UNI CEF, 2014

A SYSTEMATIC REVIEW OF PARENTING PROGRAMMES FOR YOUNG CHILDREN IN LOW AND MIDDLE INCOME COUNTRIES

AnextensiveresearchreviewofEarlyChildhoodDevelopment

parentingprogrammes,inlowandmiddle-incomecountries.The

reviewaddressestheknowledgegapandprovidesevidencefor

betterprogrammingforchildrenandfamilies.

ASystematicReviewofParentingProgrammesforYoungChildren

PiaRebelloBritto,PhDUNICEF

L.AngelicaPonguta,PhD,MPHYaleChildStudyCenter

ChinReyes,PhDYaleChildStudyCenter

RomillaKarnati,PhDConsultant,UNICEF

Dateofpublication2015

FrancesAboud,PhD McGillUniversityMarcBornstein,PhD Eunice Kennedy ShriverNational Institute

ofChildHealthandHumanDevelopmentPatriceEngle,PhD CalPolyUniversitySharonLynnKagan,PhD ColumbiaUniversityCostasMeghir,PhD YaleUniversityKylePruett,MD YaleUniversity

Funder:UNICEF

AcknowledgementsAdrian Cerezo,N. ShemrahFallon, SaimaGowani, KatherineLong,Kerrie Proulx,AnjaliRodriguesandAlexandraSoare.

CONTENTS ACRONYMLIST

EXECUTIVESUMMARY 1

Justification 1

Background 1

SummaryofResults 3

DiscussionandSummaryofthe 10

Recommendations 10

ProgrammaticRecommendations: 14

Chapter1:Introduction 15

1.1 Introduction 15

1.2 ParentsandParenting 16

1.3 DatafromtheMultipleIndicatorClusterSurvey 18

1.4 OverviewofParentingProgrammes 19

1.5 Studyobjectivesandresearchquestions 24

1.6Briefdescriptionofchaptersinthepresentreview 25

Chapter2:StudyMethods 27

2.1Literaturesearch 27

2.2Screeningcriteriaforrelevanceandeligibility 31

2.3ScreeningProcedures 33

2.4Dataextraction 36

2.5Studyevaluation 36

2.6PublicationBias 37

Chapter3: Results 39

3.1DescriptiveResults 39

3.2ProgrammeResultsbyChildandParentOutcomes 42

Chapter4:Discussion 95

4.1WhatWorksinParentingProgrammes 96

4.2Knowledgegaps 103

4.3EquitythroughParenting 107

References 108

Appendix1 145

ACRONYMLIST

ACEV-MotherandChildFoundation

ARI-AcuteRespiratoryInfection

CDW-ChildDevelopmentWorker

CONIN-CorporationforChildhoodNutrition

CRC-ConventionsontheRightsoftheChild

DHE-DentalHealthEducation

ECC–EarlyChildhoodCaries

ECD-EarlyChildhoodDevelopment

ENA-EssentialNutritionActions

IMCI-IntegratedManagementforChildhoodIllness

ITI-InternationalTrachomaInitiative

LMIC-Lowandmiddleincomecountries

MDG’s-MillenniumDevelopmentGoals

MICS-MultipleIndicatorClusterSurvey

MOCEP–MotherChildEducation

Programme

MTSP-MediumTermStrategicPlan

PICO–PopulationInterventionComparisonOutcomes

PMTCT–PreventionofMothertoChildTransmission

PROBIT-PromotionofBreastfeedingInterventionTrial

RCT–RandomControlTrials

RUTF-Ready-to-usetherapeuticfoods

SAFE-SurgeryforTrichiasis,FacialCleanlinessandEnvironmentalImprovement

TEEP–TurkeyEarlyEnrichmentProject

UNICEF-UnitedNationsChildren’s Fund

WHO-WorldHealthOrganization

EXECUTIVESUMMARY

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JUSTIFICATIONTheConventionontheRightsoftheChild(CRC)andamplescientificevidenceacknowledge

thatparentingisoneofthestrongestinfluencesonchildren,particularly,duringtheirearly

childhoodyears.Earlylifeexperiencesformthefoundationforbrainarchitectureand

scientistsnowknowthatamajoringredientinthisbraindevelopmentprocessisthe

interactionbetweenchildrenwiththeirparentsorcaregivers(CenterontheDeveloping

Child,HarvardUniversity,2015). Despitethiswidespreadrecognition,thereareseveralgaps

inourknowledgeofwhatworks,topromotepositiveparentingpractices,particularlyin

vulnerablecontexts.DatastemmingfromtheMultipleIndicatorClusterSurvey(MICS),from

LowandMiddleIncomeCountries(LMIC),suggestthatatbest,only,halfoftheparents

surveyedengageinparentingbehaviorsthatareconsideredpositiveandbeneficialforEarly

ChildhoodDevelopment(ECD).Toaddresstheseprogrammaticandknowledgegapsin

parentingpractices,UNICEFcommissionedasystematicreviewoftheliteraturetoaddress

gapsintheunderstandingofwhatpromoteseffective,sensitiveandresponsivechildrearing

andcaringpracticesthroughECDparentingprogrammesandinterventionsindifferent

national,communityandlocalcontexts. Thepurposeofthissystematicresearchreviewwas

toevaluatetheefficacyofEarlyChildhoodDevelopment(ECD)parentingprogrammesand

examinetheelementsofprogrammingthatmaximizeitsbenefitstoyoungchildrenand

theirfamilies.

BACKGROUND

Whenababyisborn,thebillionsofbraincellsareopentosculptingitselfinresponseto

earlyexperiences.Tofunction,braincellsmustbeorganizedintonetworksthatrequire

trillionsofconnections,whichdependontheinteractionbetweengenesandthe

environment. Thatoptimalenvironmentiscreatedthroughnurturingenvironmentssuch

aspositiveparenting(NationalScientificCouncilontheDevelopingChild,2004).These

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earlyconnectionsshapebraincircuitsandlaythefoundationforthedevelopmental

outcomelater.Whilegenesprovidetheblueprintfordevelopment,itistheinteraction

withtheenvironmentthatultimatelyshapesit.Theearlyyearsprovideacriticalwindowof

opportunitybutalsopresenttheriskofvulnerabilitywhenneglected.Parents,key

caregiversandfamilieshavetheinfluencingpowertodetermineachild’schancesfor

survivalanddevelopment. Rapidstridesmadebyyoungchildrenacrossalldomainsof

developmentandlearningarefosteredandsupportedthroughparents’practices,

attitudes,knowledgeandresources.Themulti-disciplinaryandtransnationalliteratureon

parentingclearlyindicatesthatparentsareoneofthemostinfluentialfactorsinchildren’s

development(Bornstein,2002;BradleyandCorwyn,2005;Rogoff,2003;Whitingand

Edwards,1998).

Poorparentingcanalterbrainchemistryandarchitectureinwaysthatreversepositive

development,notjustfortheimmediategenerationbutsubsequentgenerationsaswell

(NationalScientificCouncilontheDevelopingChild,2010).Recentworkonadverse

childhoodexperienceshasnotedtheinfluenceofriskfactorsthatcanbemediatedby

contingentandsensitiveparenting(Felitti&Anda,2008).Therefore,competentparenting

asaprotectivefactorinmoderatingriskfactorshasbeenrecognized. Parentingasa

characteristicofprimatesislinkedtotheevolutionofourspeciesandtheintergenerational

transmissionofculture,valuesandtraditions.Undeniably,parentsandkeycaregiverscould

beconsideredtheforemostandstrongestinfluenceonearlychilddevelopment(Shonkoff

&Phillips,2000).However,parentsorcaregivers,andfamiliesoftenneedsupportinbeingabletofulfilltheir

role,especially,iftheyareburdenedbyriskfactors. TheCRCwhilerecognizingthatparents

andkeycaregivershavetheprimaryresponsibilityofrearingchildren,alsorecognizethat

theyrequireassistanceincreatingthoseoptimalenvironmentsforpositivechild

development.AspertheCRC,countriesareobligatedtosupportcaregiversinthisrole

(Hodgkin&Newell,2007).

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Parentswhoareequippedwiththeknowledgeandskillstheyneedtopromotetheiryoung

child’shealthanddevelopmentareapotentiallypowerfulfactorinmitigatingtherisksof

poverty. Thequestionthenis: whatdoestheempiricalevidencesayabouttheefficacyof

ECDparentingprogrammesinLMIC,apartoftheworldthathasreceivedlittleattentioninthescientific

literature?ThisresearchpaperprovidesanextensiveandrigoroussystematicreviewofECDparenting

programmesconductedinLMIC,addressingtheknowledgegapandprovidingevidencefor

betterprogrammingforchildrenandfamilies.

SUMMARYOFRESULTSThisreportreviewed105studiesofparentingprogrammes.Thesestudieswereoperationally

definedasactivities,programmes,servicesorinterventions,forparents,aimedat

improvingparentinginteraction,behaviors,knowledge,beliefs,attitudesandpractices,

amongstchildrenaged0-8years.Theserecommendationswereintendedtoimprovethe

children’sphysicalhealthbeyondmeresurvival,encouragecognitivedevelopment,and

supporttheirsocialandemotionalwell-being.Thesystematicreviewconsistedofelectronicsearchesof10academicdatabases(including

referencelistsintheindividualstudiesidentified)aswellassearchesofthebroadergrey

literaturebetweentheyears2001-2011.Herein,wedefinegreyliteratureasreportsnot

foundinacademic,peer-reviewed,orpublishedjournals.Intheacademicsearch,multiple

disciplineswereexplored:medicineandglobalhealth,education,psychology,economics

andothersocialsciences.Searcheswereconductedusingbroadheadingsbasedonthe

geographicallocationofthestudy,thetypeofintervention,andthekindofevaluation.In

thegreyliteraturesearch,agencywebsitesweresystematicallyexplored.Keyinformant

solicitationswereconductedtoidentifyunpublishedandagencyevaluationsofECD

parentingprogrammes.StudieswereselectedforanalysisusingthePICOcriteriaaccording

topopulation,intervention,comparison(evaluationtype),andoutcome(Petticrew&

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Roberts,2006).Inter-rateragreementofthescreeningprocesswas88%(Cohen’sκ=.72),

indicatingsubstantialagreementbetweenthetworeviewers.Wedevisedaqualityscoring

systemandselected105articlesforanalysis(outofapoolof7,086studytitles).Wecoded

articlesaccordingtoprogrammecharacteristicsbasedontheirintensity,deliverymode,

deliveryapproachandcontent,staffing,andtypesofprogramme.Weincludedbothsingle-

generationprogrammesdesignedtodirectlyservecaregiversaswellasmulti-generational

programmesdesignedtoeitherservetheparentandthechildortheentirefamily.Insum,

36countriesin7regionsoftheworldwererepresentedinthissystematicreview,with

29.5%fromlow-incomecountries,33.3%fromlower-middle-incomecountries,and37.1%,

fromupper-middle-incomecountries.

WeclassifiedprogrammaticstrategiesundertwobroadECDprogrammegoals:(i)those

thatpromotednutritionandhealth;and(ii)thosethatpromotedholisticoutcomesbeyond

nutritionandhealthsuchascognitiveandsocio-emotionaldevelopment. Thesegoalswere

classifiedseparatelysincewefoundthatstudiesconductedinSub-SaharanAfricaandSouth

Asiaweremorelikelytoevaluateprogrammesaimedatimprovinghealthandnutrition,

whereasstudiesconductedinCentralandEasternEurope/CommonwealthofIndependent

States,LatinAmericaandtheCaribbeanweremorelikelytoevaluateprogrammesaimedat

improvingnon-health-relatedchilddevelopmentaloutcomes.Belowwesummarizekey

findings,firstintermsofchildoutcomesandthenintermsofparentalpractices.

Child physical wellbeing.Childnutritionandgrowthwereimprovedthroughseveral

typesofparentingprogrammes:micronutrientsupplementationprogrammes,nutrition

education,andothercomprehensivehealthandnutritionprogrammes.Toreducethe

incidenceofearlychildhoodmorbidities,especially,withrespecttodiarrheaeffective

parentingprogrammes,handwashingandbreastfeedingpromotionprogrammeswere

emphasized.Homevisitations,bytrainedparaprofessionals,arethepredominantformat

amongprogrammesthatimprovegrowthorhealthoutcomes.Findingsshowedthatgroup

settingsmustbecombinedwithothermodalitiessuchasindividualcounseling,distribution

ofpamphletsetc.Dosageshouldalsoberelativelyintensive,lastingatleastoneyear.

Programmesthataimedimprovingoralhealthweredidacticandsignificantlylessintensive

althoughpreferably,deliveredbytrainedprofessionals.Intermsofdevelopmentaltiming,

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theaverageageattimeofinterventionwasprimarilyduringthefirstyearoflifetothe

toddleryears(12-36months).

Child cognitive development.Psychosocialstimulationprogrammes,whichentail

activeengagementbetweenthecaregiverandthechild,areeffectiveinimprovingachild’s

cognitivedevelopment.Theseprogrammesinvolvedtrainedparaprofessionals,givinglive

demonstrationsthatinvolvedchildrenthroughplayactivitiesthatweretailoredaccording

tothechild’sdevelopmentallevelandthefamily’sindividualneeds.Althoughpsychosocial

stimulationprogrammesimprovedcognitiveoutcomeswhentargetingimpoverished

groups,malnourishedchildrenstillperformedwellbelowtheirnon-impoverished

counterparts.Theaverageageofchildrenparticipatingintheinterventionwasaroundone

tothreeyears.Intermsofmodalityanddose,psychosocialprogrammesaredelivered

ideallyasintensivehomevisitingprogrammesorasacombinationofgroupandindividual

sessions.Programmesdeliveredaspartofhomevisitsranbetweenoneandtwoyears,at

weekly,ormonthlyintervals.Thereisalsostrongevidenceforcombiningpsychosocial

stimulationprogrammeswithearlyeducationprogrammes.Thereispreliminaryevidence

thatnutritionalsupplementationalonemaybeinsufficientinimprovingcognitiveoutcomes

inyoungchildren.However,breastfeedingpromotioncouldbeaneffectivestrategyin

improvingcognitiveoutcomes.Thiswasdemonstratedbystudyingtheimpactonlater

cognitivedevelopment,ofchildren6.5yearsofage,fromfamiliesparticipatinginahospital-

basedbreastfeedingpromotionprogramme.

Child socioemotional outcomes. Thefrequencyofevaluationsforthisdevelopmental

domainwasrelativelylow,despitetherecognitionthatpromotingyoungchildren’ssocial

andemotionalwell-beingisessentialinbuildingstronginfrastructureforoptimal

development.Outoftheentireanalysis,onlytwoprogrammesevaluatedthesocioemotional

domain.Participationinbothprogrammesresultedingreaterinterpersonalskillsandself-

esteemandlesseranxietyanddepression.Althoughnoimpactswerefoundfor

externalizingbehaviors(antisocialbehavior,hyperactivity,andoppositionalbehaviors),

participationinaprogramme,duringtheearlyyears,resultedinlowerlikelihoodofbeing

suspendedorexpelledfromschool.

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Holistic child outcomes.Studiesimplementedinfivecountriesdemonstrated

significantoutcomesinmorethanonechilddevelopmentaldomain.Intervention

approachessreviewedinvolvedpsychosocialstimulation,integratedhealth,nutrition,and

developmentinterventions,andsocialprotectionprogrammes.Theresearchsuggeststhat

effectivestrategiesofimprovingholistichealthanddevelopmentaloutcomesinchildren

couldbeintheformofmulti-sectoralhealthandchilddevelopmentalprogrammesor

intensivepsychosocialstimulationprogrammes.Themulti-sectoralhealthandchild

developmentalprogrammeisefficientandeffectiveinimprovingahostofchildoutcomes.

Theintensivepsychosocialstimulationprogrammeentailsfrequentinteractionswith

caregiversandtheirchildren,lastingbetweenoneandtwoyears.Acrossstudies,itappears

thatdoseisimportantandhiringwell-trainedandsupervisedparaprofessionalswasacost-

effectivesolutiontodeliveringmessagestoparents.Malnourishedchildrenandyounger

agegroupsbenefitedthemostfromtheseprogrammes.Ouranalysisalsosuggeststhat

programmesincludingfathers,inthetraining,isapromisingandunderutilizedstrategy.

Thesefindingsareinagreementwithstudiesfromhigherincomecountriesthat

demonstratedstrongereffectsonbothchildandparentingbehaviorswhenfatherswere

involvedintheprogrammes.

Parenting Outcomes: Physical health-related caregiving. Atotalof20studies

addressedfouroverarchingstrategiestopromotephysicalwellbeingbytargetingparental

outcomesinrelationto(1)healthcareseekingbehaviorsandhygienepractices,(2)oral

healthpractices,(3)nutritioneducation(aloneorintegratedwithotherhealth-related

dimensions),and(4)carepractices.Programmeevaluationsrangedfrommoderatetolarge

(universal)coverage.Mostservicedeliverymodalitiescombinedmorethanoneapproach

withtheexceptionoftwoprogrammesthatutilizedonlyadidacticstrategy. Delivery

settingsalsovaried,withhomeandcommunitybeingthemostcommonformsof

programmedelivery.Datafromtwostudiessuggestthatinterpersonalcommunication,of

contextualizedandtargetedmessages,maypositivelyimpactparentalknowledgeand

specifichealthcareseekingbehaviors.Oneofthecharacteristicsoftheinterventionslikely

tobeassociatedwithpositiveimpactsonparentswasthespecificityofthehealth-related

messages.Interventionsthatusedthelocalworkforcetodeliverkeymessages,suggested

thatparaprofessionalscanimpacthealthknowledgeamongparentsofyoungchildren

bythemselvesorincombinationwithotherprofessionals.Programmescanbemore

effectiveinpromotinghealthybehaviorsiftheyarebuiltonlocalresearchanduse

contextualizeddisseminationchannels.Improvementinoralhealthknowledgecanbe

attainedthrougharangeofinterventiondosesasillustratedbytheintensityrangeofthe

programmes.Interventionsutilizinglocallyavailablefoodsdemonstratedpositiveimpact

inmicronutrientintake(forinstance,vitaminAandretinol).

Theeffectsofparentingprogrammesoncarepracticesviaantenatalprogrammesand

throughacommunity-basedapproachweremixed.Resultsfromoneoftheinterventions

suggestthatmorefrequentexposuretoeducationalmessagesthroughawiderangeof

channelsmayleadtogreaterchangesinmothers’care-seekingbehaviorduringthe

antenatalperiod.Targetedcareandhealthcareseekingpracticeswereimprovedin

responsetopaternalinterventions.However,improvementsinthesepracticesdidnot

translateintodecreaseinchildmortalityrateorchangesinchildweight.Thissuggeststhat

moreresearchisneededtounderstandthemediationofpaternalinvolvementonchild

outcomes.

Parenting Outcomes: Caregiving beyond physical care. Atotalof13studies

demonstratedimpactsoncaregivingbeyondphysicalcareandarecategorizedasfollows:(1)

childprotectionintermsofphysicalsafetyandinjuryprevention,(2)childprotectioninterms

ofabuseandneglect,(3)psychosocialstimulationandsupport,(4)responsivefeedingand

(5)integratedapproaches.Findingsfromevaluationofphysicalabuseprevention

programmessuggestthatgroup-basedprogrammesareeffectiveandusingdemonstrations

throughdidacticapproachesorviatechnologywereeffectivestrategiestodelivermessages.

Findingsfromevaluationofsafetyandpreventionprogrammessuggestthatprofessionals

areeffectivedeliverersofprogrammemessagesconcerningchildsafetyandalsochildabuse.

Itappearsthatevenshort-termprogrammesareeffective,althoughoperationalizationof

safetypracticeshasmostlybeenbasedonself-reports.Infact,onestudydemonstratedthat

theprogrammehadnoimpactonperformance-basedpractice.Responsivefeedingand

integratedprogrammeswere

1Weacknowledgethatresponsivefeedingispartofnutrition-relatedcaregiving,buthere,wefocusonthepsychosocialcomponent. 7

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also effective programmatic strategies for improving parental practices promoting child

developmentandprotection.Child and Parent Outcomes: Child Developmental Outcomes (Health) and

Associated Parenting Practices.Nineteenstudiesfoundsignificantimpactsonchild

physicalhealthandhealth-relatedcaregivingpractices.Wefoundthreestudiesof

breastfeedingpromotionprogrammesthatimpactedbothchildhealthandparenting

practices.Also,somecommunity-basedhygieneanddiseasepreventionprogrammes

utilizedavailablecommunityresourcestodisseminatehealthandhygieneinformation.

Community-basededucationprogrammesreflectedanimpactinthereductionofthe

incidenceofdisease.Theseresultsmaybesustainedwithahigherfrequencyofexposureto

therelevantmessage.Anotherimportantprogrammaticdimensionarehealth-and-nutrition

educationprogrammes.Ourreviewrevealedthatnutritioneducationprogrammesarelikely

tobemoreeffectiveifprofessionalsdeliverthemessagesintandemwiththehealth

messages.Moreover,nutritioneducationprogrammesthatareintegratedintoexisting

programmesorstructuressuchasnutritionservicesorearlychildhoodservicesaremore

effective.

Wealsorevieweddatafromeightstudiescategorizedundercomprehensivehealthand

nutritionprograms.Afewoftheprogramsreviewedcapitalizedonavailablecommunity

resources,linkingprogramstoexistingpoliciesthroughmultisectoralpartnerships,resulting

inlowerratesofstuntingandbetterparentingpractices. Fromthestudyfindings,therewas

noaddedeffectsforsupplementaryfeedingorfoodfortificationefforts,however,thereis

someevidencethatpreventivenutritionprogramscomparedtorecuperative(i.e.,targeting

malnourishedpopulations)oneshavegreaterimpacts.Impactsonanthropometrywere

strongerforchildrenwhowereexposedtotheprogramwhentheywereyounger(6-23

months).

Child and Parent Outcomes: Child Developmental Outcomes (Non-Health)

and Associated Parenting Practices. Ourreviewofthirteenprogrammeevaluations

revealedthatintensive(atleastweeklyforaperiodofoneyear)psychosocialstimulation

programmesareeffectiveinchangingparentalpracticesandthechild’smental,socialand

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emotionaldevelopmentaloutcomes.Buttheyarenoteffectiveinalteringpsychomotor

developmentaloutcomesandanthropometricmeasuresevenwhentheseprogrammesare

integratedintoexistingnutritionprogrammes.Psychosocialstimulationstudiesshowedthat

programmes,whichrequiredirectinteractionwithchildren,aresuccessfulinimproving

children’sinformationprocessingskills,languageskills,andsocialandemotionalwell-being.

Additionally,theyalsoimprovecaregiverpracticesthatpromotechildren’scognitive,social

andemotionaldevelopment.Wediscussthelongitudinalimpactofexemplarprogrammes

anddescribeitsprogrammaticattributes(twoyearduration,deliveredbycertified

paraprofessionals,utilizingmothergroups)inthisreview.

Responsivefeedinginterventionswerealsoassessedfortheirimpactoncognitionand

developmentaloutcomes.Analysisoftheprogrammaticmodelssuggestitisimportantto

includechildreninthesessionactivitiesandfocusonspecificpracticesratherthanmerely

didacticinformationtomaximizeimpact.Integratedhealthanddevelopmentprogrammes

commonlyusedstandardizedmodulessuchasWHO’sCareforDevelopment.Other

programmesutilizedmorecontextualizedcurricula.Home-visitingwasacommonmodality

inthedeliveryofintegratedhealthanddevelopmentprogrammes.Ingeneral,programmes

wereunsuccessfulinimprovingchildren’spsychomotordevelopment,butsuccessfulin

improvingnotonlychildren’scognitiveandsocialandemotionaloutcomes,butalsoin

improvingmothers’knowledgeandpracticeofchildrearing.

Studies with no impact or predominantly mixed findings. Thereviewofcertain

studieshaveshowedeithernoimpactorpredominantlymixedfindingsontheoutcomes

ofinterest:

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• ChildHealthandParentalHealth-relatedCaregivingOutcomes:Ourreviewof14

programmaticexamplesrevealedthatoverall,parentalpracticesdonotseemto

improve,overall,ifthemodalityisprimarilydidactic:—lecture-stylewithnodirect

interactionswithchildren.Moreover,communityempowermentprogrammeswere

ineffectiveinimprovinghealthoutcomes.Additionalmodalitiesandtheneedto

developsolidconcretetheory-of-changemodels,supportforpaternalinclusionand

communityapproacheslikesuchashomevisitationsmightbenecessary.Intermsof

dosage,lowdosageprogrammes(between1and9sessions)thataredelivered

didacticallywereineffective.

• ChildDevelopmentandParentalChildRearingOutcomes:Thediscussioncomprised:threelongitudinalfollow-upstudies,twochildprotectionprogrammes,

andtwointegratedhealthanddevelopmentprogrammes.Excludingtwoofthe

threefollow-upstudies,theotherswereevaluationswherethedeliveryof

instructionwasprimarilydidactic.Theevidencesuggeststhatbreastfeeding

promotion&psychosocialstimulationprogrammeshavelongtermimpacton

cognitiveoutcomesbutnotonsocialandemotionaldevelopment.Psychosocial

stimulationprogrammesmayhavelong-termimpactonsocialandemotional

outcomeiftheyweretobecombinedwithpreschooleducation.Thefindingsalso

suggestthatthedevelopmentofsocialandemotionalskillsandgeneralwell-being

requiresprogrammestotargettheseskillsdirectlyandovertime,incontextswhere

childrenhavetousethem,suchaspreschoolsettings.

DISCUSSIONANDSUMMARYOFTHE

RECOMMENDATIONSAcrossourreviewoftheliterature,weidentifiedthreekeyprogrammaticareasforexistingECD

parentingprogrammes:Timing of the Programme.Owingtotherapidchangesduringearlychildhood,there

aresensitiveandcriticalwindowsofopportunity,arounddevelopment,thatmustbe

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accountedforwhendesigningparentingprogrammes.Breastfeedingprogrammesmust

commenceintheveryfirstmomentsofachild’slife. Psychosocialstimulationprogrammes

rangedfromwhenchildrenwereafewmonthsoldto6yearolds.Impactsonanthropometry

werestrongerforchildrenwhowereexposedtotheprogrammewhentheywereyounger.

Programme Dose (duration, frequency, and intensity): Lowdoseprogrammes

acrossduration,frequencyandintensityyieldednon-significantprogrammeimpact.

Durationofaparentingprogrammeislinkedtothetypesofoutcome. Forinstance,inorder

toimproveachild’sphysicalhealth,cognitivedevelopmentandsocialandemotional

development;thereviewsuggeststhat12monthsshouldbetheminimumdurationofa

parentingprogramme.Programmethatlastedover2yearshadamoreconsistentimpact,in

particular,amongstthevulnerableanddisadvantagedpopulations.Simultaneouslyanalysis

alsosuggeststhatshorterdurationprogrammesmayworkforparentlevelresults(for

instanceprogrammesunderoneyeartargetingharshdisciplineandoralhealthpractices).

Moreover,higherfrequencyparentingprogrammesweremoreeffectiveinimprovingparent

andchildoutcomes.Threeimportantobservationsregardingthefrequencyofexposureto

theprogrammeemerged:(i)unlikeduration,effectingparentorchildoutcomesrequiresa

similarhighfrequency;(ii)thefrequencyoftheprogrammedeliverymusttakeinto

considerationthefrequencywithwhichthefamiliesapplythelearntlessons;and(iii)the

frequencyoftheprogrammecanbepacedorphased-inwithmorefrequentexposureinthe

beginning.Intermsofintensity,orhowmuchoftheinterventionisdeliveredineachsession,

datasuggeststhatmoreintensiveapproaches,suchasthosethatincludedirectinteraction

withthechild,areneededtoimprovebothparentingleveloutcomes(e.g.theabilityofthe

caregivertobeemotionallyresponsive)andchildleveloutcomes(e.g.languageabilityofthe

childinresponsetomaternalfeedingpracticeprogrammes).

Programme modality (manner in which the parenting programme was

conducted): Astrongtheoryofchangemustguidetheprogramme’soutcomesthrough

themodalityorthemannerinwhichtheparentingprogrammewasconducted.Ourreview

showedthatchildcognitiveoutcomesweresignificantlyimprovedacrossbothhome-based

modalitiesandcenter-basedprogrammesthatusedgroupsettings.However,active

engagementbetweenthecaregiverandthechildwaskeytoimprovingchildren’scognitive

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development.Further,programmeoutcomesshouldinfluencethemodality.Forexample,in

thecaseofparentingoutcomestoimprovechildprotection,providingdemonstrationsor

examplesofcontrastingapproachestosafetyareeffectiveininformingparentalpractices.

Consistently,programmesthatusedmorethanonemodalityachievedbetterresultsthan

programmesthatonlyusedonemodality.

Service Provision.Thereareseveralprogrammequalityattributesthatshouldbetaken

intoconsideration. Aprimaryfeatureofqualityistheidentityoftheserviceproviderand

theirabilitytodelivertheprogrammeeffectively. F o r e x amp l e , authorityfiguressuch

asdoctors,nursesandeducatorswereamongthemostsuccessfulserviceprovidersin

improvingparentingoutcomes. Also,trainedlocalfemalecoordinatorswitharelatively

highlevelofeducationwereeffectiveindeliveringtheprogrammeacrosshomeandinthe

groupsettings.Further,community-basedprogrammesthatpromotehealthandnutrition

indicatethatemployinglocalleaders,suchasreligiousleaders,mightbeaviablealternative

strategy.

Knowledge Gaps and Research Priorities.Inreviewingthe105articles,keyfindings

emergedwithimportantimplicationsforprogramming.Here,wediscusstheknowledge

gapsandproposedresearchprioritiesbasedonthereviewoftheliterature:

• Socialprotectionprogrammes,suchascashtransferprogrammes,areanimportant

mechanisminmanycountriestoreachpoorfamilies.Furtherresearchisneededto

addressthefeasibilityofintegratingECDparentingeducationintocashtransfer

programmes.Researchisalsoneededtoassesstheimpactofsuchintegrationon

improvingormediatingtheeffectsofcashtransfersonchildandparentoutcomes.

• Despitethefactthatakeydeterminantofparentingisthecaregiver’swellbeingand

mentalhealth,limitedresearchaddressesthisimportantmediatorbetween

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programmeandchildoutcomes.Thus,akeyresearchpriorityinvolvesprogrammes

thataccountforthepsychological,emotionalandmentalstateofcaregivers.

• Muchliteratureisbasedonsmall-scaledemonstrationprogrammes.Itiscrucial

toaddresstheimpactofprogrammesatalargerscaleandcharacterizetheir

programmaticattributes.Ingeneralmoreresearchandevidenceisneededonthe

scalingupofECDparentingprogrammes.

• Onlythreestudiesacrosstheentirereviewlookedatfathersasrecipientsof

parentingprogrammes.Itiscrucialtoengagethefathersinprogramme

designandevaluationinkeepingwitharecentreportonpaternalinvolvement.

• Attentiontothesocialandemotionaloutcomesamongstchildrenwere

limited.Studiesexaminingsocialandemotionaldevelopmentwereaminority.

• Itisnecessarytostrengthenformativeresearchinthefield.Littledataisavailable

ontheroleofthe“demand-side”ofparentingprogrammesandwaystointegrate

culturalpreferencestotheprogrammes’designs.

• Metricsforimpactevaluationofparentingprogrammeslargelyrelyonself-report.It

isanimportantresearchprioritytooptimizeinstrumentsforevaluationaswellas

diversifytheinquiryofpotentialprogrammaticimpacts(biologicaloutcomes,

hormonalandstressoutcomesandepigeneticoutcomes).

• ThereisaneedtoconnectECDprogrammeoutcomestocrucialglobalprocesses

(suchaspeacebuilding,socialtransformation,sustainabledevelopment,academic

achievement).Multidisciplinaryand,whenpossible,longitudinalevaluationsare

requiredinLMICstobolsterECDprogramming,advocacyandsustainable

financing.

• Laborlaws,socialassistance,andfamilyleavepoliciesmaybekeymediatorsto

parentingprogrammes(e.g.foodsecurity,timespentathomeafterbirth,maternal

decision-makinginthehome,etc.).Keepingthesestructuralcharacteristicsis

importantinnotonlyunderstandingtheattributesoftheprogrammesthemselves,

butalsoinidentifyingotherentrypointsforadvocacy.

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PROGRAMMATICRECOMMENDATIONS:

ResultsfromthesystematicreviewofparentingprogrammesinLMICsuggestthe

followingprogrammaticrecommendations:

• Programmaticgoal/sshoulddeterminetheprogrammaticstrategy. Inthecase

ofchildhealthandphysicalwell-being,severaltypesofparentingprogrammessuch

asmicronutrientsupplementation,nutritioneducationandcomprehensivehealth

andnutritionprogrammeswereeffective.Similarly,oralhealthprogrammes

througheducationclassesforparentsandpsychosocialstimulationprogrammesled

byprofessionalsand/ortrainedparaprofessionalswereeffectiveapproaches.

• Themostvulnerablepopulationandyoungeragegroupsbenefitthemostfrom

ECDparentingprogrammes.Amajorityoftheinterventionstargetedthemost

vulnerablepopulation.Malnourishedchildrenandyoungeragegroupsbenefitedthe

mostfromprogrammeslikeintegratedhealthandeducationprogrammes. Basedon

thesefindings,theauthorsrecommendinterventionswithanequityfocus.

• Programmequantityor“dose”(i.e.duration,frequencyandintensity)

influencesprogrammebenefits. Thesefactorsneedtobetakeninto

considerationwhendesigningeffectiveparentingprogrammes.

• Multipleprogrammemodalities(mannerinwhichtheparentingprogramme

wasconducted)–theadoptionofseveralmodalitiessuchasdemonstrations,

practiceandproblemsolvingforprogrammingwasmoreeffectivethanusingonly

onemodality. Thus,theuseofmultiplemodalitiesistherecommendedapproach

toparentingprogrammes.

• Thequalityofserviceprovisionmatterstotheprogramme’ssuccess.

Strengtheningthecapacityofserviceprovidersareassociatedwithsignificant

positiveresultsandrecommendedforprogrammesuccess.

15

CHAPTER1:INTRODUCTION

1.1 INTRODUCTIONParentingapproaches,philosophiesandculturalconstructionsabound,butthereisone

universaltenet:theprimaryfunctionofparentingistofacilitatethesurvival,development

andwell-beingofachild.However,thisfunctionmaynotalwaysbecarriedoutinfull(dueto

anynumberofindividualand/orcontextualfactors),disruptingthemechanismbywhich

positiveparentingpromoteschildren’sabilitytoachievetheirfullpotential.Thequestionis:

whatdoestheempiricalevidencesayabouttheefficacyofearlychildhooddevelopment

(ECD)parentingprogrammesinlowandmiddleincomecountries(LMICs),partsoftheworld

thathavereceivedlessattentioninthescientificliterature?

Thereisagapinourknowledgeonprogrammaticevidenceoneffectiveparenting

programmes.First,muchoftheevidenceonprogrammaticeffectivenessisfromhigh-

incomecountries,wherethesetting,resources,personalcapacitiesandunderstandingsof

programmeimplementationvarygreatlyfromlowandmiddle-incomecountries.Therefore,

thegeneralizabilityofthefindingsislimited.Second,thereistremendousvariationinECD

parentingprogrammefocus,contentandservicedeliverymechanismstherebycreatinga

challengeindelineationofeffectivenessfactors.Third,thereislittlesystematicinformation

onthescalingupofparentingprogrammes,theirsustainabilityandintegrationintoexisting

systemsofservicedeliverytoreachthemostmarginalizedanddisadvantagedpopulations.

Finally,literatureonthedevelopmentofparentingprogrammecurriculaandcontentis

limitedandoftendoesnotinclude“bottom-up”approachesthatcouldpromoteuptakeand

sustainability,giventhatparentingrepresentsthedemandsideandsocialnorms.

UNICEFisinterestedinimprovingthedevelopmentalpotentialofallyoungchildren

throughpromotingevidence-basedparentingpractices.Tothatend,itcommissioneda

systematicreviewoftheliteraturetoaddressgapsintheunderstandingofwhatpromotes

effective,sensitiveandresponsivechildrearingandcaringpracticesthroughECDparenting

programmesandinterventionsindifferentnational,communityandlocalcontexts. This

reportpresentstheresultsofasystematicreviewandidentifieseffectivecharacteristics

andfeaturesofECDparentingprogrammesandpractices.

1.2 PARENTSANDPARENTINGThetermsparentandprimarycaregiverareusedinterchangeablyinthisreport.Theword

parent/caregiverreferstotheindividualorindividualswholookaftertheinfantandyoung

childand/orwhoprovidethebulkofthecareinahomeorfamilycontext.Althoughthis

definitionoftenassumestheparent/caregiveristhebiologicalparent;fosteroradoptive

parents,grandparents,stepparents,eldersiblingorotheradultsproximaltothechild,

mayalsobetheprimarycaregiveriftheyprovideconsistentcaretothechild(Moran,Ghate

andvanderMerwe,2004).Further,someadvocatethetermparentorparentingtodenote

long-termfamilycareandthereforeparentingembodiespastandfutureperspectivesand

deepemotionalinvolvementintherearingandsocializationofayoungchild.Inthese

ways,itisdistinguishablefromthemotivesandactivitiesofpeopleinvolvedinshortterm

orprofessionalcareofchildren(WorldHealthOrganization,2004).Weusethewordparent

orcaregiverinthisreviewbecauseitisagender-neutraltermanditdoesnotexcludenon-

biologicalprogenitors.

Parentingcanbeunderstoodasinteractions,behaviors,emotions,knowledge,attitudes,

beliefsandpracticesassociatedwithchildhealth,development,learning,protectionand

well-being(Yale-AÇEV,20122). Westernmodelsidentifyfivedomainsofparenting:

caregiving,stimulation,supportandresponsiveness,structure,andsocialization(Bradley,

2004),andtheirexpressionisinfluencedbycontextualdifferences.2MotherChildEducationFoundation(ACEV).http://www.acev.org/en/anasayfa

16

17

• Caregivingreferstothebehaviorsandpracticesofcaregivers(mothers,

siblings, fathers, child care providers and those who look after infants and young

children)toprovidefood,healthcare,stimulationandemotionalsupportnecessary

forchildren’shealthysurvival,growthanddevelopment(EngleandLhotska,1999).

• Stimulationpractices are derived from the function of stimulatingneurons

(Shonkoff and Phillips, 2000). Examples include language interaction (e.g. singing,

talking, reading); provision of learning materials and exposure to learning

opportunities (e.g., books, magazines), physical interaction (e.g. sports, playing

games)andparents’behavior,which servesas amodel for children to imitateand

emulate(Brittoetal.,2002).

• Support and responsiveness, with a foundation in early bonding, are

expressedthroughsocialandemotionalrelationships,buildingtrustandattachment

and behavioral interactions such as hugging, holding and loving physical contact

(Bowlby,1988).Responsiveparentingincludespromptresponsetoachild’sbehavior

thatisappropriatetothechild’sneedsanddevelopmentalphase(Esheletal.,2006).

Responsivefeedingpracticeshavebeenpositivelyassociatedwithyoungchildren’s

nutritionstatus(Yousafzaietal.,2013).

• Structureisassociatedwithdiscipline,supervisionandprotectionofthechild

from harm, abuse and neglect (Baumrind, 1996). These parenting interactions are

expressed throughpositivedisciplinarypractices and a safe, secure and consistent

environment.

• Socializationrelatestoparentingthatpromotesthedevelopmentofvalues,

attitudes towards life, and identity; it is often an expression of cultural, social and

religiousmoralsandexpectations(Rogoff,2003).

Although these domains have been conceptualized individually,they are highly

interdependent.Responsive feeding practices involve both caregiving and supportwhile

18

sharedbook reading includesboth stimulationand responsiveness (Britto et al., 2006). In

addition,thereisnotaone-to-onecorrespondencebetweenaparentingdomainandachild

outcomedomain.For example,whenparentsexhibit responsivenesssuch as huggingand

cuddling, they influence their children’s emotionalwellbeing, foster their development of

relationships and shape their biological systems, including nervous and immune system

functioning(McCartneyandPhillips,2006). Nutritionfeedsthebrain,stimulationsparksand

strengthensitsneuralconnections,positivehealthinteractionreducestheimpactofillness

and protection buffers it from the negative impact of stress. The synergy between these

dimensionsunderscorestheimportancenotjustofparentingbutalsoofholistic,committed

parenting.

1.3 DATAFROMTHEMULTIPLEINDICATORCLUSTER

SURVEY(MICS)ONPARENTINGTrendsinparentingfromLMICarebeingcapturedbytheMICS(UNICEF,2009).The

caregivingtrendsarealarming.Forexample,only25%ofsurveyedmotherswithinfants

lessthan6monthsofagereportedexclusivebreastfeedingthepreviousday,withthe

upperlimitat57%.Thismeansthat,atbest,justoverhalfofchildreninthisagerangewere

breastfed(Arabietal.,2012).Similarly,withrespecttostimulation,theMICS3results

indicatethatinthethreedayspriortothesurvey,onanaverage,onlyonequarterof

mothersreadtotheirchild,slightlyoverathirdtoldstoriesandclosetohalf(47%)engaged

incounting,namingandotherlearningactivitieswiththeirchild(BornsteinandPutnick,

2012).However,mothersreportedhigherincidencesofsinging(50%)andplaying(64%)

withtheirchildrenduringthistime.Theresultsinthedomainofstructureareequally

alarming.66%percentofcaregiversreportedthat,inthemonthpriortothesurvey,their

childhadexperiencedpsychologicalaggression;63%reportedtheirchildexperiencedmild

physicaldiscipline,while16%reportedanexperienceofseverephysicaldiscipline.Only18%

ofcaregiversreportedthatnooneinthehouseholdhadusedaviolentformofdisciplinein

thepreviousmonth(LansfordandDeater-Deckard,2012).

19

Inconclusion,theseresultssuggestthatatbest,onlyhalfofparents(interviewedthrough

theMICS)engageinparentingbehaviorsthatareconsideredpositiveandbeneficialfor

ECD(BrittoandUlkuer,2012).

1.4 OVERVIEWOFPARENTINGPROGRAMSParentingsupporthasalwaysexisted(e.g.throughinformalkinshipandfamilynetworks),

butformalrecognitionoftheneedtosupportparentswasestablishedthroughthe

InternationalYearoftheFamilyin1994(UNESCO,1994).Parentingprogrammesare

typicallycategorizedtoinclude‘familysupport’,‘parenteducation’,and‘parenttraining’.

Sometimesthesetermsareusedinterchangeably.However,theydon’talwaysoverlap.For

example,sometimesparenteducationandsupportprogrammesincludenotonlyservices

thathelpparentsintheirrolebutmayalsoincludeotherservicessuchasjobtrainingor

adultliteracywhileparenteducationprogrammes,couldincludeonlyparentingeducation

services.

Supportforparentscomesfromavarietyofsources,oftenbroadlygroupedintoinformal

(fromfamily,friendsandneighbors,arisingfromparents’ownpre-existing‘natural’

networks),semi-formal(oftenprovidedthroughcommunity-basedorganizations,and

generallybythevoluntarysector),andformalsupport(organizedservices,oftenneeds-

based,andprovidedbythestatutorysectoraloneorinpartnershipwiththevoluntary

sector)(Ghate&Hazel,2002).Althoughinformalandsemi-formalsupportisanimportant

modality,inthisreview,onlyformalsupportprogrammeswereconsideredforanalysis.

ThedimensionsacrosswhichprogrammesvarycanbesummarizedintermsofEcological

Locus,DevelopmentalFocusandProgrammeCharacteristicsreviewedinClaveland,

Corter,Pelletier,Colley,Bertrand&Jamieson(2006).

20

TheEcologicalLocusreferstohowaprogrammefitsintothesocialsystemsandcommunity

surroundingthechild(definedbyprogrammelocation,targetpopulation,whothe

participants/staffareandhowtheyinteract).TheDevelopmentalFocusreferstothefact

thatparentprogrammesmayfocusondifferentdevelopmentaldomainsinchildrenand

stagesfromprenataltoinfancytopreschoolandtransitiontoschool(theymayvaryintheir

aimintermsoftheparent’sdevelopment,fromspecificparentingskills,toteachingskills,to

relationship-building,orevenempowerment).Someprogrammesareintendedtoimprove

parents’knowledgeandpracticesrelatedtocaregiving,nutritionandchildhealth(Aboud

andAkhter,2011),whereasothersfocusonearlyeducationandlearning(Kagitçibasietal.,

2001).Therearealsoprogrammescenteredaroundthereductionofharshparentingand

violenceathome(AlHassanandLansford,2011).Somefocusonparentswithchildrenfrom

birthto3yearsold(Hamadanietal.,2006),butothersaredesignedforparentswith

childrenfromthreeyearsandolder(e.g.,Johnsonetal,2012).Typically,programmesthat

focusontheyoungeragegrouphaveahealth,nutritionand/orstimulationfocusandthose

forolderchildrenhaveasocial,learningandeducationfocus.

ProgrammeCharacteristicsincludeintensity(frequencyandduration);deliverymode

(e.g.,face-to-face,group,individual,self-instruction,media),deliveryapproachand

content(e.g.,instructionalandskills-oriented,constructivist,relationship-building,

specificityofcontent,etc.);staffing(e.g.,professional,paraprofessional),andtypesof

programmes(e.g.,familyliteracy,homevisiting,behaviormanagementandsocial

development,center-basedparentchildprogrammes). Programmescanalsobe

differentiatedbythenumberofgenerationsthatarethetargettedbeneficiaries.Single-

generationprogrammesaredesignedtodirectlyservemothers(e.g.breastfeeding

programmes)and/orfathers(Cowanetal.,2007),whilemulti-generationalprogrammes

eitherservetheparentandthechildortheentirefamily(Wasik,2012).Programmesalso

differbasedonsetting:home-based(MotherChildEducationFoundation),clinic-based

(Needleman,1991),community-based(ThompsonandHarutyunyan,2009)andothersa

combinationofdeliverysettings.Programmescanalsobedifferentiatedbythedegreeof

standardizationwithintheircurriculum.Somefollowaverystructuredcurriculumwith

weeklylessonsplansanda

21

detailedscriptfortheserviceproviders.Othersarelessformalwithdiscussiontopics

generatedaroundparticipantneedsandinterests.

OuranalysisoftheliteratureprobedfortheEcologicalLocus,DevelopmentalFocus,and

ProgrammeCharacteristicsspecifiedintheprogrammeevaluations.Theoperational

definitionofanECDparentingprogramme,inthisreview,isanactivity,programme,service

orinterventionforparentsaimedatimprovingparentinginteraction,behaviors,knowledge,

beliefs,attitudesandpracticeswithchildren0-8yearsofage,soastoimprovetheirphysical

healthbeyondsurvival,cognitive,socialandemotionalwell-being.

Lately,parentingprogrammeshavebeeninthefocus,andconsequentlythereisagrowing

bodyofrelatedliterature. Inthelate1990s,theWorldHealthOrganization(WHO)review

ofparentingprogrammes,“ACriticalLink”,ledtotheconclusionthatthemosteffective

programmesaretheonesthatinvolveparentsandothercaregiversandfocusonchildren

whoareinthe“criticalwindow”oflifeandwhoaremostat-risk.

Inanextensivereviewofparentingprogrammesinlowandmiddle-income(LMIC)countries,

88UNICEFcountriesindicatedthattheircountryhasa“nationalprogramme”that

promotesgoodparenting(Lansford&Bornstein,2007).Afurtheranalysisof40

programmesin33ofthosecountriesrevealedinterestingdifferencesacrossthetarget

participantsserved,thedescriptionofprogrammecontentandfocus,desiredgoalsand

outcomes,thenatureofservicesprovided,theserviceproviders,andthelocationofwhere

thoseserviceswereprovidedandtheunderlyingtheoryofchange.Thesedimensionsofthe

targetageofchildrenserved(e.g.,infants,preschoolers),methodofservicedelivery(e.g.,

home-based,groups),focusoftheprogramme(e.g.,health,nutrition,cognitive

stimulation,early-education),andactorssponsoringandimplementingtheprogrammes

(e.g.,state,privatesector)havebeenvalidatedthroughareviewofECDprogrammes

implementedinLMIC(Britto,YoshikawaandBoller,2011).Basedonthereviewby

LansfordandBornstein(2007),27ofthereportedprogrammesimpactedmothers,22

impactedfathers,andasmallernumberofreportedprogrammesimpactedchildren,

schoolsandcommunities.Inmostcasestheevidencewasanecdotalandnotscientifically

rigorous.

22

Engleandothers(2011)publishedareviewof11effectivenesstrialsand4scaled-up

parentingprogrammesacrossarangeofdeliverysettings,generationoftarget

beneficiaries,curriculaandkeymessages.Theirreviewreportssubstantialpositive

outcomesforchildren(e.g.cognitive,socialandemotionaldevelopment)andtwoofthe

programmesreportsignificantimprovementinadultparentingknowledgeandthehome

environment.

Theparentingliteraturealsocoversinterventionsthatarenotfocusedonparentingandyet

haveimprovedparentingoutcomes.Forexample,socialprotectionorconditionalcash

transferprogrammesthatcombinecashandparentingserviceshavedemonstrableimpact

onparentingknowledgeandpractice(BerhmanandHoddinott,2005;Macoursetal.,2012).

Adultandfamilyliteracyprogrammeshavealsodemonstratedpositiveimpactonparent

andchildoutcomes(PadakandRasinski,2003).

Therearealsospecificprogrammemodelsthatarebeingimplementedglobally,for

example,CareforChildDevelopment(WHO/UNICEF)andMotherChildEducation

Programme(MOCEP/ACEV).CareforChildDevelopmentpackageisaholisticintervention

thatbringstogethertheessentialevidence-basedcomponentsofparentingbyaimingto

guidetheinteractionbetweenacaregiverandachildinafamilysettingtherebyimproving

thecaregivingskillsofparentsandothercaregivers.Thegoalistostrengthenfamilies’

knowledge,skillsandbeliefstoprovidethebestpossiblecare,stimulationand

environmentfortheirchildren’soptimaldevelopment.Arecentevaluation(conductedin

anexperimentalrandomizedcontrolledtrial)showedthatwithinanyearof

implementation,thechildrenoffamiliesparticipatingintheprogrammehadbetter

cognitivedevelopment,socialrelationships,emotionalbondsandlanguageand

communicationskills.Themotherswerelessdepressedandthefamilyenvironmentwas

morepositiveandstimulating(Petrovic&Yousafzai,2013).Alloftheseimpactsareamong

thestrongestpredictorsoffuturehealth,achievement,andsuccess.Thepremisebehind

theMotherChildEducationProgramme(MOCEP)isthatearlydevelopmentalneedsof

childrenmustbemetandsupportedbytheirimmediateenvironmentandparentsplayan

importantroleas"firsteducators." MOCEPhasbeendevelopedforfamilieswithchildren3

to6yearsofageandisimplementedthrougha25-weekprogrammeconductedbyACEV-

23

trainedgroupleaders,

23

alongwithaweeklycurriculumforthechildthatisimplementedathomebythemothers.

Longitudinalresultsoftheprogrammehavedemonstratedsustainedbenefitsincognitive

development,schoolachievement,schoolattainment,andsocio-emotionaldevelopment

andsocialintegration. Mothersandfamiliesalsobenefitedfromtheprogrammeinterms

ofbetterfamilyrelationsandwomen’sincreasedintra-familystatus(Kagitcibasi,Sunar&

Bekman,2001).BothCareforChildDevelopmentandMOCEParebeingimplementedin

severalcountriesaroundtheworld.

Insummary,earlychildhooddevelopment,definedastheperiodfrombirthuptoeightyears

ofage,isacriticalwindowofopportunityforachild’scognitive,social,emotionaland

physicaldevelopment.Appropriatestimulationandsupportduringearlychildhoodresultin

arangeofsocialandhealthoutcomesinthecourseoflife.Severalpreconditionsmustexist

toensurethatchildrengetthebeststartinlifeandtheopportunitytothrive,including

effective,sensitiveandresponsivecareoftheyoungchildbytheprimarycaregiver,family

andcommunity.Accordingtoanestimatetwohundredmillionorathirdoftheworld’s

youngestchildrendonotachievetheirpotentialduetolackofstimulating,nurturing,safe,

andresponsivecaregiving.Theimportanceofcaregivingcannotbeunderestimatedforearly

childdevelopment(Engleetal.,2007).However,parentsandcaregiversneedtobe

supportedinfulfillingthisrole.Theresultsfromparentingprogrammes,acrosshigh-,middle

andlow-incomecountriesindicatesignificanttrendsinobtainingpositiveresultsfor

parentsandchildren(MOCEP).However,parentingprogrammesexistwithinacomplex

landscapeandrepresentamyriadofdesigns,makingitdifficulttoisolateandcompare

effectivemechanisms. Further,evaluationsoftheseprogrammeshaveusedmixeddesigns

andoftennotrobustevaluationdesigns.Implementingeffective,scaled-upsustainable

parentingprogrammesrequiressystematicguidanceandinformationonwhatprogramme

characteristicspromoteeffective,sensitiveandresponsivechildrearingpractices,witha

specialemphasisonthemostmarginalizedfamiliesandvulnerablechildreninsupportof

UNICEF’sfocusonequity.

24

1.5 STUDYOBJECTIVESANDRESEARCHQUESTIONSTheoverarchingaimofthecurrentstudyistoidentifythemosteffectiveapproachesand

deliverymechanismsofparentingprogrammeswithaspecialfocusonthemost

marginalizedfamiliesandvulnerablechildren.ThisfocusisintandemwithUNICEF’sequity

approachinordertoprovideevidenceforbetterprogramminginaglobalcontext.Giventhe

aimsofthestudy,asystematicreviewmethodologywasconsideredappropriateand

relevant.

Systematicreviewmethodologiesweredevelopedtoovercomethebiasesthatareintrinsic

totraditionalliteraturereviews. Asystematicreviewisanexhaustiveorcomprehensive

reviewofthecurrentpublishedandunpublishedliteratureusingasetofpredetermined

criteriaandprocedures.Systematicreviewsareparticularlyusefulfortopicswherethereisa

vastamountofinformationandmanypublications. Thesystematicreviewmethodology

providesatoolforthesummaryandanalysisoftherespectiveliteraturetoanswerasetof

specificresearchquestions.Asystematicreviewisconsideredaresearchmethod

unlikeatraditionalreviewthatmerelydiscussestheliterature.Asystematicreviewfollowsa

studyprotocoltoanalyzetheliteraturetorespondtospecificresearchquestions(Petticrew

&Roberts,2006).

AccordingtotheCampbellCollaboration(2010),asystematicreviewcouldbeconsideredan

evidence-basedtoolthatusestransparentprocedurestofind,evaluate,andsynthesizethe

resultsofrelevantresearch.Theseproceduresaredesignedinadvance,similartoother

researchdesignstudies,sothatthereviewstudycanbereplicated.Further,theliteratureis

screenedforrelevanceandqualitybasedonasetofpredeterminedcriteriatoreducebias.

ThefollowingcomponentsarerecommendedbytheCampbellCollaborationfora

systematicreviewstudy:(i)anexplicitsearchstrategy;(ii)clearinclusion/exclusioncriteria;

and(iii)systematiccodingandanalysisofincludedstudies.Theaimofthissystematic

review,inparticular,istosynthesizeandanalyzemodelsofECDparentingprogrammesto

discerntheeffectivenessfactorsthatimproveparentingandchild

25

outcomes,withaspecialfocusonthemostmarginalizedfamiliesandvulnerablechildren,

inaglobalcontext.Thestudywasdesignedto:

• Provide an overview of available evaluation-based evidence of parenting

programmes,includingthemostmarginalized;

• Mapoutandcategorizeexistingprogrammesthatimproveparenting(scope,

coverage,deliverychannels,partners),includingachievements,constraintsand

lessonslearned;

• Identifythemosteffectiveapproachesanddeliverymechanisms;

• Improve understanding of the context in which parenting programmes

work/operatemosteffectively;

• Distillessonslearnedandgoodpracticesbyanalyzingwhatworksandwhatdoesnot

work (and why) in various aspects related to planning, management and

implementationofparentinginterventions.

• Identify which programmatic features such as programme dosage, programme

modality,serviceprovision,andtimingcan leadtoa theoryofchangeforeffective

programming.

1.6BRIEFDESCRIPTIONOFCHAPTERSINTHEPRESENT

REVIEWTheoverarchinggoalofthissystematicreviewistosynthesizeextantresearchonearly

childhoodparentingprogrammesinlowandmiddle-incomecountries(LMIC),wherethe

needforsuchprogrammesishighgivengrossimpoverishmentintheseglobalareas.The

reportisdividedintofourmainchapters:

• Chapter1providesthecontextualframeworkforthisreport.Itbeginswithan

introductiontoparentingfollowedbyadefinitionofkeyconcepts,thecurrent

status and overview of parenting programmes, the study objectives and

researchquestions.

26

• Chapter2 elaborateson themethodology used in the systematic review. It

includes the search strategy, inclusion criteria, and protocol for screening

data.

• Chapter 3 presents the systematic review results for LMIC, based on

descriptiveresultsandprogrammaticresults,forchildandparentoutcomes.

• Chapter 4 discusses the key findings of the review of parenting

programmes based on what constitutes effective, sensitive and responsive

childrearingandcaringpracticesthroughECDparentingprogrammes.Italso

discussestheinterventionsaswellastheknowledgegapsandfutureresearch

priorities.

27

CHAPTER2:STUDYMETHODS

2.1LITERATURESEARCHTheliteratureonECDparentingprogrammesisvastandiscoveredinbothacademicand

non-academicresources.Therefore,weconductedasystematicreviewofECDparenting

programmeevaluationsinLMICbeginningwithathree-prongsearchstrategyusingasetof

predefinedconstructs,keywords,anddiscipline-specificvocabulary.First,weconducted

electronicsearchesoftheacademicliterature(namely,peer-reviewedjournalsandreviews

ofreferencelistsinthestudiesidentified)within10databases.Multipledisciplineswere

exploredincludingmedicineandglobalhealth(Medline,EMBASE,CINHAL,GlobalHealth),

psychology(PsycINFO),socialsciences(SSCI,IBSS,andSocialServicesAbstracts),

economics(EconLit),andeducation(ERIC).Searcheswereconductedusingbroadheadings

forgeographicallocationofthestudy,typeofintervention,andtypeofevaluation(Glover

&Odato,personalcommunication).Searchstringswereadaptedtothedifferent

databases,butgenerallythesearchesincluded:(child*orearlychild*orearlyintervention

orearlylearningoryoungchild*orgirlchild*orchildcare)OR(parent*orfather*or

mother*)inconjunctionwithaproximityoperatorfollowedby(guid*ortrain*or

educationorbehav*orprogramme*orinterventionorrelation*)OR(famil*orextended

famil*orcaregiv*orgrandfather*orgrandmother*orgrandparent*orsibling*or

brother*orsister*)AND(programme*orinterv*ortrain*).

Second,toreducepotentialeffectsofpublicationbias,thebroadergreyliteraturewas

searchedthroughasystematicexplorationofagencywebsites(Table1).

28

Table1:Systematicreviewofagencywebsites

AgencyType AgenciesSearched

Multilateral

agencies/organizations

UNICEF, UNESCO, UnitedNations Population Fund,United Nations

World Food Programme, World Bank, Inter-American Development

Bank,AsianDevelopmentBank,AfricanDevelopmentBank,Save the

Children,PlanInternational,WorldVision

Foundationsand

initiatives

Aga Khan Foundation, The Gates Foundation, Bernard Van Leer

Foundation,ClintonGlobalInitiative

Relieforganizations

andcommittees

InternationalCommitteeof theRedCross, Inter-AgencyNetwork for

EducationinEmergencies,InternationalRescueCommittee,Medicine

SansFrontiers,CenterforDiseaseControl

Internationalcenters

ofexpertise

HumanSciencesResourceCouncil,AssociationfortheDevelopmentof

Africa, Young Lives, Parenting in Africa, Food Science Central - IFIS

Journals,ECDVirtualUniversity

Electronicsearcheswereconductedwithinwebsitesofagenciesandorganizationsknown

tobeactiveintheareaofECD,parenting,andhumandevelopment.Combinationsof

severalsearchtermswereadaptedtoeachagencywebsite(Table2)

29

Table2:Commonlyusedtermsinagencywebsitesearches

Exactiontermsandphrases"parenteducation""programmeevaluation"

HealthTopic:MaternalandNewbornCare

"parenteducation"evaluation

HealthTopic:MaternalandNewbornCareandKW:evaluation

"parenteducation"literaturereview

longitudinalstudyparenting

"parentprogramme" parenteducation"parenttraining" parenteducationresearch"parenttraining" parentingearlychildhoodeducation parenting"literaturereview"earlychildhoodevaluation parenting"programmeevaluation"earlychildhoodinterventions parentinganalysisearlychildhoodparentingevaluation

parentingeducation

earlychildhoodprogrammes

parentinginterventions"literaturereview"

familylifeeducation parentingprogrammeanalysisfamilyprogrammeevaluation parentingprogrammeevaluationHealthTopic:MaternalandNewbornCareandKW:evaluation

researchparentinginterventions

Third,keyinformantsolicitationswereconductedtoidentifyunpublishedandagency

evaluationsofECDparentingprogrammes(Table3).Astandardizedsolicitationemail

wassenttoProgrammeOfficersatUNICEFcountryandregionaloffices,multilateral

agencies,foundations,agencies,regionalnetworks,andassociations.

30

Table3:Listofkeyinformantsolicitations

AgencyType

Agenciestowheresolicitationwassent

Multilateralagencies/organizations

UNICEF Regional Offices: TACRO, EAPRO, ESARO, CEE/CIS, ROSA,WCARO, MENA; UNICEF Programme Offices: Child Protection,Heath,Nutrition,Education,HIV/AIDS,EvaluationOffice.

WorldBank,PlanInternational,WorldVision,SavetheChildren,AssociationfortheDevelopmentofEducationinAfrica–

Working Group on Early Childhood Development,Division forSocialPolicy&Development,ChildFundInternational

Foundations BernardvanLeerFoundation,OpenSocietyFoundations-EarlyChildhood Programme, ACEV (Mother Child EducationProgramme,AgaKhanFoundation)

Regionalnetworksandassociations

BetterCareNetwork,ECDConsultativeGroup, InternationalCentre of Education and HumanDevelopment (LatinAmerica),AsiaPacificRegionalNetworkforEarlyChildhood,ArabResourceCollective, European Early Childhood Education ResearchAssociation,InternationalStepbyStep,EuropeanAssociationonEarlyChildhoodInterventions

31

Figure1summarizesthethreesearchstagesanddatasourcesexploredinthisreview.

Ide

ntif

ica

tion

Includ

ed

Eligibility

Screen

ing

SearchesandkeyinformantconsultationswereperformedduringJuly/August2011.Figure1:SystematicReviewSearchStagesandDataSourcesExplored

Records identified

through academic

database search

(N=7,251)

Recordsidentifiedthroughothersources

(N=49)

Recordsafterduplicatesremoved(N=7,086)

Preliminaryscreeningofabstractsandtitles(N=7,086)

Recordsexcluded(failuretopasspreliminary

screening)( =6,726)

FulltextarticlesassessedforeligibilityusingPICOcriteria

(N=360)

Fulltextarticlesexcluded(failuretopassPICO

criteria)(N=255)

Studiesincluded(N=105)

2.2SCREENINGCRITERIAFORRELEVANCEANDELIGIBILITY

Asapreliminarymethodforscreening,weassessedstudyeligibilitybypublicationdate,

publicationtypeandlanguage.Onlyacademicstudiespublishedafter2001wereincluded

inordertonarrowtheanalysistorecentlypublishedstudies.Documentssuchaseditorials

andnotes,dissertations,letters,caseseries,conferencepapers,andbook

32

chaptersthatemergedfromtheacademicsearcheswereexcluded.Withingreyliterature,

onlyreportspublishedfrom2006onwardsweresearchedandscreenedinordertolimitthe

largevolumeofhitsthatcouldnotbefilteredthroughacentralizeddatabase.Publications

inEnglishandSpanishwereincludedforreview.

Followingthepreliminarymethodforscreening,next,theobtainedstudieswereselected

foranalysisusingthePICOcriteriaaccordingtopopulation,intervention,comparison

(evaluationtype),andoutcome(Petticrew&Roberts,2006):

(1)Participantsandpopulations:Tobeconsideredforinclusion,programmesmusthave

targetedcaregiversofyoungchildren(0-8yearsofage)wholiveinLMICasclassifiedunder

the2009WorldBankcountryincomeclassification

(http://data.worldbank.org/about/country-classifications). Singlegenerationprogrammes

thattargetedtheadultcaregiverinthefamily(includingparents,grandparentsandnon-

traditionalcaregiversuchaseldersinthecommunity,grandparents,and/oroldersiblings)

andtwo-generationprogrammesthattargetedboththecaregiverandthechildwere

consideredforreview.Weincludedpopulationscharacterizedbothbybiologicalrisk(i.e.,

childrenwithreversiblephysicaldisabilitiessuchaslowbirthweight)andenvironmental

risk(i.e.,childrenexposedtotoxicenvironmentsthatcannegativelyimpacttheir

developmentaloutcomesuchaspoverty)[TheConsultativeGrouponEarlyChildhoodCare

andDevelopment,1998].However,weexcludedprogrammesthattargetedpopulations

characterizedbyestablishedrisk(i.e.,childrenwithirreversiblecongenitaldisabilities)and

psychopathologybecauseofthelowergeneralizabilityoftheseinterventions.

(2)Intervention:Weincludedprogrammesthattargetedexplicitlyatleastoneofthe

followingdimensionsofparenting:caregiving,stimulation,support/responsivity,structure

andsocialization.Weexcludedprogrammesthat(i)consistedsolelyofmassmediawithno

evidenceofexplicitparentalinstruction;(ii)targetedonlymother’sempowermentand/or

mentalhealthbutnotcaregivingpractices;(iii)targetedcaregiversduringtheprenatal

periodonly.Theseexclusioncriteriawereappliedbecausewewantedtoassesstheeffects

ofprogrammeswhereparentingpracticeswereexplicitlytargeted,parentinginteractions

33

couldbeobserved,andsustainedparentingpracticesaimedat.Forinstance,weincluded

parentingsupportprogrammeswithaparentingeducationcomponentasinconditional

cashtransferprogrammesthatrequiredattendanceatparenttrainingworkshops.

(3)Evaluationdesign:ToassessECDprogrammeeffectiveness,first,weincludedimpact

evaluationstudiesfromboththeacademicandgreyliteraturethatcontainedpertinent

statisticaldata.Ameaningfulcomparisongroupmusthavebeenavailable,eitherinthe

formofcontrolgroups(experimentaldesigns),comparisongroups(quasi-experimental

designs),orwithin-groups(pre-post-testdesigns).Inaddition,theevaluationhadto

containatleast100participantsforrobustnessandgeneralizability(Terweeetal.,2012).

(4)Outcomes:Tobeincludedinthereview,theevaluationhadtoassessatleastonechildor

oneparentaloutcome(orboth).Childoutcomesincludedhealthandphysicalwell-being,

cognitivedevelopment,andsocial-emotionaldevelopment.Parentaloutcomesincluded

knowledge,attitudes,practicesbeliefs,andparentalefficacy.Programmesthatevaluated

onlyratesofimmunizationandprevalenceofbreastfeedingwereexcludedbecause

systematicevaluationsoftheseoutcomeshavebeenreviewedelsewhere(Bhuttaetal.,

2010).Moreover,programmesthatevaluatedonlytheeffectsofparentingprogrammeson

childmortalitywereexcludedbecausewewereinterestedinprogrammesthatimproved

otherdimensionsofchilddevelopmentbeyondsurvivalrates.

2.3SCREENINGPROCEDURES

Searchresultsfromacademicdatabasesandhandsearchesofreferencelistswereimported

intoareferencemanagementprogramme(EndnoteX4)whereduplicateswereremoved.

Primaryscreeningofacademicliteratureinvolvedfourreviewersscreening7,086study

titlesandabstractsfromthesearchresults.Outofthescreenedtitlesandabstracts,6,726

studieswereexcludedimmediatelyforfailingtomeetinclusioncriteria(e.g.,notan

34

ECDparentingprogrammeevaluation,notconductedinLMIC,orwrongpublication

type).Finalscreeninginvolvedtwoofthesystematicreviewauthorsassessing

independentlyeachoftheremaining360full-textarticles.Inter-rateragreementwas

88%(Cohen’sκ=.72),indicatingsubstantialagreementbetweenthetworeviewers.

ContestedarticleswerefurtherdiscussedbyapplyingPICOandfinaldecisionswere

thenmade.Ofthe360articlesthatwerepreliminarilyincluded,98articlesfromthe

academicdatabasespassedfinalscreeningforinclusionintothesystematicreview.In

additiontothearticlesobtainedfromtheacademicdatabases,agencyreportsthatmet

theinclusioncriteriawerealsoreviewed.Fortheimpactevaluations,sevenarticlesfrom

thegreyliteraturemetcriteriaforeligibilitytoassessprogrammeimpacts,totaling105

articlesincludedinthesystematicreview(98+7).Nosystematicdifferencesintermsof

studyqualitywerefoundbetweenacademicandgreyliteraturearticles(tobediscussed

indetailinthefollowingsection).Figure2describestheliteraturetypesthatwere

exploredandthesearchstrategiesapplied.

35

Figure2:Compendiumof systematicreviewresources:Literaturetypesexploredand

searchstrategiesapplied

Literature Type

Academic Grey

Medical/Global

health

Key informant

solicitation

Agency website

searches

Psychology

Multilateral agencies Multilateral agencies

Social science

Education

Economics

UNICEF Regional Offices: TACRO, EAPRO, ESARO,

CEE/CIS, ROSA, WCARO, MENA; UNICEF

Programme Offices: Child Protection, Heath,

Nutrition, Education, HIV/AIDS and Evaluation

Office. World Bank, Plan International, World

Vision, Save the Children, Association for the

Development of Education in Africa. Working

Group on Early Childhood Development, Division

for Social Policy

& Development, Child Fund International.

Foundations

Bernard van Leer Foundation, Open Society

Foundations - Early Childhood Programme,

ACEV (Mother Child Education Programme,

Aga Khan Foundation)

Regional networks and

associations Better Care Network, ECD Consultative Group,

International Centre of Education and Human

Development (Latin America), Asia Pacific

Regional Network for Early Childhood, Arab

Resource Collective, European Early Childhood

Education Research Association, International

Step by Step, European Association on Early

Childhood Interventions

UNICEF, UNESCO, United Nations Population

Fund, United Nations World Food

Programme, World Bank, Inter-American

Development Bank, Asian Development

Bank, African Development Bank, Save the

Children, Plan International, World Vision

Foundations and

initiatives Aga Khan Foundation, The Gates

Foundation, Bernard Van Leer Foundation,

Clinton Global Initiative

Relief organizations

and committees

International Committee of the Red Cross,

Inter-Agency Network for Education in

Emergencies, International Rescue

Committee, Medicine sans Frontiers,

Centers for Disease Control

International centers

of expertise

Human Sciences Resource Council,

Association for the Development of Africa,

Young Lives, Parenting in Africa, Food

36

2.4DATAEXTRACTION

Atotalof105articles(frombothacademicandgreyliterature)wereincludedfordata

extractionandanalysis.Codingsheetswereusedtostandardizedataextraction.Extraction

categoriesincludedtheprogrammeapproach(e.g.,psychosocialstimulation,nutrition

education),deliverysetting(e.g.,primaryhealthcare,communitycenter),deliveryformat

(e.g.,homevisits,grouplectures),programmecomponents(e.g.,useofprint,live

demonstrations,directinteractionswithchild),programmeimplementer(i.e.,professional

orparaprofessional),dosage,evaluationmethod(i.e.,randomornon-random),and

outcomecategories.Wecontactedstudyauthorstofillinmissingdatawheneverpossible.

Tworeaderscoded85%ofthearticlesandattendedweeklymeetingstodiscusscoding

proceduresandchallenges.Theremainingarticleswerecodedbytwooftheauthorsofthis

report,whoalsoreviewedtherestofthecodedarticles.Toensureinter-coderreliability,

15%ofthestudiesweredouble-coded(Cohen’sκ=.76).Discrepancieswerediscussed

duringtheweeklymeetings.Thestudyauthorsdeterminedcodesofcontestedarticles.

2.5STUDYEVALUATIONInthefirstphaseofthesystematicreview,thefirststepinevaluatingeachstudywasto

assessitsquality(i.e.,thestudy’smeritsandpotentialforgeneralizabilityanditsrelevance

toECDprogramminginLMIC).Wedevisedaqualityscoringsystemthatweadaptedfroma

criteriadevisedbyoutsideexperts.(Jadadetal.,1996;Terweeetal.,2012).Ourcriteria

consistedoffivebroadcategories:(1)studydesign(i.e.,participantsrandomlyassignedto

condition;presenceofcontrol/comparisongroup;atleastonepretestandoneposttest;

explicitmentionofdoubleblinding;datacollectorsblindtointervention),(2)sample(i.e.,at

leastthreedescriptionsofthesample;initialequivalencebetweengroupsassessed;

comparison/controlgroupmatchedwithprogrammegroupatbaselinewithrespectto

demographics;comparison/controlgroupmatchedwithprogrammegroupatbaselinewith

respecttooutcomesbeingassessed;sampleattritionbelow20%),(3)programme

implementation(i.e.,useofanestablishedcourseofparentingasevidencedbyauthors’

37

reportofacurriculumortrainingmanual;assessedfidelitytointervention;trainingof

parenttrainersdescribed),(4)outcomemeasures(i.e.,usedstandardizedorobjective

measuresofatleastoneoftheoutcomevariablesofinterest;post-interventionscores

testedmorethanonce;effectsizesreported),and(5)culturalresponsivity(musthave

checkedatleastoneofthefollowing:materialstranslatedintolocallanguage;

programmepractices/materialsconsistentwith—oradaptedtofitwith—localcontext,

culture,orreligion;programmeownershipgiventolocalcommunity).Codersassigned0

and1foreachitem(total17items),wherehigherscoresmeanthigherqualityratings. We

calculatedpercentagestomakeupthequalityscoreforeachstudy(M=59.12%,

SD=16.45).Nosignificantdifferenceinqualityscoringpercentageswerefoundbetween

studiesderivedfromacademicdatabases(M=59.50,SD=16.74,range=14.29-9412)and

greyliterature(M=53.73,SD=11.13,range=38.46-68.67),t(103)=0.90,ns.Thesecondstepinevaluatingfindingsineachstudywastodetermineiftheprogrammehad

a significant impact. We set the significance level at p<.05 to remain consistent as few

studies consideredp<.10as significant.Whenevera study reported significantdifferences

between study participants and non-study participants (i.e., normal populationwhowere

not in the studycomparisongroup),weusedavailabledata fromthearticle todetermine

statistical significance between programme participants and their corresponding

control/comparisonparticipants.

2.6PUBLICATIONBIASGiventhenatureofourstudy,itishighlyprobablethatevaluationsofECDparenting

programmesinLMICwereconductedbutneverpublishedinpeer-reviewedjournals.We

addressedthisissueusingthreestrategies.First,asmentionedpreviously,weincluded

studiesobtainedfromthegreyliteratureiftheymetourstandardsforinclusion.This

approachcastsawidernetofstudiesthatmayotherwisenothavebeenfoundusing

traditionalacademicsearchstrategies.Second,weincludedstudiespublishedinSpanishto

expandthenumberofhits.GiventhatECDprogrammingisgrowingrapidlyinLatinAmerica

(Vegas

38

andSantibáñez2010),includingstudiespublishedonlyinSpanishlessensthebiasin

reportingresultspublishedonlyinEnglish.Finally,weincludedinourresultsasectionon

studiesthatshowedeithernosignificantimpactorpredominantlymixedfindingsonthe

outcomesofinterest.Altogether,thesestrategies,albeitimperfect,increasethe

generalizabilityofourfindings.

39

CHAPTER3:RESULTSThe105articlesreviewedinthisstudyprovidearangeofresultswithimplicationsfor

improvingtheeffectivenessofECDProgrammesandareaswherewehaveknowledgegaps

thatneedtobeaddressedbyfutureresearch. Resultsarepresentedintwosections.First,

weprovideadescriptiveoverviewofthestudieswithinformationongeographicregionof

theworld,wheretheProgrammesarebeingimplemented,andcommonProgrammefoci

andmodalities. Inthesecondpartofthischapter,wediscusstheresultsbyoutcome

domainswheresignificantdifferenceswerefound.

3.1DESCRIPTIVERESULTSThissectionpresentsresultsofourfindings.Thirty-sixcountriesinsevenregionsofthe

worldwererepresentedinthissystematicreview:with29.5%fromlow-income,33.3%from

lower-middle-income,and37.1%,fromupper-middle-incomecountries,respectively.About

athird(31.1%)ofthestudieswereconductedinLatinAmericaandtheCaribbean

(Argentina,Belize,Brazil,Haiti,Jamaica,Mexico,Nicaragua,Paraguay,Peru,andSt.Lucia),

followedbyoveraquarter(25.7%)inSouthAsia(Bangladesh,India,Nepal,andPakistan),

11.4%inEasternandSouthernAfrica(Ethiopia,Madagascar,Malawi,SouthAfrica,

Swaziland,Uganda)9.5%inCentralandEasternEurope(Armenia,Belarus,Turkey),8.6%in

EastAsiaandthePacific(China,Philippines,Thailand,Vietnam),7.6%inSub-SaharanAfrica

(BurkinaFaso,Gambia,Niger,Nigeria,Senegal),and5.7%intheMiddleEastandNorth

Africa(Egypt,Iran,Jordan,Syria).

40

Figure3:Programmeclassificationacrossthedifferentregionsoftheworld

Thestudiesevaluatedbetween100and75,000individuals(median=470).Ofthe105

evaluations,60%(n=63)employedrandomassignment(9.5%ofwhichassignmentwasinto

differentprogrammegroupwithoutacontrolgroup),28.3%(n=30)employednon-random

assignment(quasi-experimentaldesignwithcomparisongroup),and11.3%(n=12)employed

within-subjectsdesign(ornocontrolgroup).

Asdescribedabove,weclassifiedprogrammaticstrategiesundertwobroadECD

programmegoals:(i)thosethatpromotednutritionandhealth;and(ii)thosethat

promotedholisticoutcomes(suchascognitive,psychosocialetc.)beyondnutritionand

health. TherationaleforthisclassificationislinkedwiththerealityofProgramme

implementationandrepresentationoftheProgrammeevaluation.Mostservicesfor

41

familieswithchildrenunder3

41

yearsofageareimplementedbythehealthsector.TheseProgrammestendtofocuson

healthrelatedoutcomes. Second,theliteratureonECDparentingwasbroadlydividedinto

ProgrammesthataddressedhealthandnutritionneedsandProgrammesthataddressed

otherdomainsofdevelopment. Thereforethisclassificationrepresentsthedistributionof

Programmefocusnotedintheliterature.

ECDparentingprogrammesthataimedtopromotenutritionandhealth(56.2%)consisted

ofbreastfeedingpromotion,health/nutritioneducation,micronutrientsupplementation,

hygienepromotion,diseaseprevention,oralhealthcareeducation,responsivefeeding,and

comprehensivehealthandnutrition.Comprehensivehealthandnutritionprogrammeswere

acombinationofanyofthementionedapproachesthataimtoimprovenutritionand

health.Theseprogrammesmayincludegrowthmonitoring,foodfortification,andhealth

education,forexampletheIntegratedManagementofChildhoodIllnesses,anintegrated

approachtochildhealththatfocusesonthewell-beingofthewholechildwithaprimarily

healthdrivenfocus.

Inadditiontoprogrammesthataimtopromotenutritionandhealth,otherprogrammes

aimedtopromotedomainsofchilddevelopmentotherthanhealth(43.8%).Theseincluded

psychosocialstimulation,childprotection,socialprotection(asinconditionalcashtransfer

programmes).InthiscategorywealsoincludedProgrammesthatintegratedhealthwith

development,i.e.,programmesthatcombinedhealthaimswithnon-healthchild

developmentalaims.

Certainregionsoftheworldstressedoneprogrammaticaimovertheother,χ2(6)=19.39,

p=.004(seeFigure3).StudiesconductedinSub-SaharanAfrica(87.5%)andSouthAsia

(81.5%)—regionswherefoodinsecurityandmalnutritionarepredominant—weremorelikely

toevaluateprogrammesaimedatimprovinghealthandnutrition,whereasstudies

conductedinCentralandEasternEurope/CommonwealthofIndependentStates(70.0%)

andLatinAmericaandtheCaribbean(63.6%)weremorelikelytoevaluateprogrammes

aimedatimprovingnon-health-relatedchilddevelopmentaloutcomes.

42

3.2PROGRAMRESULTSBYCHILDANDPARENTOUTCOMESWenowpresentresultsbyoutcomedomains:(1)childoutcomes(physicalwell-being,

cognitivedevelopment,socialandemotionaldevelopment,holisticdevelopment),(2)

parentoutcomes(knowledge,attitudes,andpracticesrelatedtohealth-relatedcaregiving,

caregivingbeyondphysicalcare,andacombinationofhealth-andnon-health-related

caregiving),and(3)bothchildandparentoutcomes(i.e.,comprehensiveoutcomes).(Figure

4).Programmaticdetailssuchasapproach,deliveryformatandsetting,dosage,and

implementerarediscussed.Thefinalsectionwillpresentresultsofevaluationsthatfound

noimpactorpredominantlymixedfindings.

Wearepresentingresultsseparatelyforsinglegenerationoutcomesandtwo-generation

outcomesbecausethetheoryofchangeunderlyingthesemodelsdiffer.Programmesthat

focusonsinglegenerationoutcomesmayormaynotemployafamilyfocusedecological

approach,asdiscussedinchapter1.Furthermore,theroleofparentsinmediatingchange

inchildoutcomes,isvieweddifferentlywhenonlychildrenarethefocusoftheintervention

comparedtowhenbothparentsandchildrenarethefocusoftheintervention.Finally,the

modality,doseandaimofProgrammesthattargetchildorparentoutcomesareoften

differentfromthoseprogrammesthataimtoimpactboththechildandtheparent.

43

Figure4:Resultschart

RESULTS

ChildOutcomes ParentandChildOutcomes

ParentOutcomes

ChildPhysicalHealthandWell-being(n=13)

• Micronutrients• SocialProtection• Hygiene• Breastfeeding• Oral Health

ChildPhysicalHealthandCaregivingPractices(n=19)

• Breastfeeding• Hygiene• Health&Nutrition• Comprehensive

PhysicalHealth-relatedCaregiving(n=19)

• Hygienepractices• OralHealth• Nutritioneducation• Carepractices

ChildDevelopment(n=6)

• Psychosocialstimulation

• Social&Emotional(n=2)

• PsychosocialStimulation

• IntegratedHealth,NutritionandChildDev.

• SocialProtection

ChildDevelopmentOutcomes(beyond-health)&associatedParentingPractices(n=13)

• PsychosocialStimulation

• ResponsiveFeeding

• IntegratedHealth&Development

• SocialProtection

Caregiving(beyondphysicalcare)(n=13)

• SafetyandInjuryPrevention

• PhysicalAbuse• Psychosocial

Stimulation• Responsive

44

3.2.1CHILDOUTCOMES

Childoutcomesarecategorizedintermsofthefollowingdomains:physicalwell-being(i.e.,

growth/anthropometry,morbidity,oralhealth);cognitivedevelopment(i.e.,information-

processingability,psychomotordevelopment,languagedevelopment,andacademic

achievementandperformance);socialandemotionaldevelopment(i.e.,internalizing

problems,externalizingproblems,andsocialadjustment);andholisticoutcomes(i.e.,a

combinationofoutcomesacrosstwoormoredomains).Twenty-sevenstudieswere

includedinthissection.

3.2.1.1 Child Physical Well-Being (n=13)

Inthissection,wepresentananalyticalsummaryofECDparentingprogrammesthataim

toimprovechildphysicalwell-being(SeeTable4inAppendix1).Thestudiesevaluated

between241and2,764children(median=906),spanningacrossninecountries:fourfrom

India,twofromPakistan,andoneeachfromBrazil,Iran,Malawi,Mexico,Niger,South

Africa,andVietnam.Thefollowingprogrammaticapproacheswereused:(1)micronutrient

supplementation,(2)hygienepromotion,(3)breastfeedingpromotion,(4)comprehensive

healthandnutrition,(5)oralhealthcareeducation,and(6)socialprotection.

Micronutrient Supplementation Parentalpracticesthatpromotemicronutrientintake

duringtheearlyyearsarecrucialforappropriategrowthandadequatephysical,motor,and

cognitivedevelopment.Micronutrientdeficienciesresultingfrommalnutritionmayleadto

irreversibleeffectsonbraindevelopmentandotherfunctionaloutcomes(Lozoff,Beardet

al.2006).Commonandrelatedanthropometricmeasurestoassessdelaysingrowth

trajectoriesincludestunting(height-for-agez<2),wasting(weight-for-heightz<2),and

underweight(weight-for-agez<2)(Cogill,2003).Stuntinginearlylifeisassociatedwith

impairedhealth,educationalperformance,cognitivedevelopment,andschool

achievement(DeweyandBegum,2011).Wastingoftenreflectsshort-termmalnutrition

45

(Richard,Blacketal.2012).Underweightisastrongpredictorofmortalityamongchildren

underfiveyearsofage(UNICEF2007).Oneothermeasureinassessingnutritional

developmentandstatusofdevelopingchildrenislineargrowthretardation,whichindicates

long-termexposuretonutritionaldeprivation(Allen1994).Amongthestudiesreviewed,micronutrientfortification/supplementationprogrammes

improvedgrowthandanthropometricmeasuresofchildren(Bhandari,Bahletal.2001;

Gaboulaud,Dan-Bouzouaetal.2007).Onelarge-scaletherapeuticrehabilitationprogramme

inNigersoughttoreduceseveremalnutritioninchildrenaged6-59months(Gaboulaud,

Dan-Bouzouaetal.2007).Inthisstudy,ready-to-usetherapeuticfoods(RUTF)were

distributedinhouseholds,weekly,whereparentswereinstructedtoprovidethreedaily

mealsandtwoadditionalpacketsoftheRUTF.Mealpreparationdemonstrationswere

organizedformothersatfollow-uphomevisitsforthoseassignedtothehomevisiting

group.InIndia,assignmenteithertothesupplementationgroupornutritionaleducation

groupresultedingreaterweightgainineitherinterventionrelativetothecontrolgroups

(Bhandari,Bahletal.2001).Bothprogrammeswereimplementedduringthetoddleryears

(between12-36months),onaverage,andbothprogrammesemployedprimarilydidactic

instructiontoincreaseweightgain.Dosagevariedacrossbothstudies.

Social Protection Socialprotectionprogrammessuchasconditionalcashtransfershave

beenshowntoimprovegrowthandanthropometry.Theparentingeducationcomponent

ofsuchprogrammeswaslessexplicitalthoughitwasincludedintheprogrammatic

strategy.Conditionalcashtransferprogrammesprovidemonetaryaidtofamiliesundera

contractorsetofconditions(Lindert,2005).Theconditionalcashtransferprogrammein

MexicocalledPROGRESAtargetedruralareasandwasexpandedtourbanareasundera

newname,Oportunidades(Levy,2006).Itincludedthedistributionofmicronutrient

fortifiedfoodwithhealthservicesandcashtransfertools(Rivera,Sotres-Alvarezetal.

2004).Fromanequityperspective,thePROGRESAevaluationisimportantbecausethe

nutritionalcomponentoftheprogrammeisintendedforlow-incomehouseholdsin

underprivilegedcommunitiesofSouthCentralMexico.Inourreviewoftheacademic

literature,evaluationoftheMexicanprogrammeappearedastheonlymodelof

conditionalcashtransfersthattargetednutritional

46

practicesandthatprovidedparentingeducationforcaregiversofyoungchildren.The

evaluationoftheprogrammedemonstratedthatchildrenwhowereeligibleforandenrolled

intheprogrammehadanimprovedgrowthadvantage.Inparticular,theevaluationfound

thattheeffectonheightwasstrongerininfantsyoungerthan6monthsatbaselinewholived

inthepooresthouseholds.Theparentingeducationcomponentconsistedofmandatory

sessionsonpre-andpostnatalcareaswellasnutritionandhealtheducationinadditionto

mandatoryimmunizationandwell-babycareandgrowthmonitoringsessions.

Hygiene Promotion Intermsofmorbidity,prevalenceofdiarrhealdiseaseisoften

includedasaprimaryoutcomeofinterest.Diarrhealdiseaseisasignificanthealthburden

causinganestimated1.3milliondeathseachyearinchildrenyoungerthanfiveyearsofage

(Black,Cousensetal.2010).Long-termeffectsofdiarrheaincludedecreasedphysical

fitness,delayedschoolentry,andpoorschoolperformance(Guerrant,Koseketal.2002).

Althoughcausesofinfectiousdiarrheavary,inLMICs,pathogentransmissionoccurs

primarilythroughcontactwithcontaminatedwater,viruses,andbacteria,oftenleadingto

fluidloss,dehydration,andmalnutrition(Santosham,Chandranetal.2010;Alkizim,

Mathekaetal.2011).Interventionsthatpreventthetransferofpathogens(i.e.,hygiene

promotionsuchashand-washing),increaseimmunity(i.e.,breastfeedingpromotion),and

promotethetimelyuseoftreatments(i.e.,oralrehydrationtherapy,zincsupplementation)

arecriticaltoreducingmorbidityandmortalityassociatedwithdiarrhealdiseasesamong

newborns,infants,andyoungchildren(BajaitandThawani,2011;Lamberti,Walkeretal.

2011).InPakistan,thehandwashingpromotioninterventionconsistedofthreecomponents:

demonstrations,discussionsbeforeandduringtheintervention,andpostersasrewardsfor

householdsusingsoap(Luby,Agboatwallaetal.2004).Resultsfavoredtheintervention

groups(familiessuppliedwitheitherregularorantibacterialsoap)overthecontrolgroup

withrespecttoreductionintheprevalenceandseverityofdiarrhea.Nodifferenceswere

notedwitheitherinterventiongroup,suggestingthatpromotingtheuseofeitherregular

orantibacterialsoapisaneffectivestrategyinreducingdiarrhealdiseaseinyoungchildren.

47

Breastfeeding Promotion and Comprehensive Health and Nutrition Ourfindings

revealedthatotherthanhygienepromotionprogrammes,breastfeedingpromotion

programmeshavebeenshowntolowertheratesofdiarrhea(Bhandari,Bahletal.2003)and

otherneonatalorearlychildhoodmorbidities(Sripaipan,Schroederetal.2002;Bang,

Baituleetal.2005).Moreover,breastfeedingpromotionprogrammeshavebeenfoundtobe

effectiveinimprovinganthropometricmeasureswhenbreastfeedingpromotionis

combinedwithotherinterventionapproachessuchascaregiversupport(leRoux,leRouxet

al.2010)orotherformsofcomprehensivehealthapproaches(Sripaipan,Schroederetal.

2002;Saleemi,Zamanetal.2004;Bang,Baituleetal.2005;Bang,Bangetal.2005;

Kalimbira,MacDonaldetal.2010).Forinstance,thePhilaniinterventioninSouthAfrica

stressedtheroleofrespectfulandcaringrelationshipsbetweenMentorMothersand

caregiversinadditiontoprovidinghome-basedcounseling(leRoux,leRouxetal.2010).

Indeed,thedynamic,rapport,andpersonalconnectionbetweencaregiversandprogramme

providersarekeyingredientstoprogrammaticsuccess(Forry,Moodieetal.2011).

Elsewhere,onelarge-scalehome-basedneonatalcareprogrammeinIndiaprovidesservices

topregnantwomenwhoreceivehealtheducationonthermalcare,preventionand

managementofinfections,managementofneonatalsepsis,andhealth-seekingbehaviors

inadditiontobreastfeeding(Bang,Baituleetal.2005;Bang,Bangetal.2005).Among

breastfeedingpromotionprogrammes,theprimarydeliveryformatwashomevisitsand

programmedosewasgenerallyintensive,lastingatleastuptooneyear.InIndia,local

villageworkersbelongingtotheIntegratedChildDevelopmentServicesscheme,thelargest

multi-sectoralmaternalandchildhealthandnutritionprogrammeintheworld(Kapil2002),

auxiliarynursemidwiveswhoranimmunizationclinics,andotherhealthcareproviders

(IMCI-trained)visitedmotherswithlowliteracylevels,monthly,foroneyear;thiswas

supplementedwithmonthlyneighborhoodmeetingstoreinforcethebreastfeeding

messagesledbycommunityrepresentatives(Bhandari,Bahletal.2003).InPakistan,

monthlyhomevisitslastedupto2years(Saleemi,Zamanetal.2004).Acrossthesestudies,

trainedparaprofessionalsdeliveredtheintervention.

Oral Health Care Education hasnotbeenamajorareaofinquiryintheearlychildhood

literatureinLMICeventhoughitisakeycomponentofoverallphysicalwell-being.Inthis

review,

48

twostudiesthatexaminedoralhealthoutcomesinyoungchildrenwereconductedinIran

(Mohebbi,Virtanenetal.2009)andBrazil(PereiraandFreire2004).Whereasboth

programmesfoundimprovementsintheincidenceofdentalcaries,programmemodalities

differed.IntheIranstudy,thestrategyincludedeitherdeliveryofpamphletswith

informationonfeedinghabits,sugarintake,bacteriatransmission,andoralhygiene

(“pamphletgroup”),and/orthreebi-monthlyphonecallsdeliveredduringa6-monthperiod

remindingparentsoftheoralhealthinstructionsdeliveredbyclinicstaff(“pamphlet+

reminder”).Whilethepamphlet+remindergrouphadfewerchildrenwithdentalcaries

thanthecontrolgroup,thepamphlet-onlygroupdidnotdifferwiththecontrolgroup,

signifyingthefrivolityofhandingoutpamphletsinimprovingoralhealthoutcomes.Inthe

Brazilstudy,parentsattendedthreeweeklysessionsonoralhealtheducationdeliveredby

traineddentistsandhygienists,whichresultedinadecreaseinthenumberofchildren

classifiedunderthehighcariesriskgroup.Whatwascommonbetweenthetwostudieswas

theywerebothdelivereddidacticallytoindividualparentsandwereoflowdose(three

sessionsorremindercalls).

Summary Amongstudiesthatreportedsignificantchildphysicalwell-beingoutcomes,our

findingsrevealedthatchildnutritionandgrowthareimprovedthroughseveraltypesof

parentingprogrammes:micronutrientsupplementationprogrammes,nutritioneducation,

andcomprehensivehealthandnutritionprogrammes.Toreducetheincidencesofearly

childhoodmorbiditiesespeciallydiarrhea,effectiveparentingprogrammesincludedhand

washingandbreastfeedingpromotionprogrammes.Homevisitationbytrained

paraprofessionalswasthepredominantformatamongprogrammesthatimprovegrowthor

healthoutcomes(non-oralhealth).

Moreover,findingsshowedthatgroupsettingsmustbecombinedwithothermodalitiesto

bemosteffective.Dosageshouldalsoberelativelyintensive,lastingatleastoneyearona

monthlybasis.Thesefindingssuggestthatbyhavingparentsexposedtomultiple

modalitiesforalongperiodoftime,themessageofappropriateandadequatenutrition

getsreinforced.Bycontrast,programmesthataimedtoimproveoralhealthcouldbe

didacticandsignificantlylessintensivealthoughpreferablydeliveredbytrained

professionals.In

49

termsofdevelopmentaltiming,theaverageageattimeofinterventionwasprimarily

duringthefirstyearoflifetothetoddleryears(12-36months).

Asexpected,amajorityoftheinterventionstargetedthemostvulnerablepopulations.

Programmeslikeconditionalcashtransferstargetthemostvulnerableandaretherefore

potentiallyeffectivemechanismstodeliverparentingeducationtothesepopulations.

FurtherresearchisneededtoaddressthefeasibilityofintegratingexplicitECDparenting

educationintoconditionalcashtransferprogrammesandassesstheirimpactsonimproving

ormediatingtheeffectsofcashtransfersonoutcomes.Theimpactsofthisapproachon

otheroutcomedomainsarereportedinothersectionsofthisreview.3.2.1.2 Child Cognitive Development (n=6)

Sixstudiesemergedthatshowedsignificantimpactsoncognitivedevelopment.Thesample

sizesrangedbetween103and13,889children(median=139)infivecountries:twofrom

JamaicaandoneeachfromBelarus,Brazil,SouthAfrica,andTurkey. Thesettingsinwhich

theprogrammestookplacewerehome-based,primaryhealthcaresettings,andhome-and

community-basedsettings,whichincludedhomevisitsoracombinationofhomevisitsand

groupsessions.

Psychosocial Stimulation Exceptforonestudy,theprimaryprogrammaticapproachwas

psychosocialstimulation(SeeTable4inAppendix1).Inthisapproach,primarycaregivers

aretaughttheimportanceofarangeofbehaviorsandskillsnecessarytosupportchildren’s

non-health-relateddevelopmentaloutcomes.Theseincludelearningtheimportanceof,and

usingskillsthat,promotepositiveparent-childinteractionswithchildren,providingpositive

attentionandresponsivenesstodevelopmentalmilestonesandcues,encouragingchildren’s

autonomyandexplorationoftheirenvironment,andpromotingattachment(Engleand

Lhotska,1999).Inlowresourcesettings,suchasthoseincludedinthisreview,psychosocial

stimulationactivitieswereintegratedintoafamily’sdailyroutineandcapitalizedontheuse

ofrecyclablematerialstocreatetoysforyoungchildren.

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Two examples of psychosocial stimulation programmes that combined home visits with

groupsessionswereconductedinTurkey(Bekman,Koçetal.2004)andinBrazil(Eickmann,

Limaetal.2003),theonlynon-RCTstudiesunderthecognitivedevelopmentcategory.

TheTurkishstudycombinedasummerpreschoolprogrammewithaparentingeducation

programmeformothers.Thetopicscoveredwerebroad,addressingtheholisticneedsof

youngchildren.Theparentingeducationprogrammelasted12weeks.Mothersmetonce

aweekfor2.5hoursandwereexpectedtoengageinpracticessuchasstory-tellingand

creativeactivitieswiththeirchildren,aswellasreinforcelessonschildrenlearnedintheir

preschool.Thepreschoolteachersalsoconductedhomevisitstoprovidefeedback.

InBrazil,onecommunity-basedinterventionwithahomevisitationcomponentconsisted

ofaninitialhomevisit,three3-hourworkshopsthatalsoprovidedrefreshmentsand

transportation,and10reinforcementhomevisits(totalof14contactswhenchildrenwere

betweenages13and17months).ResultsoftheTurkishandBrazilianstudiesshowed

impactsonschoolreadinessandlanguageskills(Bekman,Koçetal.2004)andmentaland

psychomotorskills(Eickmann,Limaetal.2003).

Otherprogrammescombinedpsychosocialstimulationwithnutritionsupplementation.

Twofollow-upRCTsinJamaicatestedtheefficacyofnutritionalsupplementationand

psychosocialstimulation(separatelyorcombined)inimpactingcognitiveoutcomesin

malnourishedpopulations(Gardner,Powelletal.2005;Walker,Changetal.2005).Both

studiesshowedthatsupplementationwaseffectiveinimprovingchildren’scognitive

outcomesonlywhenitwascombinedwithpsychosocialstimulation;thatis,nutritional

supplementationalonewasineffectiveinimprovingcognitivedevelopment.

Thetrainingandcredentialsoftheprogrammeprovidersweremostlytrained

paraprofessionals,althoughtwostudiesemployedprofessionals(e.g.,BrazilandSouth

Africa).IntheBrazilianpsychosocialstimulationstudy,occupationaltherapistswith

specializationsinchilddevelopmentdeliveredtheworkshopswhereastrained

paraprofessionalsperformedthehomevisits(Eickmann,Limaetal.2003).InSouthAfrica,

51

theprogrammeemployedatrainedphysiotherapisttodelivertheprogrammetolow-

incomefamilieswithyoungchildren,agesbelow2.5years,infectedwithHIV(Potterton,

Stewartetal.2010).Inthatstudy,overa12-monthperiod,thehomestimulationcurriculum

wasupdatedeverythreemonthstomatchwiththechild’sdevelopmentallevel.Although

thestudyrevealedgreaterchangeinprogrammechildren’smentaldevelopment(measured

usingBayleyScalesofInfantDevelopment—2ndedition)thancontrolchildren,the

programmechildren’smentaldevelopmentwasstillsignificantlydelayedcomparedtothe

normalpopulation.Moreover,theprogrammehadnoimpactonchildren’santhropometry.

Apartfrompsychosocialstimulationasaprogrammaticapproachinimprovingcognitive

outcomes,onestudyexaminedthelong-termimpactofabreastfeedingpromotion

programmeoncognitivedevelopment.ThisstudywasknownasthePromotionof

BreastfeedingInterventionTrial(PROBIT)interventioninBelarus,whichisthelargest

lactation-relatedRCTintheworldtodate(Kramer,Aboudetal.2008).Pediatriciansfrom

eachofthePROBIThospitalsandpolyclinicsreceivedan18-hourlactationmanagement

trainingcourse.Midwives,nurses,andphysiciansprovidedbreastfeedingsupportto

programmemothersduringlabor,delivery,thepostpartumhospitalstay,andduringvisits

tothepolyclinics.Atotalof17,046womenwithhealthyinfantswereenrolledand13,889

werefollowedupwhenchildrenwere6.5yearsofage.ResultsshowedthatPROBITchildren

scoredhigherthancontrolchildreninbothstandardizedtestsofintelligenceandteacher

ratingsofreadingandwritingperformance.

Summary Psychosocialstimulationprogrammes,whichentailactiveengagement

betweenthecaregiverandthechild,wereeffectiveinimprovingchildren’scognitive

development.Theseprogrammesinvolvedlivedemonstrationswithchildrenthroughplay

activitiesthataretailoredaccordingtothechild’sdevelopmentallevelandthefamily’s

individualneeds.Trainedparaprofessionalswereeffectiveprogrammeimplementers.

Althoughpsychosocialstimulationprogrammeswereeffectiveinimprovingcognitive

outcomeswhentargetingimpoverishedgroups,malnourishedchildrenstillperformedwell

belowtheirnon-impoverishedcounterparts.Theaverageageofinterventionwasaround

thetoddleryears.

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Intermsofdose,psychosocialprogrammesaredeliveredideallyasintensivehomevisiting

programmesorasacombinationofgroupandindividualsessions.Programmesdelivered

aspartofhomevisitsranbetweenoneandtwoyearsatweeklyormonthlyintervals.

Programmesthatwereofshorterdurationcombinedearlyeducationwiththeparenting

programme,asinthesummerpreschoolprogrammeinterventioninTurkey(Bekman,Koç

etal.2004).Ofnote,noneofthestudiesreviewedofferedgroupsessionssolely.Basedon

onecommunity-basedprogrammeinBrazil,whenofferinggroupsessions(inadditionto

homevisits),itisrecommendedthattransportationandrefreshmentsareprovided.

Providingconvenientservices—suchaschildcareserviceswhileparentsareinattendance,

ortransportationservicesforruralfamilies—aswellasofferingprogrammesatconvenient

locations(e.g.,office,preschool,communitycenters)andtimes(includingeveningsand

weekendswhenthereisademand)areknowntoincreaseparticipationrates(Moran,

Ghateetal.2004).

Thereisalsostrongevidenceforcombiningpsychosocialstimulationprogrammeswith

earlyeducationprogrammesasdemonstratedintheTurkishstudy(Bekman,Koçetal.

2004).Thisisvalidatedinresearchemergingfromnon-LMICsuggestingthatmulti-

componentprogrammes—thoseinvolvingtrainingofchildren,teachers,andparents—are

effectiveinpromotingschoolreadinessskills(Moran,Ghateetal.2004,Reese,Sparksetal.

2010).Schoolreadiness,whichgenerallyreferstoayoungchild’scapacitytobereadyfor

bothlearningandperformingintheclassroom,includesfivedimensions:(i)physicalwell-

beingandmotordevelopment,(ii)socialandemotionaldevelopment,(iii)approachesto

learning(e.g.,enthusiasm,curiosity,taskpersistence),(iv)languagedevelopment,and(v)

cognitionandgeneralknowledge(Kagan,Mooreetal.1995).Theseskillsareimportant

precursorstolifelongsuccess.

Thereispreliminaryevidencethatnutritionalsupplementationalonemaybeinsufficientin

improvingcognitiveoutcomesinyoungchildrenasdemonstratedbythelongtermfollow

upoftheJamaicastudies.However,breastfeedingpromotioncouldbeaneffectivestrategy

inimprovingcognitiveoutcomes.Giventhatbreastfeedingpromotionhasalong-term

impactonchildren’sfullscaleIQandlanguagedevelopment,thissuggeststhat

53

breastfeedingpromotionistheearliestexplicitformofECDparentinginterventionthatis

effectiveinimpactingchildren’scognition,notjusttheirphysicalwell-being.3.2.1.3 Child Social and Emotional Development (n=2)

Youngchildren’ssocialandemotionalcompetence,inadditiontotraditionalintellectual

capacities,hasbeenshowntobeessentialnotonlyforsuccessinacademicsbutalsofor

successinadultlife(Brackett,Riversetal.2011,Durlak,Weissbergetal.2011).Promoting

youngchildren’shealthysocialandemotionalwell-beingisthereforeessentialinsetting

thestageforoptimaldevelopment.

Twoevaluations,TheRovingCaregiversProgrammeinSt.Lucia(Janssens,Rosembergetal.

2009),andthe17-yearfollowupoftheJamaicanpsychosocialstimulation+

supplementationstudymentionedpreviously(Walker,Changetal.2006)makeupthis

sectionofthereview.Bothprogrammeswereintensive.TheRovingCaregivers

Programme,whichwasbothahomevisitingandgroup-basedprogrammetargeted

vulnerablefamilieswithchildrenages0-3andconsistedoftwiceweeklyvisitations

lasting45minutespersessioninadditiontomonthlyparentingmeetings.The

Jamaicanstudyconsistedofweekly1-hourhomevisitsfortwoyears.Participationin

bothprogrammesresultedingreaterinterpersonalskillsandself-esteemandlesser

anxietyanddepression.Althoughnoimpactswerefoundforexternalizingbehaviors

(antisocialbehavior,hyperactivity,andoppositionalbehaviors),participationin

programmeduringtheearlyyearsresultedinlowerlikelihoodofbeingsuspendedor

expelledfromschool.

AlthoughonlytwostudiesfoundsignificantimpactofECDparentingprogrammeson

children’ssocialandemotionaldevelopment(SeeTable4inAppendix1).),thisdoesnot

meanthattheseweretheonlytwostudiesthatexaminedthisoutcomedomain.Inthenext

section,weexamineholisticoutcomes,whichpertaintostudiesthatfoundECDprogramme

impactsacrossmultipledevelopmentaldomains,includingsocialandemotional

development.

54

3.2.1.4 Holistic Outcomes (n=6) Sixstudies,implementedinfivecountries(twoeachinJamaicaandMexico,andoneeachin

thePhilippinesandVietnam),consistedofsignificantoutcomesinmorethanonechild

developmentaloutcomedomain,suchashealth,socialandemotional(SeeTable4in

Appendix1).Thenumberofchildrenevaluatedrangedbetween140and7,922

(median=1,019).Allbutoneofthesixstudiesemployedrandomassignment(fourRCTsand

tworandomassignmentwithnocontrolgroup).Interventionapproachesinvolved

psychosocialstimulation,integratedhealth,nutrition,anddevelopmentinterventions,and

socialprotectionprogrammes.

Psychosocial Stimulation OnesuchpsychosocialstimulationprogrammeinJamaica

(twostudies)wasderivedfromWHO’sProgrammefortheEnrichmentofInteractions

betweenMothersandChildren,whichtargetedlowbirthweightchildrenbetween9-24

monthsofage(Gardner,Walkeretal.2003,Walker,Changetal.2010).Trainedfemale

paraprofessionalsconductedeightweeklyhomevisits(1hour/visit)toplayandtalkwith

childrenandteachmothershowtoengagetheirchildrenthroughtalking,singing,and

showingaffection.Duringthesecondphase,from7-24months,thetrained

paraprofessionalsconducted30-minuteweeklyhomevisits. Attheendofthe8-week

period,interventioninfantsexhibitedmoremeans-endproblem-solvingbehaviors(as

measuredbyaPiagetianproblem-solvingtaskwhereinfantsuncoveredahiddentoyor

retrievedadistanttoy)andwereratedhigherincooperationandhappinessbytrained

observerscomparedtocontrolinfants(Gardner,Walkeretal.2003).Inthesix-yearfollow-

upofthatstudy,interventionchildrenscoredhigherinmentalacuity(performance

subscaleoftheWPPSIandCorsiblockdesign)andlowerintotalbehavioraldifficultiesthan

controlchildren;however,nolong-termimpactswerefoundforthefullandverbalscalesof

theWPPSI,thePPVT,attentionalcapacity,andreadingachievement(Walker,Changetal.

2010).Thesefindingsdemonstratethatintensivepsychosocialstimulationprogrammeshave

long-termimpactsonchildren’scognitiveandsocialandemotionaloutcomes.

55

Integrated Health, Nutrition, and Child Development programmeshavelikewise

beensuccessfulinimpactingchildren’sholisticdevelopment.Inlinewiththenotionofthe

wholechildapproach,integratedprogrammesareusuallymulti-sectoralprogrammesthat

aimtodeliverabroadersetofECD-relatedservicestofamilieswithyoungchildren.

TwostudieswereconductedinSoutheastAsiaandtargetedthemostdisadvantaged

communities.Thelarge-scalePhilippineECDprogrammedeliveredacombinationof

center-based(e.g.,daycarecenters,preschools,healthcenters)andhome-based(family

daycareprogrammesandhomevisitsbyhealthworkers)services(Armecin,Behrmanetal.

2006).Tolinkthecenter-andhome-basedservices,childdevelopmentworkers(CDWs)

complementedtherolesofmidwivesandhealthworkersinprovidingfoodandnutritional

supplementsandmonitoringchildren’shealthstatus.CDWsalsoprovidedcommunity-

basedparentingeducationaboutECD.Programmechildrenperformedbetterthannon-

programmechildrenincognitiveskills,grossandfinemotorskills,expressiveandreceptive

language,andsocialandemotionalskills.Amongtwo-andthree-year-oldsexposedtothe

programme,Z-scoreswereone-halfto1.8ofastandarddeviationhigherformotorand

languagedevelopment(Armecin,Behrmanetal.2006).Moreover,therewerelower

proportionsofanemiaandlowerratesofwastinginprogrammeareasthaninnon-

programmeareas.Positiveprogrammeimpactsvariedbyage,butweremorepronounced

forchildrenyoungerthanagefour.

InruralVietnamwheretherewasahighprevalenceofstunting,SavetheChildrenJapan

implementedamulti-sectoralinterventionfortwoyears(Watanabe,Floresetal.2005).The

interventionhadtwocomponents.Thenutritioncomponentincludedbi-monthlygrowth

monitoringforallchildrenandninesessionsofa12-daynutritioneducationrehabilitation

programmeconductedeverymonthtargetingseverelymalnourishedchildren.TheECD

componentprovidedmaterialsupportandteachertrainingonchild-centeredpedagogy.

Thisalsoincludedestablishingsmalllocallibrariesforparentsandpromotedplayareasin

homes.Furthermore,whatisuniqueaboutthisinterventionisthatittargetedfathers

explicitlyinadditiontotargetingmothers.TheECDcomponentprovidedsupportforparents

throughaone-daytrainingsessionforfathersandmothersseparatelyeverymonth

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onvarioustopicsonchildcareanddevelopment.Resultsrevealedthatbothprogrammatic

componentsresultedindecreasesinstunting,butresultsfavoredtheECDcomponent+

nutritioncomponentgroupindecreasingseverestuntingoverthenutritioncomponent

onlygroup.Moreover,comparedtothenutrition-onlygroup,theECDcomponent+

nutritioncomponentgroupperformedhigherinstandardizedtestscoreswheremore

pronounceddifferenceswerefoundforstuntedchildren.Thesefindingssuggestthatan

integratedapproachtochilddevelopmentyieldseffectsonthewholechildandthathigh-

riskchildrenbenefitthemost,promotingequity.Moreover,dosagefindingssuggestthat

nutritionprogrammesareinsufficientinimpactingmoreholisticoutcomes.

Social Protection theMexicanOportunidadesmentionedpreviouslyhasbeenthemodel

conditionalcashtransferprogrammeinLatinAmerica.Inthenextsetofevaluationsthat

werefive-(Fernald,Gertleretal.2008)and10-year(Fernald,Gertleretal.2009)follow-up

studiesofOportunidades,dose-responseanalysescomparingearly(familiesenrolled

immediatelyintoprogramme)andlate(familiesenrolled18monthslater)enrollment

favoredearlyenrollmentacrossphysical,cognitive,andsocialandemotional

developmentaloutcomes(Fernald,Gertleretal.2008;Fernald,Gertleretal.2009).Inthe

10-yearfollow-up,however,greaterprogrammedosedidnotsustainitsadvantagein

height-for-agezscores,bodymassindex,andcognitiveandverbalassessments(Fernald,

Gertleretal.2009).

Summary Holisticprogrammingbegetsholisticoutcomes.Ideallyinterventionsshould

takeonawholechildapproach.Theresearchsummarizedinthissectionsuggeststhat

effectiveapproachestoimprovingholistichealthanddevelopmentaloutcomesinchildren

couldbeintheformofmulti-sectoralhealthandchilddevelopmentalprogrammes(asinthe

examplesofscale-uporlarge-scaleprogrammesinMexico,thePhilippines,andVietnam)or

intensivepsychosocialstimulationprogrammes.Theformerapproachisefficientand

effectiveinimprovingahostofchildoutcomes.Thelatterentailsfrequentinteractionswith

caregiversandtheirchildren,lastingbetweenoneandtwoyears.Acrossstudies,itappears

thatdoseisimportant.Forexample,intheMexicanOportunidadescashtransfer

programme,participatingintheprogrammeforanadditional18monthswasadvantageous

intermsofimprovingchildoutcomes.Hiringwell-trainedparaprofessionalswasacost-

57

effective

57

solutiontodeliveringmessagestoparents.Malnourishedchildrenandyoungeragegroups

benefitedthemostfromtheseprogrammes.Thissuggeststhatcaregiversmaybeutilizing

themoneytheyreceivetoenrolltheirchildreninbetterqualitycarethroughgrowth

monitoring,wellbabyvisits,andparticipationinparentinginterventions,whichweresome

oftheconditionsforenrollmentinOportunidades.Futureevaluationsshouldexamine

parentalactivitiesafterprogrammeenrollment.

AsevidencedintheVietnamstudy,includingfathersinthetrainingsisapromisingand

underutilizedstrategy(Barker,Bartlettetal.2004,UnitedNationsDepartmentof

EconomicandSocialAffairs2011).Indeed,findingsfromhigherincomecountries

demonstratedstrongereffectsonbothchildandparentingbehaviorswhenfatherswere

involvedintheprogramme(Lundahl,Tollefsonetal.2008).ConductingECDparenting

programmesthattargetfathersexplicitlyaresuggestedforfutureresearch.

3.2.2PARENTOUTCOMES

Thissectionsummarizes33studiesthatshowedsignificantimpactsonresultsforparenting

onlyintheareasofparentingattitudes,beliefs,andpractices.Thesectionisdividedinto

thefollowingbroadcategories:(1)caregivingpertainingtopromotingchildren’sphysical

healthandnutritionalstatusand(2)caregivingbeyondphysicalcare.

3.2.2.1 Physical Health-Related Caregiving (n=19)

Earlychildhoodparentingprogrammesthatevaluatedcaregivingknowledge,attitudes

andpracticestoimprovephysicalhealthappeartobewidelyimplemented.Herein,we

definephysicalhealth-relatedpracticesasthosethathavebeenshowntoreducedisease

prevalenceandpromotegrowthandphysicalwellbeingamongyoungchildren.Atotalof

20studiesaddressedfouroverarchingstrategiestopromotephysicalwellbeingby

targetingparentaloutcomesinrelationto(1)healthcareseekingbehaviorsandhygiene

practices,(2)oralhealth,(3)nutritioneducation(aloneorintegratedwithotherhealth-

relateddimensions),and(4)carepractices.Programmeevaluationsrangedfrom

moderate

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(n=129)tolarge(universal)coverage.Mostevaluations(20%)wereconductedinIndia.

African(Belize,Nigeria,SouthAfrica,Burkina,Malawi),Asian(China),SouthAsian(Nepal),

SouthEastAsian(Bangladesh,Thailand),andLatinAmericanandtheCaribbean(Haiti,

Brazil)regionswerealsorepresentedintheprogrammeevaluationsreviewed.

Theoverviewofprogrammesindicatedthatparaprofessionalsandacombinationofservice

deliverymodalitiesarecommonlyusedwhenpromotingphysicalchildhealthand

caregiving.Themajority(65%)ofinterventionsweredeliveredbyparaprofessionalssuchas

localcommunitymembersandcommunityhealthworkers.Professionalsdelivered20%of

theinterventionsand10%ofthereportsdidnotspecifytheserviceproviderswhodelivered

theintervention.Mostservicedeliverymodalitiescombinedmorethanoneapproach(e.g.,

useofprintmaterials,modeling,discussion,activeinstructionorteaching,mediaand

communityevents)withtheexceptionoftwoprogrammesthatonlyutilizedalecture

strategy. Deliverysettingsalsovaried,withcommunitybased(35%)andhomeand

community(30%)beingthemostcommonformsofprogrammedelivery.Mosttrials(40%)

usedrandomassignment,followedbynon-randomassignment(35%).Qualityofthe

programmeevaluations,asrevealedbyourqualityscoring,variedconsiderably(cumulative

scoresrangedfrom29.4to82.35).Thesectionsbelowsummarizethefindingsofthe

programmeevaluationstoassesswhatprogrammecharacteristicsareassociatedwith

positiveparentaloutcomeswithaspecialemphasisoncommonlyreportedapproachesto

culturalresponsivityintheprogrammaticdesign.

Healthcare seeking behaviors and hygiene practices Studiesinvestigatedthe

effectsofECDparentingprogrammesonhealthcareseekingbehaviorsandhygiene

practicesassociatedwithmalaria,diseaseandacuterespiratoryinfectionmanagement

(Cropleyetal.,2004;Okeke,2009;Holloway,etal.,2009;Mohanetal.2004;Curtis,et.al,

2001;andLuby,etal.,2010).ThekeycharacteristicsofthesetrialsaredisplayedinTable4

inAppendix1.

59

BelizeandCropleyetal(2004)examinedtheeffectofhealtheducationinterventions

deliveredbyparaprofessionalsonmothers’treatment-seekingbehaviorsfortheirchildren’s

malariafevers.Interpersonalchannels(e.g.voluntarycollaboratorsandvectorcontrolteam

personnel)contextualizedanddisseminatedthemessagesalongwithvisualmaterialsof

classicmalariasymptomsandrecommendedactions(e.g.displayedpamphletsandposters).

Post-interventionsurveysrevealedthatinterpersonalcommunicationimprovedsome

proxiesofhealthcareseekingbehaviorsintheinterventionbutnotinthecontrolgroups

(e.g.seekingmalariatreatmentwithin48hoursofthefirstrecognitionoffever).Knowledge

ofmalariacauses,symptomsandtreatmentalsoimprovedinresponsetotheintervention.

Thestudywasunabletoprovideevidencethatthevisualmaterialspositivelyinfluenced

treatment-seekingbehaviors.Educationandcommunicationmaterials,whichincluded

postersdepictingachildwithmildandseveremalariawithalistoftheclinicalsymptoms,

wereusedinNigeriatoimproveknowledgeofcauses,andcareformoderateandsevere

malaria(Okeke2009).Theinterventionwasacombinationofmassmedia,community-

basedactivities,andtrainingactivitiesbyleadersofwomengroups.18monthsafterthe

intervention,therewasasignificantincreaseintheknowledgeofsymptomsofmildand

severemalariaandtargetedhealthcareseekingpractices.

NepalandHollawayetal(2009)evaluatedtheimpactofamulti-modalinterventioninthe

treatmentofacuterespiratoryinfection.Messagestargetedknowledgeonsymptoms

indicativeofillnessandcorrespondingtreatmentprocedures.Professionalsand

paraprofessionalsdeliveredsmallandlargegroupactivitiesandone-to-onecounseling

sessions.ResultsvariedaccordingtoseverityofAcuteRespiratoryInfection(ARI)and

outcomeofinterest.Forinstance,attendanceathealthpostsincreasedforsevereARIand

fellinchildrenwithmildARI.Althoughthestudyprovidesimplementationstrategiesthat

utilizelocalservicedeliveryinfrastructureindifficultcircumstances,furtherresearchis

neededtoassesstheimpactofdisseminationstrategiesthatonlyusevisualmaterialsand

addresssymptomsofdifferingseveritieslikeARI.

AparentingeducationprogrammewasconductedinruralIndiatoassessiftrainingdoctors

incounseling,communicationandclinicalskillsusingthe(IMCI)approachimprovedcare

60

seekingbehaviorsinfamiliesofsickchildren(Mohanetal.,2004).Theobjectiveofthe

counselingsessionswasprimarilytoteachmothersofchildrenunder-5yearsofagetoseek

promptcareuponpresentationofdangersigns.Comparedwithcontrolsites,mothers’

acknowledgementoftheneedtoseektimelyandappropriatecareincreased,buttherewas

nosignificantdifferenceincareseekingbehaviors.Theauthors’hypothesizedchangesin

behaviormayrequireprolongedexposuretotheeducationalmessages.

Hygienepracticesweretargetedtoreducetheriskofdiarrhealdiseasesandfood-borne

illnesses.InBurkinaFaso(Curtisetal.,2001)andBangladesh(Lubyetal.,2010),

programmestargetingbehaviorsassociatedwithhygieneandhandwashingpractices

wereevaluated.Bothprogrammesutilizedacommunity-basedapproach.InBurkina,a

combinationofmonthlyhouse-to-housevisits,weeklyplay,discussiongroupsin

communityhealthcenters,andradiospotstargetedstoolmanagementpractices.In

Bangladesh,fieldworkersintroducedsoaporsanitizerandwereinstructedtowashhands

afterseveralexposures.Instructionwascomplementedwithpositivereinforcementby

encouragingparentsinthecompoundtosupporteachothertoimprovehandhygiene,

andbyplacingpostedrecognitionstickersinhouseholdsthatusedmostsoap/sanitizer.

TheBangladeshinterventiontookintoaccountlocalcustoms(e.g.sanitizeruseddidnot

containalcoholbecausemanyMuslimsinBangladesharereluctanttouseproductsthat

containalcohol).After3-yearsofimplementingtheprogrammeinBurkinaFaso,the

evaluationrevealedgreatestimprovementsin2outofthe4targetbehaviors(hand-

washingwithsoapaftercleaningachild’sbottomandtheproportionofmotherswho

washedtheirhandswithsoapafterusingthelatrine).InBangladesh,theevaluation

showedthatwaterlesshandsanitizerwasreadilyadoptedbythecommunityandreduced

handcontamination.However,itdidnotimprovethefrequencyofhandwashing

comparedwithsoap.

Oral Health TwoprogrammeevaluationsinIndia(Nairetal.,2009)andThailand

(Vachirarojpisan,Shinada,&Kawaguchi,2005)assessedtheeffectofeducation

interventionsinparentaloralhealthknowledgeorpractices.InThailand,astudytestedthe

effectsofactiveinvolvementusingaparticipatorydentalhealtheducation(participatory-

DHEprogramme)comparedtoanationalteachingDHEprogramme.Intheparticipatory

61

DHEgroup,atrainedmoderatordeliveredsmall-groupsessionsonceamonthduringa3-

month

61

participatorydentalhealthprogramme.ThenationalDHEprogrammeconsistedofdidactic

teachingaboutearlychildhoodcaries(ECC)preventionmethodsandprovidingfree

toothbrushes.TheparticipatorycomponentoftheDHEprogrammewasassociatedwith

improvedoralhealthpracticessuchasparentsbrushingchildren’steethandusingtheright

amountoffluoridetoothpaste.However,therewerenodifferencesintheincidenceof

cavitiesbetweenparticipatoryandnon-participatoryDHEprogrammegroups. InIndia,

publichealthnursesandcommunityhealthworkersfacilitatedoralhealthclasseswith

mothersduringgroupmeetings.Audiovisualaids,modules,charts,postersandbrochuresin

theregionallanguagewereutilized.Resultsrevealedastatisticallysignificantimprovement

inknowledgeregardingoralhygienehabits,importanceofmilkteeth,causesofdental

diseases,preventionofdentaldiseases,andtreatmentofsomedentalconditions.

Nutrition education Nutritioneducationinterventionsencompassawidevarietyof

approaches,includingcounselingaboutchildfeedingaloneorincombinationwithfood

supplementation,fortificationofcomplementaryfoods,andfoodpreparationtechniquesto

maximizenutrientquality.InSouthAfrica(Faber,Venter&Benade,2002)andBurkinaFaso

(Nanaetal.,2006),nutritioneducationinterventionswereevaluatedtotesttheirimpacton

vitaminAintakeandserumretinolconcentrationinchildren.Bothinterventionsused

contextualizedapproachesandtestedtheimpactoflocallyavailablefoodsorutilizinghome

gardenswithproducewithhighvitamin-Acontent.InSouthAfrica,demonstrationgardens

werecombinedwithacommunity-basedgrowth-monitoringprogramme.Oneyearafter

theintervention(whichincluded12trainingsessionsinthedemonstrationgardengiven

duringmonthlygrowthmonitoringsessions),vitaminAintakewashigheramongboth

interventionandcontrolgroups.However,theincreasewasgreaterinchildrenfromthe

interventiongroup.Theauthorshypothesizedthatcontrolgroupeffectscouldbeexplained

byanincreasedawarenessinthecommunitythatresultedfromthevisibilityofproject

gardensanddemonstrationsaswellasthenutritioneducationprogramme.InBurkinaFaso,

theprogrammeevaluationassessedtheeffectivenessofabehaviorchangeapproach

throughpromotionalactivities,withorwithoutfinancialsupport,inimprovingvitaminA

intakeandserumretinolconcentrationthroughconsumptionoflocally-availablefoods

(mangoandliver).Overall,theresultsindicatedthatbothvitaminAintakeandserum

62

retinolconcentrationimprovedsignificantlybetweenthebeginningandtheendofthe

interventionregardlessofthepresenceoffinancialsupport.Intheabsenceofatruecontrol

group,itwasdifficulttofullyattributethisimprovementtotheintervention.

Nutritioneducationprogrammesdelivered,atleastinpart,byhealthserviceprovidersand

thattargetedparentalhealthknowledgeandhealth-seekingpracticeswerealsoevaluated.

Threestudiesassessedtheimpactofintegratingnutritionandchildcareeducationin

center,hospital,andcommunityhealthcenters.Theoutcomesassessedwereparental

knowledgeandpracticesand,insomecases,childhealthindicatorsandanthropometry.In

Bangladesh,levelsofchildhoodmalnutritionwerecomparedbetweenareaswherethe

IntegratedNutritionProjecthadbeenoperationalforover5yearsincommunitynutrition

centreswithmatchednon-projectareas(Hossain,Duffield&Taylor,2005).Duringmonthly

growthmonitoringandpromotionvisits,caregiversofchildren0-23monthsofage,

receivedcounselingonhealth,familyplanning,breastfeeding,caringpractices,personal

hygieneandtheuseofiodizedsalt.Self-reportednutritionalknowledgeamongmothersin

theinterventiongroupwassignificantlyhigherascomparedtothecontrolgroup,although

nosignificantimpactwasobservedinreducingmoderateandsevereunderweightof

children.However,theevaluationdidnotcontrolformalnutritionratesatthebeginningof

thetrial.InBrazil,physiciansweretrainedwithanIMCI-derivednutritioncounseling

protocolandretentionofmessageswasexamined(Pelto,etal.,2004).Theintervention

usedlocallyappropriatemessages,toolsforassessingindividualproblems,andcounseling

skillsofserviceproviders.Motherswhoreceivedadvicefromtrainedprovidershad

significantlyhigherratesofrecallingthemessagesonspecificfoodsandfeedingpractices

aswellasrecommendationsonfoodpreparationcomparedtothosewhodidnotreceive

advice.Theproportionofthemessagesrecalledonbreast-feedingdidnotdiffer

significantlybetweentheinterventionandcontrolgroups.Furthermore,resultsfroma

studyinMadagascarsuggestedthatimplementingtheEssentialNutritionActions(ENA)

operationalframeworkandBehaviorChangeCommunicationmayleadtosignificant

improvementsinsomechildfeedingandnutritionalpractices(breastfeedinginitiationand

continuationrates,feedingratesamongchildren6-23months,rateofmaternaliron-folic

acidandvitaminAsupplementationduringtheperinatalperiod)(Guyonetal.,2009).The

providersand

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communityhealthworkersusedcounselingcards,newsprint,andchildhealthbooklets.

Recommendationsandnutritionmessageswereharmonizedwithvarioushealth

programmes(e.g.IMCI)andcomplementedwithmassmediaandothercommunity-based

activities.Noimprovementswerereportedinincreasingfoodintakeduringchildillnessor

pregnancy.

Programmeevaluationswerealsoconductedtoassesstheeffectivenessofpromoting

breastfeedingandfeedingpracticesthroughavailablehealth-deliverychannels.InIndia,a

trialevaluatedtheeffectsofdeliveringexclusivebreastfeedingandcomplementaryfeeding

practicesbytrainedhealthandnutritionworkers(Bhandarietal.,2005).Counseling

opportunitiesincludedvisitstophysicians,homevisits,andimmunizationandweighing

sessions.Anincreaseinthenumberofchannelsthroughwhichcaregiverswerecounseled

waspositivelyassociatedwithexclusivebreastfeedingprevalenceandconsumptionof

certaincomplementaryfoodsamongdifferentchildageranges.Additionally,intervention

areas,comparedwiththecontrolgroup,hadhighercoverageforvitaminAandironfolicacid

supplementation.AparticipatorynutritioneducationprogrammeinMalawiwas

implementedtointroduceavarietyofpracticesforimprovingcomplementaryfeedingHotz

&Gibson(2005).Workshops,demonstrations,andwrittenmaterialsweredevelopedand

communityHealthCommitteemembersandlocalMinistryofHealthSurveillance

Assistantsdeliveredthelocallyadaptedlessonsforcomplementaryfeedingpractices.The

studyindicatedthatthroughnutritioneducation,participatingmotherswereabletouse

existingfoodresourcestoimprovecomplementaryfeedingpracticesandthiswas

associatedwithenhancedadequacyofenergyandintakeofseveralmicronutrientsinthe

complementarydietsoftheirchildren.

InChina,townshiphospitaldoctorsweretrainedonchildnutrition,breastfeeding,

complementaryfeeding,andcounselingskills(Zhang,Shi,Chen,Wang&Wang,2009).

Participantsintheinterventiongrouphadsignificantlyhigherscoresthanparticipantsin

thecontrolgroupinknowledge,attitudes,self-efficacy,intention,normbeliefs,aswellas

feedingbehaviors.Thestudyfoundtheintervention,mothers’knowledge,intentionand

subjectivenormofvillagersindependentlypredictedmaternalfeedingbehaviorsafterthe

intervention.Theauthorsconcludedthattomotivatecaretakerstoadoptoptimalfeeding

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behaviors,itwascriticaltoprovidethemwithnecessaryknowledge,information,skills,and

asupportiveenvironment.

Care practices:Estimatessuggestthatupto1/3ofneonatalmortalitycouldbe

preventedthroughhighaccessofpreventativefamilyandcommunitynewborncare

(Darmstadtetal.,2005).

Interventionstargetingcare-seekingbehaviorsimpactnotonlysurvivalbutalsophysical

outcomesanddecreaseinmorbiditiesthatcanaffectchildhealthanddevelopment.In

India,acombinationofmonthlycommunitymeetingsfromthe2ndto3rdtrimester,

antenatalhomevisits,andneonatalvisitswereimplementedtopreventhypothermiaand

modifypracticesandreducingneonatalmorbiditiesandmortalities(Kumaretal.,2008).

Twointerventions(apackageofessentialnewborncarewithorwithoutanindicatordevice

forhypothermia)weretestedagainstacontrolgroupwhoreceivedroutineservices.The

interventionwasassociatedwithimprovementsinprenatal(e.g.birthpreparedness)and

post-natal(e.g.thermal,umbilical,andskincare,andhygienicdeliveryandbreastfeeding)

carepractices.Care-seekingbehaviordidnotdifferbetweentheinterventionandcontrol

groups.Theprogrammewasassociatedwithasignificantreductioninchildmortality.

Socioculturalcontextualizationandacommunity-baseddesigntargetedtowardshigh-risk

newborn-carepractices,weresomeofthecharacteristicstowhichimpactsofthe

interventionwereattributed.

Acommunity-basedprogrammetargetedfathersthroughfather’sclubsinHaiti(Sloand,

Astone&Gebrian,2010).TheFather’sClubinHaiticonsistedofregularmeetingsamong

fatherstodiscusstheirinvolvementinchildcare.Theyalsoattendedhealtheducation

sessionswithinputfromthenurseorvillagehealthagentwhereseveralpractices(e.g.

exclusivebreastfeedingfor6months,immunizingchildren,andprovidingadequatefluids

andseekingappropriatehealthcarewhenthechildissick)werediscussed.Fathers’

knowledge,skills,andperformanceinearlychildhoodcareweretargeted.Thepresenceof

afathers’clubwasassociatedwithincreasedvaccinationstatus,growthmonitoring,and

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vitaminAsupplementation.However,childmortalityratesandchildweightdidnotdiffer

beforeandaftertheinitiationoffather’sclubsinthevillages.Summary:Datafromtwostudiessuggestinterpersonalcommunicationofcontextualized

andtargetedmessagesmaypositivelyimpactparentalknowledgeandspecifichealthcare

seekingbehaviors.Oneofthecharacteristicsoftheinterventions,likelytobeassociated

withpositiveimpacts,wasspecificityofthehealth-relatedmessages.Interventionsthat

usedthelocalworkforcetodeliverkeymessages,suggestedthatparaprofessionalscan

impacthealthknowledgeamongparentsofyoungchildrenaloneorincombinationwith

professionals.Furtherresearchisneededtoassesstheimpactofvisualmaterialsalonein

healthcareseekingknowledgeandbehaviors.Ourreviewoftwoparentingprogrammes

targetinghygienepracticessuggeststhatprogrammescanbemoreeffectiveinpromoting

healthybehaviorsiftheyarebuiltonlocalresearchandusecontextualizeddissemination

channels.InBangladesh,(Lubyet.al.2010),thelarge-scale3-yearprogrammesuggested

thattheinterventionshouldbedeliveredrepeatedlyandforanextendedtimetoleadto

measurableimpactsatapopulationlevel.Furthermore,theBangladeshprogramme

suggeststhatuseofnewitems(likewaterlesshandsanitizers)toimprovehandwashing

practicesmaybemoreeffectiveinsettingswherewaterandsoapareunavailable.

Therefore,tomaximizetheimpactoftheintervention,designingeffectiveprogrammatic

strategiesshouldtakeintoaccountexistingpracticesandpreferences.

Theoralhealthprogrammeevaluationsindicatedthatoralhealthknowledgecanbe

strengthenedthrougheducationclassesledbyprofessionalsand/ortrained

paraprofessionals.Improvementinoralhealthknowledgecanbeattainedthrougharange

ofinterventiondoses,asillustratedbytherangeintheintensityoftheprogrammes.

Althoughaparticipatoryapproachtooralhealtheducationledtoimprovedoralhealth

practices,itdidnotcontributetoareductioninchildcaries.Furtherresearchisneededto

assesstheimpactofknowledgechangeonsustainedoralhealthpracticesandonoutcomes

foryoungchildren,andtheaddedvalueofactiveinvolvementinimprovingchildoralhealth

duringearlychildhood.

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Withthenutritionaleducationprogrammes,vitaminAandretinolintakewereassessedto

testtheimpactofprogrammestargetedtocontextualizedfoodharvestingandpreparation

bycaregiversofyoungchildren.Resultswereinconclusiveinregardstotheimpactthat

gardeningactivitiesandfinancialsupporthavebeyondparentaleducationalone.However,

thetwocommunity-basedactivitiesevaluatedshowedmodesteffectsonvitaminAintake

suggestingthatbehavioralchangecanbeinstilledthroughcontextualizedapproachesthat

involvelocally-availablefoods.Resultsoninterventionsthatcombinednutritionaland

healthcareseekingeducationinhealthsettingsshowedthatself-reportednutritional

knowledge,messagerecallofsomefeedingpractices,andimprovementsinsomenutritional

practicescanbeimprovedviatrainedprofessionals.However,inBangladeshalthough

mothersinprojectareasreportedbettercaringpracticesthanmothersinthenon-project

areas,theimprovementsinself-reportedpracticeswerenotassociatedwiththenutritional

statusofchildren.Promotionofbreastfeedingandcomplementaryfeedingpractices

throughavailablehealth-deliverychannelsweresuccessfulinIndia,MalawiandChinawhere

existinghealthcarechannelswereusedtodelivermessagesandcounseling.InChina,

mediatorsofprogrammeeffectivenessincludedparticipantintentionandcontext.

Theeffectofparentingprogrammesoncarepracticesviaantenatalprogrammesand

throughacommunity-basedapproachweremixed.InIndia,althoughtherewasno

differenceincare-seekingbehaviorsbetweenthecontrolandexperimentalarms,the

interventionwasassociatedwithasignificantreductioninchildmortality.Thestudyresults

suggestthatmorefrequentexposuretoeducationalmessagesthroughawiderrangeof

channelsmayleadtogreaterchangesinmothers’care-seekingbehaviorsthanwe

observed.However,prenatalandneonatalcarepracticeswereimprovedinresponsetothe

interventionsuggestingthatsomepracticescanbemodifiedusingtheimplemented

strategies.Conversely,inHaitisometargetedcareandhealthcareseekingpracticeswere

improvedinresponsetoFathers’Clubs.Improvementsonthosepracticesdidnottranslate

todecreasesinchildmortalityrateorchangesinchildweight.Furtherinvestigationis

neededtoassesshowpaternaleducationandimprovedpracticestranslateintofavorable

childdevelopmentandhealthoutcomes.

3.2.2.2 Caregiving Beyond Physical Care (n=13) Theprogrammeapproachesemployedinthe13studiesthatdemonstratedimpactson

caregivingbeyondphysicalcarearecategorizedasfollows:(1)childprotectionintermsof

safetyandinjuryprevention,(2)childprotectionintermsofphysicalabuse,(3)psychosocial

stimulationandresponsiveness,(4)responsivefeeding3andintegratedhealthand

developmentapproaches.Programmeswereimplementedin11countries,almosthalfof

whichwereintheMiddleEast:threeinTurkey,andoneeachinBangladesh,Brazil,Egypt,

Mexico,Iran,SouthAfrica,Pakistan,Jordan,Thailand,andUganda.Thenumberofparents

evaluatedrangedbetween126and2,250(median=337).Theevaluationswerecomprisedof

sevenRCTs,threequasi-experimentswithcomparisongroups,andthreewithnocontrol

groups.Eightofthestudiesemployedprofessionals(Ertem,Atayetal.2006;Farahat,

Farahatetal.2009;Issler,Marosticaetal.2009;Oveisi,Ardabilietal.2010;

Sawasdipanich,Srisuphanetal.2010;Özyazıcıoğlu,Polatetal.2011)oracombination

ofprofessionalsandparaprofessionals(Mock,Arreola-Risaetal.2003;AlHassanand

Lansford2011)todelivertheprogramme.Thechild’sageatinterventionwasprimarily

duringthetoddlerandpreschoolyears.

Child Protection: Safety and Injury Prevention Amongparentsofinfantsandyoung

children,safetyisoneofthemostsalientconcerns.InLMIC,accidentalinjuriesarethe

causeofdeathanddisabilityamongmillionsofchildreneachyear,withratesestimatedto

beatleastfivetimeshigherthanthoseinnon-LMIC(Bartlett2002).Fourstudiesexamined

childprotectionintermsofphysicalsafetyandinjurypreventionthataimedtoincrease

parentalknowledgeaboutpesticidehazards(Farahat,Farahatetal.2009)andparental

practicesconcerningsafety(Mock,Arreola-Risaetal.2003;Issler,Marosticaetal.2009;

Özyazıcıoğlu,Polatetal.2011).Inallfourstudies,professionalsoracombinationof

professionalsandparaprofessionalsdeliveredtheprogramme.Moreover,allthese

programmesdeliveredservicestotheparentsingroups.Itappearsthereforethatgroup

modalityisacommonapproachtoparentingprogrammesthatareaimedatpromoting

childsafety.

3Weacknowledgethatresponsivefeedingispartofcaregiving,buthere,wefocusonthepsychosocialcomponent.

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Concerningprotectionagainstpesticidehazards,parentsofpreschoolchildreninone

farmingcommunityinEgyptreceived15healtheducationsessionsonpesticidehazards

(Farahat,Farahatetal.2009).Parentswereassignedrandomlytooneoftwoconditions:

eithertheylistenedtostudyinvestigatorslectureortheyviewedavideotapeonhazards

andsafeuseofpesticides.Althoughthevideogroupscoredhigherthanthelecturegroup

onatestofpesticideknowledge,neithergroupdifferedonatestofpesticidepractice,

whichsuggeststhattheapproachusedwaseffectiveinimprovingknowledgebutnot

practice.

Concerningparentalpracticesaroundsafety,threestudiesfoundsignificantimpacts.All

threeprogrammesuseddidacticapproachesorlivedemonstrationswithindividualized

counseling.InBrazil,interventionmothersreceivedindividualizedinstructionprovidedby

hospitalstaffandmedicalstudentsinadditiontobeinginstructedusingdemonstrations

withababydollmodelonhowtopositioninfantswhenasleeptoreducetheincidenceof

SuddenInfantDeathSyndrome(Issler,Marosticaetal.2009).InTurkey,study

investigatorsconducted60-minutegroupsessionsonsuitablefirst-aidandtreatmentsfor

burns,lacerations,fractures,andpoisoninginadditiontohandingoutinformationon

availablecommunityresourcesformotherstocontact(Özyazıcıoğlu,Polatetal.2011).

Bothstudiesshowedthatprovidingdemonstrationsorexamplesofcontrastingapproaches

tosafetyareeffectiveininformingparentalpracticesofsafety.InMexico,oneprogrammeusedavarietyofapproachesinadditiontolivedemonstrations

andindividualizedcounseling(Mock,Arreola-Risaetal.2003).Theprogrammewasbased

onbothanestablishedprogramme(TheInjuryPreventionProgramme)andalocally

developedone(PalKai,or“healthychild).Thestudysites,whichwerecontingentuponthe

safetyneedsofeachsocioeconomicstratum(SES)group,wereprivateclinicsthatcharged

lowfees,andpubliclysubsidizedforupper-,middle-,andlow-SESgroups,respectively.Inall

clinics,thebasicprogrammemodelconsistedofelementsofinjurypreventioncounseling

deliveredbynursesandtrainedhealthcareworkersaspartofoverallhealthpromotion.

Counselingwasupgradedaspartofthisintervention.ForupperandmiddleSESgroups,the

upgrading

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involvedlecturesanddemonstrationslastingsixhoursandutilizingaudio-visualmaterials

fromseveralsources.Inaddition,themiddleSESgroupreceivedclinic-basedcounseling

thatlasted15-20minutes,whereasthelowerSESgroupreceived30-minutehomevisitsby

trainednursesandhealthpromoters.Resultsrevealedthatwithrespecttousingcaution,all

threeSESgroupsdemonstratedimprovementspre-andpost-intervention. Howeverfor

otherdimensions(activitiesthatrequiredtheuseofsafety-relateddevices),theresults

weremixed.Thenon-randomizationofthedesign,thelackofdetailsregardingselection

criteria,andthelackofgeneralizabilityacrossSESgroupslimittheinterpretationofresults.Child Protection: Physical Abuse Althoughtheprevalenceofchildabusevariesacross

LMIC(LansfordandDeater-Deckard2012),thepercentageofchildrenexperiencing

psychologicalabuse,moderatephysicalabuse,andseverephysicalabuseishigherin

Africancountries(medianrates=83%,64%,and43%,respectively)thaninotherregions

(medianrates=56%,46%,and9%,respectively)(Akmatov2011).Oursystematicsearch

yieldedfourstudiesinfourcountries,threeofwhichwereMiddleEasterncountries.None

wereconductedinAfricancountries.Allprogrammesweregroup-basedexceptforone

group-basedprogrammewithahomevisitingcomponent.

Threeofthefourprogrammesweregroup-based,allfromtheMiddleEast(Koçak2004,

Oveisi,Ardabilietal.2010,AlHassanandLansford2011).InIran,Oveisi(2010)exploredthe

viabilityofusingprimaryhealthcaresettingsasvenuesforpreventiveinterventionsfor

childphysicalandemotionalabuse.Inthefirsttrainingsession,traineddoctorseducated

parentsinparentalskillbuildingincludingdiscussionsoncommonparentingmistakes.In

thesecondsession,mothersrole-playedandwatchedvideoclips.Bothsessionslastedfor

twohoursintwosuccessiveweeks.Resultsshoweddeclinesinparentalreportsof

instancesofabuseaswellasindysfunctionalformsofparenting.

The other two group-based programmes targeted fathers (Koçak 2004) in addition to

mothers(AlHassanandLansford2011).TheprogrammeswereimplementedinTurkeyand

Jordan. The Father Support Programme in Turkey targeted low-income immigrantswho

werefathers

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(Koçak2004).Theprogrammewasa13-weekgroup-basedintervention(2.5hours/week)

thatwaslimitedto15fathers.Thesessionsweredesignedtopromotesocializationamong

fathersbysharingtheirproblemsandexperienceswitheachother.Bytheendofthe

programme,fatherattitudesbecamelesstraditionalandlessauthoritarianandtheyused

moreopenformsofcommunicationwiththeirfamilies.Theotherprogrammethat

targetedexplicitlyfathers(inadditiontomothers)wastheBetterParentingProgrammein

Jordanthatwasbroughtaboutbyanationalparentingstudy(AlHassanandLansford

2011).Thisprogrammehasbeenbroughttoscale,withmorethan200centersnationwide

implementingtheprogramme.Onedistinguishingfeatureoftheprogrammeisitsflexible

approachtotraining.Sessionscouldbeimplementedonceaweekforonemonthorthree

tofourconsecutivedays,ortwiceaweekfortwoweeks.Althoughonly6%offathers

participatedintheevaluation,resultsshowedsmallbutpositiveeffectsonknowledgeof

childneglect,spendingtimewithchild,anduseofexplanationsinthecourseofdiscipline.

Noimpactwasfoundonknowledgeofchildabuseandexpressionsofcontentment.Finally,oneprogrammecombinedgroupeducationwithhomevisiting.Thisprogramme

aimedtochangeparentalcognitiveprocessesregardingchildrearingamongThaiparents

(Sawasdipanich,Srisuphanetal.2010).Thegroupeducationcomponentusedvarious

programmecomponents:groupdiscussions,valuessharing,scenarioanalysisofvideotaped

presentations,andhomeworkusingabooklettoevaluatethecontentofthegroupsessions

andrecordtheirbehaviorsathomewithrespecttodealingwiththeirchildren’sbehaviors.

Thehomevisitswereusedtoidentifyparentalchallengesaswellastoproblem-solveand

increaseparentalefficacy. Resultsshowedprogrammeimpactsonparentalattitudes

towardchildrearingbutnotonpotentialforchildphysicalabuse.

Psychosocial Stimulation and Responsiveness Threestudiesfoundsignificant

impactsoncaregivers’abilitytoprovidestimulationandemotionalsupport(Ertem,Atayet

al.2006;Cooper,Tomlinsonetal.2009;Rahman,Iqbaletal.2009).InTurkey,an

adaptationoftheIMCICareforDevelopmentprogrammewasimplementedtoenhance

caregivers’playandcommunicationwiththeirtoddlers(Ertem,Atayetal.2006).During

theclinicvisit,trainedpediatriciansdeliveredtheintervention,whichconsistedof

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strategiesforlisteningandobservingpositiveinteractions,usingspecificpraiseand

positivereinforcement,andprovidingthecaregiverwithideasonplayandhomemadetoys

forage-appropriatestimulation.Thislastedapproximately30minutes.Resultsofthe

evaluationshowedimpactsonavailabilityofstimulationopportunitiesbutnotoncaregiver

responsiveness,suggestingthatmoreintensiveapproaches(e.g.,directinteractionwith

child)areneededtoimprovecaregivers’abilitytobeemotionallyresponsive.

Thenexttwostudiesaimedtoimprovematernalsensitivityandresponsiveness,both

adaptedtofitlocalcontext.TheLearningThroughPlayprogramme,whichhasbeen

introducedin10countriesincludingIndia,hasbeenadaptedinruralPakistan(Rahman,

Iqbaletal.2009).Theprogrammehadaflexibleformat,allowingforbothindividualand

groupbasedformats.Theindividual-basedformatwasdeliveredinparents’homesbylocal

villagehealthworkerswhoknewthemotherswell.Thegroup-basedformatconsistedofa

one-weekworkshopthatwasintegratedintoroutinepre-andpostnatalvisits,orspread

overthefirst3yearsofthechild’slife.Theprogrammerequiredminimalamountsof

literacy.

TheotherstudywasSouthAfrica’sadaptationofBritain’sSocialBabyprogramme,which

aimedtoimprovematernalsensitivityandresponsivenesstowardtheirinfantsfollowing

WHO’sprinciplesofpsychosocialstimulation(Cooper,Tomlinsonetal.2009).Inthat

programme,trainedfemalecommunityworkersvisitedhomesconsideredhighriskfor

parentingproblemstoprovideparentingsupportandguidance.Theinterventiongroup

wasvisitedforatotalof16sessions(endingat5monthspostpartum).Consistentwith

resultsfoundinmoredevelopedcountries,theprogrammesfoundimpactsoncaregiving

knowledge(Rahman,Iqbaletal.2009)andonthequalityofmother-infantrelationships

(Cooper,Tomlinsonetal.2009).Bothstudies,however,wereunsuccessfulinalleviating

maternaldepression.Bothprogrammesemployedtrainedparaprofessionals,suggesting

thataddressingmaternaldepressionmayrequiremorehighlytrainedprofessionals.

Alternatively,treatingmaternaldepressionmayrequiremoretargetedprogrammesaimed

specificallyatthisissue.Recommendationstotreatmaternaldepressiongivenitssizeable

impactnotonlyonmaternalmentalhealthbutalsoonchilddevelopmentincludeinvolving

policymakers,researchers,andprogrammeproviders(Knitzer,Thebergeetal.2008).

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Responsive Feeding and Integrated Health and Development Approaches

Twostudiesfoundsignificantimpactsonparentalcaregivingrelatedtobothhealth-and

non-healthpractices.OnestudyinBangladeshusedaresponsivefeedingapproach(Aboud,

Shafiqueetal.2009)andtheotherinUgandawasanintegratedhealthanddevelopment

programme(Britto,Engleetal.2007).

Intheresponsivefeedingapproach,thecaregiverfeedsthechildinresponsetothechild’s

cuesandpsychomotorabilitiestoensurethatthechildisfedwhenhungryandalsosatisfied

withthefeedingsituation(EngleandLhotska1999).IntheBangladeshstudy,programme

mothersreceived12sessionsonchilddevelopmentandrearinginadditiontosixweekly

sessionsonresponsivefeeding(Aboud,Shafiqueetal.2009).Althoughnoprogramme

impactswerefoundforweightgain,programmemothersbecamemoreresponsiveand

morehygienicthancontrolmothers.Theauthorsofthestudy(Aboud,Shafiqueetal.

2009)concludedthatforweightgainmorenutritionalinputisrequiredmainlyinareasof

highfoodinsecurity.

IntheUgandastudy,childhealthdayswereheldeverysixmonthscombinedwithan

educationalcampaignonhealth-seekingbehaviors,breastfeedingandcomplementary

feedingintheformofradiobroadcasts,posters,andotherlocalmedia(Britto,Engleetal.

2007).Moreover,familyandcommunitycapacitieswerestrengthenedviajobskillstraining

andcommunitygrantsandincentives.Thisprogrammehappenedforaperiodoftwoyears.

In addition to improvements in attitudes toward learning support for children,

improvementswith practices relating to physical care and school readiness skill building

werefound.

Summary Findingsfromevaluationsofsafetyandpreventionprogrammessuggestthat

professionalsareeffectivedeliverersofprogrammemessagesconcerningchildsafety.

Findingsfromnon-LMICsupportthisbyshowingthatauthorityfigures—doctors,nurses,

educators,forexample—aresuccessfulatincreasingparentingknowledge(Moran,Ghate

etal.2004).Commonstrategiestodeliveringmessagesincludedemonstrationsusing

didacticapproachesorusingtechnology.Groupsettingsmaybeeffectiveinincreasing

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knowledgebutnotactualpractice.Itappearsthatevenshort-termprogrammesare

effective,althoughoperationalizationofsafetypracticeshavemostlybeenbasedonself-

reports.Infact,onestudydemonstratedthattheprogrammehadnoimpacton

performance-basedpractice(Farahat,Farahatetal.2009).Innon-LMIC,ECDparenting

programmesthataimtoimprovesafetyaremosteffectivewhentheycatertofamilieswith

childrenlessthanthreeyearsofage,andprovidecasemanagementservicesandparent-

childactivities(Kendrick,Barlowetal.2007).

Moreover,findingsfromevaluationsofphysicalabusepreventionprogrammessuggestthat

group-basedprogrammesareeffectiveinpreventingchildabuse.Althoughimpactswere

foundforparentalknowledge,attitudes,andpractices,onlyonestudyoperationalizedchild

abuseintermsofactualcommitmentofabuse.Itisimportanttodistinguishbetween

potentialforandactualabuse.Indeed,onesystematicreviewof298publicationsconducted

inprimarilynon-LMICrevealedfourtypesofprogrammesconsideredtobepromising

approachestopreventactualchildabuseasopposedtopotentialtocommitabuse(Mikton

andButchart2009).Theseprogrammesareideally:(i)earlychildhoodhomevisitation

programmeswheretrainedpersonnelvisitparentsandtheirchildrenintheirhomesto

providesupport,education,andinformationtopreventchildmaltreatment;(ii)center-

basedparenteducationprogrammesdeliveredingroupsthataimtopreventchild

maltreatmentbyimprovingparents’childrearingskills,increasingECDknowledge,and

encouragingtheuseofappropriatebehaviormanagementstrategies;(iii)programmesthat

includeabusiveheadtrauma(ShakenBabySyndrome)prevention;and(iv)multi-sectoral

programmesthatincludeservicessuchasfamilysupport,preschooleducation,andchild

care.Lesssuccessfultypesofprogrammesinclude:(i)childsexabuseprevention

programmesintheformofuniversalprogrammesdeliveredinschoolsthatteacheschildren

aboutbodyownershipandhowtodetectabusivesituations;(ii)media-basedinterventions

intheformofmediacampaignstoraisepublicawareness;and(iii)supportgroupsthat

aimedtostrengthenparents’socialnetworks.Moreover,thatreviewnotedthathome

visitationandparenteducationprogrammeswerebotheffectivenotjustinpreventing

actualabusebutalsoinreducingriskfactorsassociatedwithit(MiktonandButchart2009).

GiventhatratesofabusearehigherinAfricancountries(Akmatov,2011),noneofthe

studieswereconducted

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intheAfricancontinentwithinthepastdecade,suggestingthatnotenoughchild

protectionprogrammesarebeingevaluatedinhighriskregions.

Insummary,acrossstudiesthatshowedsignificantimpactsoncaregivingthatpromoted

childdevelopment(non-health),thefindingssuggestthatprofessionalswereregardedas

individualswithauthorityandexpertiseandwereeffectiveinincreasingparental

knowledgeaboutchildprotection.Group-basedprogrammesappearedtobeeffectivein

impactingknowledgeaboutchildprotection,althoughitsimpactonactualasopposedto

self-reportedabuseremainsinconclusive.Singledoseprogrammeswereinsufficientin

improvingparentalemotionalresponsiveness.Combininghomevisitingwithgroup

sessionsappearedtobepromisingeveniftheyweredeliveredbytrainedparaprofessionals.

Responsivefeedingandintegratedprogrammeswerealsoeffectiveprogrammatic

strategiesforimprovingparentalpracticespromotingchilddevelopmentandprotection.

3.2.3COMPREHENSIVE(BOTHCHILDANDPARENT)OUTCOMES

Parentingprogrammesgenerallyaimtochangeparentalknowledge,attitudes,and

practicesthatwould,inturn,improvechildoutcomes.Notallparentingprogrammes

evaluatebothparentandchildoutcomesandfindimpactsonboth.Inthissection,studies

thatshowedsignificantimpactsonbothparentandchildoutcomes(i.e.,comprehensive

outcomes)arepresented.Here,comprehensiveoutcomesareorganizedaccordingto(1)

childphysicalhealthandhealth-relatedcaregivingpracticesand(2)childdevelopmental

outcomesandassociatedparentingpractices.3.2.3.1 Child Physical Health and Health-Related Caregiving Practices (n=19)

Nineteenstudies,halfofwhichwereRCTs,foundsignificantimpactsonchildphysical

healthandhealth-relatedcaregivingpractices.Thestudiesevaluatedbetween121and

6,144child-caregiverpairs(median=744)across9countries:Bangladesh,Brazil,Egypt,

Ethiopia,Haiti,India,Peru,Senegal,andUganda.Theprogrammaticapproachesusedwere

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intheformofbreastfeedingpromotion,hygieneanddiseaseprevention,nutrition

education,andcomprehensivehealthandnutritionprogrammes.

Breastfeeding Promotion programmesinLMIChavebeenshowntoeffectivelyinform

newmothersofbreastfeeding’sbenefitsandtoincreasethechancesofactually

breastfeeding(Imdad,Yakoobetal.2011).Indeed,studieshaveshownthatknowledgeof

breastfeedingbenefitsareassociatedwithconfidenceinbreastfeedingandactuallactation

duration(Chezem,Friesenetal.2006),whichareimportantinensuringneonatalhealth.

Inourreview,wefoundthreestudiesofbreastfeedingpromotionprogrammesthatfound

impactsonbothchildhealthandparentingpractices.OnewasconductedinIndia

(Bhandari,Mazumderetal.2004)andtwowereconductedinBrazil(Cardoso,Vicenteet

al.2008,Vitolo,Bortolinietal.2008).InIndia,the12-and18-monthfollow-upofa

breastfeedingpromotionprogrammementionedinprevioussections(Bhandari,Bahletal.

2003;Bhandari,Mazumderetal.2005)showedsmallgainsinheight,withgreatergains

foundinboysthaningirls(Bhandari,Mazumderetal.2004).Thisstudyalsofound

programmeeffectsonparentalhealthpractices(SeeTable4inAppendix1).InBrazil,one

programmewasbasedonWHOguidelinesthatwasdeliveredinthehomesetting(Vitolo,

Bortolinietal.2008)andtheotherwasbasedonasystematicreviewofstrategies

appropriatetoaprimaryhealthcaresettingthateffectivelyincreasesthedurationof

breastfeeding(Cardoso,Vicenteetal.2008).Bothprogrammesshowedlowerratesof

respiratorymorbidity(butonlyfor<4monthsofageinCardosoetal.(2008))andmore

appropriatehealth-relatedcaregivingpractices.IntheCardosoetal.(2008)study,

reductionsindiarrheawerefoundbutonlyforthe4-12monthsagegroup,nottheyounger

group.Thisstudyisalsotobeinterpretedcautiously,givenitslowqualityscore(23%).

Hygiene and Disease Prevention Thenextsetofstudieswasacommunity-based

hygieneanddiseasepreventionprogrammeconductedinEthiopia(Cumberland,Edwards

etal.2008;Edwards,Harding-Eschetal.2008).Theseprogrammesutilizedavailable

communityresourcestodisseminatehealthinformation.InEthiopia,theprogrammewas

knownasthe

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InternationalTrachomaInitiative(ITI),whichwasderivedfromtheSurgery,Antibiotics,

FacialCleanlinessandEnvironmentalImprovement(SAFE)strategyanddisseminatedin

randomlyselectedcommunitiesthroughmassdrugadministration,information,education

andcommunicationmaterials,andcommunityvideobroadcasts(Cumberland,Edwardset

al.2008;Edwards,Harding-Eschetal.2008).Post-interventiondataindicatedthatITIled

toareductioninoddsofactivetrachomaamongyoungchildrenlivinginprogrammeareas

andincreasesinparentalknowledgeofeyediseasepreventionbutnotinreportedor

observedhygienepractices(Cumberland,Edwardsetal.2008).Thethree-yearfollow-up

showedloweroddsofinfectioninolderchildren(6-9yearsold)thaninyoungerchildren,and

inchildrenwhoreceivedtwoorthreedosesratherthanone(Edwards,Harding-Eschetal.

2008).Thereisevidenceofimprovementinsanitarypracticessurroundingwaterusageand

thepresenceofflypopulationsinthefollow-upstudy.

Health and Nutrition Education Sixstudiesevaluatedhealthandnutritioneducation

programmes. Except for one study (Santos, Victora et al. 2001), five evaluated

programmes that targeted malnourished populations (Ghoneim, Hassan et al. 2004;

Kilaru,Griffithsetal.2005;Penny,Creed-Kanashiroetal.2005;Roy,Fuchsetal.2005;

Waters,Pennyetal.2006).ExceptforKilaruandothers(2005),professionalsandexperts

(Santos, Victora et al.2001; Ghoneim, Hassan et al. 2004) or a combination of

professionalsandparaprofessionals(Penny,Creed-Kanashiroetal.2005;Roy,Fuchset

al. 2005; Waters, Penny et al. 2006) delivered the health messages. For example, in

Bangladesh,doctors received20-hour training innutritioncounselingfollowingthe IMCI

feeding guidelines (Santos, Victora et al. 2001). Maternal recall of dietary

recommendationsand useof recommendedfoods and feedingpracticeswerehigher in

the programme group than in the control group, although gains in anthropometry

(weight-for-ageandweight-for-height)werefoundonlyfortheoldestagegroup(between

12and18months).

Infoodinsecureregions,theprogrammeswereviewedutilizedlocalresourcestoeducate

caregivers.InIndia,forexample,locallytrainedcounselorsprovidedmonthlynutrition

educationtocaregiverswithchildrenbetweenfiveand11monthsofage(Kilaru,Griffithset

al.2005).Thecounselingmessagesfocusedonthepreparationandtheuseof

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developmentallyappropriatelocalfoodsandthepreparationofthesefoodsaswellas

feedingadvice.Thecounselorsweretrainedtobesensitiveofhouseholdconstraints(e.g.,

limitedfinancialresources,availablehouseholdfood,decision-makingcapacityand

privilegewithinthefamilystructure).TheIndianprogrammeresultedingreaterweight

velocityandgreaterdietarydiversity.

Deliverysettingsalsovariedforhealthandnutritionprogrammesreviewed.InPeru,the

extenttowhichlocalcommunitiescouldserveasdeliverysettingsfornutritioneducation

programmestobeintegratedwithexistingnutritionserviceswastested(Penny,Creed-

Kanashiroetal.2005;Waters,Pennyetal.2006).Localfieldworkersvisitedfamilies

duringcrucialstagesofdevelopmenttoassessnutrition,feedingpractices,andgrowth:

afterbirthandat3,4,6,8,9,12,15,and18monthsofage.Reductionsinstuntingand

increasesinage-specificfeedingknowledgeandhealth-seekingbehaviorswerereported.

Thus,thehealthcentersimprovedtheirqualityandcoverageoftheirnutritioneducation

throughlocalfieldworkers(Penny,Creed-Kanashiroetal.2005).

Inadditiontocommunity-basedsettings,theutilizationofdaycarecentersasdelivery

settingsofnutritioneducationprogrammeswastestedinEgypt(Ghoneim,Hassanet

al.2004).Theprogrammeconsistedofestablishingkitchensinthecentersand

providingtwomealsperday.Inaddition,parentsreceived12healtheducationsessions

fromuniversitystaffonfeedingpracticesandfeedingschedules.Improvementsin

maternalnutritionknowledgeandinanthropometricmeasuresanddecreasesinthe

percentageofanemicchildrenwereobservedpost-intervention.ThePeruvianand

Egyptianstudieshighlighttheimportanceofintegratinghealthandnutritioneducation

programmesintoexistingstructures.

InBangladesh,theamountofparentinginstructionneededtoimpactchangewas

examinedbyRoyandcolleagues(2005). Moderatelymalnourishedmotherswererandomly

assignedtooneofthefollowingnutritioneducationconditions:(1)twiceaweekforthree

months,(2)twiceaweekforthreemonthsinadditiontosupplementaryfeedingforsix

daysaweek,and(3)twiceamonthnutritioneducationaspartofstandardroutineservice

oftheBangladeshIntegratedNutritionProject(thecontrolcondition).Nodifferences

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betweenthetwointerventiongroupswerefoundintermsofchildanthropometry,

morbidity,andparentalfeedingpractices,butbothinterventionswerefavoredoverthe

controlcondition.Thisstudyshowedthatadditionalsupplementaryfeedinghadno

additiveimpactonearlychildhoodhealthwhencombinedwithhealtheducation.This

finding,however,shouldbeinterpretedwithcaution,asunintendedimpactswerereported

(e.g.,higherratesofdiarrheaandfebrileepisodesininterventiongroupsthanincontrol

group).

Nutritioneducationprogrammesaremoreeffectivewhenprofessionalsdeliverthe

healthmessages.Parentsmayinterprethealthcareprofessionalsasexpertsinthefield

andarethereforemoreamenabletodidacticinstruction.Nutritioneducation

programmesthatareintegratedintoexistingprogrammesorstructuressuchasnutrition

services(Penny,Creed-Kanashiroetal.2005;Waters,Pennyetal.2006)orearly

childhoodservices(Ghoneim,Hassanetal.2004)aremoreeffective.

Comprehensive Health and Nutrition Programmes Eightstudieswerecategorized

undercomprehensivehealthandnutritionprogrammes.Theprogrammingmodalities

werecommunity-basedprogrammes(Alderman2007,Dubowitz,Levinsonetal.2007;

Roy,Jollyetal.2007;Alderman,Ndiayeetal.2009,Arifeen,Hoqueetal.2009)and

homevisits(Ruel,Menonetal.2008;Donegan,Maluccioetal.2010;Feldens,Giugliani

etal.2010).

Fivestudieswerecommunity-basedprogrammesthatpromotedhealth,growth,and

nutrition.TwostudieswereconductedinBangladesh.OnetestedtheefficacyoftheIMCI

strategyinchildhoodmortalityandnutrition(Arifeen,Hoqueetal.2009)andtheotherone

wasacomprehensivehealthandnutritioneducationprogrammethattargetedmothersof

moderatelymalnourishedchildrenaged6-9months(Roy,Jollyetal.2007).IntheIMCI

study,allthreecomponentsoftheIMCIstrategy(i.e.,health-workertraining,health-

systemsimprovements,andfamilyandcommunityactivities)wereimplemented.Village

practitionersdeliveredinformationonmanagementofsickchildren,avoidanceofharmful

treatmentpractices,andreferralofseverelyillchildren.Thestudyalsotrainedand

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supportedMuslimimamsidentifiedintheprogrammeareastoconveycrucialmessages

duringsermons.Moreover,atheaterscriptaddressingIMCImessageswasdevelopedand

twocommunitytheatergroupsweretrainedandsupportedtoundertakeopen-airtheater

showsintheIMCIareavillagesonceeveryeighttoninemonthstocommunicatekey

messages.Caregiversinprogrammeareasweremorelikelythanthoseincontrolareasto

utilizeavailablecommunityresources(e.g.,counseledbyvillagehealthworkers,attended

meetingsonmaternalandchildhealth).Therewasalsoevidenceoflowerprevalenceof

stuntingandwastinginprogrammeareasthanincontrolareas.

IntheotherstudyinBangladesh,theprogrammegroupreceivedweeklynutritioneducation

inadditiontostandardcareforthefirstthreemonthsandthenonceeverytwoweeksfor

thenextthreemonthswhereasthecontrolgroupreceivedregularservicesfromthe

BangladeshIntegratedNutritionProject.Mothersintheprogrammegrouphadbetter

feedingpracticesthanmothersinthecontrolgroup.Moreover,childrenintheprogramme

grouphadlowerratesofstunting,werelessunderweight,andhadgreaterweightgainthan

childreninthecontrolgroup.Thenutritionprogrammesreviewedthereforewereeffectivein

improvingbothanthropometricmeasuresandmaternalcaregivingpractices.

Thenextsetofcommunity-basedhealthandnutritionProgrammeswereimplementedin

Uganda,Senegal,andIndia.TheUgandaandSenegalprogrammes,whichcapitalizedon

thesupportofparishactivitiesandanationalmultisectoralcoordinatingbody,respectively,

weresuccessfulinimpactingratesofbeingunderweightandparentalcaregivingbehaviors

(Alderman2007;Alderman,Ndiayeetal.2009).ThegoaloftheDularprogrammeinIndia

wastocapitalizeanddevelopcommunityresourcesatthegrassrootsleveltoimprove

nutritionalpracticesanddecreasemalnutrition.Activitiesincludedtheestablishmentofa

community-basedtrackingsystemofthehealthstatusofwomenandchildrenamongother

growthandnutritionactivities.IntheevaluationoftheDularprogramme,the

interventionwasdividedintothree:onereceivingtheregularDularprogramme(regularhealth

andnutritionactivities,trainingandadvocacy,distributionofeducationmaterials),one

receivingtheintensiveDularprogramme(regularprogrammewiththeadditionof

trainingandassignmentoflocalresourcepersons,monitoring,andfollow-upactivity),

andonenon-

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Dulargroup(receivingregularhealthandnutritionactivities)(Dubowitz,Levinsonetal.

2007).Eitherregularorintensiveprogrammeswerefavoredoverthenon-Dularinterms

ofparentalhealthandnutritionpracticesandratesofbeingunderweight.Rateof

immunizationwashigherintheregularDulargroupthanbothintensiveDularandnon-

Dulargroups.

OneinterventioninBrazilcombinedoralhealthpromotionwithTenStepsforHealthy

Feeding,whichwasapartnershipbetweenWHOandtheBrazilianNationalHealthPolicy

(Feldens,Giuglianietal.2010).TheotherinterventionwasconductedinHaiti(Ruel,

Menonetal.2008;Donegan,Maluccioetal.2010).IntheBrazilianstudy,12university-

levelnutritionstudentswhowereextensivelytraineddelivered30-minutemonthlyhome

visitsuptosixmonthsandthenbi-monthlyhomevisitsforthenextsixmonths.Although

theprogrammedidnotimpactconsumptionoffruitsandvegetables,significantimpacts

favoringtheinterventionwerefoundforfewercariesandcaregiversgivinglowerdensityof

sugarinfoods(Feldens,Giuglianietal.2010). TheevaluationoftheHaitianprogramme

involved13-14homevisitsfornewborninfantsandseverelyundernourishedchildrenin

additiontootherprogrammeactivities(foodassistance,nutritioncounselingprovidedat

rallypostsandmothers’clubs,vaccination,vitaminAsupplementation,oralrehydration

salts,anddrugsthatattackparasites)(Ruel,Menonetal.2008;Donegan,Maluccioetal.

2010).Fortheevaluation,twoversionsoftheprogrammewereimplemented.The

preventiveprogrammetargetedallchildren(6-23monthsold)whereastherecuperative

programmetargetedunderweightchildren(6-59monthsold).Comparedtothecomparison

group,caregiversfromeitherprogrammeversionsweremorelikelytotaketheirchildrento

rallypostsforhealtheducation,growthmonitoringandgettingfullvaccinationsfortheir

children.Moreover,childrenassignedtothepreventive(universal)programmehadlower

incidencesofstunting,wasting,andbeingunderweightthanchildreninthecomparison

group;therewasnodifferencebetweenchildrenassignedtotherecuperativeprogramme

andthoseassignedtothecomparisongroup.Theeffectsonanthropometricmeasureswere

strongerforyoungerchildren(i.e.,thoseexposedtotheprogrammeduringtheages6-23

months).Theyprovidehelpfulguidanceontheleveloftrainingofserviceprovidersand

programmedose.

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Summary Thissectionreviewedstudiesthatexaminedandshowedimpactsonbothchild

andparentingoutcomesrelatedtophysicalwell-being.Acommonstrategyusedinthe

programmesreviewedcapitalizedonavailablecommunityresourcesandcommunityevents

todelivertheprogramme.Placesofworshipservedasprogrammedeliverysettingsinsome

cases.Further,linkingprogrammestoexistingpoliciesprovidesanillustrationofhowtotest

theefficacyofpolicyimplementation.Multisectoralpartnershipshavebeennotedasthekey

ingredienttoprogrammaticsuccess.Noadditiveeffectswerefoundforsupplementary

feedingorfoodfortificationefforts.Thereissomeevidencethatpreventivenutrition

programmes(i.e.,targetingentirepopulations)asopposedtorecuperative(i.e.,targeting

malnourishedpopulations)oneshavegreaterimpacts.Intermsofdevelopmentaltiming,

impactsonanthropometrywerestrongerforchildrenwhowereexposedtotheprogramme

whentheywereyounger.3.2.3.2 Child Developmental Outcomes (Non-Health) and Associated

Parenting Practices (n=13) Thirteenstudiesconductedineightcountries--Bangladesh,China,India,Jamaica,Mexico,

Nicaragua,Paraguay,andTurkey—evaluatedbetween100and4,465child-caregiverpairs

(median=202)andfoundsignificantimpactsonbothchildandparentoutcomesconcerning

non-health-relatedoutcomes.EightwereRCTs.Over¾oftheprogrammesmentionedwere

deliveredbyparaprofessionals.Successfulprogrammaticapproachestoimpactingchild

developmentaloutcomesandassociatedparentingpracticeswereintheformof

psychosocialstimulationprogrammes,integratedhealthanddevelopmentprogrammes,

andsocialprotectionprogrammes.

Psychosocial Stimulation Studiesthatexaminedpsychosocialstimulationprogrammes

wereconductedinIndia(SharmaandNagar2009),Turkey(Kagitcibasi,Sunaretal.2001),

Jamaica(Walker,Changetal.2004),andMexico(Solis-CamaraandRomero2002).These

studieshaveshownthatpsychosocialstimulationprogrammes,whichrequiredirect

interactionswithchildren,aresuccessfulnotonlyinimprovingchildren’sinformation

processingskills,languageskills,andsocialandemotionalwell-being,butalsoinimproving

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caregiverpracticesthatpromotechildren’scognitiveandsocialandemotional

development.Itappearsthatparaprofessionalsareaseffectiveparenttrainersas

professionalsgiventhattheprogrammesreviewedusedeitheroneortheother.

ThelongitudinalimpactofonemodelpsychosocialstimulationprogrammeinTurkey

hasreceivedinternationalattention.TheTurkishEarlyEnrichmentProject(TEEP)was

designedtotrainmotherstodeveloptheirchildren’scognitiveabilitiesandimproveparent-

childinteractions(Kagitcibasi,Sunaretal.2001;Kagitcibasi,Sunaretal.2009).Two

hundredeightymothersandtheirpreschool-agedchildren,whobelongedtothree

categoriesofearlychildcareenvironments(i.e.,educationalnurseryschool,custodialday

care,andhomecare)participatedinthestudy.Childreninthehomecaregroupwere

randomlyassignedtoreceivetheprogrammeornot.Theprogrammeconsistedofa

cognitivecomponentandamotherenrichmentcomponent.Thecognitivecomponent

consistedof60bi-weeklyguidedgroupdiscussionsovertwoyears.Trainedlocalfemale

coordinators,withrelativelyhighlevelsofeducation,deliveredthesessionsbothinthe

homeandinthegroupsettings.Bothrole-playinganddirectinstructionwereusedtoteach

mothershowtointeractwiththeirchildren.Mothersworkedwiththeirchildren15-20

minutesaday. Themotherenrichmentprogrammeconsistedof30bi-weeklyguidedgroup

discussionsthatlastedforonehour.Thetopicsforthediscussionsincludednutrition,child

development,parent-childinteractions,andparentalwell-being.Thediscussionscateredto

mothers’everydayexperiences.Resultsofthefour-year,follow-upevaluationshowedthat

mothersintheprogrammeweremorelikelytobeinvolvedincognitivestimulationactivities

thanthosewhowerenotintheprogramme.Inaddition,thechildreninthemother

programmescoredhigherinanalyticability,andtheprogrammehadsustainedeffectsin

schoolattainment,vocabularyscores,favorableattitudestowardschool,andfamilyand

socialadjustmentattheseven-year,follow-upstudy(Kagitcibasi,Sunaretal.2001).

Findingshighlighttheimportanceofthehomeenvironmentasasupportmechanismto

earlychildhoodeducation.

Thestudiesreviewedheresuggestthatintensiveprogrammesaresuccessfulinimpacting

childandparentoutcomes.

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Responsive Feeding: TheInternationalCentreforDiarrhealDiseasesResearchin

Bangladeshexaminedtheimpactsofaresponsivestimulationandfeedinginterventionon

childnutritionanddevelopmentaloutcomesaswellascaregivingpractices(Aboud2007;

Aboud,Mooreetal.2008;AboudandAkhter2011).Inthefirststudythatusedapost-test

onlydesign,trainedlocalfemalepeereducatorsimpartedinformationtogroupsofmothers

onacomprehensivesetoftopics(e.g.,healthandsanitation,cognitiveandlanguage

development)overanaverageof16sessionsforoneyear(Aboud2007).Inadditionto

improvementsinchildren’sweight-for-heightzscores,improvementsinbothknowledge

andactualpracticesthatpromotechilddevelopmentwerefound.However,no

improvementinlanguagecomprehensionwasfound.Thisfindingsuggeststheneedto

includechildreninthesessionactivitiesandfocusonspecificpracticesratherthan

information.AsubsequentRCTthatincludedchildrenandfocusedonresponsive

interactionsfoundlanguagedifferences(AboudandAkhter2011). Inthatstudy,control

mothersreceived13informationalsessionsonhealthandnutrition.Inadditiontowhat

controlmothersreceived,interventionmothersreceived6weekly90-minutegroup

sessionsonfeedingandstimulationdeliveredbylocalpeereducators.Theprogramme

taughtparentsabouthygiene(e.g.,howtowashtheirchild’shandsbeforeeating)and

promotedhealthandnutritionstrategies(e.g.,dietarydiversity,allowingforself-feeding).

Verbalresponsivenesswasalsostressed,aswerecopingwithrefusals.Oneadditional

interventiongroupreceivedalso6monthsoffoodpowderfortifiedwithmineralsand

vitamins.Resultsoftheimpactevaluationshowedthattheinterventiongrouphadmore

stimulatinghomeenvironmentsandmother-childresponsivetalkingthanthecontrol

group.Moreover,interventionchildrenhadhigherscoresthancontrolchildrenonlanguage

development,mouthfulseaten,andhandwashing.Foodfortificationcontributedonlyto

weightgainbutnotlanguagedevelopment.Insummary,theresponsivefeedingapproach,

ifimplementedatleastbetween16and18sessions,areeffectiveinimprovingweightand

maternalfeedingpractices(Aboud2007,Aboud,Mooreetal.2008);languageabilityis

morelikelytobeimprovediftheprogrammeinvolveschildrendirectly(AboudandAkhter

2011).

Integrated Health and Development Programmes Theevaluationsof

integratedhealthanddevelopmentprogrammes,wereconductedinChina(Jin,Sun

etal.2007),

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Bangladesh(Hamadani,Hudaetal.2006),Jamaica(Powell,Baker-Henninghametal.

2004),andParaguay(Peairson,Austinetal.2008).Allprogrammesweredeliveredby

localcommunityhealthworkerswhoweremostlywell-trainedexceptforoneprogramme

thatemployedvolunteerswithminimaltrainingandsupervision(Peairson,Austinetal.

2008).Onlyoneevaluationemployednon-randomassignment(Peairson,Austinetal.

2008).

TheChinastudywasbasedonWHO’sCareforDevelopmentprogramme,whichoffered

anintegratedpackageconsistingofpsychosocialstimulationinadditiontotheIMCI

healthandnutritionpackage(Jin,Sunetal.2007).Trainedhealthprofessionals

counseledcaregiversforatotaloftwocounselingsessionsthatcontainedage-specific

messagesonhowcaregiverscouldengagetheirchildrenbothinplayandineveryday

communication.Theprogrammehadnodiscernibleimpactonpsychomotor

development,buttheprogrammeimpactedchildren’slanguageandadaptiveandsocial

behaviorsaswellasmothers’knowledgeofchildrearing.

TheBangladeshandJamaicastudiesincludedahomevisitingcomponent.Bothstudies

integratedearlystimulationintoeitheranexistingnationalnutritionprogramme

(Hamadani,Hudaetal.2006)orintoprimaryhealthcaresettings(Powell,Baker-

Henninghametal.2004).Bothprogrammestargetedmalnourishedpopulations.Although

bothprogrammeswereunsuccessfulinimprovingchildren’spsychomotordevelopment,

bothweresuccessfulinimprovingnotonlychildren’scognitiveandsocialandemotional

outcomes,butalsoinimprovingmothers’knowledgeandpracticeofchildrearing.Both

programmesalsowereintensiveintermsofdosage.TheBangladeshprogramme

consistedofweeklygroupmeetingsfor10monthsfollowedbybi-weeklymeetingsfor2

months,andbi-weeklyhomevisitsfor8months,followedbyweeklyhomevisitsfor4

months.TheJamaicanprogrammeconsistedof30-minutesweeklyhomevisitsforone

year.Bothprogrammesinvolveddirectinteractionwiththechild.TheBangladesh

curriculum,whichoriginatedinJamaica,wasadaptedtotheculturebyincluding

traditionalgamesandsongsandbyproducinglow-costpicturebookssuitablefor

Bangladeshichildrenandtheirmothers.Thecurriculumstressedthe

importanceofparent-childinteractionsandprovideddevelopmentallyappropriate

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activitiesforthechild.Parentswereeducatedontheimportanceofpraisingandgiving

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positivefeedback,engaginginconversationwithchildren,anddiscouragingpunishment,

amongothers.

TheotherintegratedprogrammewasthePastoraldelNiño,inParaguay,whichhasbeenan

ongoinglow-costprogrammesince1995thatcaterstochildren0-5yearsofage(Peairson,

Austinetal.2008).Minimallytrainedandsupervisedvolunteersmeetwithfamiliesin

chapelsorcommunitycentersonceamonthtoengageparentsinadiscussionaboutchild

health,nutrition,safety,anddevelopment.Volunteersalsoconducthomevisitsaswellas

accompanypregnantwomentohealthpostsforprenatalcheckups.Althoughno

programmeeffectswerefoundforstuntingandunderweight,theprogrammehadimpacts

onotherchilddevelopmentaloutcomesandparentalcaregivingandchildrearingpractices

(SeeTable4inAppendix1).Thelowqualityscoreratingofthestudy,however,warrants

cautionintheinterpretationoffindings.

Social Protection TwoevaluationsofNicaraguanconditionalcashtransferprogrammes

havebeenshowntoeffectivelyimpactholisticdevelopmentandparentingoutcomes.

(MaluccioandFlores2004,Macours,Schadyetal.2008). TheReddeProtecciónSocialwas

modeledaftertheMexicanPROGRESAprogramme,andtheAtenciónaCrisispilot

programmewasmodeledafterReddeProtección.Forbothprogrammes,duringenrollment

andpaydays,programmestaffrepeatedlystressedtheimportanceofvarieddiets,health,

andeducationtocaregivers.Thisformofcommunicationwasmeanttoinstructparents

wheretoinvesttheirmoneyandwhattoconsume(Macours,Schadyetal.2012).Toremain

eligibleintheprogramme,caregiverswererequiredtotaketheirpreschool-agedchildrenfor

regularvisitstohealthcentersforgrowthmonitoring,vaccination,andreceiptoffood

supplements.ThedifferencebetweenReddeProtecciónandtheAtenciónaCrisispilot

programmewasthelatter’srelianceonpublichealthinfrastructureincontrasttoRedde

Protección‘srelianceonprivatehealthproviders.TheevaluationofbothprogrammeswerebasedonclusteredRCTs.ResultsoftheRedde

Protecciónrevealedthatparentsinprogrammeareasweremorelikelythanparentsinnon-

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programmeareastotaketheirchildrenages0-3tohealthcontrolcentersandfeedtheir

childrenwithmorevarieddiets(MaluccioandFlores,2004).Theeffectswerestronger

amongthepoorandextremepoorbutnotfornon-poorpopulations.Furthermore,the

increasedvarietyinhouseholddietandincreaseduseofpreventivehealthcareservicesfor

childrenwereaccompaniedbyanimprovementinthenutritionalstatusofbeneficiary

childrenunderage5.Theneteffectwasadeclineinthenumberofstuntedchildren.

Despiteimprovementsinthedistributionofironsupplementstothesesamechildren,

however,ReddeProtecciónSocialwasunabletoimprovehemoglobinlevelsorlowerrates

ofanemia(MaluccioandFlores,2004).

FortheevaluationofAtenciónaCrisis,parentswereassignedrandomlyintooneoffour

conditions:(1)aconditionalcashtransfercontingentuponchildren’sprimaryschooland

healthserviceattendance(CCTonly),(2)aconditionalcashtransferplusascholarshipthat

allowedoneofthehouseholdmemberstochooseamonganumberofvocationaltraining

coursesofferedinthemunicipalheadquarters(CCT+training),(3)aconditionalcash

transferplusaproductiveinvestmentgrantaimedtoencouragingbeneficiariestostarta

smallnon-agriculturalactivity(CCT+investment),or(4)controlcondition(Macours,

Schadyetal.2008). Ninemonthsafterprogrammereceipt,effectsforthethree

programmepackagesweresimilarthroughout.Impactsfavoringanyoftheprogramme

groupsoverthecontrolgroupwerenotedforvocabulary,memory,psychomotorskills,and

social-personalskills(Macours,Schadyetal.2008).Theseweredomainswherechildren

hadparticularlylargedelays,andwheresocioeconomicgradientsweresteeper.Caregiver

practicesalsochanged,whichmayaccountforimpactsfoundinchildren’sdevelopment.

Overallfoodexpendituresincreasedamongprogrammehouseholds,andexpenditureson

nutrient-richfoodsuchasanimalproteins,fruitandvegetablesincreasedmorethan

proportionally.Moreover,programmecaregiversweremorelikelythancontrolcaregivers

totaketheirchildrenforgrowthcheck-upstoreceivecareandnutritionservices.

Furthermore,earlystimulationactivitiessuchasreadingtothechildweregreaterin

programmehouseholdsthanincontrolhouseholds.Althoughprogrammechildrenhad

lowerratesofstuntingthancontrolchildren,noeffectswerefoundforratesof

underweight(under5months)andcaregiverreportofproblembehaviors.

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Summary Findingsareconsistentwithresultsfromprevioussections.Thatis,intensive(at

leastweeklyforoneyear)psychosocialstimulationprogrammesareeffectiveinchanging

parentalpracticesandchildmentalandsocialandemotionaldevelopmentaloutcomesbut

noteffectiveinchangingpsychomotordevelopmentaloutcomesandanthropometric

measuresevenwhentheseprogrammesareintegratedintoexistingnutritionprogrammes.

Psychosocialstimulationprogrammescombinedwithformalearlyeducationyieldedrobust

longitudinaleffectsasevidencedintheTurkishdemonstrations.Thefindingsalsostressthe

importanceofincludingchildrenintheprogrammeasevidencedintheresponsivefeeding

programmesimplementedinBangladesh.Thesefindingsareconsistentwiththosefrom

non-LMIC,whichrevealedthatstrategiesassociatedwithimprovingbothchildandparent

outcomesincluded:(i)trainingparentshowtointeractpositivelywiththeirchildrenona

dailybasis(real-lifeeverydayscenarios)and(ii)livemodeling(practicingnewlylearned

skillswiththeirownchild)vs.role-playingwithapeerortrainer(Kaminski,Valleetal.

2008).Inadditiontopsychosocialstimulationprogrammes,socialprotectionprogrammesinthe

formofconditionalcashtransferprogrammesappeartobepromisinginspiteofthe

inexplicitparentaltraininginvolved.Indeed,findingsfromwelfaredemonstration

programmesintheUSyieldsimilarresults.Duncanandothers(2011)pooleddatafromfour

studiesthatevaluatedRCTsofeightwelfareandantipovertyprogrammes(closeto

N=20,000).Likeconditionalcashtransferprogrammes,noneoftheprogrammesevaluated

weredesignedtoaffectchildoutcomesdirectlynorweretheydesignedtotargetparenting

outcomes.Resultsrevealedthatthepreschoolperiodwasespeciallyvulnerabletoincome

fluctuations.Specifically,a$1,000increaseinannualincomesustainedforatleasttwoyears

resultedina6%SDincreaseinachievementtestscores.ThisfindingintheUSsuggeststhat

thesmallbutsignificanteffectsizeoftheprogrammesmaybecomelargerifthewelfare

programmestargetedexplicitlyparentingandchildoutcomes.Thepathwaysbywhichincreasesinincomeleadtobetterparentandchildoutcomescanbe

explainedbydatadrawnfromthePanelStudyofIncomeDynamics(Yeung,Linveretal.

2002).Here,Yeungandothers(2002)demonstratedthattherearetwopathwaysbywhich

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incomeislinkedtooutcomes. Thefirstpathwayisthroughtheimpactofincreasedincome

onincreasedaccesstostimulatingenvironments—forexample,increaseduseofcenter-

basedservicesforearlyeducationandcare—which,inturn,impactschildren’scognitive

development.Thesecondpathwayisthroughtheimpactofincreasedincomeonmaternal

emotionalwell-being—forexample,reductionsinmaternalstress—which,inturn,impacts

children’ssocialandemotionalwell-being.Althoughtheeffectsofincomesupplementsare

generallypositive,onestudyfoundthatthiswasonlytrueforparentswhowere“hard-to-

employ”butnotforparentswhowere“hardest-to-employ”(Yoshikawa,Magnusonetal.

2003).Ofnote,althoughcashtransfersappeartobeeffectivetoacertainextent,theyare

insufficientinreducingthedetrimentalimpactsofpovertyonyoungchildren;aligningsuch

strategieswithhealth,education,andotherECDservicesisanimportantstep(Aber,

Bierstekeretal.2013).3.2.4STUDIESWITHNOIMPACTORPREDOMINANTLYMIXEDFINDINGS

The14studiesreviewedinthissectionshowedeithernoimpactorpredominantlymixed

findingsontheoutcomesofinterest.Halfofthestudiesreviewedwereintheareaofhealth

andtheotherhalfwereintheareaofchilddevelopment(non-health),includingassociated

parentingoutcomes.

3.2.4.1 Child Health and Parental Health-related Caregiving Outcomes (n=7)

Sevenstudieswiththefollowingprogrammaticapproachesmakeupthissection:(1)

hygienepromotioninNiger(Abdou,Munozetal.2010),(2)nutritioneducationinChina

(Strand,Pengetal.2002)andSenegal(Gartner,Kamelietal.2007),(3)

comprehensivehealthandnutritionwithcaregiversupportcomponentinSyria

(Bashour,Kharoufetal.2008),(4)communityempowermentviapositivedeviance

approachinVietnam(Schroeder,Pachetal.2002)andviaparticipatorylearningin

India(Tripathy,Nairetal.2010),and(4)socialprotectionintheformofconditional

cashtransfersinMexico(BehrmanandHoddinott2005).Sixofthesevenstudieswere

RCTs.Onlyonestudyusedhomevisiting.Thecommonthreadacrossthese

programmeswasthattheyweremostly

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delivereddidacticallybyparaprofessionals.Therewas,however,considerablevariation

acrossprogrammesintermsofprogrammaticdesignandstrategies.

Twocommunityempowermentprogrammesdifferedintheirdesign.Oneprogrammein

Vietnamwasdesignedasacommunity-basednutritionprogrammeusingthehearthmodel

andthepositivedevianceapproach(Schroeder,Pachetal.2002).Inthisstrategy,

communitymembersidentifypoorfamilieswithwell-nourishedchildrenanddocumenttheir

caregivingbehaviors—feedingpractices,caring,andhealth-seekingbehaviors(Marshand

Schroeder2002).Programmersthendesigntheinterventionbasedontheadoptionofthese

behaviors.Theotherprogrammewasdesignedasaparticipatorylearningprogrammein

women’sgroupsinIndia(Tripathy,Nairetal.2010).Inthisprogramme,healthcommittees

wereformedinbothprogrammeandcontrolareas,allowingforcommunitymembersto

expresstheiropinionsoflocalhealthservices.Inprogrammebutnotincontrolareas,local

womenfacilitated20monthlygroupmeetings.Findingsrevealednoimpacton

anthropometricmeasuresfortheVietnamprogrammebutrevealedthatprogramme

childrenlessthan15monthsandprogrammechildrenwhoweremoremalnourished

deterioratedsignificantlylessthanthecontrolgroup(Schroeder,Pachetal.2002).Forthe

Indianprogramme,significantimpactwasfoundonlyoninfantmortalityrates,whichwas

notanoutcomeunderinvestigationinthisreview(Tripathy,Nairetal.2010).No

programmeeffectswerefoundformaternaldepression,illnessindicators,andcare-seeking

behaviors.Thefindingsfrombothprogrammessuggestthatcommunityempowerment

programmesinandofthemselvesmaynotbeaseffectiveinimprovingchildphysicalwell-

beingandmaternalcaregivingbehaviorsbeyondchildhoodsurvival.Otherprogramming

modalities,suchashomevisitsmayhavetobecombinedwiththisprogrammaticapproach

toyieldmorepositiveprogrammeimpacts.Anothersetofstudiesconsistedofrelativelylow-doseprogrammes(between1and9

sessions)andmayhaveaccountedforthelackofprogrammeeffectiveness.Thesewere

implementedinNiger(Abdou,Munozetal.2010),inChina(Strand,Pengetal.2002),andin

Syria(Bashour,Kharoufetal.2008).ThehygienepromotionprogrammeinNigerconsisted

ofonetotwovillagemeetings(betweenoneandtwohourspermeeting)facilitatedby

villagehealthworkerstrainedonthespreadoftrachomaandstrategiestopreventits

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transmission.Atleastonehandpumpwellwithpotablewaterwasalsoconstructedineach

programmevillage.ThericketspreventionprogrammeinChinaconsistedofdoctors

examiningchildrenforatotalofnineexamsandinstructingcaregiversonbasicnutritionand

vitaminDandcalciumsupplementation.InSyria,wherepostpartumcareisratherignored,

Bashourandcolleagues(2008)testedtheefficacyofhomevisitingbyregisteredmidwives.

Firsttimemotherswererandomlyassignedintooneofthreeconditions:(1)fourhomevisits

(1st,3rd,7thdayafterdelivery+4thweekafterdelivery),(2)onehomevisit,or(3)nohome

visits.

Homevisitationactivitiesincludedphysicalexaminations,educatingmothersonpostnatal

care,andprovidingemotionalsupport.Acrossallthementionedlow-dosagestudies,no

impactsontheoutcomesofinterestweredetected(SeeTable4inAppendix1).

FinallytwostudiesconductedinSenegalandMexicofoundnooverallimpactsbutimpacts

werefoundbasedonsub-groupanalyses.Bothstudiesgarneredlowqualityscores(<50%).

TheprogrammeinSenegalyieldedasignificantimpactondietarydiversitybutonlyforthe

oldestagegroup(24-35monthsofage)(Gartner,Kamelietal.2007).Moreover,the

evaluationalsoyieldedcounterintuitivefindings,favoringthecontrolgroup. Forinstance,

thecontrolgrouphadhigherratesofimmunizationagainstmeasles,butonlyforthe

youngestagegroup(6-11monthsofage),andgreaterratesofdeclineinwastingandbeing

underweightthantheprogrammegroup.TheprogrammeinMexicowastheevaluationof

theconditionalcashtransferprogramme,PROGRESA,onchildheight(Behrmanand

Hoddinott2005).Resultsoftheintent-to-treatanalysesshowednoimpactonheight;

however,afteremployingchildfixed-effectsestimatesthataccountedforunobserved

heterogeneitycorrelatedwithaccesstonutritionsupplements,theprogrammeaccounted

foranincreaseofaboutonesixthinchesperyear.Notethatintheprevioussection,

PROGRESA’seffectonheightwasstrongeramongtheyoungestinfantsatbaselinewho

livedinthepooresthouseholds(Rivera,Sotres-Alvarezetal.2004).

Summary Overall,appropriateparentalpracticesdonotseemtoimproveifthemodalityis

primarilydidactic—lecture-stylewithnodirectinteractionswithchildren,resultinginmaking

changesinchilddevelopmentlesslikely.Moreover,communityempowermentprogrammes

asevidencedintheVietnampositivedevianceapproachtocommunitynutrition

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andintheIndianparticipatorylearningprogrammeamongwomen’sgroupswereineffective

inimprovinghealthandnutritionoutcomesbeyondsurvivalrateswhenimplemented

throughonlyonemodality. Additionalmodalitiesmaybenecessarysuchashome

visitationstocomplementtheseprogrammes.Intermsofdosage,lowdosageprogrammes

(between1and9sessions)thataredelivereddidacticallyareineffective.Evenhome

visitation,ifitconsistsofamaximumof4sessions,isineffectiveinimpactinginfanthealth

andhealthpracticesoffirsttimemothers.Finally,manyofthestudiesreviewedhaveshown

impactsonsub-groupsbyage,gender,oractualuptake.

3.2.4.2 Child Development and Parental Child Rearing Outcomes (n=7)

Thediscussioniscomprisedofthreelongitudinalfollow-upstudies,twochildprotection

programmes,andtwointegratedhealthanddevelopmentprogrammes.Exceptfortwo

ofthethreefollow-upstudies,therestwereevaluationsdeliveryofinstructionwas

primarilydidactic.

Longitudinal Follow-Up Evaluations.Threelongitudinalfollow-upevaluationsofa

breastfeedingpromotionprogrammeinBelarus(Kramer,Fombonneetal.2008),a

psychosocialstimulationprogrammeinJamaica(Chang,Walkeretal.2002),andanearly

careandstimulationprogrammeinTurkey(Kagitcibasi,Sunaretal.2009)makeupthis

section.ThestudyinBelaruswasthe6.5-yearfollow-upofthePROBITbreastfeeding

promotionprogramme(Kramer,Fombonneetal.2008);thestudyinJamaicawasthe

eight-yearfollowupof9-24montholdstuntedchildrenwhowereassignedrandomlyto

receiveeithernointervention,supplementationonly,stimulationonly,oracombinationof

stimulationandsupplementation(Chang,Walkeretal.2002);andthestudyinTurkeywas

the22-yearfollowupstudyofTEEP(Kagitcibasi,Sunaretal.2009).Thesethreestudies

examinedwhethertherewereanysustainedprogrammeimpactsonprimarilybehavioral

adjustmentoutcomes.Inthefollow-upofPROBIT,noevidenceoflong-termintervention

effectsonchildbehavioralproblemsormaternaladjustmentwasfound(Kramer,

Fombonneetal.2008).Inthefollow-upofJamaicaninfantswhowerenowbetween11-12

yearsofage,nodifferencesamongthefourconditionsweredetectedinimpactingparental

orteacher

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ratingsofbehaviorandstandardizedtestsofacademicachievement(Chang,Walkeretal.

2002).Inthe22-yearfollow-upofTEEPchildren,nomaineffectsoneducationaloutcomes

orsocialadjustmentweredetected(Kagitcibasi,Sunaretal.2009).Child Protection Programmes. Twostudiesexaminedchildprotectionoutcomes.They

wereverydifferentintermsofstudygoals.Thefirststudyexaminedtheefficacyof

integratingpostnatalvisitsintoSwaziland’spreventionofmother-to-childtransmission

(PMTCT)programme—aformofpreventiveinterventionforHIV-positivewomen(Mazia,

Narayananetal.2009).Healthworkersvisitedhomestwicewithinoneweekofdeliveryto

delivercounselingmessagesonbasicpreventivecare,identificationofdangersigns,and

appropriatecare-seekingbehaviors.Theprogrammehadnoimpactonmothers’recallof

informationonbasiccareanddangersigns.Giventhatthemodeloftrainingwasatrain-

the-trainermodelandthat43%ofthestaffwereleftuntrainedduetoconflictingactivities,

thisstudyunderscorestheimportanceofensuringthatthesecondleveloftraineesreceive

adequatetraining.

Thesecondstudyexaminedtheeffectsofprolongedswaddling,acommontraditionin

Mongolia,onchilddevelopment(Manaseki-Holland,Spieretal.2010).Thehypothesis

ofthesecondstudywas,infact,toacceptthenullhypothesis—thatis,toprovethat

swaddlinghasnodeleteriouseffectsonchilddevelopment.Programmemotherswere

instructedtofollowatraditionalMongolianpatternofswaddling.Thepatternofswaddling

forthefirsttwomonthsweremoreintensive,butby7months,swaddlingwasrestrictedto

timeswheninfantswereasleep.Compliancewasmonitoredviahomevisitsanddiaries.

Resultsdemonstratedthatnosignificantdifferencesbetweenprogrammeandcontrol

infantswerefoundinstandardizedtestsofmentalandpsychomotorskills.Swaddling

infantsthroughoutinfancy,therefore,hadnodetrimentaleffectsonchildren’s

development.

Integrated Health and Development Programmes Twointegratedhealthand

developmentprogrammeswereunsuccessful:theCONIN(CorporationforChildhood

Nutrition)programmeinArgentinaandtheParentalEducationProgrammeinthe

Gambia.The

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CONINstudyinArgentinawasaretrospectivequasi-experimentalstudyofchildrenages5-

17exposedtotheCONINunder-nutritionpreventioncenters(from1996-2005)andthose

whowerenotexposedtotheprogramme(Ortiz-Andrellucchi,Peña-Quintanaetal.2009).

Thestudytestedtheeffectsoftheprogrammeonahostofanthropometricmeasuresand

childdevelopmentaloutcomes.TheGambianstudywasaquasi-experimentalevaluationof

theParentalEducationProgrammeattheendofafour-yearperiod(Sidibeh2008).

Althoughbothprogrammesweresimilarintheirgoalofpromotingnutritionand

psychosocialsupportandstimulation,theyalsodifferedinafewways.

First,thetargetofinterventiondifferedforbothprogrammes.TheCONINprogramme

targetedmotherswhereastheParentalEducationProgrammetargetedparentsandother

caregivers(includingsiblings)aswellascommunityleadersandcivilservantsfrom

differentsocialsectors.Second,programmaticstrategiesdifferedalsoforboth

programmes.TheCONINprogrammeconsistedofnutritionworkshopsthatincluded

communitygardenswiththeaimofteachingparentshowtopreparenutritiousfoodsas

wellasofhomevisitswiththeaimofprovidingsupportandeducationontheimportance

ofstimulationandattachmentrelationships.Ontheotherhand,theParentalEducation

ProgrammeintheGambiaemployedatwo-prongedapproach:(1)acomprehensive

communicationstrategywithkeymessagesonnutrition,health,waterandsanitation,and

childdevelopmentandprotection;and(2)thedevelopmentofacomprehensiveparental

education(“train-the-trainer”)manualthatservedasaguidefortrainingnon-literate

communityvolunteers.Communityvolunteersthenconductedtheprogrammeinthe

formoffocusgroupdiscussions.Differentmaterialsweregeneratedtodisseminate

programme’scontent(i.e.songsweredevelopedthateducatedparentsonthe

relationshipbetweenearlylearningandtoys).Attheendoftheprogrammeperiod,nosignificantdifferenceswerefoundbetween

programmeandcomparisongroups(Sidibeh2008;Ortiz-Andrellucchi,Peña-Quintanaet

al.2009).Moreover,countertohypotheses,thenon-CONINchildrenhadlowerratesof

visualimpairmentandhigherlevelsofschoolachievementthanCONINchildren(Ortiz-

Andrellucchi,Peña-Quintanaetal.2009).Thenon-significantfindingsofbothstudies

maybeattributedtotheirlowqualityscoreratings(<50%)andtothefactthattheywere

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primarilydidacticwithnomentionofdirectinteractionswithchildren.Programdosage

informationcouldnotbedeterminedineitherprogramme.Summary Thestudiesreviewedhereshowedthatbreastfeedingpromotion&psychosocial

stimulationprogrammeshavelongtermimpactsoncognitiveoutcomesbutnotonsocial

andemotionaldevelopment.Breastfeedingpromotionprogrammeshavebeenshownto

benefitextendedbreastfeeding,childhealthandgrowth,andmentaldevelopment,butnot

tomoredistaloutcomessuchaschildsocialandemotionaladjustmentandmaternalwell-

being.Psychosocialstimulationprogrammesmayhavelongtermimpactsonsocialand

emotionaloutcomesiftheyaretobecombinedwithpreschooleducationasseeninthe

TEEPstudy.Asahomevisitationprogrammeinitself,psychosocialstimulation

programmesmaynotbeaseffectiveinimprovingchildren’ssocialandemotional

developmentinthelongrun.Thisfindingsuggeststhatthedevelopmentofsocialand

emotionalskillsandwell-beingrequiresprogrammestotargettheseskillsdirectlyandover

timeincontextswherechildrenhavetousethem,e.g.preschoolProgrammesintheTEEP

model.Evidencefromsocialandemotionallearningprogrammessuggestthatteaching

theseskillsrequirebothqualitydeliveryandpositiveattitudesofimplementersto

effectivelyimpactchildren’ssocialandemotionalskills(Reyes,Brackett,Rivers,

Elbertson,&Salovey,2012).Intermsofevaluationdesign,quasi-experimentalstudieswithlowqualityscoresmaynot

havebeeneffectiveinfindingarepresentativecontrolgrouptomatchtheintervention

group.Finally,inevaluatingourfindings,onemusttakeintoconsiderationthedistinction

betweenimmediateprogrammeimpactsandlong-termfollow-upimpacts,andthe

distinctionbetweenpilotsandscaledupprogrammes.

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CHAPTER4:DISCUSSIONThereistremendousdiversityaroundtheworldinparentingapproaches,philosophiesand

culturalconstructions.Howevertherearealsoafewuniversalpropertiesandcharacteristics

inparentingpractices,primaryamongwhichisthefunctionofparentingtonurturethe

survival,developmentandwellbeingofthechild. Thisfunctionisatriskformorethan1/3

oftheworld’syoungestchildrenasnotedbylackofstimulating,responsiveandsafe

parentingpracticesduetoanynumberofindividualand/orcontextualfactors. Parents,

especiallythemostvulnerableones,needtobesupportedintheirroleandabilitytocarry

outthefunctionofparenting. Thereforeparentingsupport,educationandtraining

programmesneedourattentiontoimplementeffectiveservicestohelpparentsand

families.

TheaimofthissystematicreviewhasbeentosynthesizetherecentmodelsofECD

parentingprogrammes,evaluatetheireffectivenessandidentifyprogramme

characteristicsthatcouldbescaleduptopromoteeffective,sensitiveandresponsivechild

rearingandcaringpractices,withaspecialfocusonthemostmarginalizedfamiliesand

vulnerablechildreninsupportofUNICEF’sequityapproach,inaglobalcontext. One

hundredandfivearticleswerereviewedcoveringECDparentingprogrammesfromLMIC

witharangeinfocifromhealth,nutrition,socialprotection,psychosocialsupportandearly

learningtoprogrammemodalities,deliverymechanisms,dose,andimpactonimproving

childandparentoutcomes.

Ingeneral,mostreportedprogrammesthatmetourinclusioncriteriashowedsignificant

resultsinimprovingchildand/orparentingoutcomes.ECDparentingprogrammesthat

aimedtopromotenutritionandhealth(56.2%)andprogrammesaimedtopromote

domainsofchilddevelopmentotherthanhealth(43.8%),ofthetotalnumberof

programmesthatmettheeligibilitycriteriaforthecurrentstudy.Thissuggeststhat

parentingprogrammesaremakingadifferenceinthelivesofchildrenandfamilies.Inthis

chapterwepresentourreviewandanalysesoftheresultsthatemergedfromeffective

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practiceswiththeintentionofinformingimplementation.Wefocusonthecharacteristicsof

effectiveECDparentingprogrammeswiththeobjectiveofmakingrecommendationsforthe

nextgenerationofprogramming. Thecharacteristicsarepresentedinthreesections:what

weknowworks,knowledgegaps,andaddressingvulnerablefamilies.

4.1WHATWORKSINPARENTINGPROGRAMS

Acrossthereviewofthe105articles,weidentified3areasthatareimportanttoconsiderin

designing and implementing effective parenting programmes: programme dose;

programmequalityandprogrammetimingwithrespecttotheageofthechild.

4.1.1ProgrammeDose

Dosagehasbeenidentifiedasimportantforprogrammeeffectiveness.Howeverthereis

stillalackofconsensusinthedefinitionandmeasurementofdosage.Statedsimply,doseis

theamountoftheprogrammethatisdelivered(Wasik,Mattera,Lloyd,&Boller,2013).

Followingtheacceptedconceptualizationofinterventiondose,wereviewthethree

components:duration,frequency,andintensity.

Lowdoseprogrammesacrossduration,frequencyandintensityyieldednon-significant

programmeimpacts. Forexample,therelativelylow-doseprogrammes(between1and9

sessions)forhygienepromotioninNiger(Abdou,Munozetal.,2010),ricketsprevention

inChina(Strand,Pengetal.,2002),andpostpartumcareinSyria(Bashour,Kharoufetal.,

2008)hadnoimpactonchildorparentoutcomes.Thelowdose,inpart,mayhave

accountedforthelackofprogrammeeffectiveness,makingitanimportantcomponent

toconsiderinprogramming.

Duration isthelengthofthefullprogrammefromstarttofinish.Acrossthestudies,

tremendousvariationwasnotedinthelengthoftheparentingprogrammes. Ananalysis

of

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theresultsrevealsthattheoptimallengthofaparentingprogrammeislinkedtothetypes

ofresultsitisabletoimpact.

Forimprovingchildleveloutcomes,indomainsofphysicalhealth,cognitivedevelopment

andsocialandemotionaldevelopment,thereviewsuggeststhat12monthsisthe

minimumdurationofaparentingprogramme.However,forprogrammesthatwere

implementedovera2-yearperiod,moreconsistentimpactwasnoted,inparticularfor

vulnerableanddisadvantagedpopulations. Forexample,theprogrammedurationofan

effectiveparentingprogrammeimplementedbySavetheChildrenJapaninruralVietnam,

wheretherewasahighprevalenceofstunting,wastwoyears(Watanabe,Floresetal.,

2005).ThecashtransferinterventioninMexico,Opportunidades,childreninfamilieswho

enrolledearlyorhadan18monthleadcomparedtochildreninthefamilieswhoenrolled

laterdidbetteronarangeofholisticchildoutcomes(Fernald,Gertleretal.,2009).With

respecttocognitivedevelopment,theTurkishEnrichmentProgramme,TEEP(Kagitcibasi,

Sunaretal.,2001),consistedof60bi-weeklyguidedgroupdiscussionsovertwoyears.

TheseexamplesillustratethattherecommendedECDparentingprogrammedurationis24

monthstoimpactchilddevelopmentaloutcomes.Forotheroutcomessuchasoralhealth,it

appearsthatlowdoseswillsuffice(e.g.,Mohebbietal.,2009;Pereira&Freire,2004).

Wealsocoveredprogrammesthatonlyreportedonparentleveloutcomes. Itappearsthat

shorterdurationprogrammesmightworkforparentlevelresults.Forexample,

programmestoreduceharshdisciplinelastonlyseveralmonthswhilethosetargetingto

changechildoutcomestook1to2years.Howeversuchacomparisonshouldbetreated

withcaution,sincechildoutcomesweremeasuredinareasofhealthanddevelopment

whileparentingoutcomesaremeasuredinadifferentdomain,suchasdiscipline.Also,the

latterisoftenmeasuredintermsofchangeinknowledgebutnotwithrespecttochangein

behavior.Regardless,itappearsthatreviewedprogrammesthataimtochangeparenting

knowledgecouldbeshorterindurationcomparedtoprogrammesthataimtoimprove

resultsforchildren.

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The second component of dose is frequency orhowoftentheprogrammeis

delivered. Ascanbeexpectedhigherfrequencyparentingprogrammesweremoreeffective

inimprovingparentandchildoutcomes. Thelongitudinalresultsfromparenting

programmesarederivedprimarilyfromTEEPinTurkeyandthepsychosocialandnutrition

interventioninJamaicaindicatethattheprogrammefrequencyneedstobeatleastoncea

week.TheRovingCaregiversprogrammeinJamaicawasdeliveredtwiceperweek,aneven

higherfrequency.

Therearethreenotablepointswithrespecttoparentingprogrammefrequency. First,unlike

duration,impactingparentorchildoutcomesrequiresahighfrequency. Second,the

frequencyoftheprogrammedeliveryneedstobematchedwiththefrequencyofthe

parentsimplementingintheirdailylifewhattheyhavelearned. IntheTEEPmodel,for

example,mothersworkedwiththeirchildren15-20minutesaday. T h e frequencyof

parentingprogrammesneedtohaveafollowupathomefortheparentstodowithchildren

almostdaily.Third,thefrequencyoftheprogrammecanbepaced.Forexamplethe

integratedearlystimulationandnutritionprogramme(Hamadani,Hudaetal.,2006)for

malnourishedpopulationsvariedprogrammefrequencyoverthecourseofimplementation.

Theprogrammeconsistedofweeklygroupmeetingsfor10monthsfollowedbybi-weekly

meetingsfor2months,andbi-weeklyhomevisitsfor8months,followedbyweeklyhome

visitsfor4months.Theprogrammewaseffectiveinimprovingparentingpracticesandchild

outcomes.

Intensity isthethirdcomponentofdoseandhasbeendefinedasthestrengthofan

interventionorhowmuchoftheinterventionisdeliveredwithineachsession.Withrespect

tointensity,weexamineseveralcharacteristics.

First,thetimeallottedforeachsessionisanindicatorofintensity. Amongststudiesthat

reportedthetimeofeachsession,theyappearedtohavelastedfor45to60minutes. For

example,intheJamaicaintervention,eachhomevisitwas1hourlong.

Second,withrespecttointensityitisimportanttounderstandwhoisinvolvedinthe

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session,suchastheparentonlyortheparentandthechild. Resultsfromthereview

suggestthatmoreintensiveapproaches,e.g.,directinteractionwithchild,areneededto

improveparentingleveloutcomes,forexample,caregivers’abilitytobeemotionally

responsive(Ertem,etal.,2006).Inthecaseoftheresponsivefeedingprogrammein

Bangladesh,resultsindicatedimprovementinchildweightandmaternalfeeding

practicesbutnotincognitiveandlanguagedevelopment,whentheprogrammetargeted

onlyparents.Howeverwhentheprogrammeinvolvedchildren,theirlanguageabilitywas

improvedsignificantly(AboudandAkhter,2011).Therefore,involvingchildreninthe

sessionscouldbeanapproachtoincreasingtheprogrammeintensity.

4.1.2ProgrammeModality

Programmemodalityreferstothemodeormannerinwhichtheparenting

programmewasconducted.

Fromthereviewofstudies,wefoundthatmodalityofaprogrammeisakeydeterminantin

thetheoryofchange.Modalityofaprogrammeinfluencesthetheoryofchangeand

consequentlytheprogrammeoutcome/s.Forexample,childcognitiveoutcomeswere

significantlyimprovedacrossbothhome-basedmodalitiesandcenter-basedprogrammes

thatusedgroupsettings.Howeveritwasthepsychosocialstimulationaspectofthe

programmes,whichentailsactiveengagementbetweenthecaregiverandthechildthatwas

effectiveinimprovingchildren’scognitivedevelopment.Therefore,ifthetheoryofchangeis

usedastheguidingfactorthentheprogrammemodality(inthiscase,groupsettingsand

psychosocialstimulation)canbeselectedaccordingly.

Besidesthetheoryofchange,thedesiredoutcomesoftheprogrammeshouldinfluence

themodality.Forexample,inthecaseofimprovingchildprotection,evidencefrom

programmesinBrazilandTurkeyshowedthatprovidingdemonstrationsorexamplesof

contrastingapproachestosafetyareeffectiveininformingparentalpracticesofsafety.

(Issler,Marosticaetal.2009);(Özyazıcıoğlu,Polatetal.2011).Groupmodalitieswerea

morecommonapproachtoparentingprogrammesthatareaimedatpromotingchild

protection

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throughreducingharshdiscipline.However,inthecaseofpromotingbreastfeeding

practicesandhealthoutcomes,homevisitswerefoundtobeeffectivemodalities.

Therefore,decisionsregardingtheprogrammemodalityneedstobeguidedbytheaimsof

theprogramme.

Furthermore,thenumberofmodalitiesalsoprovidesanindicationofprogrammestrength

orintensity. Acrossthereviewedstudies,aconsistentresultwasthatprogrammesthat

usedmorethanonemodalityachievedbetterresultsthanprogrammesthatonlyusedone

modality.Forexample,thestudiesthatimprovedchildphysicalhealthoutcomesshowed

thatgroupsettingsmustbecombinedwithothermodalities.Thesefindingssuggestthat

byhavingparentsexposedtomultiplemodalitiesforalongperiodoftime,themessageof

appropriateandadequatenutritiongetsreinforced.Thereforecombinghomevisitswith

groupsessionsismoreeffectivethanonlyhomevisitsoronlygroupsessions(Engle,etal.,

2011).However,combiningprogrammemodalitiesisnotanadhocarrangementofservices.

Rather,thereneedstobecriteriathatguidetheapproach.Modalitiesneedtobebridged.

Forexample,inthePhilippines(Armecin,Behrmanetal.2006),thecenter-andhome-

basedserviceswerelinkedbytheCDWswhocomplementedtherolesofmidwivesand

healthworkersinprovidingfoodandnutritionalsupplementsandmonitoringchildren’s

healthstatus.CDWsalsoprovidedcommunity-basedparentingeducationaboutECD.In

providingthisbridge,theprogrammewasabletomaximizethestrengthorintensityofthe

dosetoachieveimpactonparentandchildoutcomes.

4.1.3ServiceProvision

Thethirdelementofwhatworkswithparentingprogrammesisensuringhighquality

programmes. Oneofthemainfeaturesofqualityasgleanedthroughthereviewisthe

serviceproviderandtheirabilitytodeliverandmaintaintheprogrammeeffectively.

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Authorityfigures,suchasdoctors,nurses,educators,forexamplewereamongthemost

successfulserviceprovidersinimprovingparentingoutcomes. Forexample,asignificant

increaseinparentingknowledgewasassociatedwithprofessionalserviceproviders(Moran,

Ghateetal.2004).Nutritioneducationprogrammesweremoreeffectivewhenthe

professionalsdeliveredthehealthmessages.Thereasonwhyauthorityfiguresmightbe

effectiveisbecauseparentsmayinterprethealthcareprofessionalsasexpertsinthefield

andarethereforemoreamenabletolisteningtothemandfollowingtheirguidance.

However,therealityofthesituationwithrespecttoECDprogrammesisthatthevast

majorityoftheprogrammesaredeliveredbycommunityworkersorparaprofessionals.The

fieldasawholeisfarfromhavingaprofessionalworkforce.Thereforeinourreview,wealso

examinedcommunity-basedapproachestoidentifyeffectivefactorsassociatedwith

servicesdeliveredbynon-professionalsorserviceproviderswithlimitedtraining.

Trainedlocalfemalecoordinatorswithrelativelyhighlevelsofeducationwerealsoeffective

indeliveringtheprogrammeacrosshomeandinthegroupsettings.Theseserviceproviders

thoughneedfairlyintensivetrainingnotonlyintheprogrammeapproachbutalsointerms

oftechniques.Forexample,bothlivemodelinganddirectinstructionhavebeenusedwith

successtoteachmothershowtointeractwiththeirchildren.Thesearetechniquesinwhich

serviceprovidersneedtobetrained.Thesefindingsareconsistentwiththosefromnon-

LMIC,whichrevealedthatstrategiesassociatedwithimprovingbothchildandparent

outcomesincluded:(i)trainingparentshowtointeractpositivelywiththeirchildrenona

dailybasis(real-lifeeverydayscenarios)and(ii)livemodeling(practicingnewlylearnedskills

withtheirownchild)vs.role-playingwithapeerortrainer(Kaminski,Valleetal.

2008).Thecommunity-basedprogrammesthatpromotehealthandnutritionindicatethat

employinglocalleaders,e.g.,theImamsinBangladeshandcommunitytheatreactorswith

scriptwrittenforthelocalcommunitymightbealternativestrategiestoconsider(Arifeenet

al.,2009). Acommonstrategyusedintheprogrammesreviewedcapitalizedonavailable

communityresourcestodelivertheprogramme.ForexampletheDularmodelinIndia

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capitalizedanddevelopedcommunityresourcesatthegrassrootsleveltoimprove

nutritionalpracticesanddecreasemalnutrition(Dubowitz,Levinsonetal.2007).

Insummary,oneofthemainissuesofprogrammequalityappeartobelinkedwiththe

abilityoftheserviceproviderandcurrentlythevastmajorityofECDparenting

programmesusecommunityworkersorparaprofessionalstodeliverservices.The

strategiesforimprovingprogrammequalityarestillunclear,thoughstrengtheningthe

capacityoftheserviceproviders,usingprofessionalsandlocalleadershavebeen

associatedwithsignificantpositiveresults.

4.1.4TimingofProgramme

Giventhattheearlyyearsareatimeofextraordinarilyrapidgrowthandchange,parents’

interestinissuesofchilddevelopmentiscloselylinkedtotheageofthechildandthestage

oftheirdevelopment.Certaintypesofnutritionalprogrammesaremoreappropriatefor

certainagegroupsofchildren. Furthermore,giventhatchilddevelopmenthassensitive

windowsitisimportanttomaximizetheinfluenceofparentingbydesigningprogrammes

thatareageappropriate.

Ingeneral,acrossthestudiesreviewed,therewasnoclearsetofresultswithrespectto

programmetimingandageofthechild.Howeverafewillustrativeexamplesdoprovide

guidanceforprogrammedesign.Oneoftheclearestexamplesfortimingofaparenting

interventionarebreastfeedingprogrammesbecausetheyhavetocommenceinthefirst

momentsofachild’slife.Resultsfrombreastfeedingprogrammesdidshowresultsfor

improvedhealthpracticesformothersandforinfantsintermsoflong-termbenefitsfor

theircognitivedevelopmentandphysicalhealth. Thepsychosocialstimulation

programmesrangedfromwhenchildrenwereafewmonthsoldtoalmost6yearsofage.

Thereforediscerningtheappropriatetimingtocommenceapsychosocialinterventionis

challengingbasedonthisreview. Finally,intermsofdevelopmentaltiming,impactson

anthropometrywerestrongerforchildrenwhowereexposedtotheprogrammewhen

theywereyoungerasseenin

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thenutritionandhealthprogrammefromHaiti(Ruel,Menonetal.2008,Donegan,

Maluccioetal.2010).

4.2KNOWLEDGEGAPS

ThereviewhasbeenincrediblyinformativeinunderstandingwhatworksforECDparenting

programmestoimproveparentandchildoutcomes. Howevertherearestillseveralareas

thatneedfurtherresearchandexamination,ifwearetotrulyimprovetheeffectivenessof

programmes.

4.2.1Socialprotectionprogrammesandparenting

Oneofthelargestinfluencesonparentingistheavailabilityofresourcesthatallowparents

toprovidefortheirchildreninthebestpossiblemanner.Low-incomefamiliesandthose

livinginpovertyareoftenatriskforpoorerdevelopmentaloutcomesandthereforein

greaterneedofparentinginterventions. Socialprotectionprogrammes,suchascash

transferprogrammesareemergingasoneofthemostimportantmeanstoreachpoor

families.Parentingprogrammestargetthemostvulnerablepopulations.Thereforecash

transferprogrammesarepotentiallyeffectivemechanismstodeliverparentingeducationto

thesepopulations.TheresearchfromMexicoandNicaraguasuggeststhatsucha

combinationmaybeverybeneficialforthefamiliesbecausenotonlydoesitprovidethe

financialresourcesthattheparentsneedtoraisetheirfamilybutalsotheinformationand

skillstousethosefundsandparenttheirchildren. Furtherresearchisneededtoaddressthe

feasibilityofintegratingexplicitlyECDparentingeducationintocashtransferprogrammes

andassesstheirimpactsonimprovingormediatingtheeffectsofcashtransferson

outcomes.Theimpactsofthisapproachonotheroutcomedomainsarereportedinother

sectionsofthisreview.

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4.2.2MaternalmentalhealthOneofthesignificantinfluencesonparentingismaternalmentalhealth. However,fewto

noneofthestudiesexplicitlyaddressedthisimportantmediatorbetweenprogrammesand

childoutcomes(Shawetal.,2009).Althoughweexcludedstudiesofprogrammesspecifically

targetingwomendiagnosedwithdepressionandotherhealthproblems;twoofthestudies

wefoundconsideredmaternaldepressionasanareatoaddressthroughtheirparenting

programmes.Bothprogrammes,however,wereunsuccessfulinalleviatingmaternal

depression(Cooperetal.,2009;Rahmanetal.,2009).Bothprogrammesemployedtrained

paraprofessionals,suggestingthataddressingmaternaldepressionmayrequiremorehighly

trainedprofessionals.Alternatively,treatingmaternaldepressionmayrequiremore

targetedprogrammesaimedspecificallyatthisissue.Thisisanareaforfurtherworkand

inquiry.

4.2.3ScalingUpofECDParentingProgrammes

Mostofthestudiesincludedinthereviewwerebasedonsmall-scaledemonstration

programmes.Therewereahandfulofstudiesthatwerebasedonscaledupprogrammes.In

thestudies,ingeneraltherewaslittleinformationonscale-up. Afewexampleswere

presentedthatwedrawontopresentasetofconclusions. First,linkingprogrammesto

existingpoliciesprovidedamechanismtoenhancepolicyimplementation.Multisectoral

partnershipshavebeennotedasthekeyingredienttoprogrammaticsuccess.Theworkfrom

UgandanandSenegaleseprogrammes,whichcapitalizedonthesupportofparishactivities

andanationalmultisectoralcoordinatingbody,respectively,weresuccessfulinimpacting

ratesofbeingunderweightandparentalcaregivingbehaviors(Alderman2007;Alderman,

Ndiayeetal.2009).Nutritioneducationprogrammesthatareintegratedintoexisting

programmesorstructuressuchasnutritionservices(Penny,Creed-Kanashiroetal.

2005;Waters,Pennyetal.2006)orearlychildhoodservices(Ghoneim,Hassanetal.2004)

aremoreeffective.Howeversuchexampleswerefewandfarbetween.

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Scalingupatthecommunitylevelwasalsoexploredinthereview. Theresultssuggestthat

communityempowermentprogrammesinandofthemselvesmaynotbeaseffectivein

improvingchildphysicalwell-beingandmaternalcaregivingbehaviorsbeyondchildhood

survival.Otherprogrammingmodalities,suchashomevisitsmayhavetobecombined

withthisprogrammaticapproachtoyieldmorepositiveprogrammeimpacts(Schroeder,Pach

etal.2002;Tripathy,Nairetal.2010).Ingeneralmoreresearchandevidenceisneededintheimplementationscienceofscalingup

ECDParentingprogrammes.4.2.4RoleofFathersintheParentingProcess

Fathersingeneralareunder-studiedinECDparentingprogrammes(Barker,Bartlettetal.

2004,UnitedNationsDepartmentofEconomicandSocialAffairs2011).Threestudies

acrosstheentirereviewlookedatfathersasrecipientsofparentingprogrammes.(Koçak

2004)(AlHassanandLansford2011).Twoofthethreewereondiscipline.Theresultsclearly

indicateamuchgreaterneedtoincludefathersinparentinginterventions,notmerelyas

maternalsupportbutasfactorsinfluencingchildoutcomes.

4.2.5NextGenerationIssuesforECDParenting

Effectiveparentingprogrammesrequireabalancebetweensupplyofservicesanddemand

forservices. Parentingisademandsideissue.But,acrossourreview,noworkhadbeen

completedonthedemandsideofparentingprogrammes.

Afewstudiesexaminedincreasinguptakeoftheprogrammes.Forexamplethe

community-basedprogrammeinBrazil,whenofferinggroupsessions(inadditionto

homevisits),recommendedthattransportationandrefreshmentsshouldbeprovided.

Otherrecommendationsincludedprovidingconvenientservice,suchaschildcareservices

while

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parentsareinattendance,ortransportationservicesforruralfamilies—aswellasoffering

programmesatconvenientlocations(e.g.,office,preschool,communitycenters)andtimes

(includingeveningsandweekendswhenthereisademand)wereexaminedasfactorsthat

increaseparticipationrates(Moran,Ghateetal.2004).HoweverdemandforECDparenting

programmeswasnotstudiedconsistently.

Alsotheattentiontochildsocialandemotionaloutcomeswaslimited.Inordertoimprove

holisticoutcomesforchildren,parentingprogrammeshavetomovebeyondphysicalhealth

andcognition.Althoughsomestudiesdidexaminesocialandemotionaldevelopment,they

wereinaminority.

4.2.6ComprehensiveandContextualMeasures

Regardingmetricsandstudydesigns,thesystematicreviewalsorevealedthatmeasuresto

assesstheimpactofprogrammesontheattitudes,practicesandbehaviorsofparents

consistprimarilyofself-reports,whichpresentrisksofreportingbiases.Furthermore,there

isvirtuallynopresenceofimpactevaluationsthataddressbiophysiologicalimpactsof

programmesatthechildlevel.Mostphysicaleffectsaddressanthropometricindicatorsbut

ignoreimportantdimensionssuchasbiomarkersofstressandattachment.Longitudinal

studiesofECDparentingprogrammesarelacking,inparticularonoutcomeslinkedwith

long-termhealth,prosocialbehaviors,adultproductivity,andothersustainableimpacts

associatedwithsocialtransformation.Lastly,programmeevaluationsoftendonotcontrol

formacro-levelcovariates(e.g.accesstoservices,presenceorabsenceof

conflict/displacement,environmentaldeterminants,etc.),providinganincompletepicture

ofthecontextofthechild.

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4.3EQUITYTHROUGHPARENTING

Mostparentingprogrammesaddressvulnerablefamiliesandclearresultswerenotedfor

improvingequityinchildoutcomes. Forexample,malnourishedchildrenandyoungerage

groupsbenefitedthemostfromtheseprogrammes(Watanabe,Floresetal.2005).

Howevertheprogrammesalsohadtobeofahigherquality.Malnourishedpopulations

benefitedfromservicesthatinvolvedprofessionalsandexperts(Santos,Victoraetal.2001;

Ghoneim,Hassanetal.2004)oracombinationofprofessionalsandparaprofessionals

(Penny,Creed-Kanashiroetal.2005;Roy,Fuchsetal.2005;Waters,Pennyetal.2006).

Sincethesituationofvulnerablepopulationsismorecomplexthereisagreaterneedfor

proficiencyintheimplementationprocess.Forexample,inBangladesh,doctorsreceived20-

hourtraininginnutritioncounselingfollowingtheIMCIfeedingguidelines(Santos,Victora

etal.2001)resultinginbettermaternalrecallofdietaryrecommendationsandmaternal

reporteduseofrecommendedfoodsandfeedingpractices.Althoughpsychosocial

stimulationprogrammeswereeffectiveinimprovingcognitiveoutcomeswhentargeting

impoverishedgroups,malnourishedchildrenstillperformedwellbelowtheirnon-

impoverishedcounterparts.

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stateofHaryanainIndia.Wedevelopedtheinterventionthroughformativeresearch.Eightcommunitieswerepairmatchedontheirbaselinecharacteristics;oneofeachpairwasrandomlyassignedtoreceivetheinterventionandtheothernospecificfeedingintervention.Healthandnutritionworkersintheinterventioncommunitiesweretrainedtocounselonlocallydevelopedfeedingrecommendations.Newbornswereenrolledinallofthecommunities(552intheinterventionand473inthecontrol)andfollowedupevery3monthstotheageof18months.Themainoutcomemeasureswereweightsandlengthsat6,9,12,and18monthsandcomplementaryfeedingpracticesat9and18months.Allanalyseswerebyintenttotreat.Intheoverallanalyses,therewasasmallbutsignificanteffectonlengthgainintheinterventiongroup(differenceinmeans0.32cm,95%CI,0.03,0.61).Theeffectwasgreaterinthesubgroupofmaleinfants(differenceinmeanlengthgain0.51cm,95%CI0.03,0.98).Weightgainwasnotaffected.Energyintakesfromcomplementaryfoodsoverallweresignificantlyhigherintheinterventiongroupchildrenat9months(mean±SD:1556±1109vs.1025±866kJ;P<0.001)and18months(3807±1527vs.2577±1058kJ;P<0.001).Improvingcomplementaryfeedingpracticesthroughexistingservicesisfeasiblebuttheeffectonphysicalgrowthislimited.Factorsthatlimitphysicalgrowthinsuchsettingsmustbebetterunderstoodtoplanmoreeffectivenutritionprogrammes.

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BACKGROUND:Stuntinginearlychildhoodiscommonindevelopingcountriesandisassociatedwithpoorercognitionandschoolachievementinlaterchildhood.Theeffectofstuntingonchildren’sbehaviorsisnotaswellestablishedandisexaminedhere.METHOD:Childrenwhowerestuntedatage9to24monthsandhadtakenpartina2–yearinterventionProgrammeofpsychosocialstimulationwithorwithoutnutritionalsupplementationwerereexaminedatage11–12yearsandcomparedwithnonstuntedchildrenfromthesameneighbourhoods.TheirschoolandhomebehaviorswereassessedusingtheRutterTeacherandParentScalesandschoolachievementwasmeasuredusingtheWideRangeAchievementTest(WRAT)andtheSuffolkReadingScales.RESULTS:Nosignificantinterventioneffectswerefoundamongthestuntedgroups.Thusdatafromthefourinterventiongroupswereaggregatedforsubsequentanalyses,comparingall116stuntedchildrenwith80non–stuntedchildren.Controllingforsocialbackgroundvariables,thestunted

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grouphadmoreconductdifficulties(p<.05)asratedbytheirparents.Theyalsohadsignificantlylowerscoresinarithmetic,spelling,wordreadingandreadingcomprehensionthanthenon–stuntedchildren(allp<.001).Conductdifficultiesand

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hyperactivitywererelatedtopoorerschoolachievement.Controllingforthechildren’sIQ,thestuntedchildren’sarithmeticscoresremainedsignificantlylowerthanthoseofthenon–stuntedchildren,butreadingandspellingscoreswerenotdifferent.Conclusions:Previouslystuntedchildrenhadmoreconductdifficultiesathome,regardlessoftheirsocialbackground,thannon–stuntedchildren.Theireducationalattainmentwasalsopoorerthannon–stuntedchildrenandtheseresultsaresuggestiveofaspecificarithmeticdifficulty.Childrenwithbehaviorproblemsperformedlesswellatschool.[ABSTRACTFROMAUTHOR]

CopyrightofJournalofChildPsychology&Psychiatry&AlliedDisciplinesisthepropertyofWiley-Blackwellanditscontentmaynotbecopiedoremailedtomultiplesitesorpostedtoalistservwithoutthecopyrightholder'sexpresswrittenpermission.However,usersmayprint,download,oremailarticlesforindividualuse.Thisabstractmaybeabridged.Nowarrantyisgivenabouttheaccuracyofthecopy.Usersshouldrefertotheoriginalpublishedversionofthematerialforthefullabstract.(CopyrightappliestoallAbstracts.)

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*Cumberland,P.,etal.(2008)."TheimpactofcommunityleveltreatmentandpreventativeinterventionsontrachomaprevalenceinruralEthiopia."InternationalJournalof

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Epidemiology37(3):549-558.

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BACKGROUND:TheInternationalTrachomaInitiative(ITI)trachomacontrolProgrammebasedontheSAFEstrategy(Surgery,Antibiotics,FacialcleanlinessandEnvironmentalimprovement)wasimplementedin2002intworuralEthiopianzones,withmassdeliveryofazithromycinstartingin2003.WeevaluatetheimpactofcombinedantibioticandhealtheducationalinterventionsonactivetrachomaandChlamydiatrachomatisdetectedfromocularswabs,inchildrenaged3–9years.METHOD:Three-yearfollow-upcross-sectionalsurveywascarriedoutin40ruralEthiopiancommunitiestoevaluatetheProgramme.Householdswererandomlyselectedandallchildrenwereinvitedforeyeexaminationforactivetrachoma.In2005,eyeswabsweretakenforPolymeraseChainReaction(PCR)detectionofocularC.trachomatisDNA.Adultknowledgeandbehaviorrelatedtotrachomawereassessed.RESULTS:Communitysummarizedmeanprevalence,overall,was35.6%(SD=17.6)foractivetrachoma,34.0%(18.7)fortrachomatousinflammation,follicular(TF)aloneand4.3%(5.3)forPCRpositivityforC.trachomatis.Afteradjustment,oddsofactivetrachomawerereducedincommunitiesreceivingantibioticsandoneortwoeducationalinterventioncomponents(OR=0.35,95%CI:0.13–0.89orOR=0.31,0.11–0.89,respectively).TheoddsofbeingPCRpositivewerelowerintheseinterventionarms,comparedwithcontrol(OR=0.20,0.06–0.62andOR=0.07,0.02–0.30,respectively).Knowledgeoftreatmentandpreventativemethodswerereportedwithmuchhigherfrequency,comparedwithbaseline.CONCLUSIONS:TrachomaremainsapublichealthprobleminEthiopia.Antibioticadministrationremainsthemosteffectiveinterventionbutcommunity-basedhealtheducationprogrammescanimpact,toadditionallyreduceprevalenceofC.trachomatis.

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Dewey,K.G.andK.Begum(2011)."Long-termconsequencesofstuntinginearlylife."Maternal&ChildNutrition7(s3):5-18.

*Donegan,S.,etal.(2010)."Twofood-assistedmaternalandchildhealthnutritionprogrammeshelpedmitigatetheimpactofeconomichardshiponchildstuntinginHaiti."TheJournalofNutrition140(6):1139-1145.

Rigorousevaluationsoffood-assistedmaternalandchildhealthandnutritionprogrammesarestymiedbytheethicsofrandomizingrecipientstoacontroltreatment.Usingnonexperimentalmatchingmethods,weevaluatedtheeffectof2

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suchprogrammesonchildlineargrowthinHaiti.The2well-implementedprogrammesofferedthesameservices(foodassistance,behaviorchangecommunication,andpreventivehealthservices)topregnantandlactatingwomenandyoungchildren.Theydifferedinthatone(thepreventiveprogramme)usedblankettargetingofallchildren6–23months,whereastheother(therecuperativeprogramme)targetedunderweight(weight-for-ageZscore<−2)children6–59months,astraditionallydone.Weestimatedprogrammeeffectsonheight-for-ageZscores(HAZ)andstunting(HAZ<−2)bycomparingoutcomesofchildreninprogrammeareaswithmatchedchildrenfromcomparablepopulationsintheHaitiDemographicandHealthSurvey.Children12–41mointhepreventiveandrecuperativeprogrammeareashadlowerprevalenceofstuntingthanthoseinthematchedcontrolgroup[16percentagepoints(pp)lowerinpreventiveand11ppinrecuperative].Childreninthe2programmeareasalsoweremorelikelythanthoseinthematchedcontrolgrouptobebreast-fedupto24months(25pphigherinpreventive,22inrecuperative)andchildren12monthsandolderweremorelikelytohavereceivedtherecommendedfullscheduleofvaccinations(32pphigherinpreventive,31inrecuperative).Bothprogrammesimprovedtargetedbehaviorsandprotectedchildgrowthinatimeofdeterioratingeconomiccircumstances.

Dubowitz,T.,etal.(2007)."IntensifyingeffortstoreducechildmalnutritioninIndia:AnevaluationoftheDularprogrammeinJharkhand,India."FoodNutrtionBulletin28(3):266-273.

Duncan,G.J.,etal.(2011)."Doesmoneyreallymatter?Estimatingimpactsoffamilyincomeonyoungchildren'sachievementwithdatafromrandom-assignmentexperiments."DevelopmentalPsychology47(5):1263.

*Durlak,J.A.,etal.(2011)."Theimpactofenhancingstudents'socialandemotionallearning:Ameta-analysisofschool-baseduniversalinterventions."ChildDevelopment82(1):405-432.

Thisarticlepresentsfindingsfromameta-analysisof213school-based,universalsocialandemotionallearning(SEL)programmesinvolving270,034kindergartenthroughhighschoolstudents.Comparedtocontrols,SELparticipantsdemonstratedsignificantlyimprovedsocialandemotionalskills,attitudes,behavior,andacademicperformancethatreflectedan11-percentile-pointgaininachievement.SchoolteachingstaffsuccessfullyconductedSELprogrammes.Theuseof4recommendedpracticesfordevelopingskillsandthepresenceofimplementationproblemsmoderatedprogrammeoutcomes.ThefindingsaddtothegrowingempiricalevidenceregardingthepositiveimpactofSELprogrammes.Policymakers,educators,andthepubliccancontributetohealthydevelopmentof

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childrenbysupportingtheincorporationofevidence-basedSELprogrammingintostandardeducationalpractice.[ABSTRACTFROMAUTHOR]

CopyrightofChildDevelopmentisthepropertyofWiley-Blackwellanditscontentmaynotbecopiedoremailedtomultiplesitesorpostedtoalistservwithoutthecopyrightholder'sexpresswrittenpermission.However,usersmayprint,download,oremailarticlesforindividualuse.Thisabstractmaybeabridged.Nowarrantyisgivenabouttheaccuracyofthecopy.Usersshouldrefertotheoriginalpublishedversionofthematerialforthefullabstract.(CopyrightappliestoallAbstracts.)

Edwards,T.,etal.(2008)."RiskfactorsforactivetrachomaandChlamydiatrachomatisinfectioninruralEthiopiaaftermasstreatmentwithazithromycin."TropicalMedicine&InternationalHealth13(4):556-565.

Eickmann,S.H.,etal.(2003)."Improvedcognitiveandmotordevelopmentinacommunity-basedinterventionofpsychosocialstimulationinnortheastBrazil."DevelopmentalMedicine&ChildNeurology45(8):536-541.

Engle,P.L.andL.Lhotska(1999)."Theroleofcareinprogrammaticactionsfornutrition:DesigningProgrammesinvolvingcare."FOODANDNUTRITIONBULLETIN-UNITEDNATIONSUNIVERSITY-20(1):121-135.

Engle,P.L.,Black,M.M.,Behrman,J.R.,CabraldeMello,M.,Gertler,P.J.,Kapiri,L.,Martorell,R.,&Young,M.E,andtheInternationalChildDevelopmentSteeringGroup.(2007)Strategiestoavoidthelossofdevelopmentalpotentialinmorethan200millionchildreninthedevelopingworld.Lancet,369,229-242.

Engle,P.L,Fernald,L.C.H.,Alderman,H.,Behrman,J.,O’Gara,C.,Yousafzai,A.,CabraldeMello,M.,Hidrobo,M.,Ulkuer,N.,Ertem,I.,Iltus,S.,andtheGlobalDevelopmentSteeringgroup(2011).Strategiesforreducinginequalitiesandimprovingdevelopmentaloutcomesforyoungchildreninlow-incomeandmiddle-incomecountries.TheLancet,37,1339-1353.

*Ertem,I.O.,etal.(2006)."Promotingchilddevelopmentatsick-childvisits:Acontrolledtrial."Pediatrics118(1):e124-e131.

OBJECTIVE.Indevelopingcountries,thehealthcaresystemoftenistheonlyexistinginfrastructurethatcanreachyoungchildren,andhealthcareencountersmaybetheonlyopportunityforprofessionalstohaveapositiveinfluenceonchilddevelopment.ToaddressthediscrepancybetweenWesternanddevelopingcountriesrelatedtotheinformationthatisavailableforcaregiversonhowtosupporttheirchild'sdevelopment,theWorldHealthOrganizationDepartmentofChildandAdolescentHealthandDevelopmentandUnitedNationsInternational

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Children'sEducationFundhavedevelopedtheCareforDevelopmentIntervention.

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TheCareforDevelopmentInterventionaimsduringacutehealthvisitstoenhancecaregivers'playandcommunicationwiththeirchildren.Forfacilitationofitsdeliveryworldwide,theCareforDevelopmentInterventionwasdevelopedasanadditionalmoduleoftheIntegratedManagementofChildhoodIllnesstrainingcourse.ThepurposeofthisstudywastodeterminetheefficacyandthesafetyoftheCareforDevelopmentInterventionwhenimplementedduringayoungchild'svisitforacuteminorillness.METHODS.Thestudydesignisasequentiallyconductedcontrolledtrial,withthecomparisonarmcompletedfirst,CareforDevelopmentInterventiontrainingprovidedforthecliniciansnext,followedbytheinterventionarm.AtthePediatricDepartmentofAnkaraUniversitySchoolofMedicine,2pediatricianswhowereblindedtothestudyaimsandhypothesesbeforeCareforDevelopmentInterventiontrainingprovidedstandardhealthcaretothecomparisongroup;theythenreceivedCareforDevelopmentInterventiontrainingandprovidedstandardhealthcareplustheCareforDevelopmentInterventiontotheinterventiongroup.Compliancewithtreatmentandtheoutcomeofillnessweredeterminedbyafollow-upexaminationintheclinic1weeklater.Onemonthaftertheclinicvisits,anadaptedHomeObservationforMeasurementoftheEnvironmentwasadministeredinthehomesbyresearcherswhowereblindedtostudyaimsandhypotheses.RESULTS.Childrenwhowereaged≤24monthsandattendedtheclinicwithminorornoillnesseswererecruitedforthestudy:113inthecomparisongroupand120intheinterventiongroup.Atthe1-monthhomevisit,significantlymorefamilieshadoptimalHomeObservationforMeasurementoftheEnvironmentscores(17.5%vs6.2%),morehomemadetoyswereobserved(42.5%vs10.6%),andmorecaregiversreportedreadingtotheirchildren(20.0%vs3.5%)intheinterventionthaninthecomparisongroup.ThreeindependentpredictorsofoptimalHomeObservationforMeasurementoftheEnvironmentscoreemergedfromthelogisticregressionanalysis:beingintheinterventiongroup,childages>6months,andmaternaleducationgreaterthansecondaryschool.Compliancewithmedicaltreatmentandillnessoutcomeswerenotsignificantlydifferentbetweenthe2groups.CONCLUSIONS.TheCareforDevelopmentInterventionisaneffectivemethodofsupportingcaregivers'effortstoprovideamorestimulatingenvironmentfortheirchildrenandcanbeusedbyhealthcareprofessionalsduringvisitsforacuteminorillness.

Eshel,N.,etal.(2006).“Responsiveparenting:interventionsandoutcomes.”BulletinoftheWorldHealthOrganization,84(12):991-998.

Eyberg,S.M.,etal.(2008)."Evidence-basedpsychosocialtreatmentsforchildrenandadolescentswithdisruptivebehavior."JournalofClinicalChild&AdolescentPsychology37(1):215-237.

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Farahat,T.M.,etal.(2009)."Evaluationofaneducationalinterventionforfarmingfamiliestoprotecttheirchildrenfrompesticideexposure."EasternMediterraneanHealthJournal15(1):47-56.

Faber,M.,Venter,S.L.,&Benadé,A.J.S.(2002).IncreasedvitaminAintakeinchildrenaged2-5yearsthroughtargetedhome-gardensinaruralSouthAfricancommunity.PublicHealthNutrition,5(1),11-16.

Feldens,C.A.,etal.(2010)."Long-termeffectivenessofanutritionalprogrammeinreducingearlychildhoodcaries:arandomizedtrial."CommunityDentistryandOralEpidemiology38(4):324-332.

FelittiVJ,AndaRF.TheRelationshipofAdverseChildhoodExperiencestoAdultHealth,Well-being,SocialFunction,andHealthcare. ChapterinLaniusR,VermettenE.TheHiddenEpidemic:TheImpactofEarlyLifeTraumaonHealthandDisease. CambridgeUniversityPress.2008.

Fernald,L.C.H.,etal.(2008)."RoleofcashinconditionalcashtransferProgrammesforchildhealth,growth,anddevelopment:ananalysisofMexico'sOportunidades."Lancet371(9615):828-837.

Fernald,L.C.H.,etal.(2009)."10-yeareffectofOportunidades,Mexico'sconditionalcashtransferProgramme,onchildgrowth,cognition,language,andbehavior:Alongitudinalfollow-upstudy."TheLancet374(9706):1997-2005.

Forry,N.D.,etal.(2011).Family-providerrelationships:Amultidisciplinaryreviewofhighqualitypracticesandassociationswithfamily,child,andprovideroutcomes.IssueBriefOPRE2011-26a.Washington,DC,OfficeofPlanning,ResearchandEvaluation,AdministrationforChildrenandFamilies,U.S.DepartmentofHealthandHumanServices.

*Gaboulaud,V.,etal.(2007)."CouldNutritionalRehabilitationatHomeComplementorReplaceCentre-BasedTherapeuticFeedingProgrammesforSevereMalnutrition?"JournalofTropicalPediatrics53(1):49-51.

TomeasurethesuccessrateofthreedifferentstrategiesusedinMédecinsSansFrontièreslarge-scaletherapeuticnutritionalrehabilitationProgrammeinNiger,weanalysedthreecohortsofseverelymalnourishedpatientsintermsofdailyweightgain,lengthofstay,recovery,casefatalityanddefaulting.Atotalof1937childrenaged6–59monthswerefollowedprospectivelyfrom15August2002to21October2003.Forthethreecohorts,660childrenweremaintainedinthetherapeutic

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feedingcentre(TFC)duringtheentiretreatment,937childrenwereinitiallytreatedattheTFCandcompletedtreatmentathomeand340childrenwereexclusivelytreatedathome.Forallcohorts,averagetimeintheProgrammeandaverageweightgainmettheinternationalstandards(30–40days,>8 g/kg/day).Defaultrateswere28.1,16.8and5.6%forTFConly,TFCplushome-basedandhome-basedalonestrategies,respectively.TheoverallcasefatalityratefortheentireProgrammewas6.8%.Casefatalityrateswere18.9%forTFConlyand1.7%forhome-basedalone.Nodeathswererecordedinchildrentransferredtorehabilitationathome.Thisstudysuggeststhatsatisfactoryresultsforthetreatmentofseveremalnutritioncanbeachievedusingacombinationofhomeandhospital-basedstrategies.

Gardner,J.M.,etal.(2003)."Arandomizedcontrolledtrialofahome-visitinginterventiononcognitionandbehaviorintermlowbirthweightinfants."TheJournalofPediatrics143(5):634-639.

*Gardner,J.M.M.,etal.(2005)."Zincsupplementationandpsychosocialstimulation:effectsonthedevelopmentofundernourishedJamaicanchildren."TheAmericanJournalofClinicalNutrition82(2):399-405.

BACKGROUND:Undernourishedchildrenhavepoorlevelsofdevelopmentthatbenefitfromstimulation.Zincdeficiencyisprevalentinundernourishedchildrenandmaycontributetotheirpoordevelopment.Objective:Weassessedtheeffectsofzincsupplementationandpsychosocialstimulationgiventogetherorseparatelyonthepsychomotordevelopmentofundernourishedchildren.DESIGN:Thiswasarandomizedcontrolledtrialwith4groups:stimulationalone,zincsupplementationalone,bothinterventions,andcontrol(routinecareonly).Subjectswere114childrenaged9–30monthsandbelow–1.5zscoresoftheNationalCenterforHealthStatisticsweight-for-agereferenceswhowererecruitedfrom18healthclinics.Clinicswererandomlyassignedtoreceivestimulationornot;individualchildrenwererandomlyassignedtoreceivezincorplacebo.Thestimulationprogrammecomprisedweeklyhomevisitsduringwhichplaywasdemonstratedandmaternal-childinteractionswereencouraged.Thesupplementationwas10mgZnassulfatedailyorplacebo.Development(assessedbyuseoftheGriffithsMentalDevelopmentScales),length,andweightweremeasuredatbaselineand6molater.Weeklymorbidityhistoriesweretaken.RESULTS:Significantinteractionswerefoundbetweenzincsupplementationandstimulation.Zincbenefitedthedevelopmentalquotientonlyinchildrenwhoreceivedstimulation,andbenefitsfromzinctohandandeyecoordinationweregreaterinstimulatedchildren.Zincsupplementationaloneimprovedhandandeyecoordination,andstimulationalonebenefitedthedevelopmentalquotient,hearingandspeech,andperformance.Zincsupplementationalsoreduceddiarrhealmorbiditybutdidnotsignificantlyimprove

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growth.CONCLUSION:Zincsupplementationbenefitsdevelopmentinundernourishedchildren,andthebenefitsareenhancedifstimulationisalsoprovided.

Gartner,A.,etal.(2007)."HasthefirstimplementationphaseoftheCommunityNutritionProjectinurbanSenegalhadanimpact?"Nutrition23(3):219-228.

Ghate,D.,Hazel,N.(2002).Parentinginpoorenvironments:Stress,supportandcoping.London:JessicaKingsleyPublications.

Ghoneim,E.,etal.(2004)."AninterventionProgrammeforimprovingthenutritionalstatusofchildrenaged2-5yearsinAlexandria."EastMediterrHealthJ10(6):828-843.

Guerrant,R.L.,etal.(2002)."Magnitudeandimpactofdiarrhealdiseases."ArchivesofMedicalResearch33(4):351-355.

Guyon,A.B.,Quinn,V.J.,Hainsworth,M.,Ravonimanantsoa,P.,Ravelojoana,V.,

Rambeloson,Z.,&Martin,L.(2009).Implementinganintegratednutritionpackageatlargescalein

Madagascar:theEssentialNutritionActionsframework.Food&NutritionBulletin,30(3),233-244.

*Hamadani,J.D.,HudaS.N.,Khatun,F.&Grantham-McGregorS.M.(2006)."PsychosocialstimulationimprovesthedevelopmentofundernourishedchildreninruralBangladesh."TheJournalofNutrition136(10):2645-2652.

Undernutritioninearlychildhoodisassociatedwithpoormentaldevelopmentandaffects45%ofchildreninBangladesh.Althoughlimitedevidenceshowsthatpsychosocialstimulationcanreducethedeficits,nosuchinterventionshavebeenreportedfromBangladesh.TheBangladeshIntegratedNutritionProgramme(BINP)hasprovidednutritionsupplementationtoundernourishedchildrenthroughcommunitynutritioncenters(CNCs).Weaddedpsychosocialstimulationtothetreatmentofundernourishedchildreninarandomizedcontrolledtrialtoassesstheeffectsonchildren'sdevelopmentandgrowthandmothers'knowledge.TwentyCNCswererandomlyassignedtointerventionorcontrolgroupswith107childrenineachgroup.Wealsostudied107nonintervenedbetter-nourishedchildrenfromthesamevillages.Pre-andpostinterventionmeasurementsincludedchildren'sheight,weight,developmentassessedonBayleyScales,behaviorratingsduringthetest,andaquestionnaireonmothers'knowledgeofchildrearing.Theinterventioncomprisedhomevisitsandgroupmeetingswithmothersandchildrenfor12mo.Interventionbenefitedchildren'smentaldevelopment(4.6±2.0,P=0.02),vocalization(0.48±0.23,P=0.04),cooperation(0.45±0.16,P=0.005),response-

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to-examiner(0.50±0.15,P=0.001),emotionaltone(0.33±0.15,P=0.03),andmothers'knowledge(3.5±0.49,P<0.001).Attheend,undernourishedcontrolshad

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poorermental(–4.6±2.0,P=0.02)andmotor(–6.6±2.2,P=0.003)development,weremoreinhibited(–0.35±0.16,P=0.03),fussier(–0.57±0.16,P<0.001),lesscooperative(–0.48±0.17,P=0.005),andlessvocal(–0.76±0.23,P=0.001)thanbetter-nourishedchildren.Intervenedchildrenscoredloweronlyinmotordevelopment(–4.4±2.3,P=0.049).Neithergroupofundernourishedchildrenimprovedinnutritionalstatus,indicatingthattreatmenthadnoeffect.Inconclusion,addingchilddevelopmentactivitiestotheBINPimprovedchildren'sdevelopmentandbehaviorandtheirmothers'knowledge;however,thelackofimprovementingrowthneedstobeexaminedfurther.

Hodgkin,R.andP.Newell(2007).“ImplementationhandbookfortheConventionontheRightsofaChild.”Geneva,Switzerland:UnitedNationsChildren’sFund.

HollowayK.A.,KarkeeS.B,,TamangA,, GurungY.B,,KafleK.K.,PradhanR,&ReevesB.C.(2009)CommunityinterventiontopromoterationaltreatmentofacuterespiratoryinfectioninruralNepal.TropicalMedicineandInternationalHealth,14:101–110

Hossain,S.M.M.,Duffield,A.,&Taylor,A.(2005).AnevaluationoftheimpactofaUS$60millionnutritionProgrammeinBangladesh.HealthPolicyandPlanning,20(1),35-40.doi:10.1093/heapol/czi004

Hotz,C.,&Gibson,R.S.(2004).Participatorynutritioneducationandadoptionofnew

feedingpracticesareassociatedwithimprovedadequacyofcomplementarydietsamongruralMalawianchildren:apilotstudy.Europeanjournalofclinicalnutrition,59(2),226-237.

Imdad,A.,etal.(2011)."Effectofbreastfeedingpromotioninterventionsonbreastfeedingrates,withspecialfocusondevelopingcountries."BMCPublicHealth11(Suppl3):S24.

Issler,R.M.S.,etal.(2009)."Infantsleepposition:ArandomizedclinicaltrialofaneducationalinterventioninthematernitywardinPortoAlegre,Brazil."Birth36(2):115-121.

Jaded,A.R.etal,(1996).“Assessingthequalityofreportsofrandomizedclinicaltrials:Isblindingnecessary?.ControlledClinicalTrials.17(1):1-12.

Janssens,W.,etal.(2009).Theimpactofahome-visitngearlychildhoodinterventionintheCaribbeanoncognitiveandsocioemotionalchilddevelopment.Amsterdam,AmsterdamInstituteforInternationalDevelopment.

*Jin,X.,etal.(2007).""CareforDevelopment"interventioninruralChina:Aprospectivefollow-upstudy."JournalofDevelopmental&BehavioralPediatrics28(3):213-218

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210.1097/dbp.1090b1013e31802d31410b.

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OBJECTIVE:TheaimofthisstudywastotesttheefficacyandappropriatenessoftheWorldHealthOrganization'sCareforDevelopment(CFD)counselingmaterials,whichformpartoftheIntegratedManagementofChildhoodIllness(IMCI)strategy.TheCFDmaterialsarebasedontheMother'sCard,whichcontainedage-specificmessagesonhowcaregiverscanbetterplayandcommunicatewithachild.METHOD:Weenrolled100familieswithachildofyoungerthan2yearsofagefromsevenrandomlyselectedvillagesinanimpoverishedruralcountyinAnhuiProvince,China.Twocounselingsessions,usingtheCFDMother'sCard,wereprovidedto50familiesrandomlyselectedfromamongthestudyparticipants.AllchildrenwereassessedwithGesellDevelopmentalSchedulesbeforecounselingandafter6months.Aquestionnaireonfamilysituationandknowledge,attitudes,andpracticesregardingchilddevelopmentwasalsoadministeredatthestartandconclusionofthestudy.RESULTS:Atbaselineassessment,bothcontrolandinterventiongroupswereequal,withaveragedevelopmentalscoreslessthanthenationalnorms.Childreninfamilieswhoreceivedcounselinghadsignificantlyhigherdevelopmentquotientscoresincognitive,social,andlinguisticdomains.Questionnairedataonchildrearingsuggestedthatresponsiveandrichinteractionsandconsistentcaregiverscorrelatedwithhigherscores.TheCFDMother'sCardwasfoundtobefeasibleandhelpfulinthosefamilieswhoreceivedcounseling.CONCLUSION:ThereisurgentneedforfurtherworkonpromotionofchilddevelopmentinruralChina.TheWorldHealthOrganization'sCFDapproachandMother'sCardisfeasibleandeffectiveandshouldbeexpandedinuse,especiallywithinthenationalIMCIprogramme.(C)2007LippincottWilliams&Wilkins,Inc.

Kagan,S.L.,etal.(1995).Reconsideringchildren’searlydevelopmentandlearning:Towardscommonviewsandvocabulary.Washington,DC,NationalEducationalGoalsPanel.

Kagitcibasi,C.,Sunar,D.,&Bekman,S.(2001)."Long-termeffectsofearlyintervention:Turkishlow-incomemothersandchildren."JournalofAppliedDevelopmentalPsychology22(4):333-361.

Kagitçibasi,C.,Sunar,D.,Bekman,S.,Baydar,N.,&Cemalcilar,Z.(2009)."Continuingeffectsofearlyenrichmentinadultlife:TheTurkishEarlyEnrichmentProject22yearslater."JournalofAppliedDevelopmentalPsychology30(6):764-779.

*Kalimbira,A.A.,etal.(2010)."Theimpactofanintegratedcommunity-basedmicronutrientandhealthProgrammeonstuntinginMalawianpreschoolchildren."PublicHealthNutrition13(05):720-729.

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OBJECTIVE:Toassesstheimpactofthe1996–2005integratedcommunity-basedmicronutrientandhealth(MICAH)Programmeonlineargrowthretardation(stunting)inMalawianpreschoolchildrenlivinginruralareas.DesignProspectivestudyofthreelarge-scalecross-sectionalsurveysconductedin1996,2000and2004inMICAHandComparisonpopulations.SETTING:RuralareasinMalawi.SUBJECTS:Preschoolchildren(6·0–59·9months)fromrandomlyselectedhouseholds(474fromthe1996baselinesurvey;1264from2000MICAHareas;1500from2000Comparisonareas;1959from2004MICAHareas;and1008from2004Comparisonareas),whorespondedtoahouseholdquestionnaire,wereweighedandmeasuredusingstandardprotocols.RESULTS:Atthebaselinein1996,theprevalenceofstunting(60·2%)wasveryhigh.By2000,theprevalenceofstuntinghaddeclinedto50·6%and56·0%(χ2=7·8,P=0·005)inMICAHandComparisonareas,respectively.In2004,theprevalenceofstuntingdidnotdiffersignificantlybetweenMICAHandComparisonareas(43·0%v.45·1%;χ2=1·11,P=0·3).Severestuntingaffected34·7%ofchildrenatbaseline,whichdeclinedto15·8%and17·1%(χ2=0·86,P=0·4)inMICAHandComparisonareas,respectively,by2004.Regionalvariationsexisted,withproportionatelyfewerchildrenfromtheNorthernregionbeingstuntedcomparedtotheirCentralandSouthernregioncounterparts.CONCLUSION:Giventhelengthofimplementation,wide-scalecoverageandpositiveimpactonchildgrowthinPhaseI(1996–2000),theMICAHProgrammeisapotentialmodelforcombatinglineargrowthretardationinruralareasinMalawi,althoughthecatch-upimprovementinComparisonareasduringPhaseII(2000–2004)cannotbeadequatelyexplained.

*Kaminski,J.W.,etal.(2008)."Ameta-analyticreviewofcomponentsassociatedwithparenttrainingprogrammeeffectiveness."JournalofAbnormalChildPsychology:AnofficialpublicationoftheInternationalSocietyforResearchinChildandAdolescentPsychopathology36(4):567-589.

Thiscomponentanalysisusedmeta-analytictechniquestosynthesizetheresultsof77publishedevaluationsofparenttrainingprogrammes(i.e.,programmesthatincludedtheactiveacquisitionofparentingskills)toenhancebehaviorandadjustmentinchildrenaged0-7.Characteristicsofprogrammecontentanddeliverymethodwereusedtopredicteffectsizesonmeasuresofparentingbehaviorsandchildren'sexternalizingbehavior.Aftercontrollingfordifferencesattributabletoresearchdesign,programmecomponentsconsistentlyassociatedwithlargereffectsincludedincreasingpositiveparent-childinteractionsandemotionalcommunicationskills,teachingparentstousetimeoutandtheimportanceofparentingconsistency,andrequiringparentstopracticenewskillswiththeirchildrenduringparenttrainingsessions.Programmecomponentsconsistentlyassociatedwithsmallereffectsincludedteachingparentsproblemsolving;teachingparentstopromotechildren'scognitive,academic,orsocialskills;andprovidingother,additionalservices.Theresultshave

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implicationsforselectionandstrengtheningofexistingparenttrainingprogrammes.(PsycINFODatabaseRecord(c)2010APA,allrightsreserved)(journalabstract)

*Kapil,U.(2002)."Integratedchilddevelopmentservices(ICDS)scheme:AprogrammeforholisticdevelopmentofchildreninIndia."IndianJournalofPediatrics69(7):597-601.

TheIntegratedChildDevelopmentServices(ICDS)schemeisthelargestprogrammeforpromotionofmaternalandchildhealthandnutritionnotonlyinIndiabutinthewholeworld.Theschemewaslaunchedin1975inpursuanceoftheNationalPolicyforChildren.Theschemehasexpandedinthelasttwenty-sevenyearsform33projectsto5171blocks.ICDSisamulti-sectoralprogrammeandinvolvesseveralgovernmentdepartments.Theprogrammeservicesarecoordinatedatthevillage,block,district,stateandcentralgovernmentlevels.TheprimaryresponsibilityfortheimplementationoftheprogrammelieswiththeDepartmentofWomen&ChildDevelopmentattheCentreandnodaldepartmentatthestates,whichmaybeSocialWelfare,RuralDevelopment,TribalWelfareorHealthDepartmentoranindependentDepartment.Thebeneficiariesarechildrenbelow6years,pregnantandlactatingwomenandwomenintheagegroupof15to44yrs.ThebeneficiariesofICDSaretoalargeextentidenticalwiththoseundertheMaternalandChildHealthProgramme.Theprogrammeprovidesanintegratedapproachforconvergingallthebasicservicesforimprovedchildcare,earlystimulationandlearning,healthandnutrition,waterandenvironmentalsanitationaimedattheyoungchildren,expectantandlactatingmothers,otherwomenandadolescentgirlsinacommunity.ICDSprogrammeisthereflectionoftheGovernmentofIndiatoeffectivelyimprovethenutritionandhealthstatusofunderprivilegedsectionofthepopulationthroughdirectinterventionmechanism.Theprogrammecovers27.6millionbeneficiarieswithsupplementarynutrition.Theprogrammeservicesandbeneficiarieshasessentiallyremainedthesamesince1975.Recentlyareviewoftheschemewasheld,sponsoredbyGovernmentofIndia,whichsuggestedmodificationsinthehealthandnutritioncomponentofICDSschemetoimprovetheprogrammeimplementationandefficiency

*Kendrick,D.,etal.(2007)."Parentinginterventionsforthepreventionofunintentionalinjuriesinchildhood."CochraneDatabaseofSystematicReviews(4).

BACKGROUNDParenteducationandtrainingProgrammescanimprovematernalpsychosocialhealth,childbehavioralproblemsandparentingpractices.Thisreviewassessestheeffectsofparentinginterventionsforreducingchildinjury.ObjectivesToassesstheeffectsofparentinginterventionsforpreventingunintentionalinjuryaswellasincreasingpossessionanduseofsafetyequipmentandparentalsafetypractices.SEARCHSTRATEGYWesearchedCENTRAL,MEDLINE,EMBASE,BiologicalAbstracts,PsychINFO,Sociofile,SocialScienceCitationIndex,CINAHL,

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DissertationAbstracts,ERIC,DARE,ASSIA,WebofScience,SIGLEandZETOC.WealsohandsearchedabstractsfromtheWorldConferencesonInjuryPrevention&ControlandthejournalInjuryPrevention.ThesearcheswereconductedinMay2005.SelectioncriteriaWeincludedrandomisedcontrolledtrials(RCTs),non-randomisedcontrolledtrials(non-RCTs)andcontrolledbeforeandafterstudies(CBAs),whichevaluatedparentinginterventionsadministeredtoparentsofchildrenaged18yearsandunder,andreportedoutcomedataoninjuries(unintentionalorunspecifiedintent),andpossessionanduseofsafetyequipmentorsafetypractices.Parentinginterventionsweredefinedasthosewithaspecifiedprotocol,manualorcurriculumaimedatchangingknowledge,attitudesorskillscoveringarangeofparentingtopics.DATACOLLECTIONANDANALYSISStudieswereselected,datawereextractedandqualityappraisedindependentlybytwoauthors.Pooledrelativerisks(RR)wereestimatedusingrandomeffectmodels.MainresultsFifteenstudieswereincludedinthereview:11RCTs(oneincludedaCBAwithinthesamestudy),onenon-RCT,onestudycontainedbothrandomisedandnon-randomisedarmsandtwoCBAs.Twoprovidedsolelyeducationalinterventions.Thirteenprovidedinterventionscomprisingparentingeducationandothersupportservices;11ofwhichwerehomevisitingProgrammesandtwoofwhichwerepaediatricpractice-basedinterventions.Thirteenstudiesrecruitedfamiliesatriskofadversechildhealthoutcomes.NineRCTswereincludedintheprimarymeta-analysis,whichindicatedthatinterventionfamilieshadasignificantlylowerriskofinjury(RR0.82,95%CI0.71to0.95).Severalstudiesfoundfewerhomehazards,ahomeenvironmentmoreconducivetochildsafety,oragreaternumberofsafetypracticesininterventionfamilies.AUTHORS'CONCLUSIONSParentinginterventions,mostcommonlyprovidedwithinthehomeusingmulti-facetedinterventionsmaybeeffectiveinreducingchildinjury.Theevidencerelatesmainlytointerventionsprovidedtofamiliesatriskofadversechildhealthoutcomes.Furtherresearchisrequiredtoexploremechanismsbywhichtheseinterventionsreduceinjury,thefeaturesofparentinginterventionsthatarenecessaryorsufficienttoreduceinjuryandthegeneralisabilitytodifferentpopulationgroups.

Kilaru,A.,etal.(2005)."Community-basednutritioneducationforimprovinginfantgrowthinruralKarnataka."Indianpediatrics42(5):425.

Knitzer,J.,etal.(2008).Reducingmaternaldepressionanditsimpactonyoungchildren:Towardaresponsiveearlychildhoodpolicyframework.NewYorkCity,NationalCenterforChildreninPoverty,MailmanSchoolofPublicHealth,ColumbiaUniversity.

Koçak,A.(2004).EvaluationreportoftheFatherSupportProgramme.Turkey,MotherChildEducationFoundation.

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*Kramer,M.S.,etal.(2008)."Breastfeedingandchildcognitivedevelopment:newevidencefromalargerandomizedtrial."ArchivesofGeneralPsychiatry65(5):578-584.

CONTEXT The evidence that breastfeeding improves cognitive development isbasedalmostentirelyonobservationalstudiesandisthuspronetoconfoundingbysubtle behavioral differences in the breastfeeding mother's behavior or herinteractionwiththeinfant.OBJECTIVEToassesswhetherprolongedandexclusivebreastfeedingimproveschildren'scognitiveabilityatage6.5years.DesignCluster-randomized trial,withenrollmentfromJune17, 1996, toDecember31, 1997,andfollow-upfromDecember21,2002,toApril27,2005.SettingThirty-oneBelarussianmaternity hospitals and their affiliated polyclinics. Participants A total of 17 046healthybreastfeedinginfantswereenrolled,ofwhom13889(81.5%)werefollowedupatage6.5years.InterventionBreastfeedingpromotioninterventionmodeledontheBaby-FriendlyHospitalInitiativebytheWorldHealthOrganizationandUNICEF.MainOutcomeMeasuresSubtestandIQscoresontheWechslerAbbreviatedScalesofIntelligence,andteacherevaluationsofacademicperformanceinreading,writing,mathematics,andothersubjects.RESULTSTheexperimentalinterventionledtoalargeincreaseinexclusivebreastfeedingatage3months(43.3%fortheexperimentalgroupvs6.4%forthecontrolgroup;P<.001)andasignificantlyhigherprevalenceofanybreastfeedingatallagesuptoandincluding12months.TheexperimentalgrouphadhighermeansonalloftheWechslerAbbreviatedScalesofIntelligencemeasures,withcluster-adjustedmeandifferences(95%confidenceintervals)of+7.5(+0.8to+14.3)forverbalIQ,+2.9(-3.3to+9.1)forperformanceIQ,and+5.9(-1.0to+12.8)forfull-scaleIQ.Teachers'academicratingsweresignificantlyhigherintheexperimentalgroupforbothreadingandwriting.CONCLUSIONTheseresults,basedonthelargestrandomizedtrialeverconductedintheareaofhumanlactation,providestrongevidencethatprolongedandexclusivebreastfeedingimproveschildren'scognitivedevelopment.TrialRegistrationisrctn.orgIdentifier:ISRCTN37687716

*Kramer,M.S.,etal.(2008)."Effectsofprolongedandexclusivebreastfeedingonchildbehaviorandmaternaladjustment:Evidencefromalarge,randomizedtrial."Pediatrics121(3):e435-e440.

OBJECTIVE.Theobjectiveofthisstudywastoassessthelong-termeffectsofbreastfeedingonchildbehaviorandmaternaladjustment.METHODS.WefollowedupchildrenwhowereinthePromotionofBreastfeedingInterventionTrial,acluster-randomizedtrialofabreastfeedingpromotioninterventionbasedontheWorldHealthOrganization/UnitedNationsChildren'sFundBaby-FriendlyHospitalInitiative.Atotalof17046healthy,breastfeedingmother–infantpairswereenrolledfrom31Belarussianmaternityhospitalsandaffiliatedpolyclinics;13889(81.5%)

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werefollowedupat6.5years.MothersandteacherscompletedtheStrengthsandDifficultiesQuestionnaireandsupplementalquestionsbearingoninternalizingandexternalizingbehavioralproblems.Mothersalsorespondedtoquestionsconcerningtheirrelationshipstotheirpartnerandchildandtheirbreastfeedingofsubsequentlybornchildren.RESULTS.Theexperimentalinterventionledtoalargeincreaseinexclusivebreastfeedingat3months(43.3%vs6.4%)andasignificantlyhigherprevalenceofanybreastfeedingatallagesuptoandincluding12months.NosignificanttreatmenteffectswereobservedoneitherthemotherortheteacherStrengthsandDifficultiesQuestionnaireratingsoftotaldifficulties,emotionalsymptoms,conductproblems,hyperactivity,peerproblems,orprosocialbehaviororonthesupplementalbehavioralquestions.Wefoundnoevidenceoftreatmenteffectsontheparent'smarriageoronthemother'ssatisfactionwithherrelationshipswithherpartnerorchild,buttheexperimentalinterventionsignificantlyincreasedthedurationofanybreastfeeding,andmothersintheexperimentalgroupwerenearlytwiceaslikelytobreastfeedexclusivelythenext-bornchildforatleast3months.CONCLUSIONS.Onthebasisofthelargestrandomizedtrialeverconductedintheareaofhumanlactation,wefoundnoevidenceofrisksorbenefitsofprolongedandexclusivebreastfeedingforchildandmaternalbehavior.Breastfeedingpromotiondoes,however,favorablyaffectbreastfeedingofthesubsequentchild.

Kumar,V.,Mohanty,S.,Kumar,A.,Misra,R.P.,Santosham,M.,Awasthi,S.,...&Darmstadt,G.L.(2008).Effectofcommunity-basedbehaviorchangemanagementonneonatalmortalityinShivgarh,UttarPradesh,India:acluster-randomisedcontrolledtrial.TheLancet,372(9644),

1151-1162.Lamberti,L.M.,etal.(2011)."Breastfeedingandtheriskfordiarrheamorbidityandmortality."BMCPublicHealth11(Suppl3):S15.

Lansford,J.E.andK.Deater-Deckard(2012)."Childrearingdisciplineandviolenceindevelopingcountries."ChildDevelopment83(1):62-75.

Lansford,J.E.,&Bornstein,M.H.(2007).Reviewofparentingprogrammesindevelopingcountries.NewYork:UNICEF.

leRoux,I.,etal.(2010)."HomevisitsbyneighborhoodMentorMothersprovidetimelyrecoveryfromchildhoodmalnutritioninSouthAfrica:resultsfromarandomizedcontrolledtrial."NutritionJournal9(1):1-10.

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Levy,S.(2006).Progressagainstpoverty:SustainingMexico'sProgresa-Oportunidadesprogramme.Washington,DC,BrookingsInstitutePress.

Lindert,K.(2005).ReducingpovertyandinequalityinLatinAmerica:Thepromiseofconditionalcashtransfers.Washington,DC,TheWorldBank.

Lozoff,B.,Beard,J.,Connor,J.,Felt,B.,Georgieff,M.&Schallert,T.(2006)."Long-lastingneuralandbehavioraleffectsofirondeficiencyininfancy."NutritionReviews64:S34-S43.

*Luby,S.P.,etal.(2004)."Effectofintensivehandwashingpromotiononchildhooddiarrheainhigh-riskcommunitiesinpakistan:Arandomizedcontrolledtrial."JAMA:TheJournaloftheAmericanMedicalAssociation291(21):2547-2554.

CONTEXT Washinghandswithsoappreventsdiarrhea,butchildrenatthehighestriskofdeathfromdiarrheaareyoungerthan1year,tooyoungtowashtheirownhands.Previousstudieslackedsufficientpowertoassesstheimpactofhouseholdhandwashingondiarrheaininfants.OBJECTIVE Toevaluatetheeffectofpromotinghouseholdhandwashingwithsoapamongchildrenatthehighestriskofdeathfromdiarrhea.Design,Setting,andParticipantsAclusterrandomizedcontrolledtrialof36low-incomeneighborhoodsinurbansquattersettlementsinKarachi,Pakistan.FieldworkersvisitedparticipatinghouseholdsatleastweeklyfromApril15,2002,toApril5,2003.Eligiblehouseholdslocatedinthestudyareahadatleast2childrenyoungerthan15years,atleast1ofwhomwasyoungerthan5years.INTERVENTIONSWeeklyvisitsin25neighborhoodstopromotehandwashingwithsoapafterdefecationandbeforepreparingfood,eating,andfeedingachild.Withininterventionneighborhoods,300households(1523children)receivedaregularsupplyofantibacterialsoapand300households(1640children)receivedplainsoap.Elevenneighborhoods(306householdsand1528children)comprisedthecontrolgroup.MAINOUTCOMEMEASURE Incidencedensityofdiarrheaamongchildren,definedasthenumberofdiarrhealepisodesper100person-weeksofobservation.RESULTSChildrenyoungerthan15yearslivinginhouseholdsthatreceivedhandwashingpromotionandplainsoaphada53%lowerincidenceofdiarrhea(95%confidenceinterval[CI],–65%to–41%)comparedwithchildrenlivingincontrolneighborhoods.Infantslivinginhouseholdsthatreceivedhandwashingpromotionandplainsoaphad39%fewerdayswithdiarrhea(95%CI,–61%to–16%)vsinfantslivingincontrolneighborhoods.Severelymalnourishedchildren(weightforagezscore,&lt;–3.0)youngerthan5yearslivinginhouseholdsthatreceivedhandwashingpromotionandplainsoaphad42%fewerdayswithdiarrhea(95%CI,–69%to–16%)vsseverelymalnourishedchildreninthecontrolgroup.Similarreductionsindiarrheawereobservedamongchildrenlivinginhouseholdsreceivingantibacterialsoap.CONCLUSION Inasettinginwhichdiarrheaisaleadingcauseof

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childdeath,improvementinhandwashinginthehouseholdreducedtheincidence

ofdiarrheaamongchildrenathighriskofdeathfromdiarrhea.

Luby,S.P.,Kadir,M.A.,Sharker,Y.,Yeasmin,F.,Unicomb,L.,Islam,M.S.(2010.“ACommunityrandomizedcontrolledtrialpromotingwaterlesshandsanitizerandhandwashingwithsoap,Dhaka,Bangladesh”.TropicalMedicineandInternationalHealth.15(12):1508-1516

*Lundahl,B.,etal.(2006)."Ameta-analysisofparenttraining:Moderatorsandfollow-upeffects."ClinicalPsychologyReview26(1):86-104.

Ameta-analysisof63peer-reviewedstudiesevaluatedtheabilityofparenttrainingprogrammestomodifydisruptivechildbehaviorsandparentalbehaviorandperceptions.Thisanalysisextendspreviousworkbydirectlycomparingbehavioralandnonbehavioralprogrammes,evaluatingfollow-upeffects,isolatingdependentvariablesexpresslytargetedbyparenttraining,andexaminingmoderators.Effectsimmediatelyfollowingtreatmentforbehavioralandnonbehavioralprogrammesweresmalltomoderate.Fornonbehavioralprogrammes,insufficientstudiesprecludedexaminingfollow-upeffects.Forbehavioralprogrammes,follow-upeffectsweresmallinmagnitude.Parenttrainingwasleasteffectiveforeconomicallydisadvantagedfamilies;importantly,suchfamiliesbenefitedsignificantlymorefromindividuallydeliveredparenttrainingcomparedtogroupdelivery.Includingchildrenintheirowntherapy,separatefromparenttraining,didnotenhanceoutcomes.(PsycINFODatabaseRecord(c)2010APA,allrightsreserved)(journalabstract)

*Lundahl,B.W.,etal.(2008)."Ameta-analysisoffatherinvolvementinparenttraining."ResearchonSocialWorkPractice18(2):97-106.

OBJECTIVE:Investigate(a)whetherincludingfathersinparenttrainingenhancesoutcomesand(b)whethermothersandfathersbenefitequallyfromparenttraining.METHOD:Usingtraditionalmeta-analysismethodology,26studiesthatcouldanswertheresearchquestionswereidentifiedandmeta-analyzed.Results:Studiesthatincludedfathers,comparedwiththosethatdidnot,reportedsignificantlymorepositivechangesinchildren'sbehavioranddesirableparentingpractices,butnotinperceptionstowardparenting.Comparedwithmothers,fathersreportedfewerdesirablegainsfromparenttraining.CONCLUSIONS:Fathersshouldnotbeexcludedfromparenttrainingandshouldbeencouragedtoattend.Furtherresearchshouldseektounderstandhowparent-trainingprogrammesmightbettermeettheneedsoffathers.

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Macours,K.,etal.(2008).Cashtransfers,behavioralchanges,andcognitivedevelopmentinearlychildhood.Evidencefromarandomizedexperiment.PolicyResearchWorking

Paper4759.Washington,DC,TheWorldBank.*Macours,K.,etal.(2012)."Cashtransfers,behavioralchanges,andcognitivedevelopmentinearlychildhood:Evidencefromarandomizedexperiment."AmericanEconomicJournal:AppliedEconomics4(2):247-273.

Cashtransferprogrammeshavebecomeextremelypopularinthedevelopingworld.Alargeliteratureanalyzestheireffectsonschooling,healthandnutrition,butrelativelylittleisknownaboutpossibleimpactsonchilddevelopment.Thispaperanalyzestheimpactofacashtransferprogrammeonearlychildhoodcognitivedevelopment.Childreninhouseholdsrandomlyassignedtoreceivebenefitshadsignificantlyhigherlevelsofdevelopmentninemonthsaftertheprogrammebegan.Thereisnofade-outofprogrammeeffectstwoyearsaftertheprogrammeended.Additionalrandomvariationshowsthattheseimpactsareunlikelytoresultfromthecashcomponentoftheprogrammealone.

Maluccio,J.A.andR.Flores(2004).Impactevaluationofaconditionalcashtransferprogramme:TheNicaraguanReddeProtecciónSocial.FCNDDiscussionPaperNo.184.Washington,DC,FoodConsumptionandNutritionDivision,InternationalFoodPolicyResearchInstitute.

*Manaseki-Holland,S.,etal.(2010)."Effectsoftraditionalswaddlingondevelopment:Arandomizedcontrolledtrial."Pediatrics126(6):e1485-e1492.

OBJECTIVE:Evidenceoftheeffectsoftight,prolongedbindingofinfantsondevelopmentisinconclusiveandbasedonsmallethnographicstudies.ThenullhypothesiswasthatMongolianinfantsnotswaddledorswaddledtightlyinatraditionalsetting(to>7monthsofage)donothavesignificantlydifferentscoresfortheBayleyScalesofInfantDevelopment,SecondEdition(BSID-II).PATIENTSANDMETHODS:Inarandomizedcontrolledtrial,1279healthynewbornsinUlaanbaatar,Mongolia,wereallocatedatbirthtotraditionalswaddlingornonswaddling.Thefamiliesreceived7monthsofhomevisitstocollectdataandmonitorcompliance.At11to17monthsofage,theBSID-IIwasadministeredto1100children.RESULTS:Nosignificantbetween-groupdifferenceswerefoundinmeanscaledmentalandpsychomotordevelopmentalscores.Theunadjustedmeandifferencebetweenthegroupswas−0.69(95%confidenceinterval[CI]:−2.59to1.19)forpsychomotorand−0.42(95%CI:−1.68to0.84)formentalscoresinfavoroftheswaddlinggroup.Asubgroupanalysisofthecompliantsampleproducedsimilarresults.BSID-II–scaledpsychomotorandmentalscoreswere99.98(95%CI:99.03–100.92)and105.52(95%CI:104.89–106.14),respectively.Backgroundcharacteristicswerebalancedacross

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thegroups.CONCLUSIONS:IntheMongoliancontext,prolongedswaddlinginthefirstyearoflifedidnothaveanysignificantimpactonchildren'searlymentalor

psychomotordevelopment.Additionalstudiesinothersettingsneedtoconfirmthisfinding.TheMongolianinfantsinthistrialhadscaledBSID-IImentalandpsychomotorscorescomparabletoUnitedStatesnorms.

Marsh,D.R.andD.G.Schroeder(2002)."Thepositivedevianceapproachtoimprovehealthoutcomes:Experienceandevidencefromthefield."Food&NutritionBulletin23(4):3-6.

Mazia,G.,etal.(2009)."IntegratingqualitypostnatalcareintoPMTCTinSwaziland."GlobalPublicHealth4(3):253-270.

McCartney,K.,&Phillips,D.A.(Eds.)(2006).HandbookofEarlyChildhoodDevelopment.Oxford:BlackwellPublishing.

MeaneyM.(2010).Epigeneticsandthebiologicaldefinitionofgenexenvironmentinteractions.ChildDevelopment,81(1),41–79.

*Mikton,C.andA.Butchart(2009)."Childmaltreatmentprevention:Asystematicreviewofreviews."BulletinoftheWorldHealthOrganization87(5):353-361.

OBJECTIVE:Tosynthesizerecentevidencefromsystematicandcomprehensivereviewsontheeffectivenessofuniversalandselectivechildmaltreatmentpreventioninterventions,evaluatethemethodologicalqualityofthereviewsandoutcomeevaluationstudiestheyarebasedon,andmapthegeographicaldistributionoftheevidence.METHODS:Asystematicreviewofreviewswasconducted.Thequalityofthesystematicreviewswasevaluatedwithatoolfortheassessmentofmultiplesystematicreviews(AMSTAR),andthequalityoftheoutcomeevaluationswasassessedusingindicatorsofinternalvalidityandoftheconstructvalidityofoutcomemeasures.FINDINGS:Thereviewfocusedonsevenmaintypesofinterventions:homevisiting,parenteducation,childsexabuseprevention,abusiveheadtraumaprevention,multi-componentinterventions,media-basedinterventions,andsupportandmutualaidgroups.Fouroftheseven-home-visiting,parenteducation,abusiveheadtraumapreventionandmulti-componentinterventions-showpromiseinpreventingactualchildmaltreatment.Threeofthem-homevisiting,parenteducationandchildsexualabuseprevention-appeareffectiveinreducingriskfactorsforchildmaltreatment,althoughtheseconclusionsaretentativeduetothemethodologicalshortcomingsofthereviewsandoutcomeevaluationstudiestheydrawon.Ananalysisofthegeographicaldistributionoftheevidenceshowsthatoutcomeevaluationsofchildmaltreatmentpreventioninterventionsareexceedinglyrareinlow-andmiddle-incomecountries

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andmakeuponly0.6%ofthetotalevidencebase.CONCLUSION:Evidenceforthe

effectivenessoffourofthesevenmaintypesofinterventionsforpreventingchildmaltreatmentispromising,althoughitisweakenedbymethodologicalproblemsandpaucityofoutcomeevaluationsfromlow-andmiddle-incomecountries.CopyrightCO2009WorldHealthOrganization

*Mock,C.,etal.(2003)."InjurypreventioncounsellingtoimprovesafetypracticesbyparentsinMexico."BulletinoftheWorldHealthOrganization81(8):591-598.

OBJECTIVES:ToevaluatetheeffectivenessofeducationalcounsellingProgrammesaimedatincreasingparents'practiceofchildhoodsafetyinMonterrey,Mexico,andtoprovideinformationaimedathelpingtoimprovetheeffectivenessoffutureeffortsinthisfield.METHODS:ThreedifferentcounsellingProgrammesweredesignedtomeettheneedsoftheupper,middleandlowersocioeconomicstrata.Evaluationinvolvedtheuseofbaselinequestionnairesonparents'existingsafety-relatedpracticesforinterventionandcontrolgroupsandtheadministrationofcorrespondingquestionnairesaftertheProgrammeshadbeencarriedout.FINDINGS:Datawereobtainedon1124childrenbeforecounsellingtookplaceandon625afterithadbeengiven.Overallsafetyscores(%saferesponses)increasedfrom54%and65%fortheloweranduppersocioeconomicstrata,respectively,beforecounsellingto62%and73%aftercounselling(P<0.001forallgroups).Improvementsoccurredbothforactivitiesthatrequiredcautionandforactivitiesthatrequiredtheuseofsafety-relateddevices(e.g.helmets,carseats).However,scoresfortheuseofsuchdevicesremainedsuboptimalevenaftercounsellingandtherewerewidediscrepanciesbetweenthesocioeconomicstrata.Thepost-counsellingscoresfortheuseofsafety-relateddeviceswere55%,38%and19%fortheupper,middleandlowersocioeconomicstrata,respectively.CONCLUSIONS:Briefeducationalinterventionstargetingparents'practiceofchildhoodsafetyimprovedsafebehaviors.Increasedattentionshouldbegiventospecificsafety-relateddevicesandtothesafetyofpedestrians.Educationaleffortsshouldbecombinedwithotherstrategiesforinjuryprevention,suchastheuseoflegislationandtheimprovementofenvironmentalconditions.Copyright©2003WorldHealthOrganization.

MohanP., Iyengar,S.D.,Martines,J,,Cousens,S,,Sen,K.(2004). Impactofcounsellingoncare-seekingbehaviorinfamilieswithsickchildren:clusterrandomizedtrialinruralIndia.BMJPublishingGroupLimited.329(7460):266.

Moran,P.,Ghate,D.,andvanderMerwe,A.(2004).WhatWorksinParentingSupport?AReviewoftheInternationalEvidence.ResearchReportRR57420014,PolicyResearchBureau.

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Mohebbi,S.Z.,etal.(2009)."Aclusterrandomisedtrialofeffectivenessofeducationalinterventioninprimaryhealthcareonearlychildhoodcaries."CariesResearch43(2):110-118.329(7460):266.

Moran,P.,Ghate,D.,andvanderMerwe,A.(2004).Whatworksinparentingsupport?Aninternationalreviewofliterature.London,DepartmentforEducationandSkills.

Nair,M.,Renjit,M.,Siju,K.,Leena,M.,George,B.,&Kumar,G.S.(2009).Effectivenessofacommunityoralhealthawarenessprogramme.Indianpediatrics,46,s86.

Nana,C.,Brouwer,I.,Zagré,N.,Kok,F.,&Traoré,A.(2006).Impactofpromotionofmango

andliverassourcesofvitaminAforyoungchildren:apilotstudyinBurkinaFaso.PublicHealthNutrition,9(06),808-813.doi:doi:10.1079/PHN2005911

NationalScientificCouncilontheDevelopingChild(2004).YoungChildrenDevelopinanEnvironmentofRelationships:WorkingPaperNo.1.RetrievedJuly21,2014fromwww.developingchild.harvard.edu

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Needleman,J.,(1991).“HandbookofEarlyChildhoodIntervention”.JournalofDevelopmental&BehavioralPediatrics,12(4):275-280.

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Ogilvie,D.,Fayter,D.,Petticrew,M.,Sowden,A.,Thomas,S.&Whitehead,M.(2008)."Theharvestplot:Amethodforsynthesisingevidenceaboutthedifferentialeffectsofinterventions."BMCmedicalresearchmethodology8(1):8.Okeke,T.A.,&Uzochukwu,B.SC.(2009).Improvingchildhoodmalariatreatmentandreferralpracticesbytrainingpatentmedicinevendorsinruralsouth-eastNigeria.MalariaJournal,8,260.

Ortiz-Andrellucchi,A.,etal.(2009)."Facingmalnutritionandpoverty:EvaluatingtheCONINexperience."NutritionReviews67:S47-S55.

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Oveisi,S.,etal.(2010)."Primarypreventionofparent-childconflictandabuseinIranianmothers:Arandomized-controlledtrial."Childabuse&neglect34(3):206.

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Padak,N.andT.Rasinski(2003).“FamilyLiteracyProgrammes:WhoBenefits?”OhioLiteracyResourceCenter.KentStateUniversity.

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Peairson,S.,etal.(2008)."CognitivedevelopmentandhomeenvironmentofruralParaguayaninfantsandtoddlersparticipatinginPastoraldelNiño,anearlychilddevelopmentprogramme."JournalofResearchinChildhoodEducation22(4):343-362.

Pelto,G.H.,Santos,I.,Gonçalves,H.,Victora,C.,Martines,J.,&Habicht,J.P.(2004).Nutritioncounselingtrainingchangesphysicianbehaviorandimprovescaregiverknowledgeacquisition.TheJournalofnutrition,134(2),357-362.

Penny,M.E.,etal.(2005)."Effectivenessofaneducationalinterventiondeliveredthroughthehealthservicestoimprovenutritioninyoungchildren:acluster-randomisedcontrolledtrial."TheLancet365(9474):1863-1872.

Pereira,M.B.B.andM.d.C.M.Freire(2004)."AninfantoralhealthProgrammeinGoiânia-GO,Brazil:resultsafter3yearsofestablishment."BrazilianOralResearch18(1):12-17.

Petrovic,O.&Yousafzai,A.K.(2013). PromotingCareforChildDevelopmentinCommunityHealthServices. ASummaryofthePakistanEarlyChildDevelopmentScale-up(PEDS)Trial. UNICEFReport. RetrievedonJuly23,2014fromhttp://www.unicef.org/earlychildhood/files/3_PEDS_Trial_Summary_Report.pdf

Petticrew,M.&Roberts,H.(2006).SystematicReviewsintheSocialSciences. APracticalGuide. BlackwellPublishing.

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Powell,C.,etal.(2004)."FeasibilityofintegratingearlystimulationintoprimarycareforundernourishedJamaicanchildren:Clusterrandomisedcontrolledtrial."BritishMedicalJournal329(7457):89.

Rahman,A.,etal.(2009)."Clusterrandomizedtrialofaparent-basedinterventiontosupportearlydevelopmentofchildreninalow-incomecountry."Child:Care,HealthandDevelopment35(1):56-62.

*Reese,E.,etal.(2010)."Areviewofparentinterventionsforpreschoolchildren’slanguageandemergentliteracy."JournalofEarlyChildhoodLiteracy10(1):97-117.

Itiswellknownthatchildren’slanguagedevelopmentlaysthefoundationfortheirliteracydevelopment,thoughitisdifficultforpreschoolteachersalonetoconsistentlyengageintheindividualinteractionsnecessarytoboostchildren’slanguageskills.Giventhatparentsaretheirchildren’sfirstteachers,itisimperativetoconsiderhowparentscanhelpimprovetheirchildren’slanguageandemergentliteracydevelopmentpriortoformalschooling.Thisarticlereviewsparent-trainingstudiesofchildren’slanguageandliteracyinthreecontexts:parent—childbook-reading;parent—childconversations;andparent—childwriting.Parenttrainingineachofthesecontextshasthecapacitytoimprovechildren’slanguageandliteracy,withtheeffectsbeingspecifictothetargetedskill.Allthreecontextsarepotentiallyvaluablesitesfortrainingparentstohelptheirchildren’slanguageandliteracy.Inconclusion,parentsareanundertappedresourceforimprovingchildren’slanguageandliteracy.

Reyes,M.R.,etal.(2012)."Theinteractioneffectsofprogrammetraining,dosage,andimplementationqualityontargetedstudentoutcomesforTheRulerApproachtoSocialandEmotionalLearning."SchoolPsychologyReview41(1):82-99.

Richard,S.A.,Black,R.E.,&Checkley,W.(2012)."Revisitingtherelationshipofweightandheightinearlychildhood."AdvancesinNutrition:AnInternationalReviewJournal3(2):250-254.

Richter,L.(2004).“Theimportanceofcaregiver-childinteractionsforthesurvivalandhealthydevelopmentofyoungchildren.”Areview.

*Rivera,J.A.,etal.(2004)."ImpactoftheMexicanprogrammeforeducation,health,andnutrition(PROGRESA)onratesofgrowthandanemiaininfantsandyoungchildren:A

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randomizedeffectivenessstudy."JAMA:TheJournaloftheAmericanMedicalAssociation291(21):2563-2570.

CONTEXT Malnutritioncausesdeathandimpairedhealthinmillionsofchildren.Existinginterventionsareeffectiveundercontrolledconditions;however,littleinformationisavailableontheireffectivenessinlarge-scaleprogrammes.ObjectiveTodocumenttheshort-termnutritionalimpactofalarge-scale,incentive-baseddevelopmentprogrammeinMexico(Progresa),whichincludedanutritionalcomponent.DESIGN,SETTING,ANDPARTICIPANTS:Arandomizedeffectivenessstudyof347communitiesrandomlyassignedtoimmediateincorporationtotheprogrammein1998(interventiongroup;n=205)ortoincorporationin1999(crossoverinterventiongroup;n=142).Arandomsampleofchildreninthosecommunitieswassurveyedatbaselineandat1and2yearsafterward.Participantswerefromlow-incomehouseholdsinpoorruralcommunitiesin6centralMexicanstates.Children(N=650)12monthsofageoryounger(n=373interventiongroup;n=277crossoverinterventiongroup)wereincludedintheanalyses.INTERVENTIONChildrenandpregnantandlactatingwomeninparticipatinghouseholdsreceivedfortifiednutritionsupplements,andthefamiliesreceivednutritioneducation,healthcare,andcashtransfers.MAINOUTCOMEMEASURES Two-yearheightincrementsandanemiaratesasmeasuredbybloodhemoglobinlevelsinparticipatingchildren.RESULTS Progresawasassociatedwithbettergrowthinheightamongthepoorestandyoungerinfants.Age-andlength-adjustedheightwasgreaterby1.1cm(26.4cmintheinterventiongroupvs25.3cminthecrossoverinterventiongroup)amonginfantsyoungerthan6monthsatbaselineandwholivedinthepooresthouseholds.After1year,meanhemoglobinvalueswerehigherintheinterventiongroup(11.12g/dL;95%confidenceinterval[CI],10.9-11.3g/dL)thaninthecrossoverinterventiongroup(10.75g/dL;95%CI,10.5-11.0g/dL)whohadnotyetreceivedthebenefitsoftheintervention(P=.01).Therewerenodifferencesinhemoglobinlevelsbetweenthe2groupsatyear2afterbothgroupswerereceivingtheintervention.Theage-adjustedrateofanemia(hemoglobinlevel&lt;11g/dL)in1999washigherinthecrossoverinterventiongroupthanintheinterventiongroup(54.9%vs44.3%;P=.03),whereasin2000thedifferencewasnotsignificant(23.0%vs25.8%,respectively;P=.40).CONCLUSION Progresa,alarge-scale,incentive-baseddevelopmentprogrammewithanutritionalintervention,isassociatedwithbettergrowthandlowerratesofanemiainlow-income,ruralinfantsandchildreninMexico.

Rogoff,B.(2003).Theculturalnatureofhumandevelopment.NewYork:OxfordUniversityPress.

Roy,S.K.,etal.(2005)."Intensivenutritioneducationwithorwithoutsupplementaryfeedingimprovesthenutritionalstatusofmoderately-malnourishedchildreninBangladesh."

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Roy,S.K.,etal.(2007)."PreventionofmalnutritionamongyoungchildreninruralBangladeshbyafood-health-careeducationalintervention:Arandomized,controlledtrial."Food&NutritionBulletin28(4):375-383.

Ruel,M.T.,etal.(2008)."Age-basedpreventivetargetingoffoodassistanceandbehaviorchangeandcommunicationforreductionofchildhoodundernutritioninHaiti:Aclusterrandomisedtrial."TheLancet371(9612):588-595.

*Saleemi,M.A.,etal.(2004)."FeedingPatterns,DiarrhoealIllnessandLinearGrowthin0–24-Month-oldChildren."JournalofTropicalPediatrics50(3):164-169.

Theaimwastostudytheimpactofsimplehealthcareinterventionsin0–24-month-oldchildrenlivinginruralcommunitiesoutsideLahore,Pakistan.Newbornsbelongingtofourbirthcohortswerefollowedmonthlyfrom0–24monthsofagelivinginruralcommunities.Threecohortswerefromthesamevillage:CohortA(1984–1987),n=485;CohortB(1990–1992),n=544;andCohortC(1995–1997),n=518.Afourth,CohortD,wasfromneighbouringvillages(1995–1997),n=444.FindingsfromCohortAformedthebasisofahealthcareProgramme,includingpromotionofoptimalbreastfeedingpractices,adviceonoralrehydrationtherapy,andcontinuedfeedingduringdiarrhoea.Theoutcomemeasuresstudiedweretimeofinitiationofbreastfeeding,feedingofprelacteals,exclusivebreastfeeding,diarrhoealillnesses,andpostnatallineargrowth.Themediantimeofinitiationofbreastfeedingdecreasedfrom47to3handexclusivebreastfeedingincreasedfrom5percentinCohortAtomorethan80percentinthesubsequentcohorts,at1monthofage.Noprelactealsweregivento34percentofnewbornsinlatercohortscomparedwith100percentinCohortA.Diarrhoealillnessesduringthefirst6monthshadreducedsignificantly.Postnatallineargrowthimprovedbyabout3cminthelatercohorts.Appropriatechangesinbreastfeedingpracticesthroughintegratedandfocusedhealthcare,especiallyantenatally,canreducediarrhoealillnesses,andsustainandimprovelineargrowthinyoungchildren.

*Santos,I.,etal.(2001)."NutritioncounselingincreasesweightgainamongBrazilianchildren."TheJournalofNutrition131(11):2866-2873.

Toassesstheimpactonchildgrowthofthenutrition-counselingcomponentoftheIntegratedManagementofChildhoodIllnesses(IMCI)strategy,arandomizedtrialwasimplemented.All28governmenthealthcentersinaSouthernBrazilcitywerepairedaccordingtobaselinenutritionalindicators.Onecenterfromeachpairwasrandomlyselectedanditsdoctorsreceived20-htraininginnutritioncounseling.Thirty-threedoctorswereincludedand12–13patients<18monthsofagefromeachdoctorwererecruited.Thestudyincludedtestingtheknowledgeofdoctors,

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observingconsultationsandvisitingthechildrenathome8,45and180daysaftertheinitialconsultation.Maternalknowledge,practicesandadherencetonutritionalrecommendationswereassessed,andanthropometricmeasurementsweretaken.Day-longdietaryintakewasevaluatedonasubsampleofchildren.Doctorsintheinterventiongrouphadbetterknowledgeofchildnutritionandimprovedassessmentandcounselingpractices.Maternalrecallofrecommendationswashigherintheinterventionthaninthecontrolgroup,aswassatisfactionwiththeconsultation.Reporteduseofrecommendedfoodswasalsoincreased.Dailyfatintakewashigherintheinterventionthaninthecontrolgroup;meandailyintakesofenergyandzincalsotendedtoimprove.Children12monthsofageorolderhadimprovedweightgainandapositivebutnonsignificantimprovementinlength.Nutrition-counselingtrainingimproveddoctors’performances,maternalpracticesandthedietsandweightgainofchildren.Therandomizeddesignwithblindoutcomeevaluationstronglysupportsacausallink.Theseresultsshouldbereplicatedinothersettings.

Santosham,M.,etal.(2010)."Progressandbarriersforthecontrolofdiarrhoealdisease."TheLancet376(9734):63-67.

Sawasdipanich,N.,etal.(2010)."EffectsofacognitiveadjustmentprogrammeforThaiparents."Nursing&healthsciences12(3):306-313.

*Schroeder,D.G.,etal.(2002)."Anintegratedchildnutritioninterventionimprovedgrowthofyounger,moremalnourishedchildreninnorthernVietNam."FoodandNutritionBulletin23(Supplement2):50-58.

Integratednutritionprogrammesarewidelyusedtopreventand/orreversechildhoodmalnutrition,butrarelyrigorouslyevaluated.TheimpactofsuchaprogrammeonthephysicalgrowthofyoungruralVietnamesechildrenwasmeasured.WerandomizedsixcommunestoreceiveanintegratednutritionprogrammeimplementedbySavetheChildren.Wematchedsixcommunestoserveascontrols.Oursampleconsistedof238children(<I>n</I>=119pergroup)whowere5to30monthsoldonentry.BetweenDecember1999andDecember2000,wemeasuredweightandheightmonthlyforsixmonthsandagainatmonth12.Principleoutcomeswereweight-for-ageZscore(WAZ),height-for-ageZscore(HAZ),andweight-for-heightZscore(WHZ),andthechangesamongthesemeasures.Asexpected,anthropometricindicatorsrelativetointernationalreferencesworsenedasthechildrenaged.Overall,childrenintheinterventioncommuneswhowereexposedtotheintegratednutritionprogrammedidnotshowstatisticallysignificantbettergrowththancomparisonchildren.Interventionchildrenwhowereyounger(15monthsorless)andmoremalnourished(lessthan&#8722;2Z)atbaseline,however,deteriorated

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significantlylessthantheircomparablecounterparts.Betweenbaselineandmonthfour,forexample,interventionchildrenwhoweremalnourishedandlessthan15monthsoldatentrylostonaverage0.05WAZwhilesimilarcomparisonchildrenlost0.25WAZ(<I>p</I>=.02).Lackofoverallimpactongrowthmaybeduetoalowerthanexpectedprevalenceofmalnutritionatbaselineand/ordewormingofcomparisonchildren.Targetingnutritioninterventionsatveryyoungchildrenwillhavethemaximumimpactongrowth.

Sharma,S.andS.Nagar(2009)."InfluenceofhomeenvironmentofpsychomotordevelopmentofinfantsinKangraDistrictofHimachalPradesh."JournalofSocialSciences21(3):225-229.

Shaw,D.S.,Connell,A.,Dishion,T.J.,Wilson,M.N.,&Gardner,F.(2009).Improvementsinmaternaldepressionasamediatorofinterventioneffectsonearlychildhoodproblembehavior.Developmentandpsychopathology,21(02),417-439.

Shonkoff,JackP.andPhillips,DeborahA.,(eds.),(2000)FromNeuronstoNeighborhoods:TheScienceofEarlyChildhoodDevelopmen.Washington,NationalAcademyPress.

Sidibeh,L.(2008)EvaluationoftheparentaleducationProgrammeatLRR,CRR&URR,TheGambia.

Sloand,E.,Astone,N.M.,&Gebrian,B.(2010).Theimpactoffathers’clubsonchildhealthinruralHaiti.FieldActionReport,100(2),201-204.

Solis-Camara,P.andM.D.Romero(2002)."Effectsofaparentingprogrammeformothersandfathersofyoungchildren:Theimportanceofparents'schooling"RevistaLatinoamericanadePsicologia34(3):203-215.

*Sripaipan,T.,etal.(2002)."EffectofanintegratednutritionprogrammeonchildmorbidityduetorespiratoryinfectionanddiarrheainnorthernVietNam."Food&#38;NutritionBulletin23(Supplement2):67-74.

Infectiousdiseaseandpoordietarethetwoproximalcausesofmalnutritioninchildren.Duringthe1990s,integratednutritionprogrammesimplementedbySavetheChildren(SC)inVietnamreducedseverechildmalnutrition,butithasnotbeenclearifthisimpactwasdueprimarilytoimproveddietorreduceddisease.Theaimofthisstudywastodeterminewhetheracommunity-based,integratednutritionprogrammeinVietnamreducedchildmorbidityduetodiarrheaoracuterespiratoryinfections.Children5to25monthsoldwererandomlyselectedfromrandomlyassignedinterventionandcomparisoncommunes.Caregiversofchildrenfromtheinterventionandcomparisongroups(<I>n</I>=119pergroup)wereinterviewedabouttheirchild'smorbidityatprogrammebaselineandatstudymonths2,4,6,and

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12.Multiplelogisticregressionandgeneralestimatingequations(GEE)wereusedtoevaluatetheeffectoftheinterventionontheoccurrenceofanydiarrheaandrespiratoryillnessintheprecedingtwoweeks.Respiratoryillness,mainlyupperrespiratoryillness,wasmorecommonthandiarrhealdiseaseatbaseline(54%vs.6%,respectively).Duringfollow-up,childrenintheinterventioncommuneshadapproximatelyhalftherespiratoryillnessexperiencedbythoseincomparisoncommunes(AOR=0.5;<I>p</I>=.001).Diarrhealdiseasewasalsolowerintheinterventiongroup,althoughdifferenceswerenotstatisticallysignificant.WeconcludethatSC'sintegratednutritionprogrammewasassociatedwithreducedupperrespiratoryillness,perhapsduetoimprovedhygienepracticesand/orimprovedmicronutrientintakes.

Stokes,T.F.andD.M.Baer(1977)."Animplicittechnologyofgeneralization."Journalofappliedbehavioranalysis10(2):349.

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Terwee,C.B.et.al(2012). Qualitycriteriawereproposedformeasurementpropertiesofhealthstatusquestionnaires.JournalofClinicalEpidemiology,60(1):34-42.

*Thomas,R.andM.Zimmer-Gembeck(2007)."BehavioraloutcomesofParent-ChildInteractionTherapyandTripleP—positiveparentingprogramme:Areviewandmeta-analysis."JournalofAbnormalChildPsychology35(3):475-495.

Weconductedareviewandmeta-analysesof24studiestoevaluateandcomparetheoutcomesoftwowidelydisseminatedparentinginterventions—Parent-ChildInteractionTherapyandTripleP-PositiveParentingProgramme.Participantsinallstudieswerecaregiversand3-to12-year-oldchildren.Ingeneral,ouranalysesrevealedpositiveeffectsofbothinterventions,buteffectsvarieddependingoninterventionlength,components,andsourceofoutcomedata.Bothinterventionsreducedparent-reportedchildbehaviorandparentingproblems.TheeffectsizesforPCITwerelargewhenoutcomesofchildandparentbehaviorswereassessedwithparent-report,withtheexclusionofAbbreviatedPCIT,whichhadmoderateeffectsizes.AllformsofTriplePhadmoderatetolargeeffectswhenoutcomeswereparent-reportedchildbehaviorsandparenting,withtheexceptionofMediaTripleP,whichhadsmalleffects.PCITandanenhancedversionofTriplePwereassociatedwithimprovementsinobservedchildbehaviors.ThesefindingsprovideinformationabouttherelativeefficacyoftwoprogrammesthathavereceivedsubstantialfundingintheUSAandAustralia,andfindingsshouldassistinmakingdecisionsaboutallocationsoffundinganddisseminationoftheseparentinginterventionsinthefuture.

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Thompson,M.E.andT.L.Harutyunyan(2009).“Impactofacommunity-basedintegratedmanagementofchildhoodillness(IMCI)ProgrammeinGegharkunik,Armenia”.HealthPolicyandPlanning,24(2):101-107.

Tripathy,P.,etal.(2010)."Effectofaparticipatoryinterventionwithwomen'sgroupsonbirthoutcomesandmaternaldepressioninJharkhandandOrissa,India:acluster-randomisedcontrolledtrial."TheLancet375(9721):1182-1192.

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UNICEF(2009). EvaluationofUNICEFMultipleIndicatorClusterSurveyRound3(MICS3).FinalReport. RetrievedonJuly22,2014fromhttp://www.unicef.org/evaldatabase/files/MICS.pdf

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Vachirarojpisan,T.,K.Shinada,&Y.Kawaguchi,(2005).“TheprocessandoutcomeofaProgrammeforpreventingearlychildhoodcariesinThailand”.CommunityDentalHealth.22(4):235-259.

Vegas,E.andL.Santibáñez(2010).ThepromiseofearlychildhooddevelopmentinLatinAmericaandtheCaribbean.WashingtonDC,WorldBankPublications.

Vitolo,M.R.,etal.(2008)."Effectivenessofanutritionprogrammeinreducingsymptomsofrespiratorymorbidityinchildren:Arandomizedfieldtrial."Preventivemedicine47(4):384-388.

*Walker,S.P.,etal.(2004)."Psychosocialinterventionimprovesthedevelopmentoftermlow-birth-weightinfants."TheJournalofNutrition134(6):1417-1423.

Itisestimatedthat11%ofbirthsindevelopingcountiesaretermlow-birth-weight(LBW);however,thereislimitedinformationonthedevelopmentoftheseinfants.OurobjectivesweretodeterminetheeffectofpsychosocialinterventiononthedevelopmentofLBWinfantsandtocomparetermLBWandnormal-birth-weight(NBW)infants.TermLBW(n=140)andNBWinfants(n=94)wereenrolledfromthemainmaternityhospitalinKingston,Jamaica.TheLBWinfantswererandomly

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assignedtocontrolorinterventioncomprisingweeklyhomevisitsfrombirthto8wkandfrom7to24moofage.Developmentwasassessedat15and24mowiththeGriffithsScales.Theinterventionbenefitedtheinfants’developmentalquotient(DQ,P<0.05)andperformancesubscaleat15mo(P<0.02),thehandandeye(P<

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0.05)andperformancesubscales(P<0.02)at24mo,andhomeenvironmentat12mo.Theeffectoftheinterventionondevelopmentwasmediatedinpartbytheimprovementinthehomeenvironment.ThecontrolLBWinfantshadsignificantlylowerscoresthantheNBWinDQandseveralsubscales,whereastherewerenosignificantdifferencesbetweentheNBWandtheLBWinfantsafterintervention.Inconclusion,termLBWwasassociatedwithdevelopmentaldelays,whichwerereducedwithpsychosocialintervention.

Walker,S.P.,etal.(2005)."Effectsofearlychildhoodpsychosocialstimulationandnutritionalsupplementationoncognitionandeducationingrowth-stuntedJamaicanchildren:Prospectivecohortstudy."TheLancet366(9499):1804-1807.

Walker,S.P.,etal.(2006)."Effectsofpsychosocialstimulationanddietarysupplementationinearlychildhoodonpsychosocialfunctioninginlateadolescence:Follow-upofrandomisedcontrolledtrial."BMJ333(7566):472.

Walker,S.P.,etal.(2010)."Theeffectofpsychosocialstimulationoncognitionandbehaviorat6yearsinacohortofterm,low-birthweightJamaicanchildren."DevelopmentalMedicine&ChildNeurology52(7):e148-e154.

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*Watanabe,K.,etal.(2005)."EarlychildhooddevelopmentinterventionsandcognitivedevelopmentofyoungchildreninruralVietnam."TheJournalofNutrition135(8):1918-1925.

Littleisknownaboutthelong-termbenefitsofinterventionsthataimtopromoteearlychildhooddevelopmentprogrammes.Thegoalofthisresearchwastodeterminewhetheranearlychildhooddevelopmentinterventionaddedtoanutritioninterventionduringpreschoolageshadlastingeffectsonthecognitivedevelopmentofschool-agechildrenincommunesofThanhHoaprovinceinruralVietnam.Thestudyfocusedonatotalof313childrenaged6.5–8.5y(grades1and2inprimaryschool)in2communesthatwereexposedtonutritioninterventionornutritionandearlychildhooddevelopment(ECD)interventionfrom1999to2003.Measurementsofheightandcognitivetestscores(Raven’sProgressiveMatricesTest)werecollectedfromthechildren;householdcharacteristicsweredeterminedbyinterviewswithmothers.Longitudinalanalysiswasperformedbyintegratingthedatawiththatcollectedfromthesamechildreninpastsurveys.SignificanteffectsoftheECDinterventioncomparedwiththenutritioninterventionweredetected.ThebeneficialeffectofECDinterventiononthecognitivetestscoreswaslargeforthemostnutritionallychallengedchildrenwhoseheight-for-ageZ-scoresdeclined

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orremainedinthestuntedrange.Thefindingshelpprovideusefulinsightsintothe

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developmentofaneffectiveintegratedmodelofECDandnutritioninterventionforchildreninruralVietnam.

*Waters,H.R.,etal.(2006)."Thecost-effectivenessofachildnutritioneducationProgrammeinPeru."HealthPolicyandPlanning21(4):257-264.

Thisarticlereportsimpactandcostresultsfromahealthfacility-basednutritioneducationProgrammetargetingchildrenlessthan2yearsofageinTrujillo,Peru.KeyelementsoftheProgrammeincludedparticipativecomplementaryfeedingdemonstrations,growthmonitoringsessionsandanaccreditationprocess.Datawerecollectedfromsixinterventionandsixcontrolhealthfacilitiestomeasureutilizationandcostsassociatedwiththeintervention.Tocalculatetheunitcostsofservices,thesecostsareallocatedusingactivity-basedcosting.Tomeasuretheeffectsoftheintervention,338childrenwerefollowedthroughhouseholdsurveysatregularintervalsfrombirthuntiltheageof18months.Theinterventionhadaclearpositiveimpactbothontheuseofnutrition-relatedservicesandonchildren'sgrowthoutcomes.Childrenintheinterventionareasmade17.6visitstohealthfacilitiesinthefirst18monthsoflife,comparedwith14.1visitsforchildreninthecontrolareas(P<0.001).Thispatternholdstrueforallsocioeconomicgroups.Theinterventionprevented11.1casesofstuntingper100children.Inmultivariatelogisticregressionanalysis,childrenintheinterventionwere0.33timesaslikelytobestuntedasthecontrols(P=0.002).Themarginalcostoftheintervention–includingexternalcosts,training,healtheducationmaterialsandextratravelandequipment–isUS$6.12perchildreachedandUS$55.16percaseofstuntingprevented.TheestimatedmarginalcostoftheinterventionperdeathavertedisUS$1952.

Whiting,B.B.,&Edwards,C.P.(1988).Childrenofdifferentworlds:Theformationofsocialbehavior.Cambridge,MA:HarvardUniversityPress.

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Yoshikawa,H.,etal.(2003)."Effectsofearnings-supplementpoliciesonadulteconomicandmiddle-childhoodoutcomesdifferforthe“hardesttoemploy”."ChildDevelopment74(5):1500-1521.

Yousafzaietal.(2013).“AnnualResearchReview:ImprovedNutrition-Apathwaytoresilience”.JournalofChildPsychologyandPsychiatry,54(4):367-377.