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Although prior reviews have documented the effectiveness of engaging male caregivers in early childhood interventions, little is known about how these interventions have been designed and implemented to reach, engage, and support male caregivers in low-resource global settings. We searched five bibliographic databases for intervention studies that engaged male caregivers to improve nurturing care for children under 5 years of age in low- and middle-income countries. Forty-four articles met the inclusion criteria, which represented 33 interventions. Fathers specifically were the most common type of male caregivers targeted in these interventions. The majority of interventions invited fathers to participate alongside their female partners. Community-based peer-groups were the most common delivery model. Most interventions used the same program structure for fathers as applied to mothers, with few considering whether implementation adaptations were needed for men. Intervention curricula were multicomponent and largely targeted child nutrition, health, and couples' relationships. A minority of programs addressed parenting, psychosocial wellbeing, violence prevention, gender attitudes, or economic support. Behavior change techniques were limited to interactive counseling and peer learning. Male caregivers remain missing from caregiving interventions for young children. A greater focus on implementation research can inform better inclusion, engagement, and support for male caregivers in nurturing care interventions.

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Despite health gains over the past 30 years, children and adolescents are not reaching their health potential in many low-income and middle-income countries (LMICs). In addition to health systems, social systems, such as schools, communities, families, and digital platforms, can be used to promote health. We did a targeted literature review of how well health and social systems are meeting the needs of children in LMICs using the framework of The Lancet Global Health Commission on high-quality health systems and we reviewed evidence for structural reforms in health and social sectors. We found that quality of services for children is substandard across both health and social systems. Health systems have deficits in care competence (eg, diagnosis and management), system competence (eg, timeliness, continuity, and referral), user experience (eg, respect and usability), service provision for common and serious conditions (eg, cancer, trauma, and mental health), and service offerings for adolescents. Education and social services for child health are limited by low funding and poor coordination with other sectors. Structural reforms are more likely to improve service quality substantially and at scale than are micro-level efforts. Promising approaches include governing for quality (eg, leadership, expert management, and learning systems), redesigning service delivery to maximise outcomes, and empowering families to better care for children and to demand quality care from health and social systems. Additional research is needed on health needs across the life course, health system performance for children and families, and large-scale evaluation of promising health and social programmes.

ImportanceApproximately 1 in 4 women experience intimate partner violence (IPV) or nonpartner sexual violence during their lifetime. Mothers exposed to IPV are more likely to experience depressive symptoms and to discipline their children harshly, which may affect their children’s socioemotional development; however, there is limited evidence on these outcomes.ObjectiveTo examine the association between IPV, maternal depressive symptoms, harsh child discipline, and child stimulation with child socioemotional development.Design, Setting, and ParticipantsThis study used cross-sectional follow-up data collected from February 19 to October 10, 2014, from a birth cohort of children aged 18 to 36 months who were enrolled in a randomized, double-blind, placebo-controlled trial of neonatal vitamin A supplementation in the Morogoro region of Tanzania. Data analysis occurred between September 10, 2019, and January 20, 2020.ExposuresLifetime experience of IPV was assessed using an abbreviated module of the Tanzania Demographic and Health Survey, maternal depressive symptoms were assessed with the Patient Health Questionnaire, and data on harsh child discipline and maternal stimulation of their children were collected using modules of the United Nations Children's Fund Multiple Indicator Cluster Survey.Main Outcomes and MeasuresChild socioemotional development was measured by the Caregiver-Reported Early Childhood Development Instruments.ResultsA total of 981 mother-child dyads were included in the analytic sample; 388 children (39.6%) were between ages 18 and 24 (mean [SD] age, 27.06 [6.08]) months, and 515 (52.5%) were male children. A negative association was observed between maternal report of physical IPV only (mean difference, −0.022; 95% CI, −0.045 to −0.006) and physical and sexual IPV (mean difference, −0.045; 95% CI, −0.077 to −0.013) with child socioemotional scores, but neither was statistically significant after including depressive symptoms in the model, which is consistent with mediation. Furthermore, a negative association was observed between maternal mild to severe depressive symptoms and child socioemotional development, including adjustment for IPV (mean difference, −0.073; 95% CI, −0.103 to −0.043). Harsh disciplinary practices and stimulation were not associated with child socioemotional development after adjusting for IPV, maternal depressive symptoms, and other factors.Conclusions and RelevanceThe findings of this study suggest that maternal depressive symptoms may explain the negative association between IPV and child socioemotional development.

The next 1000 days - the period from 2 to 5 years of age - has been highlighted as a key developmental stage in the life-course. A mapping review was conducted to categorize existing literature on interventions in the next 1000 days that promote key developmental outcomes, including publications between 1990 and July 2020. A total of 805 intervention studies were included for data extraction in the review. The number of intervention studies has increased substantially from 2010. Most interventions were from high-income countries, with few (5%) from low- and lower-middle-income countries. Interventions including typically developing children (n = 593, 74%) were mostly (80%) implemented in early childhood care and education (ECCE) settings, with 15% taking place in the home or with families and 5% in community or healthcare settings. Children's literacy and language outcomes were the target of 27% of these interventions, while 25% of interventions targeted early childhood development more holistically or targeted multiple developmental domains. Social-emotional development and social skills were the target of 15% of interventions, motor development 13%, numeracy 8% and cognitive development 8%. For children with any developmental delay, disability, disease or exposure (n = 212), interventions frequently targeted Autism Spectrum Disorder (24%), language or literacy delays (21%), developmental delays or disability more generally (20%); 16% targeted behavioral (or conduct) problems; and 5% targeted attention deficit hyperactivity disorder. Almost half (49%) took place in ECCE settings; 24% occurred in the home or with families, or in community (13%) and/or healthcare (14%) settings. This review highlights the need for more intervention research in low- and middle-income countries and for interventions supporting development in the next 1000 days. While the evidence base for interventions to promote development in this age group continues to expand, the most vulnerable children are not benefiting from this evidence.

BackgroundThe Sustainable Development Goals (SDGs) highlight the importance of investments in early childhood care and education (ECCE) for young children and youth development. Given Pakistan’s large young population, and gender and urban-rural inequalities in access to education, training and employment, such investments offer opportunities. LEAPS is a youth-led ECCE program that trains female youth, 18-24 years, as Community Youth Leaders (CYLs) to deliver high-quality ECCE for children, 3.5-5.5 years, in rural Sindh, Pakistan.MethodsWe use a stepped-wedge cluster randomized trial to evaluate implementation of LEAPS. Ninety-nine clusters will be randomized to receive the intervention in one of three seven-month steps (33 clusters/step). Primary outcomes are children’s school readiness (measured with the International Development and Early Learning Assessment) and executive functions. Secondary outcomes are youth personal and professional development, depressive symptoms, and executive functions. Data is collected in cross-sectional surveys of 1,089 children (11 children/cluster from 99 clusters) aged 4.5-5.5 years at four time points (baseline and at the end of each step). We will enroll three youth participant open cohorts, one per step (33 CYLs: 66 comparison youth per cohort; 99:198 in total). Youth cohorts will be assessed at enrollment and every six to seven months thereafter (i.e., once per consecutive Step). A school cohort of 330 LEAPS students (10 students/cluster from 33 clusters) will be enrolled and assessed during Step 1 after intervention rollout and at endline. The quality of the learning environment will be assessed in each LEAPS ECCE center and in a comparison center at two time points midway following rollout and at endline. A concurrent mixed-methods implementation evaluation will assess program fidelity and quality, as well as the extent to which a technical support strategy is successful in strengthening systems for program expansion. A cost evaluation will assess cost-per-beneficiary. Data collection for implementation and cost evaluations will occur in Step 3.DiscussionYouth-led models for ECCE offer a promising approach to support young children and youth; however, there is little empirical evidence on real-world implementation. This study will contribute to the evidence as a means to promote sustainable human development across multiple SDG targets.Trial RegistrationClinicalTrials.gov:NCT03764436. Registered December 5th, 2018,https://clinicaltrials.gov/ct2/show/NCT03764436.

The present study examines the link between children's number of older siblings and their cognitive development, as measured by executive function (EFs) skills and verbal skills (VIQ) in a sample of 1,302 4-year-old children (54% boys) living in rural Pakistan. Specifically, we investigate whether the links between the number of older siblings and preschoolers' EFs and VIQ are moderated by preschoolers' quality of home stimulation and gender. Multivariate regressions revealed that the number of older siblings was positively associated with EFs for boys in homes with both higher and lower levels of stimulation, and for girls in homes with lower levels of stimulation (

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

Early child development (ECD) programs are increasingly combined with targeted cash transfers for poor households to break intergenerational poverty. However, few evidence-based, scalable, and sustainable ECD programs that complement cash transfer programs exist in in low- and-middle-income countries. We conducted a cluster-randomized pilot study to assess whether Sugira Muryango, a strengths-based home-visiting intervention to promote child development and prevent violence among children aged 6–36 months, could be delivered by community-based lay workers to poor families participating in Rwanda’s cash-for-work Vision Umurenge Program (VUP). Data collection occurred among 38 families at baseline, endline, and 6 months after the intervention and included child-level (child engagement, caretaking, and health and development), caregiver-level (family unity and mental health) and household-level (water and sanitation practices and family conflict) outcomes. We compared trajectories of Sugira Muryango families vs. families receiving the cash transfer only over time using mixed-effect models. Sugira Muryango children experienced significantly greater ECD engagement than children in control families and marginally significant reductions in exposure to violent disciplinary methods. Sugira Muryango caregivers reported greater shared decision-making between parents and marginally significant improvements in family unity and anxiety. Conflict within intervention households halved between baseline and follow-up. Satisfaction was high. This randomized pilot demonstrates that Sugira Muryango can be delivered by community-based lay workers, improves access to nurturing care and stimulation among children living in poverty, and may reduce intra-family conflict. A large-scale effectiveness study is underway to assess the intervention’s impact on child development and health outcomes.

Performance-based measures of children's executive functions (EFs) do not capture children's application of these skills during everyday emotionally-laden and socially-mediated interactions. The current study demonstrates the value of using assessor report of self-regulation behaviors (inhibitory control and positive affect/engagement) in addition to EF tasks when studying early childhood experiences and development in a rural lower-middle-income country setting. In a sample of 1302 disadvantaged 4-year-olds living in rural Pakistan, we found that directly assessed EFs were significantly related to assessor observations of children's inhibitory control and positive affect/engagement during a structured assessment protocol. However, EFs and two types of self-regulation behaviors demonstrated unique associations with children's (1) contextual experiences, as indexed by family socio-economic resources, participation in parenting interventions, and children's physical growth; and (2) age-salient developmental outcomes, as indexed by direct assessment of pre-academic skills and maternal report of prosocial behaviors and behavior problems. First, family wealth uniquely predicted only observed positive affect/engagement, whereas maternal education uniquely predicted only EFs. Second, children's antecedent linear growth was a significant predictor of both EFs and positive affect/engagement, but exposure to an enhanced nutrition intervention during the first 2 years of life and preschoolers' hair cortisol concentration were associated only with observed self-regulation behaviors. Finally, both EFs and observed positive affect/engagement uniquely predicted children's pre-academic skills. In contrast, only assessors' ratings of positive affect/engagement uniquely predicted maternal report of prosocial behaviors and only assessors' ratings of inhibitory control uniquely predicted maternal report of behavioral problems.

Background Effective integration of home visit interventions focused on early childhood development into existing service platforms is important for expanding access in low- and middle-income countries (LMICs). We designed and evaluated a home visit intervention integrated into community health worker (CHW) operations in South Africa. Methods and findings We conducted a cluster-randomized controlled trial in Limpopo Province, South Africa. CHWs operating in ward-based outreach teams (WBOTs; clusters) and caregiver–child dyads they served were randomized to the intervention or control group. Group assignment was masked from all data collectors. Dyads were eligible if they resided within a participating CHW catchment area, the caregiver was at least 18 years old, and the child was born after December 15, 2017. Intervention CHWs were trained on a job aid that included content on child health, nutrition, developmental milestones, and encouragement to engage in developmentally appropriate play-based activities, for use during regular monthly home visits with caregivers of children under 2 years of age. Control CHWs provided the local standard of care. Household surveys were administered to the full study sample at baseline and endline. Data were collected on household demographics and assets; caregiver engagement; and child diet, anthropometry, and development scores. In a subsample of children, electroencephalography (EEG) and eye-tracking measures of neural function were assessed at a lab concurrent with endline and at 2 interim time points. Primary outcomes were as follows: height-for-age z-scores (HAZs) and stunting; child development scores measured using the Malawi Developmental Assessment Tool (MDAT); EEG absolute gamma and total power; relative EEG gamma power; and saccadic reaction time (SRT)—an eye-tracking measure of visual processing speed. In the main analysis, unadjusted and adjusted impacts were estimated using intention-to-treat analysis. Adjusted models included a set of demographic covariates measured at baseline. On September 1, 2017, we randomly assigned 51 clusters to intervention (26 clusters, 607 caregiver–child dyads) or control (25 clusters, 488 caregiver–child dyads). At endline (last assessment June 11, 2021), 432 dyads (71%) in 26 clusters remained in the intervention group, and 332 dyads (68%) in 25 clusters remained in the control group. In total, 316 dyads attended the first lab visit, 316 dyads the second lab visit, and 284 dyads the third lab visit. In adjusted models, the intervention had no significant impact on HAZ (adjusted mean difference (aMD) 0.11 [95% confidence interval (CI): −0.07, 0.30]; p = 0.220) or stunting (adjusted odds ratio (aOR) 0.63 [0.32, 1.25]; p = 0.184), nor did the intervention significantly impact gross motor skills (aMD 0.04 [−0.15, 0.24]; p = 0.656), fine motor skills (aMD −0.04 [−0.19, 0.11]; p = 0.610), language skills (aMD −0.02 [−0.18, 0.14]; p = 0.820), or social–emotional skills (aMD −0.02 [−0.20, 0.16]; p = 0.816). In the lab subsample, the intervention had a significant impact on SRT (aMD −7.13 [−12.69, −1.58]; p = 0.012), absolute EEG gamma power (aMD −0.14 [−0.24, −0.04]; p = 0.005), and total EEG power (aMD −0.15 [−0.23, −0.08]; p < 0.001), and no significant impact on relative gamma power (aMD 0.02 [−0.78, 0.83]; p = 0.959). While the effect on SRT was observed at the first 2 lab visits, it was no longer present at the third visit, which coincided with the overall endline assessment. At the end of the first year of the intervention period, 43% of CHWs adhered to monthly home visits. Due to the COVID-19 pandemic, we were not able to assess outcomes until 1 year after the end of the intervention period. Conclusions While the home visit intervention did not significantly impact linear growth or skills, we found significant improvement in SRT. This study contributes to a growing literature documenting the positive effects of home visit interventions on child development in LMICs. This study also demonstrates the feasibility of collecting markers of neural function like EEG power and SRT in low-resource settings. Trial registration PACTR 201710002683810; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=2683; South African Clinical Trials Registry, SANCTR 4407

Little is known about the COVID-19 pandemic-related disruptions in health services and the resilience of the health system response in rural low-resource settings. We conducted a phenomenological qualitative study (October–November 2020) to understand COVID-19-related influences on the utilization and delivery of child health services in Monapo district, rural Mozambique. We interviewed 36 caregivers with children

BackgroundEarly childhood development (ECD) sets the foundation for healthy and successful lives with important ramifications for education, labour market outcomes and other domains of well-being. Even though a large number of interventions that promote ECD have been implemented and evaluated globally, there is currently no standardised framework that allows a comparison of the relative cost-effectiveness of these interventions.MethodsWe first reviewed the existing literature to document the main approaches that have been used to assess the relative effectiveness of interventions that promote ECD, including early parenting and at-home psychosocial stimulation interventions. We then present an economic evaluation framework that builds on these reviewed approaches and focuses on the immediate impact of interventions on motor, cognitive, language and socioemotional skills. Last, we apply our framework to compute the relative cost-effectiveness of interventions for which recent effectiveness and costing data were published. For this last part, we relied on a recently published review to obtain effect sizes documented in a consistent manner across interventions.FindingsOur framework enables direct value-for-money comparison of interventions across settings. Cost-effectiveness estimates, expressed in $ per units of improvement in ECD outcomes, vary greatly across interventions. Given that estimated costs vary by orders of magnitude across interventions while impacts are relatively similar, cost-effectiveness rankings are dominated by implementation costs and the interventions with higher value for money are generally those with a lower implementation cost (eg, psychosocial interventions involving limited staff).ConclusionsWith increasing attention and investment into ECD programmes, consistent assessments of the relative cost-effectiveness of available interventions are urgently needed. This paper presents a unified analytical framework to address this need and highlights the rather remarkable range in both costs and cost-effectiveness across currently available intervention strategies.

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).

Health systems offer unique opportunities for integrating services to promote early child development (ECD). However, there is limited knowledge about the implementation experiences of using health services to target nurturing care and ECD, especially in sub-Saharan Africa. We conducted a qualitative implementation evaluation to assess the delivery, acceptability, perceived changes, and barriers and facilitators associated with a pilot strategy that integrated developmental monitoring, nutritional screening, and early learning and nutrition counseling into the existing health facility, and community-based services for young children in rural Mozambique. We completed individual interviews with caregivers (N = 36), providers (N = 27), and district stakeholders (N = 10), and nine facility observational visits at three primary health facilities in October-November 2020. We analyzed data using thematic content analysis. Results supported fidelity to the intended pilot model and acceptability of nurturing care services. Respondents expressed various program benefits, including strengthened health system capacity and improved knowledge, attitudes, and practices regarding nurturing care and ECD. Government leadership and supportive supervision were key facilitators, whereas health system resource constraints were key barriers. We conclude that health systems are promising platforms for supporting ECD and discuss several programmatic recommendations for enhancing service delivery and maximizing potential impacts on nurturing care and ECD outcomes.

Background Approximately 40% of children 3 to 4 years of age in low- and middle-income countries have suboptimal development and growth. Women’s empowerment may help provide inputs of nurturing care for early development and growth by building caregiver capacity and family support. We examined the associations between women’s empowerment and child development, growth, early learning, and nutrition in sub-Saharan Africa (SSA). Methods and findings We pooled data on married women (15 to 49 years) and their children (36 to 59 months) from Demographic and Health Surveys that collected data on child development (2011 to 2018) in 9 SSA countries (N = 21,434): Benin, Burundi, Cameroon, Chad, Congo, Rwanda, Senegal, Togo, and Uganda. We constructed a women’s empowerment score using factor analysis and assigned women to country-specific quintile categories. The child outcomes included cognitive, socioemotional, literacy–numeracy, and physical development (Early Childhood Development Index), linear growth (height-for-age Z-score (HAZ) and stunting (HAZ, Lilia Bliznashka and co-workers study empowerment of women and associated child health outcomes in sub-Saharan Africa., Author summary Why was this study done? Nearly 40% of children 3 to 4 years of age in low- and middle-income countries have suboptimal development and growth. Children require multiple health, nutrition, early learning, and care inputs to reach their full developmental and growth potential. Women’s empowerment may help provide these inputs by increasing shared caregiving, building caregiver capacity, and improving family support. Even though women’s empowerment is predictive of better child health, nutrition, and growth, less is known about the relationship between women’s empowerment and child development and early learning outcomes. What did the researchers do and find? We pooled Demographic and Health Surveys data from married women (15 to 49 years) and their children (36 to 59 months) in 9 sub-Saharan African countries to investigate the association between women’s empowerment and child development, growth, early learning, and nutrition outcomes. Our results showed that higher women’s empowerment was predictive of better child cognitive development, growth, and nutrition. More empowered women and their partners also had access to more learning resources and provided more stimulation activities to their child. What do these findings mean? Our findings indicate that improving women’s empowerment is one potential strategy to help provide the nutrition and early learning inputs children require to reach their full developmental and growth potential. Efforts to improve early child development and growth should consider the role of women’s empowerment in improving early learning and nutrition outcomes. Future research should assess the longitudinal and causal relationships between women’s empowerment and child development, growth, early learning, and nutrition outcomes.

Primary care services are on average of low quality in Nepal. However, there is marked variation in performance of basic clinical and managerial functions between primary health care centers. The determinants of variation in primary care performance in low- and middle-income countries have been understudied relative to the prominence of primary care in national health plans. We used the positive deviance approach to identify best and worst performing primary health care centers in Nepal and investigated perceived drivers of best performance. We selected eight primary health care centers in Province 1, Nepal, using an index of basic clinical and operational activities to identify four best and four worst performing primary health care centers. We conducted semi-structured, in-depth interviews with managers and clinical staff from each of the eight primary health care centers for a total of 32 interviews. We identified the following factors that distinguished best from worst performers: 1) Managing the facility effectively, 2) engaging local leadership, 3) building active community accountability, 4) assessing and responding to facility performance, 5) developing sources of funding, 6) compensating staff fairly, 7) managing clinical staff performance, and 8) promoting uninterrupted availability of supplies and equipment. These findings can be used to inform quality improvement efforts and health system reforms in Nepal and other similarly under-resourced health systems.

Fine motor skills enable children to make precise and coordinated movements with their hands and support their ability to engage in everyday activities and learning experiences. In a longitudinal study of 1,058 4-year-old children in rural Pakistan (n = 488 girls), we examined how prior and concurrent levels of home stimulation relate to change in fine motor skills from ages 2 to 4 while controlling for family wealth, maternal education, number of siblings at birth, prior and concurrent measures of children's physical growth and food insecurity, and prior motor skills at age 2. Moreover, we tested whether the association between early home stimulation and subsequent fine motor skills was mediated by physical growth, food insecurity, motor skills at age 2, and concurrent home stimulation. Results revealed that home stimulation at 18 months was positively associated with change in fine motor skills from ages 2 to 4, over and above family socioeconomic resources. This association was mediated by physical growth, food insecurity and motor skills at age 2. In contrast to home stimulation at 18 months, home stimulation at age 4 was positively associated with concurrent motor skills at age 4 when controlling for all antecedent family factors, as well as prior and concurrent measures of physical growth and food insecurity, and prior motor skills at age 2. Findings suggest that the preschool period may be an important window of time when physically and cognitively stimulating experiences at home uniquely relate to variability in fine motor development. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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.