVES: There is little information regarding motor development of children born at term with low birth weight (LBW), a group that constitutes a large proportion of children in South Asia. We used data from infancy and at school age from a LBW cohort to investigate children's motor performance using causal inference. DESIGN: Cross-sectional follow-up study. SETTING: Delhi, India. PARTICIPANTS: We recruited 912 children aged 5 years who had participated in a trial of vitamin D for term LBW infants in the first 6 months of life. OUTCOME MEASURES: We focused on gross motor development, using the Ages and Stages Questionnaire (ASQ) gross motor scale and several measures of motor performance. We examined the effects on these of current anthropometry, vitamin D status and bone health, controlling for age, sex, season of interview, socioeconomic variables, early growth, recent morbidity, sun exposure and animal food intake. RESULTS: In adjusted analyses, stunted children (height-for-age Z (HAZ)

Summary Background A previous study in Pakistan assessed the effectiveness of delivering responsive stimulation and enhanced nutrition interventions to young children. Responsive stimulation significantly improved children's cognitive, language, and motor development at 2 years of age. Both interventions significantly improved parenting skills, with responsive stimulation showing larger effects. In this follow-up study, we investigated whether interventions had benefits on children's healthy development and care at 4 years of age. Methods We implemented a follow-up study of the initial, community-based cluster-randomised effectiveness trial, which was conducted through the Lady Health Worker programme in Sindh, Pakistan. We re-enrolled 1302 mother–child dyads (87% of the 1489 dyads in the original enrolment) for assessment when the child was 4 years of age. The children were originally randomised in the following groups: nutrition education and multiple micronutrient powders (enhanced nutrition; n=311), responsive stimulation (n=345), combined responsive stimulation and enhanced nutrition (n=315), and routine health and nutrition services (control; n=331). The data collection team were masked to the allocated intervention. The original enrolment period included children born in the study area between April 1, 2009, and March 31, 2010, if they were up to 2·5 months old without signs of severe impairments. The primary endpoints for children were development and growth at 4 years of age. Interventions were given in monthly group sessions and in home visits. The primary endpoint for mothers was wellbeing and caregiving knowledge, practices, and skills when the child was 4 years of age. Analysis was by intention to treat. The original trial is registered with ClinicalTrials.gov, number NCT00715936. Findings 1302 mother–child dyads were re-enrolled between Jan 1, 2013, and March 31, 2013, all of whom were followed up at 4 years of age. Children who received responsive stimulation (with or without enhanced nutrition) had significantly higher cognition, language, and motor skills at 4 years of age than children who did not receive responsive stimulation. For children who received responsive stimulation plus enhanced nutrition, effect sizes (Cohen's d) were 0·1 for IQ (mean difference from control 1·2, 95% CI −0·3 to 2·7), 0·3 for executive functioning (0·18, −0·07 to 0·29), 0·5 for pre-academic skills (7·53, 5·14 to 9·92) and 0·2 for pro-social behaviours (0·08, 0·03 to 0·13). For children who received responsive stimulation alone, effect sizes were 0·1 for IQ (mean difference with controls 1·7, −0·3 to 3·7), 0·3 for executive functioning (0·17, 0·07 to 0·27), 0·2 for pre-academic skills (3·86, 1·41 to 6·31), and 0·2 for pro-social behaviours (0·07, 0·02 to 0·12). Enhanced nutrition improved child motor development, with effect size of 0·2 for responsive stimulation plus enhanced nutrition (0·56, −0·03 to 1·15), and for enhanced nutrition alone (0·82, 0·18 to 1·46). Mothers who received responsive stimulation (with or without enhanced nutrition) had significantly better responsive caregiving behaviours at 4 years of child age than those who did not receive intervention. Effect size was 0·3 for responsive stimulation plus enhanced nutrition (1·95, 0·75 to 3·15) and 0·2 for responsive stimulation (2·01, 0·74 to 3·28). The caregiving environment had a medium effect size of 0·3 for all interventions (responsive stimulation plus enhanced nutrition 2·99, 1·50 to 4·48; responsive stimulation alone 2·82, 1·21 to 4·43; enhanced nutrition 3·52, 1·70 to 5·34). Interpretation Responsive stimulation delivered in a community health service can improve child development and care, 2 years after the end of intervention. Future analyses of these data are needed to identify which children and families benefit more or less over time. Funding Grand Challenges Canada.