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Integrated early childhood development (ECD) programs boost child health and developmental outcomes. However, the factors contributing to the successful implementation of such programs in informal urban settlements are not well researched. We conducted 14 focus group discussions and 13 key informant interviews with 125 caregivers of children under the age of 5 years and stakeholders, exploring their views on enablers and barriers to implementing an integrated ECD program in an informal settlement in Kenya. Strategic engagement, capacity building, transparency, fair compensation of ECD workforce, communication skills, and the need to tailor ECD programs to local realities were discussed. An equity-focused implementation approach for integrated ECD programs is timely. [ABSTRACT FROM AUTHOR]

Background: Programs supporting initiatives for children younger than three years are inadequate and not accessible to many families, particularly in resource-limited settings. Many primary caregivers have little knowledge on how to monitor the development of their children or the importance of engaging children in stimulative activities during the course of early development. Health system limitations make it difficult for health workers to educate and demonstrate stimulative engagement to caregivers. The massive use of technology can be used to facilitate access to growth and development programs for children. We developed and implemented a mobile phone technology to help caregivers monitor and stimulate their children's development in real-time. This study explored the influence that this intervention had on the caregivers' early child development (ECD) knowledge, attitudes and practices. Methods: In this qualitative cross-sectional study, we conducted interviews through eight (8) focus group discussions, three (3) key informant interviews and 9 indepth interviews among a total of 111 participants including primary caregivers (n = 87), community health volunteers (CHVs) (n = 21) health managers and workers (n = 3) to determine their attitudes and experience with the intervention with regards to improving their KAP. Interviews were audio-recorded, transcribed, and analyzed thematically. Results: Caregivers and CHVs reported that the intervention had provided them with new knowledge that positively influenced their ECD caregiving attitudes and practices. CHVs and health workers and managers reported that the intervention had provided caregivers with confidence in caring for their children while increasing their knowledge on how to monitor and stimulate their children's development. Conclusion: Mobile phone technology can be effectively used to enhance caregivers' knowledge of ECD and enable them to monitor and support their children's development in real-time. Trial registration: The trial was registered with the Pan African Clinical Trial Registry (www.pactr.org) database (ID number: PACTR201905787868050 Date: 6/05/2019. [ABSTRACT FROM AUTHOR]

Background: Evidence is needed to understand factors that influence child development and caregiving experiences, especially in marginalized contexts, to inform the development and implementation of early childhood development (ECD) interventions. This study explores caregiving practices for young children in an urban informal settlement with Kenyans and embedded refugees, and identifies factors shaping these caregiving experiences, to inform the design and development of potentially appropriate ECD interventions., Methods: A qualitative formative study, which included 14 focus group discussions (n = 125 participants), and 13 key informant interviews was conducted between August and October 2018. Purposive sampling approaches were used to select a diverse range of respondents including caregivers of children below three years of age and stakeholders of Kenyan nationality and refugees. Data were analysed using a thematic approach and the Nurturing Care Framework was used as an interpretative lens., Results: There was a fusion of traditional, religious and modern practices in the care for young children, influenced by the caregivers' culture, and financial disposition. There were mixed views/practices on nutrition for young children. For example, while there was recognition of the value for breastfeeding, working mothers, especially in the informal economy, found it a difficult practice. Stimulation through play was common, especially for older children, but gaps were identified in aspects such as reading, and storytelling in the home environment. Some barriers identified included the limited availability of a caregiver, insecurity, and confined space in the informal settlement, all of which made it difficult for children to engage in play activities. Physical and psychological forms of discipline were commonly mentioned, although few caregivers practiced and recognized the need for using non-violent approaches. Some overarching challenges for caregivers were unemployment or unstable sources of income, and, particularly for refugee caregivers, their legal status., Conclusion: These findings point to the interplay of various factors affecting optimal caregiving for young children in an urban informal settlement with Kenyans and refugees. Integrated ECD interventions are needed for such a mixed population, especially those that strive to anchor along caregivers' social support system, co-designed together with community stakeholders, that ideally focus on parent skills training promoting nurturing care and economic empowerment., (© 2024. The Author(s).)

Background: An estimated 43% of children under age 5 in low- and middle-income countries (LMICs) experience compromised development due to poverty, poor nutrition, and inadequate psychosocial stimulation. Numerous early childhood development (ECD) parenting interventions have been shown to be effective at improving ECD outcomes, at least in the short-term, but they are (a) still too expensive to implement at scale in low-resource and rural settings, and (b) their early impacts tend to fade over time. New approaches to deliver effective ECD parenting interventions that are low-cost, scalable, and sustainable are sorely needed., Methods: Our study will experimentally test a traditional in-person group-based delivery model for an evidence-based ECD parenting intervention against a hybrid-delivery model that increasingly substitutes in-person meetings with remote (mHealth) delivery via smartphones, featuring audiovisual content and WhatsApp social interactions and learning. We will assess the relative effectiveness and cost of this hybrid-delivery model compared to in-person delivery and will extend the interventions over two years to increase their ability to sustain changes in parenting behaviors and ECD outcomes longer-term. Our evaluation design is a cluster Randomized Controlled Trial (cRCT) across 90 villages and approximately 1200 households. Midline and endline surveys collected 12 and 24 months after the start of the interventions, respectively, will examine short- and sustained two-year intention-to-treat impacts on primary outcomes. We will also examine the mediating pathways using mediation analysis. We hypothesize that a hybrid-delivery ECD intervention will be lower in cost, but remote interactions among participants may be an inferior substitute for in-person visits, leaving open the question of the most cost-effective program., Discussion: Our goal is to determine the best model to maximize the intervention's reach and sustained impacts to improve child outcomes. By integrating delivery into the ongoing operations of local Community Health Promoters (CHPs) within Kenya's rural health care system, and utilizing new low-cost technology, our project has the potential to make important contributions towards discovering potentially scalable, sustainable solutions for resource-limited settings., Trial Registration: NCT06140017 (02/08/2024) AEARCTR0012704., (© 2024. The Author(s).)

Background: Fathers are often perceived to be mainly responsible for the provision of the family's economic needs. However, past studies have demonstrated that fathers' involvement in parenting has great significance for the child's holistic growth and development. Few studies have investigated fathers' roles in the nurturing care of young children, particularly responsive care and stimulation, in sub-Saharan Africa. The study reported here was carried out as part of a larger study that sought to evaluate the effectiveness of the Moments That Matter (MTM) program in improving the nurturing care of young children in rural communities in Zambia and Kenya. The MTM program uses a parenting empowerment approach to promote bonding and interactions between caregivers and their children within the home, focusing on responsive care, early learning, and security and safety so that children reach their full developmental potential. Trained volunteers facilitated monthly primary caregiver support and learning groups and ECD home visits. Fathers were encouraged to participate in the home visits and to attend some of the group meetings on specific topics. The study reported in this paper aimed to establish the impact of the parenting empowerment program in promoting more gender-equal attitudes and practices on parenting among fathers (who were not the primary caregivers). Methods: Qualitative data were collected at three time points (pre-intervention before the implementation began; mid-intervention after 6 months of implementation; and post-intervention, after 24 months). We conducted focused group discussions with primary caregivers (n = 72) and fathers (n = 24) with children below 3 years. In-depth interviews were conducted with ECD Promoters (n = 43) and faith leaders (= 20). We also conducted key informant interviews with the MTM program implementers (n = 8) and government officials (n = 5) involved in the program implementation. We employed thematic analysis to analyse the qualitative data. Results: The findings showed that the MTM program resulted in improved gender-equal parenting attitudes and practices among mothers/other primary caregivers and fathers. Study participants reported that most fathers spent more time playing and interacting with their children and were more involved in household chores due to their participation in the MTM program. Conclusion: The study findings provide evidence for policy formulation and a guide for implementation of policies that can influence changes in perceived gender roles in parenting. [ABSTRACT FROM AUTHOR]

Abstract: This study examines the association between 3 dimensions of food insecurity (timing, intensity, and duration) and 3 domains of child development (gross motor, communication, and personal social). Longitudinal data from 303 households (n = 309 children) visited 9 times over 2 years were collected. Children in households experiencing severe food insecurity 3 months prior (timing) had significantly lower gross motor (β −0.14; 95% CI [0.27, −0.0033]; p = .045), communication (β −0.16; 95% CI [−0.30, −0.023]; p = .023), and personal social (β −0.20; 95% CI [−0.33, −0.073]; p = .002) Z‐scores, using lagged longitudinal linear models controlling for current food insecurity; these results were attenuated in full models, which included maternal education, household asset index, and child anthropometry. Children in households that experienced greater aggregate food insecurity over the past 2 years (intensity) had significantly lower gross motor (β −0.047; 95% CI [−0.077, −0.018]; p = .002), communication (β −0.042; 95% CI [−0.076, −0.0073]; p = .018), and personal social (β −0.042; 95% CI [−0.074, −0.010]; p = .010) Z‐scores; these results were also attenuated in full models. Children with more time exposed to food insecurity (duration) had significantly lower gross motor (β −0.050; 95% CI [−0.087, −0.012]; p = .010), communication (β −0.042; 95% CI [−0.086, 0.0013]; p = .057), and personal social (β −0.037; 95% CI [−0.077, 0.0039]; p = .076) Z‐scores; these results were no longer significant in full models. Our findings suggest that acute and chronic food insecurity and child development are related, but that many associations are attenuated with the inclusion of relevant covariates. [ABSTRACT FROM AUTHOR]

Introduction: The Nurturing Care Framework (NCF) describes "nurturing care" as the ability of nations and communities to support caregivers and provide an environment that ensures children's good health and nutrition, protects them from threats, and provides opportunities for early learning through responsive and emotionally supportive interaction. We assessed the extent to which Kenyan government policies address the components of the NCF and explored policy/decision makers' views on policy gaps and emerging issues., Methods: A search strategy was formulated to identify policy documents focusing on early childhood development (ECD), health and nutrition, responsive caregiving, opportunities for early learning and security and safety, which are key components of the NCF. We limited the search to policy documents published since 2010 when the Kenya constitution was promulgated and ECD functions devolved to county governments. Policy/decision-maker interviews were also conducted to clarify emerging gaps from policy data. Data was extracted, coded and analyzed based on the components of the NCF. Framework analysis was used for interview data with NCF being the main framework of analysis. The Jaccard's similarity coefficient was used to assess similarities between the themes being compared to further understand the challenges, successes and future plans of policy and implementation under each of the NCF domains., Results: 127 policy documents were retrieved from government e-repository and county websites. Of these, n = 91 were assessed against the inclusion criteria, and n = 66 were included in final analysis. The 66 documents included 47 County Integrated Development Plans (CIDPs) and 19 national policy documents. Twenty policy/decision-maker interviews were conducted. Analysis of both policy and interview data reveal that, while areas of health and nutrition have been considered in policies and county level plans (coefficients >0.5), the domains of early learning, responsive caregiving and safety and security face significant policy and implementation gaps (coefficients ≤ 0.5), particularly for the 0-3 year age group. Inconsistencies were noted between county level implementation plans and national policies in areas such as support for children with disabilities and allocation of budget to early learning and nutrition domains., Conclusion: Findings indicate a strong focus on nutrition and health with limited coverage of responsive caregiving and opportunities for early learning domains. Therefore, if nurturing care goals are to be achieved in Kenya, policies are needed to support current gaps identified with urgent need for policies of minimum standards that provide support for improvements across all Nurturing Care Framework domains., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Abboah-Offei, Amboka, Nampijja, Owino, Okelo, Kitsao-Wekulo, Chumo, Muendo, Oloo, Wanjau, Mwaniki, Mutisya, Haycraft, Hughes, Griffiths and Elsey.)

Background: Community engagement is crucial for the design and implementation of community-based early childhood development (ECD) programmes. This paper aims to share key components and learnings of a community engagement process for an integrated ECD intervention. The lessons shared are drawn from a case study of urban informal settlement with embedded refugees in Nairobi, Kenya., Methods: We conducted three stakeholder meetings with representatives from the Ministry of Health at County and Sub-County, actors in the ECD sector, and United Nations agency in refugee management, a transect walk across five villages (Ngando, Muslim, Congo, Riruta and Kivumbini); and, six debrief meetings by staff from the implementing organization. The specific steps and key activities undertaken, the challenges faced and benefits accrued from the community engagement process are highlighted drawing from the implementation team's perspective., Results: Context relevant, well-planned community engagement approaches can be integrated into the five broad components of stakeholder engagement, formative research, identification of local resources, integration into local lives, and shared control/leadership with the local community. These can yield meaningful stakeholder buy-in, community support and trust, which are crucial for enabling ECD programme sustainability., Conclusion: Our experiences underscore that intervention research on ECD programmes in urban informal settlements requires a well-planned and custom-tailored community engagement model that is sensitive to the needs of each sub-group within the community to avoid unintentionally leaving anyone out., (© 2022. The Author(s).)

The first two to three years of life are critical for early child development (ECD), which affects later life trajectories in health, development, and earning potential. Global calls for early stimulation activities to support optimal development among young children are increasing and there is a need to better understand the factors associated with maternal engagement in early stimulation activities, particularly maternal mental health. This study examined important factors associated with early stimulation activities performed by mothers of children ages 0–2 in rural Kenya. Baseline cohort data from an evaluation of an integrated maternal mental health and an ECD intervention included 374 interviews with mothers of children under 24 months. Descriptive and multivariable analyses were performed. Maternal mental health was not associated with maternal early stimulation activities. Having worked in the past week was associated with more frequent early stimulation activities. At the child level, female sex was associated with more frequent early stimulation activities but prematurity at birth was associated with less frequent early stimulation activities. At the household level, ownership of children's toys and books was associated with more frequent early stimulation activities. This study indicates that both mothers and families could benefit from availability of ECD-friendly resources such as homemade toys and children's books (particularly for low-income families), and tailored messaging to support early stimulation activities for both girl and boy children and for those prematurely-born. Local governments and community-based programs can aim to both raise awareness about the importance of early childhood development and educate caregivers on specific age-appropriate early stimulation activities that promote optimal growth. Future research should also explore the reciprocal and temporal relationships between maternal mental health and early stimulation activities to inform and elucidate their potential synergistic impact on ECD. • Maternal mental health was not associated with early stimulation behaviors. • Ownership of children's toys/books was associated with early stimulation behaviors. • Prematurity at birth was associated with less frequent early stimulation behaviors. • Relevant interventions should support maternal-, child-, and household-level factors. [ABSTRACT FROM AUTHOR]

The early years are critical and inform the developmental trajectory of children. This is justifiably attracting growing policy attention. Much of this attention is focused on interventions and policies directed at parents, especially mothers. Yet emerging evidence suggests that increasing numbers of children in rapidly urbanizing low- and middle-income countries are now spending much of their day with other formal and informal childcare providers, including largely unregulated paid childcare providers. This paper summarizes the limited literature about the use of such paid childcare in low- and middle-income countries in sub-Saharan Africa, before considering possible reasons behind the lack of research evidence. Finally, key research gaps and their implications for public health practice are explored, with reference to the ongoing British Academy funded Nairobi Early Childcare in Slums research programme in Nairobi, Kenya. We argue that improving childcare may be an under-explored strategy to help some of the world's most disadvantaged children in the most important period of their lives, and that interventions in this largely informal market should be built on a rigorous research base. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

Early childhood development (ECD) parenting interventions can improve child developmental outcomes in low-resource settings, but information about their implementation lags far behind evidence of their effectiveness, hindering their generalizability. This study presents results from an implementation evaluation of Msingi Bora ("Good Foundation" in Swahili), a group-based responsive stimulation and nutrition education intervention recently tested in a cluster randomized controlled trial across 60 villages in rural western Kenya. Msingi Bora successfully improved child cognitive, receptive language, and socioemotional outcomes, as well as parenting practices. We conducted a mixed methods implementation evaluation of the Msingi Bora trial between April 2018 and November 2019 following the Consolidated Advice for Reporting ECD implementation research (CARE) guidelines. We collected qualitative and quantitative data on program inputs, outputs, and outcomes, with a view to examining how aspects of the program's implementation, such as program acceptance and delivery fidelity, related to observed program impacts on parents and children. We found that study areas had initially very low levels of familiarity or knowledge of ECD among parents, community delivery agents, and even supervisory staff from our partner non-governmental organization (NGO). We increased training and supervision in response, and provided a structured manual to enable local delivery agents to successfully lead the sessions. There was a high level of parental compliance, with median attendance of 13 out of 16 fortnightly sessions over 8 months. For delivery agents, all measures of delivery performance and fidelity increased with program experience. Older, more knowledable delivery agents were associated with larger impacts on parental stimulation and child outcomes, and delivery agents with higher fidelity scores were also related to improved parenting practices. We conclude that a group-based parenting intervention delivered by local delivery agents can improve multiple child and parent outcomes. An upfront investment in training local trainers and delivery agents, and regular supervision of delivery of a manualized program, appear key to our documented success. Our results represent a promising avenue for scaling similar interventions in low-resource rural settings to serve families in need of ECD programming. This trial is registered at ClinicalTrials.gov, NCT03548558, June 7, 2018. https://clinicaltrials.gov/ct2/show/NCT03548558., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Luoto, Lopez Garcia, Aboud, Singla, Zhu, Otieno and Alu.)

Malaria is a leading cause of morbidity and mortality among children under five years of age, with most cases occurring in Sub-Saharan Africa. Children in this age group in Africa are at greatest risk worldwide for developmental deficits. There are research gaps in quantifying the risks of mild malaria cases, understanding the pathways linking malaria infection and poor child development, and evaluating the impact of malaria on the development of children under five years. We analyzed the association between malaria infection and gross motor, communication, and personal social development in 592 children age 24 months in rural, western Kenya as part of the WASH Benefits environmental enteric dysfunction sub-study. Eighteen percent of children had malaria, 20% were at risk for gross motor delay, 21% were at risk for communication delay, and 23% were at risk for personal social delay. Having a positive malaria test was associated with increased risk for gross motor, communication, and personal social delay while adjusting for child characteristics, household demographics, study cluster, and intervention treatment arm. Mediation analyses suggested that anemia was a significant mediator in the pathway between malaria infection and risk for gross motor, communication, and personal social development delays. The proportion of the total effect of malaria on the risk of developmental delay that is mediated by anemia across the subscales was small (ranging from 9% of the effect on gross motor development to 16% of the effect on communication development mediated by anemia). Overall, malaria may be associated with short-term developmental delays during a vulnerable period of early life. Therefore, preventative malaria measures and immediate treatment are imperative for children's optimal development, particularly in light of projections of continued high malaria transmission in Kenya and Africa.

Background: Forty-three percent of children under five in low and middle-income countries (LMICs) experience compromised cognitive and psychosocial development. Early childhood development (ECD) interventions that promote parent-child psychosocial stimulation and nutrition activities can help remediate early disadvantages in child development and health outcomes, but are difficult to scale. Key questions are: 1) how to maximize the reach and cost-effectiveness of ECD interventions; 2) what pathways connect interventions to parental behavioral changes and child outcomes; and 3) how to sustain impacts long-term.Methods: Msingi Bora ("good foundation" in Swahili) is a multi-arm cluster randomized controlled trial across 60 villages and 1200 households in rural Western Kenya that tests different, potentially cost-effective and scalable models to deliver an ECD intervention in biweekly sessions lasting 7 months. The curriculum integrates child psychosocial stimulation with hygiene and nutrition education. The multi-arm study will test the cost-effectiveness of two models of delivery: a group-based model versus a mixed model combining group sessions with personalized home visits. Households in a third study arm will serve as a control group. Each arm will have 20 villages and 400 households with a child aged 6-24 months at baseline. Primary outcomes are child cognitive and socioemotional development and home stimulation practices. In a 2 × 2 design among the 40 treatment villages, we will also test the role of including fathers in the intervention. We will estimate intention-to-treat and local average treatment effects, and examine mediating pathways using Mediation Analysis. One treatment arm will receive quarterly booster visits for 6 months following the end of the sessions. A follow-up survey 2 years after the end of the main intervention period will examine sustainability of outcomes and any spillover impacts onto younger siblings. Study protocols have been approved by the Maseno Ethics Review Committee (MUERC) in Kenya (00539/18) and by RAND's institutional review board. This study is funded by the National Institute for Child Health and Human Development (R01HD090045).Discussion: Results can provide policymakers with rigorous evidence of how best to design ECD interventions in low-resource rural settings.Trial Registration: Clinical Trial NCT03548558 registered June 7, 2018 at clinicaltrials.gov; AEA-RCT registry AEARCTR-0002913. [ABSTRACT FROM AUTHOR]