Scaling Early Childhood Development – what to read this month (August 2024)

In this monthly blog – also available as a newsletter – we highlight recent advances in research, materials, tools and practices related to how to design, implement, monitor and evaluate scalable early childhood development (ECD) programmes in low- and middle-income countries (LMICs) worldwide. The inspiration for this new series came from Ugo Gentilini’s excellent Weekly Social Protection Links.   

Scaling Early Childhood Development – What to Read this Month is curated by Bet Caeyers (Lead Editor, Chr. Michelsen Institute), Gemma Knights (Editor, Oxford Policy Management) and Meghan Taylor (Editor, Oxford Policy Management). 

We open this month’s edition with Boo, Ferro and Carneiro’s experimental evaluation of an at-scale government-implemented home visiting programme in Brazil’s fourth largest city, Fortaleza. The weekly Programa Cresça com seu Filho (PCCSF) parenting programme, integrated into the work of existing community health workers, was launched in 2014 and now serves nearly 30,000 children aged 0–3. With a monthly cost of USD 14.71 per child, the programme had a moderately positive effect on responsive caregiving but had no impact on parental use of stimulating activities or child development. This is likely due to low visit compliance because of a high workload among community health workers and insufficient incentives. On average per beneficiary family, the community health workers conducted only 2 of the 40 additional home visits that they were expected to carry out as part of the programme. 

This begs the question – how can community health worker capacity be strengthened to deliver quality child services at scale? This is the focus of Ekpin et al.’s systematic review of interventions delivered by community health workers in sub-Saharan Africa that involve at least some degree of supervision and support. The review concludes that successful interventions rely on a multitude of factors (see pages 15–17 for a full breakdown). Critical elements include effective stakeholder engagement in the design and implementation, ongoing in-service and refresher training for community health workers, integration into existing systems and continuous supervision. Quality management, use of technological tools (for supportive supervision, quality assurance, communication and client tracking), and financial incentives for community health workers were also cited as key.

Moving on to centre-based care and the release of a new handbook edited by Durning, Baker and Ramchandani – Empowering Play in Primary Education. Topics range from inclusive practices of play, play from the perspective of the researcher and the practitioner, and the pedagogy of play. Short on time? Take a look at Chapter 7 on BRAC Play Labs where Marian, Ahmad and Tabassum discuss the design and implementation of a low-cost, high-quality, play-based childcare centre model for children aged 3–5 in low-resource settings.

What can implementation science tell us about scaling interventions in school settings? Ryan et al.’s scoping study identifies 28 implementation factors as important for scaling (although the authors are careful not to make any causal claims). These include appropriate staff training, technical support during implementation, the benefit of feedback loops, engagement and buy-in across stakeholders, marketing and communication, and the need to invest and address logistical difficulties (including human resources, investing in organisational systems and financial capacity). See Table 7 on page 15 for the full list of criteria for successful scaling.

Another systematic review, but this time on mobile health in South Africa. Mbunge and Sibiya report positive impacts on access to health services from programmes such as MomConnect, where pregnant women and new mothers nationwide receive free maternal health messaging via SMS or WhatsApp and can access a text-based helpdesk for ratings or queries. However, lack of digital infrastructure, inadequate funding, high SMS and data costs, lack of digital skills, inadequate awareness and data security all pose a challenge to the deployment and utilisation of these innovative interventions.

How can supplementary nutrition programmes be contextualised and optimised within budget? To support India’s Supplementary Nutrition Programme (SNP), Ayoob et al. cleverly used a linear programming model to create an innovative user-friendly web-based tool that helps identify the most nutritious weekly food menus for a given context and budget (see Figure 1 for a demonstration of one utility of the tool). The optimisation tool considers local supplies, prices and dietary preferences and prioritises optimal nutrient provision at minimal cost. This is expected to become a useful tool for policymakers, implementing officials and researchers, enabling better and more efficient decisions regarding the provision and subsidisation of foods that meet nutritional requirements.

Figure 1: Demonstration of the Integrated Child Development Services-Supplementary Nutrition Programme (ICDS-SNP) tool utility. Source: Ayoob et al. (2024). Notes: (A) Each segment in the doughnut diagram represents a particular food group and the proportionate allocation of thatfood group inthe optimised hot-cooked meal (HCM) expressed as percentage of total weight of optimised foods. Details are displayed when thecursor hovers on a section, whenusing the online ICDS-SNP tool (https://www.datatools.sjri.res.in/SNP/). (B) Radar chartrepresenting the ratio of quantity of different nutrientsin the optimised HCM to their recommended values, such that the linecorresponding to 1 represents the optimised nutrient value meeting therecommended value of nutrient intake in HCM giving a ratio of 1.

What is the status (coverage and experience) of midwifery services in humanitarian and fragile settings? A new article by Dey et al. uses a mixed methods approach to answer this question, focusing on sexual, reproductive, maternal, newborn, child and adolescent health services. The study highlights a critically low density of midwives in humanitarian and fragile settings (predominant in sub-Saharan Africa). It also confirms the inherent struggle that both mothers and midwives in these settings face due to inadequate services, the complexity and risky nature of the environment (sexual violence is particularly high, for example), and insufficient resources. The authors call for a governmental prioritisation of the recruitment and retention of midwives, adequate remuneration and a strengthening of healthcare platforms more generally, which would allow midwives to focus more effectively on their specialisation and provide more focused care. 

In keeping with vulnerable, more marginalised groups, Olusanya et al. put forward a framework for developing a successful global ECD strategy for children with disabilities. The overarching goals are early identification, appropriate support and facilitation to access inclusive education. The authors maintain that a successful strategy should include a well-defined policy, which is supported by legislation, operational guidelines, a fit-for-purpose funding mechanism and a solid monitoring system.

What makes for effective ECD monitoring and can it be extended globally? A recent review by Cloney et al. considers the battery of ECD monitoring tools that are available today, alongside and in comparison to UNICEF’s Early Childhood Development Index 2030 (ECDI2030), which tracks progress in ‘the proportion of children aged 24–59 months who are developmentally on track in health, learning and psychosocial well-being, by sex’. The authors observe that several assessment tools could potentially strengthen ECDI2030 monitoring (in particular, the Early Development Instrument (EDI), the International Development and Early Learning Assessment (IDELA), the International Early Learning Study (IELS), the Measuring Early Learning Quality and Outcomes (MELQO) framework and the Global Scale for Early Development (GSED)). However, they also note that there is significant potential to enhance these assessments, particularly by expanding item pools and adopting advanced methods like item response theory (IRT).

From the measurement of ECD outcomes,we move on to the measurement of ECD drivers. A recent paper by Almas et al., published in Econometrica, convincingly argues that the assumption often made in economic modelling, that parents fully understand the process of child development, may simplify analysis but could lead to misleading conclusions. Using innovative pilot data from Tanzania, Almas et al. demonstrate that models allowing for potential distortions in parental beliefs are more realistic and provide deeper insights into the factors influencing parental behaviour. Overall, this work is crucial for advancing the field of survey measurement in household decision making and offers important considerations for evaluating the effectiveness of interventions aimed at changing household behaviours. And finally, the journal Pilot and Feasibility Studies has announced a call for papers for its new special collection, Breaking Barriers: Shaping Global Health Futures with Pilot and Feasibility Initiatives. The call is focused on submissions that address issues faced while planning, conducting and/or interpreting results of feasibility studies on health and child development in LMIC settings. Specifically, the following topics are of interest: exploring cultural and contextual sensitivities; challenges impacting the feasibility and adaptation of methodologies in LMICs; community engagement; challenges of data collection in low-resource settings; and unexpected situations and their resolution. The submission deadline is 15 December 2024. You can find out more about the call and submit your paper here.