Effects of a parenting intervention to address maternal psychological wellbeing and child development and growth in rural Uganda: a community-based, cluster-randomised trial

Effects of multi-component parenting and parental mental health interventions on early childhood development and parent outcomes: a systematic review and meta-analysis

BACKGROUND

Interventions supporting parents of young children often target parenting or parental mental health separately. Multi-component parenting and parental mental health interventions have the potential to improve parenting practices, mental health, and early childhood development. We aimed to examine their impact on child and parent outcomes.

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, Web of Science Core Collection, APA PsycINFO, CINAHL Complete, the Cochrane Central Register of Controlled Trials, and the Global Health Database from inception to Jan 23, 2024. Eligible studies were randomised controlled trials of interventions explicitly targeting parenting behaviours and parental mental health antenatally or in children's first 3 years of life. Screening, extraction, and quality assessment were done independently by two authors. Primary outcomes were cognitive and social-emotional functioning in children and depressive symptoms in parents, meta-analysed as standardised mean differences (SMDs), relative to control. This study is registered with PROSPERO, CRD42022302848.

FINDINGS

We found 5843 records. After screening 2636 (45·1%) titles and abstracts, we manually identified and screened three additional articles and excluded 2177 records. After screening 462 full-length articles, 25 articles, representing a sample size of 8520 children and caregivers, were included. At baseline, mean caregiver age was 27·7 years (SD 5·9) and mean child age (excluding those enrolled during pregnancy) was 14·4 months (8·0). Interventions lasted a mean of 14 months (SD 11) and used a mean of 3·7 behaviour change techniques (2·0). Most interventions dedicated more time to parenting behaviours than to parental mental health. We found significant intervention effects on children's cognitive (SMD 0·19 [95% CI 0·04 to 0·34]; I2=69%) and social-emotional (0·26 [0·17 to 0·34]; I2=47%) outcomes but not on depressive symptoms in female caregivers (-0·18 [-0·36 to 0·002]; I2=86%) relative to control conditions. Risk of bias across studies was moderate, and we found heterogeneity across results.

INTERPRETATION

Multi-component parenting and mental health interventions had a positive effect on child cognitive and social-emotional outcomes, but not on depressive symptoms in parents, suggesting that other factors might contribute to positive ECD outcomes. Interventions might lack adequate focus on mental health to make a discernible impact, highlighting a need for future studies to differentiate and assess contributions of parenting and mental health components to understand independent and collective effects on family outcomes.

FUNDING

Canadian Institutes of Health Research.

In-person versus remote (mHealth) delivery for a responsive parenting intervention in rural Kenya: A cluster randomized controlled trial

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

Postpartum Depression: A Clinical Review of Impact and Current Treatment Solutions

Depression during the first year postpartum (postpartum depression) impacts millions of women and their families worldwide. In this narrative review, we provide a summary of postpartum depression, examining the etiology and consequences, pharmacological and psychological treatments, and potential mechanisms of change and current barriers to care. Psychological treatments are effective and preferred by many perinatal patients over medications, but they often remain inaccessible. Key potential mechanisms underlying their effectiveness include treatment variables (e.g., dosage and therapeutic alliance) and patient behaviors (e.g., activation and avoidance and emotional regulation). Among pharmacological treatments, the selective serotonin reuptake inhibitor (SSRI) sertraline is generally the first-line antidepressant medication recommended to women in the postpartum period due to its minimal passage into breastmilk and the corresponding decades of safety data. Importantly, most antidepressant drugs are considered compatible with breastfeeding. Neurosteroids are emerging as an effective treatment for postpartum depression, although currently this treatment is not widely available. Barriers to widespread access to treatment include those that are systematic (e.g., lack of specialist providers), provider-driven (e.g., lack of flexibility in treatment delivery), and patient-driven (e.g., stigma and lack of time for treatment engagement). We propose virtual care, task-sharing to non-specialist treatment providers, and collaborative care models as potential solutions to enhance the reach and scalability of effective treatments to address the growing burden of postpartum depression worldwide and its negative impact on families and society.

Father involvement is a protective factor for maternal mental health in Western Kenya

Depression is a major global health concern especially among mothers of young children in low- and middle-income countries (LMICs). While various risk and protective factors have been well-established, the role of fathers in potentially mitigating maternal depression remains understudied. This study aimed to investigate the association between father involvement and maternal depressive symptoms in rural Western Kenya. We used cross-sectional baseline data collected in February-March 2023 from a cluster-randomized controlled trial evaluating the effectiveness of a community-based parenting program for improving early childhood development. Primary caregivers with children 0-18 months of age were enrolled into the trial across 51 villages in Nyamira and Vihiga counties. We analyzed data from 413 mothers who were in a relationship with a male partner (i.e., father of the young child). Maternal depressive symptoms were measured using the CESD-10. Father involvement was reported using a multidimensional measure of men's engagement in childcare activities, household chores, early learning activities, and affection towards their child. We used multilevel regression models to estimate the adjusted associations between father involvement (overall score and by specific domains) and maternal depressive symptoms. We also conducted exploratory subgroup analyses to assess whether this association differed by child age. Overall, greater father involvement was associated with fewer maternal depressive symptoms. Specifically, fathers' engagement in household chores and childcare activities had the strongest protective associations. Exploratory subgroup analyses revealed larger associations for mothers with younger children under 6 months. Our findings suggest that father involvement is a protective factor for maternal mental health. Engaging fathers in early childhood interventions and encouraging men's involvement in caregiving activities may potentially benefit maternal well-being.

The impact of the parenting for respectability programme on violent parenting and intimate partner relationships in Uganda: A pre-post study

BACKGROUND

There is a growing need for interventions that reduce both violence against children and intimate partner violence in low- and middle-income countries. However, few parenting interventions deliberately address this link. We tested the feasibility of a 16-session group-based parenting programme, Parenting for Respectability, in semi-rural Ugandan communities.

METHODS

This was a pre-post study with parents and their children (N = 484 parents; 212 children).

RESULTS

Pre-post comparisons found large effects for parent-reported reduced harsh parenting (Cohen's f2 = 0.41 overall; f2 = 0.47 (among session attendees); with an overall reduction of 26% for harsh parenting. Session attendees reported higher reductions than non-attendees (p = 0.014), and male caregivers reported higher reductions than female caregivers (p<0.001). Children also reported reduced harsh parenting by attending fathers (f2 = 0.64 overall; f2 = 0.60) and attending mothers (f2 = 0.56 overall; f2 = 0.51); with reduction in harsh parenting ranging between 27% to 29% in the various categories. Overall, spousal violence reduced by 27% (f2 = 0.19 overall; f2 = 0.26 (among session attendees). Both parents and children reported reduced dysfunctional parent relationships; parents: f2 = 0.19 overall; f2 = 0.26 (among session attendees); and children: f2 = 0.35 overall; f2 = 0.32 (for attending parents); with reductions ranging between 22% to 28%. Parents who attended more than 50% of the program reported greater effects on reduced dysfunctional relationships than those who attended less than half of the program (B = -0.74, p = 0.013). All secondary outcomes were improved with f2 ranging between 0.08 and 0.39; and improvements ranging between 6% and 28%.

CONCLUSION

Results suggest the importance of more rigorous testing to determine program effectiveness.

Effects of engaging fathers and bundling parenting and nutrition interventions on early child development and maternal and paternal parenting in Mara, Tanzania: a factorial cluster-randomized controlled trial

BACKGROUND

Multicomponent interventions are needed to address the various co-occurring risks that compromise early child nutrition and development. We compared the independent and combined effects of engaging fathers and bundling parenting components into a nutrition intervention on early child development (ECD) and parenting outcomes.

METHODS

We conducted a 2×2 factorial cluster-randomized controlled trial across 80 villages in Mara Region, Tanzania, also known as EFFECTS (Engaging Fathers for Effective Child Nutrition and Development in Tanzania; ClinicalTrials.gov, NCT03759821). Households with children under 18 months of age residing with their mother and father were enrolled. Villages were randomly assigned to one of five groups: a nutrition intervention for mothers, a nutrition intervention for couples, a bundled nutrition and parenting intervention for mothers, a bundled intervention for couples, and a standard-of-care control. Interventions were delivered by trained community health workers through peer groups and home visits over 12 months. Mothers, fathers, and children were assessed at baseline, midline, and endline or postintervention. We used a difference-in-difference approach with intention-to-treat analysis to estimate intervention effects on ECD (Bayley Scales of Infant and Toddler Development, third edition) and maternal and paternal parenting and psychosocial well-being.

RESULTS

Between October 29, 2018, and May 24, 2019, 960 households were enrolled (n = 192 per arm). Compared to nutrition interventions, bundled interventions improved children's cognitive (β = .18 [95% CI: 0.01, 0.36]) and receptive language development (β = .23 [0.04, 0.41]). There were no differences between interventions for other ECD domains. Compared to nutrition interventions, bundled interventions achieved additional benefits on maternal stimulation (β = .21 [0.04, 0.38]) and availability of home learning materials (β = .25 [0.07-0.43]) and reduced paternal parenting distress (β = -.34 [-0.55, -0.12]). Compared to interventions with mothers only, interventions that engaged fathers improved paternal stimulation (β = .45 [0.27, 0.63]).

CONCLUSIONS

Jointly bundling parenting components into nutrition interventions while also engaging both mothers and fathers is most effective for improving maternal and paternal parenting and ECD outcomes.

Long-term effects on depressive symptoms among Ugandan mothers - Findings from a follow-up of a cluster-randomized education trial in a rural low-resource setting

INTRODUCTION

Depression is increasingly affecting mothers in poor countries such as Uganda. Various interventions have been implemented to tackle this problem, but their sustainability is under-researched. Here we present follow-up data on maternal depression six years after a cluster-randomized controlled maternal education trial in rural Uganda.

METHODS

The intervention lasted six months and consisted of nutrition, hygiene, sanitation and child stimulation education, delivered to 511 mothers of 6 to 8 months' old children. Six years later we assessed maternal depressive symptoms using two psychometric tools; the Beck Depression Inventory II (BDI-II) and Center for Epidemiologic Studies Depression scale (CESD).

RESULTS

For this follow-up study, data was available from 307/511 (60 %) mothers. Intention-to-treat analyses adjusting for clustering showed that the intervention mothers had non-significantly less depression symptoms (absolute score difference - 2; 95 % CI -5 to 0; p = 0.07) on BDI-II, and borderline significantly less depression symptoms (absolute score difference - 3; 95 % CI -5 to 0; p = 0.05) on CES-D compared to the controls. For categorized depression scores, the control mothers had significantly higher proportion of women classified in the worse depression categories for both BDI-II and CESD. We did not find any baseline characteristics associated with maternal depression.

LIMITATIONS

The BDI-II and CES-D tools are both self-reported and we cannot rule out the possibility of social desirability bias in reporting of depression symptoms.

CONCLUSION

Six years after the maternal education trial, some benefits on maternal mental health were sustained. More studies are warranted on sustainability and scale-up of such interventions.

Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS): study protocol for a five-arm, cluster-randomized trial

BACKGROUND

Globally, 144 million children under 5 years are undernourished and 250 million do not meet their developmental potential. Multi-input interventions, such as bundled nutrition and parenting interventions, are designed to mitigate risks for multiple child outcomes. There is limited evidence that bundled interventions have additive benefits to nutrition, growth, or development outcomes. These outcomes share common risks; therefore, designing interventions to tackle these risks using a common theory of change may optimize effectiveness. Emerging evidence suggests explicit engagement of fathers may benefit child outcomes, but few trials have tested this or included data collected from fathers.

METHODS

Engaging Fathers for Effective Child Nutrition and Development in Tanzania (EFFECTS) is a community-based cluster-randomized controlled trial that will be implemented in the rural Mara Region, Tanzania. The trial aims (1) to test a bundled nutrition and parenting program delivered to mothers' groups, with or without fathers' groups, over 12 months on child and caregiving outcomes compared to a nutrition program alone, and (2) to test nutrition or bundled nutrition and parenting programs delivered to mothers' and fathers' groups over 12 months on child and caregiving outcomes compared to programs delivered to mothers alone. The trial comprises five arms: (1) mothers' groups receiving a nutrition program, (2) mothers' groups receiving a bundled nutrition and parenting program, (3) mothers' and fathers' groups receiving a nutrition program, (4) mothers' and fathers' groups receiving a bundled nutrition and parenting program, and (5) control receiving standard of care health services. The primary outcomes are child dietary diversity and early child development (mental and motor development). Parents with a child under 18 months will be enrolled in peer groups and receive twice monthly intervention by trained community health workers. Data will be collected from mothers, fathers, and children at baseline (pre-intervention), midline, and endline (post-intervention).

DISCUSSION

EFFECTS will generate evidence on the effects of bundled nutrition and parenting interventions on child nutrition, growth, and development outcomes; determine the benefits of engaging fathers on child, caregiving, and caregiver outcomes; and investigate common and unique pathways between treatments and child outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03759821. Registered on November 30, 2018.

A meta-analytic review of the implementation characteristics in parenting interventions to promote early child development

This review summarizes the implementation characteristics of parenting interventions to promote early child development (ECD) outcomes from birth to 3 years. We included 134 articles representing 123 parenting trials (PROSPERO record CRD42022285998). Studies were conducted across high-income (62%) and low-and-middle-income (38%) countries. The most frequently used interventions were Reach Up and Learn, Nurse Family Partnership, and Head Start. Half of the interventions were delivered as home visits. The other half used mixed settings and modalities (27%), clinic visits (12%), and community-based group sessions (11%). Due to the lack of data, we were only able to test the moderating role of a few implementation characteristics in intervention impacts on parenting and cognitive outcomes (by country income level) in the meta-analysis. None of the implementation characteristics moderated intervention impacts on cognitive or parenting outcomes in low- and middle-income or high-income countries. There is a significant need in the field of parenting interventions for ECD to consistently collect and report data on key implementation characteristics. These data are needed to advance our understanding of how parenting interventions are implemented and how implementation factors impact outcomes to help inform the scale-up of effective interventions to improve child development.

Is child anemia associated with early childhood development? A cross-sectional analysis of nine Demographic and Health Surveys

Anemia is a significant public health problem in many low- and middle-income countries (LMICs), with young children being especially vulnerable. Iron deficiency is a leading cause of anemia and prior studies have shown associations between low iron status/iron deficiency anemia and poor child development outcomes. In LMICs, 43% of children under the age of five years are at risk of not meeting their developmental potential. However, few studies have examined associations between anemia status and early childhood development (ECD) in large population-based surveys. We examined the associations between severe or moderate anemia and ECD domains (literacy-numeracy, physical, social-emotional, and learning) and an overall ECD index among children age 36-59 months. Nine Demographic and Health Surveys (DHS) from phase VII of The DHS Program (DHS-7) that included the ECD module and hemoglobin testing in children under age five years were used. Bivariate and multivariate logistic regressions were run for each of the five outcomes. Multivariate models controlled for early learning/interaction variables, child, maternal, and paternal characteristics, and socio-economic and household characteristics. Results showed almost no significant associations between anemia and ECD domains or the overall ECD index except for social-emotional development in Benin (AOR = 1.00 p < 0.05) and physical development in Maldives (AORs = 0.97 p < 0.05). Attendance at an early childhood education program was also significantly associated with the outcomes in many of the countries. Our findings reinforce the importance of the Nurturing Care Framework which describes a multi-sectoral approach to promote ECD in LMICs.

Community-based models of care for adolescent and adult depression, suicidal behavior, anxiety, trauma, and substance use in Africa: a scoping review

Background

Community-based care (CBC), where care is delivered outside of the traditional health facility setting, has been proposed to narrow the mental health (MH) and substance use (SU) treatment gap in Africa.

Objective

This scoping review aims to comprehensively summarize CBC models addressing adolescent and adult MH (depression, anxiety, trauma, suicidal behavior) and (non-tobacco) SU problems in Africa.

Methods

We searched PsycINFO, Embase, Scopus, CINAHL, and Medline Ovid. Studies and protocols were included if they reported on CBC intervention's effects on MH or SU symptoms/ diagnoses, acceptability, feasibility, or patient engagement in care, regardless of whether the intervention itself was designed specifically for MH or SU.

Results

Among 11,477 screened publications, 217 were eligible. Of the unique intervention studies (n = 206), CBC models were classified into the following approaches (non-mutually exclusive): psychotherapeutic (n = 144), social (n = 81), lifestyle/physical health (n = 55), economic (n = 26), and psychopharmacological (n = 2). While quantitative results suggest possible efficacy of CBC models, description of CBC location was often poor. Fewer interventions addressed suicidal behavior (n = 12), the needs of adolescents (n = 49), or used traditional healers or religious figures as providers (n = 3).

Conclusion

Many CBC models have been tested on MH and SU in Africa and should be critically appraised and meta-analyzed in subsequent reviews, where possible.

Promoting responsive care and early learning practices in Northern Ghana: results from a counselling intervention within nutrition and health services

OBJECTIVE

This study assesses change in caregiver practices after integrating responsive care and early learning (RCEL) in nutrition and health services and community platforms in northern Ghana.

DESIGN

We trained health facility workers and community health volunteers to deliver RCEL counselling to caregivers of children under 2 years of age through existing health facilities and community groups. We assessed changes in caregivers' RCEL practices before and after the intervention with a household questionnaire and caregiver-child observations.

SETTING

The study took place in Sagnarigu, Gushegu, Wa East and Mamprugu-Moagduri districts from April 2022 to March 2023. Study sites included seventy-nine child welfare clinics (CWC) at Ghana Health Service facilities and eighty village savings and loan association (VSLA) groups.

PARTICIPANTS

We enrolled 211 adult caregivers in the study sites who had children 0-23 months at baseline and were enrolled in a CWC or a VSLA.

RESULTS

We observed improvements in RCEL and infant and young child feeding practices, opportunities for early learning (e.g. access to books and playthings) in the home environment and reductions in parental stress.

CONCLUSIONS

This study demonstrates the effectiveness of integrating RCEL content into existing nutrition and health services. The findings can be used to develop, enhance and advocate for policies integrating RCEL into existing services and platforms in Ghana. Future research may explore the relationship between positive changes in caregiver behaviour and improvements in child development outcomes as well as strategies for enhancing paternal engagement in care practices, improving child supervision and ensuring an enabling environment.

Predictors, moderators and mediators of psychological therapies for perinatal depression in low- and middle-income countries: a systematic review

Psychological interventions have demonstrated effectiveness in treating perinatal depression (PND), but understanding for whom, how and under what conditions they improve symptoms in low- and middle-income countries (LMICs) is largely unknown. This review aims to synthesise current knowledge about predictors, moderators and mediators of psychological therapies to treat PND in LMICs. Five databases were searched for studies quantitatively examining the effects of at least one mediator, moderator or predictor of therapies for PND in LMICs. The review sampled seven publications evaluating findings from randomised trials conducted in Asia and sub-Saharan Africa. The small number of included studies limited generalisability of findings. Analyses of trials with acceptable quality suggest that patient activation in Pakistan and social support in both India and Pakistan may mediate psychotherapy effectiveness, higher baseline depression severity may moderate treatment response in South Africa, and shorter depression duration at baseline may moderate intervention response in India. This review highlights current gaps in evidence quality and the need for future trials exploring PND psychotherapy effectiveness in LMICs to follow reporting guidelines to facilitate appropriate predictor, moderator and mediator analyses.

A cluster randomised controlled trial of an early childhood parenting programme delivered through early childhood education centres in rural Zimbabwe

BACKGROUND

Early childhood is a critical period for child development. Effective approaches to support families in low-resource settings in the use of responsive and stimulating parenting are needed.

AIM

The aim of this study was to examine the effects of the Reach Up early childhood parenting programme on children's development, parenting attitudes and practices, when delivered through early childhood development (ECD) centres in Zimbabwe.

METHODS

A cluster randomised controlled trial was conducted in Sanyati, a rural district in Zimbabwe. Twenty-four of 51 available centres were randomised to intervention (n = 12) or control (n = 12) groups. Sixteen mothers with a child aged 12-30 months were recruited from each centre's catchment area (n = 189 intervention; n = 193 control). The intervention comprised two home visits per month delivered by centre teaching assistants over a period of 27 months. Primary outcomes were child Developmental Quotient (DQ), Language, Eye and Hand coordination, Performance and Practical Reasoning subscale scores assessed at follow-up. Secondary outcomes were mothers' attitudes about child development, parenting practices and maternal depressive symptoms all measured at baseline and follow-up. Intention to treat analyses was conducted using mixed-effects regression models with the standard error adjusted for cluster and inverse proportionality weights to adjust for attrition. Significance was set at P < 0.05.

RESULTS

A total of 285 (74.6%) of 382 children enrolled were tested, with 97 children lost to follow-up. The intervention improved the children's DQ by 3.55 points (95% CI 0.82 to 6.28), Eye and Hand by 3.58 (95% CI 0.59 to 6.56) and Practical Reasoning by 4.19 (95% CI 0.96 to 7.42). No significant improvements to Performance or Language scores, parenting attitudes, parenting practices and depressive symptoms were identified.

CONCLUSIONS

A home visiting intervention delivered by ECD teaching assistants promoted children's development. This suggests that outreach from preschools may be an effective platform for delivery of parenting interventions.

Family responsive care mediating the home visiting effects on left-behind children's early development in rural China

BACKGROUND

The early development of left-behind children requires great concern and improvement. Yet, current interventions for left-behind children are mainly focussed on children older than 3. This study aims to assess the effectiveness of a home visiting programme on family responsive care and early development of rural left-behind children and examine whether family responsive care mediates the effects of intervention on child development.

METHODS

A quasi-experimental study design was utilized in this study. A stratified clustered sampling was employed to choose villages in programme towns into intervention group. A control village was matched with every intervention village. All of the left-behind children and their caregivers meeting the inclusion criteria in the chosen villages were enrolled in the survey. The outcomes included child development, caregiver's early stimulation, parent-child communication, and learning materials. Baseline assessments were conducted in 2018, and endline assessments were conducted in 2020.

RESULTS

In the endline survey, we enrolled 608 children with 258 in the intervention group and 350 in the control group. Left-behind children in the intervention group were less likely to have development delay compared with the control group (odds ratio [OR] = 0.59, 95% confidence interval [CI]: 0.36, 0.96). Migrant parents of children in the intervention group showed higher proportion of expressing emotional support to their children when communicating (OR = 1.69, 95% CI: 1.05, 2.72). Children who received home visits more than once per 2 months had lower level of suspected development delay than children in the control group (OR = 0.34, 95% CI: 0.18, 0.68). Caregiver's early stimulation and migrant parents' emotional support to left-behind children mediated the intervention dose and left-behind children's development.

CONCLUSION

Caregiver's early stimulation mediates the intervention and child's development. The findings suggest a promising future for scaling similar early childhood development interventions for left-behind children in rural settings.

The deinstitutionalization of children and adolescents in El Salvador's child protection system

BACKGROUND

In 2010, El Salvador introduced legislation aimed at reforming the country's Child Protective System (CPS), with a focus on promoting deinstitutionalization.

OBJECTIVE

The study aim was to explore the impact of deinstitutionalization on the Salvadoran CPS.

PARTICIPANTS AND SETTING

The study was conducted in El Salvador, granting authors unique access to key informants with extensive experience in the country's CPS. Unlike the United States, which is divided into states, El Salvador is divided into departments, and CPS providers were recruited from all 14 departments. Focus groups were facilitated in the East, West, and Central zones to ensure representation from all regions.

METHODS

Qualitative semi-structured interviews (n = 26) were conducted in June/July of 2019, which were then followed by focus groups (n = 4) in August 2019. The analysis of the data employed a combination of deductive and inductive thematic coding methods.

RESULTS

CPS providers offered valuable insights, categorized into five main themes: (1) Strengths of El Salvador's CPS, (2) Deinstitutionalization policy encompassing socioenvironmental contextual factors, (3) Challenges in the deinstitutionalization process, including insufficient follow-up on deinstitutionalized children, (4) Recommendations from participants, highlighting the importance of enhancing stakeholder coordination/collaboration, and (5) The necessity for a paradigm shift, emphasizing the need to redefine the social contract on protecting children from child maltreatment.

CONCLUSIONS

The Salvadoran CPS requires substantial systemic changes. Encouragingly, key informants have demonstrated a commitment to reform not only the deinstitutionalization process but also the broader CPS system in El Salvador including case management and quality of care in institutional settings.

Comparing the effectiveness of mother-focused interventions to that of mother-child focused interventions in improving maternal postpartum depression outcomes: A systematic review

BACKGROUND

Most empirically researched interventions for postpartum depression (PPD) tend to target mothers' depression alone. Harmful effects of PPD on physical and mental health of both mother and child has led researchers to investigate the impact of interventions on PPD and child outcomes together. So far, the evidence is limited regarding how these interventions compare with those focusing only on mothers' depression. This review compares the effectiveness of PPD-improving interventions focusing only on mothers with those focusing on mother and child together.

METHODS

Nine electronic databases were searched. Thirty-seven studies evaluating mother-focused (n = 30) and mother-child focused interventions (n = 7) were included. Under each category, three theoretical approaches-psychological, psychosocial and mixed-were compared using standardized qualitative procedures. The review's primary outcome was maternal PPD.

RESULTS

A higher proportion of mother-focussed interventions [20/30 (66.7%)] brought significant reduction in PPD outcomes as compared to a lower proportion of mother-child focused interventions [4/7 (57.14%)]. Mother-focused mixed approaches [3/3 (100%)] performed better in improving PPD than psychological [16/24 (67%)] or psychosocial approaches [1/3 (33.3%)] alone. Amongst mother-child focused interventions, psychosocial approaches performed well with two-thirds demonstrating positive effects on PPD.

CONCLUSION

The evidence strongly favors mother-focused interventions for improving PPD with mixed interventions being more effective. Psychosocial approaches performed better with PPD once child-related elements were added, and also seemed best for child outcomes. Psychological approaches were most practiced and effective for PPD, irrespective of the intervention's focus. Further trials are needed to unpack intervention components that improve PPD and increase uptake, especially in lower-and middle-income countries.

Effectiveness of a government-led, multiarm intervention on early childhood development and caregiver mental health: a study protocol for a factorial cluster-randomised trial in rural China

INTRODUCTION

The high incidences of both the developmental delay among young children and the mental health problems of their caregivers are major threats to public health in low-income and middle-income countries. Parental training interventions during early childhood have been shown to benefit early development, yet evidence on strategies to promote caregiver mental health remains limited. In addition, evidence on the optimal design of scalable interventions that integrate early child development and maternal mental health components is scarce.

METHODS AND ANALYSIS

We design a single-blind, factorial, cluster-randomised controlled, superiority trial that will be delivered and supervised by local agents of the All China Women's Federation (ACWF), the nationwide, government-sponsored social protection organisation that aims to safeguard the rights and interests of women and children. We randomise 125 villages in rural China into four arms: (1) a parenting stimulation arm; (2) a caregiver mental health arm; (3) a combined parenting stimulation and caregiver mental health arm and (4) a pure control arm. Caregivers and their children (aged 6-24 months at the time of baseline data collection) are selected and invited to participate in the 12-month-long study. The parenting stimulation intervention consists of weekly, one-on-one training sessions that follow a loose adaptation of the Reach Up and Learn curriculum. The caregiver mental health intervention is comprised of fortnightly group activities based on an adaptation of the Thinking Healthy curriculum from the WHO. Primary outcomes include measures of child development and caregiver mental health. Secondary outcomes include a comprehensive set of physical, psychological and behavioural outcomes. This protocol describes the design and evaluation plan for this programme.

ETHICS AND DISSEMINATION

This study received approval from the Institutional Review Board of Stanford University (IRB Protocol #63680) and the Institutional Review Board of the Southwestern University of Finance and Economics in Chengdu, Sichuan, China. Informed oral consent will be obtained from all caregivers for their own and their child's participation in the study. The full protocol will be publicly available in an open-access format. The study findings will be published in economics, medical and public health journals, as well as Chinese or English policy briefs.

TRIAL REGISTRATION NUMBER

AEA RCT Registry (AEARCTR-0010078) and ISRCTN registry (ISRCTN84864201).

Navigating relationship dynamics, pregnancy and fatherhood in the Bukhali trial: a qualitative study with men in Soweto, South Africa

BACKGROUND

South Africa has a complex range of historical, social, political, and economic factors that have shaped fatherhood. In the context of the Bukhali randomised controlled trial with young women in Soweto, South Africa, a qualitative study was conducted with the male partners of young women who had become pregnant during the trial. This exploratory study aimed to explore individual perceptions around relationship dynamics, their partner's pregnancy, and fatherhood of partners of young women in Soweto, South Africa.

METHODS

Individual, in-depth interviews were conducted with male partners (fathers, n = 19, 25-46 years old) of Bukhali participants. A thematic approach was taken to the descriptive and exploratory process of analysis, and three final themes and subthemes were identified: (1) relationship dynamics (nature of relationship, relationship challenges); (2) pregnancy (feelings about the pregnancy, effect of the pregnancy on their relationship, providing support during pregnancy; and 3) fatherhood (view of fatherhood, roles of fathers, influences on views and motivation, challenges of fatherhood).

RESULTS

While most male participants were in a committed ("serious") relationship with their female partner, less than half of them were cohabiting. Most reported that their partner's pregnancy was not planned, and shared mixed feelings about the pregnancy (e.g., happy, excited, shocked, nervous), although their views about fatherhood were overwhelmingly positive. Many were concerned about how they would economically provide for their child and partner, particularly those who were unemployed. Participants identified both general and specific ways in which they provided support for their partner, e.g., being present, co-attending antenatal check-ups, providing material resources. For many, the most challenging aspect of fatherhood was having to provide financially. They seemed to understand the level of responsibility expected of them as a father, and that their involvement and presence related to love for and connection with their child. Participants' responses indicated that there were some changes in the norms around fatherhood, suggesting that there is a possibility for a shift in the fatherhood narrative in their context.

CONCLUSIONS

These findings suggest that the complex array of factors influencing fatherhood in South Africa continue to play out in this generation, although promising changes are evident.

Associations Between Social Support and Symptoms of Antenatal Depression with Infant Growth and Development Among Mothers Living with HIV in Tanzania

Children born to mothers living with HIV may experience greater risk of poor growth and development outcomes than their HIV-unexposed peers. Few studies have examined the relationship between maternal depression and social support with infant growth and development in the context of HIV. We conducted a prospective cohort study of 2,298 pregnant women living with HIV in Dar es Salaam, Tanzania, assessing antenatal depression (Hopkins Symptoms Checklist-25) and social support (Duke-UNC Functional Social Support Questionnaire) at 12-27 weeks of gestation. At one-year age, infant anthropometry and caregiver-reported infant development were assessed. Generalized estimating equations were used to assess mean differences (MD) and relative risks (RR) for growth and developmental outcomes. Symptoms consistent with maternal antenatal depression had 67% prevalence and were associated with infant wasting (RR 2.61; 95% confidence interval (CI) 1.03-6.65; z = 2.02; p = 0.04), but no other growth or developmental outcomes. Greater maternal social support was not associated with infant growth outcomes. Greater affective support was associated with better cognitive (MD 0.18; CI 0.01-0.35; z = 2.14; p = 0.03) and motor (MD 0.16; CI 0.01-0.31; z = 2.04; p = 0.04) development scores. Greater instrumental support was associated with better cognitive (MD 0.26; CI 0.10-0.42; z = 3.15; p < 0.01), motor (MD 0.17; CI 0.02-0.33; z = 2.22; p = 0.03), and overall (MD 0.19; CI 0.03-0.35; z = 2.35; p = 0.02) development scores. Depressive symptoms were associated with greater risk of wasting, while social support was associated with better infant development scores. Strategies to improve mental health and social support for mothers living with HIV during the antenatal period may benefit infant growth and development.

Is Early Childhood Development Care at Public Health Facilities in Pakistan Effective? A Cluster Randomized Controlled Trial

BACKGROUND

Significant brain development in children occurs from birth to 2 years, with environment playing an important role. Stimulation interventions are widely known to be effective in enhancing early childhood development (ECD). This study aims to assess the feasibility and effectiveness of integrating ECD care delivered by lady health visitors (LHVs) at public health facilities in rural Pakistan.

METHOD

A cluster randomized controlled trial was conducted through public health facilities in 2 districts of Punjab, Pakistan. A total of 22 clusters (rural health centers and subdistrict hospitals) were randomly allocated to receive routine care (control: n=11 clusters, 406 mother-child pairs) or counseling (intervention: n=11 clusters, 398 mother-child pairs). All children aged 11-12 months without any congenital abnormality were eligible for enrollment. The intervention was delivered by the LHVs to mothers with children aged 12-24 months in 3 quarterly sessions.

RESULTS

The primary outcome was the prevention of ECD delays in children aged 24 months (assessed with the Ages and Stages Questionnaire-3). Analysis was done on an intention-to-treat basis. A total of 804 mother-child pairs were registered in the study, of which 26 (3.3%) pairs were lost to follow-up at the endpoint. The proportion of children with 2 or more developmental delays was significantly less in the intervention arm (13%) as compared to the control arm (41%) at an endpoint (odds ratio=0.21; 95% confidence interval=0.11, 0.42). Children in the intervention arm also had significantly better anthropometric measurements when aged 24 months than the children in the control arm.

CONCLUSION

The integrated ECD care intervention for children aged 12-24 months at public health facilities was found to be effective in enhancing ECD and reducing the proportion of children with global development delays.

'Children awaken by playing': a qualitative exploration of caregivers' norms, beliefs and practices related to young children's learning and early childhood development in rural Burkina Faso

INTRODUCTION

Evidence suggests that responsive caregiving and early learning activities positively impact developmental outcomes, with positive effects throughout the life course. Early childhood development interventions should align with local values, beliefs and resources but there has been little research of caregiver beliefs and perspectives on development and learning, especially in sub-Saharan Africa. This qualitative study explored norms, beliefs, practices and aspirations around child development of caregivers of young children in rural Burkina Faso.

METHODS

We conducted 32 in-depth interviews with mothers and fathers of young children and 24 focus group discussions with mothers, fathers and grandmothers, which included trying behaviours and reporting on experiences. The research informed the development of Scaling Up Nurturing Care, a Radio Intervention to Stimulate Early Childhood Development (SUNRISE), an early child development radio intervention.

RESULTS

Caregivers described a process of 'awakening', through which children become aware of themselves and the world around them.Perceptions of the timing of awakening varied, but the ability to learn was thought to increase as children became older and more awake. Consequently, talking and playing with babies and younger children were perceived to have little developmental impact. Caregivers said children's interactions with them, alongside God-given intelligence, was believed to impact later behaviour and development. Caregivers felt their role in helping their children achieve later in life was to pay for education, save money, provide advice and be good role models. Interaction and learning activities were not specifically mentioned. Caregivers who trialled interaction and learning activities reported positive experiences for themselves and their child, but interactions were often caregiver led and directive and play was often physical. Key barriers to carrying out the behaviours were poverty and a lack of time.

CONCLUSIONS

Exploring early childhood beliefs and practices can reveal important sociocultural beliefs which, if incorporated into programme planning and implementation, could help achieve more impactful, acceptable and equitable programmes.

TRIAL REGISTRATION NUMBER

NCT05335395.

Primary-level and community worker interventions for the prevention of mental disorders and the promotion of well-being in low- and middle-income countries

BACKGROUND

There is a significant research gap in the field of universal, selective, and indicated prevention interventions for mental health promotion and the prevention of mental disorders. Barriers to closing the research gap include scarcity of skilled human resources, large inequities in resource distribution and utilization, and stigma.

OBJECTIVES

To assess the effectiveness of delivery by primary workers of interventions for the promotion of mental health and universal prevention, and for the selective and indicated prevention of mental disorders or symptoms of mental illness in low- and middle-income countries (LMICs). To examine the impact of intervention delivery by primary workers on resource use and costs.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Global Index Medicus, PsycInfo, WHO ICTRP, and ClinicalTrials.gov from inception to 29 November 2021.

SELECTION CRITERIA

Randomized controlled trials (RCTs) of primary-level and/or community health worker interventions for promoting mental health and/or preventing mental disorders versus any control conditions in adults and children in LMICs.

DATA COLLECTION AND ANALYSIS

Standardized mean differences (SMD) or mean differences (MD) were used for continuous outcomes, and risk ratios (RR) for dichotomous data, using a random-effects model. We analyzed data at 0 to 1, 1 to 6, and 7 to 24 months post-intervention. For SMDs, 0.20 to 0.49 represented small, 0.50 to 0.79 moderate, and ≥ 0.80 large clinical effects. We evaluated the risk of bias (RoB) using Cochrane RoB2.

MAIN RESULTS

Description of studies We identified 113 studies with 32,992 participants (97 RCTs, 19,570 participants in meta-analyses) for inclusion. Nineteen RCTs were conducted in low-income countries, 27 in low-middle-income countries, 2 in middle-income countries, 58 in upper-middle-income countries and 7 in mixed settings. Eighty-three RCTs included adults and 30 RCTs included children. Cadres of primary-level workers employed primary care health workers (38 studies), community workers (71 studies), both (2 studies), and not reported (2 studies). Interventions were universal prevention/promotion in 22 studies, selective in 36, and indicated prevention in 55 RCTs. Risk of bias The most common concerns over risk of bias were performance bias, attrition bias, and reporting bias. Intervention effects 'Probably', 'may', or 'uncertain' indicates 'moderate-', 'low-', or 'very low-'certainty evidence. *Certainty of the evidence (using GRADE) was assessed at 0 to 1 month post-intervention as specified in the review protocol. In the abstract, we did not report results for outcomes for which evidence was missing or very uncertain. Adults Promotion/universal prevention, compared to usual care: - probably slightly reduced anxiety symptoms (MD -0.14, 95% confidence interval (CI) -0.27 to -0.01; 1 trial, 158 participants) - may slightly reduce distress/PTSD symptoms (SMD -0.24, 95% CI -0.41 to -0.08; 4 trials, 722 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD -0.69, 95% CI -1.08 to -0.30; 4 trials, 223 participants) Indicated prevention, compared to usual care: - may reduce adverse events (1 trial, 547 participants) - probably slightly reduced functional impairment (SMD -0.12, 95% CI -0.39 to -0.15; 4 trials, 663 participants) Children Promotion/universal prevention, compared to usual care: - may improve the quality of life (SMD -0.25, 95% CI -0.39 to -0.11; 2 trials, 803 participants) - may reduce adverse events (1 trial, 694 participants) - may slightly reduce depressive symptoms (MD -3.04, 95% CI -6 to -0.08; 1 trial, 160 participants) - may slightly reduce anxiety symptoms (MD -2.27, 95% CI -3.13 to -1.41; 1 trial, 183 participants) Selective prevention, compared to usual care: - probably slightly reduced depressive symptoms (SMD 0, 95% CI -0.16 to -0.15; 2 trials, 638 participants) - may slightly reduce anxiety symptoms (MD 4.50, 95% CI -12.05 to 21.05; 1 trial, 28 participants) - probably slightly reduced distress/PTSD symptoms (MD -2.14, 95% CI -3.77 to -0.51; 1 trial, 159 participants) Indicated prevention, compared to usual care: - decreased slightly functional impairment (SMD -0.29, 95% CI -0.47 to -0.10; 2 trials, 448 participants) - decreased slightly depressive symptoms (SMD -0.18, 95% CI -0.32 to -0.04; 4 trials, 771 participants) - may slightly reduce distress/PTSD symptoms (SMD 0.24, 95% CI -1.28 to 1.76; 2 trials, 448 participants).

AUTHORS' CONCLUSIONS

The evidence indicated that prevention interventions delivered through primary workers - a form of task-shifting - may improve mental health outcomes. Certainty in the evidence was influenced by the risk of bias and by substantial levels of heterogeneity. A supportive network of infrastructure and research would enhance and reinforce this delivery modality across LMICs.

Neurodevelopment among children exposed to HIV and uninfected in sub-Saharan Africa

INTRODUCTION

The population of 16 million children exposed to HIV and uninfected (CHEU) under 15 years of age continues to expand rapidly, and the estimated prevalence of CHEU exceeds 20% in several countries in sub-Saharan Africa with high HIV prevalence. Some evidence suggests that CHEU experience suboptimal neurodevelopmental outcomes compared to children born to women without HIV. In this commentary, we discuss the latest research on biologic and socio-behavioural factors associated with neurodevelopmental outcomes among CHEU.

DISCUSSION

Some but not all studies have noted that CHEU are at risk of poorer neurodevelopment across multiple cognitive domains, most notably in language and motor skills, in diverse settings, ages and using varied assessment tools. Foetal HIV exposure can adversely influence infant immune function, structural brain integrity and growth trajectories. Foetal exposure to antiretrovirals may also influence outcomes. Moreover, general, non-CHEU-specific risk factors for poor neurodevelopment, such as preterm birth, food insecurity, growth faltering and household violence, are amplified among CHEU; addressing these factors will require multi-factorial solutions. There is a need for rigorous harmonised approaches to identify children at the highest risk of delay. In high-burden HIV settings, existing maternal child health programmes serving the general population could adopt structured early child development programmes that educate healthcare workers on CHEU-specific risk factors and train them to conduct rapid neurodevelopmental screening tests. Community-based interventions targeting parent knowledge of optimal caregiving practices have shown to be successful in improving neurodevelopmental outcomes in children and should be adapted for CHEU.

CONCLUSIONS

CHEU in sub-Saharan Africa have biologic and socio-behavioural factors that may influence their neurodevelopment, brain maturation, immune system and overall health and wellbeing. Multidisciplinary research is needed to disentangle complex interactions between contributing factors. Common environmental and social risk factors for suboptimal neurodevelopment in the general population are disproportionately magnified within the CHEU population, and it is, therefore, important to draw on existing knowledge when considering the socio-behavioural pathways through which HIV exposure could impact CHEU neurodevelopment. Approaches to identify children at greatest risk for poor outcomes and multisectoral interventions are needed to ensure optimal outcomes for CHEU in sub-Saharan Africa.

Maternal adverse childhood experiences, child mental health, and the mediating effect of maternal depression: A cross-sectional, population-based study in rural, southwestern Uganda

OBJECTIVES

This study aimed to examine the intergenerational effects of maternal adverse childhood experiences (ACEs) and child mental health outcomes in rural Uganda, as well as the potentially mediating role of maternal depression in this pathway. Additionally, we sought to test the extent to which maternal social group membership attenuated the mediating effect of maternal depression on child mental health.

METHODS

Data come from a population-based cohort of families living in the Nyakabare Parish, a rural district in southwestern Uganda. Between 2016 and 2018, mothers completed surveys about childhood adversity, depressive symptoms, social group membership, and their children's mental health. Survey data were analyzed using causal mediation and moderated-mediation analysis.

RESULTS

Among 218 mother-child pairs, 61 mothers (28%) and 47 children (22%) showed symptoms meeting cutoffs for clinically significant psychological distress. In multivariable linear regression models, maternal ACEs had a statistically significant association with severity of child conduct problems, peer problems, and total child difficulty scores. Maternal depression mediated the relationship between maternal ACEs and conduct problems, peer problems, and total difficulty, but this mediating effect was not moderated by maternal group membership.

CONCLUSIONS

Maternal depression may act as a potential mechanism linking maternal childhood adversity with poor child mental health in the next generation. Within a context of elevated rates of psychiatric morbidity, high prevalence of childhood adversity, and limited healthcare and economic infrastructures across Uganda, these results emphasize the prioritization of social services and mental health resources for rural Ugandan families.

Cognitive development among children in a low-income setting: Cost-effectiveness analysis of a maternal nutrition education intervention in rural Uganda

Inadequate nutrition and insufficient stimulation in early childhood can lead to long-term deficits in cognitive and social development. Evidence for policy and decision-making regarding the cost of delivering nutrition education is lacking in low and middle-income countries (LMIC). In rural Uganda, we conducted a cluster-randomized controlled trial (RCT) examining the effect of a maternal nutrition education intervention on developmental outcomes among children aged 6-8 months. This intervention led to significantly improved cognitive scores when the children reached the age of 20-24 months. When considering the potential for this intervention's future implementation, the desired effects should be weighed against the increased costs. This study therefore aimed to assess the cost-effectiveness of this education intervention compared with current practice. Health outcome data were based on the RCT. Cost data were initially identified by reviewing publications from the RCT, while more detailed information was obtained by interviewing researchers involved in processing the intervention. This study considered a healthcare provider perspective for an 18-months' time horizon. The control group was considered as the current practice for the future large-scale implementation of this intervention. A cost-effectiveness analysis was performed, including calculations of incremental cost-effectiveness ratios (ICERs). In addition, uncertainty in the results was characterized using one-way and probabilistic sensitivity analyses. The ICER for the education intervention compared with current practice was USD ($) 16.50 per cognitive composite score gained, with an incremental cost of $265.79 and an incremental cognitive composite score of 16.11. The sensitivity analyses indicated the robustness of these results. The ICER was sensitive to changes in cognitive composite score and the cost of personnel. The education intervention can be considered cost-effective compared with the current practice. The outcome of this study, including the cost analysis, health outcome, cost-effectiveness, and sensitivity analysis, can be useful to inform policymakers and stakeholders about effective resource allocation processes in Uganda and possibly other LMIC.

Effectiveness of father-inclusive interventions on maternal, paternal, couples, and early child outcomes in low- and middle-income countries: A systematic review

Most caregiving interventions for young children are directed to female caregivers. Relatively few have included male caregivers as program participants especially in low- and middle-income countries (LMICs). The range of potential benefits that can be achieved through the engagement of fathers and male caregivers has not been adequately explored from a family systems perspective. We reviewed interventions that engaged male caregivers to support young children in LMICs and summarized impacts on maternal, paternal, couples, and child outcomes. We searched MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and Global Health Library for quantitative evaluation studies of social and behavioral interventions that included fathers or other male caregivers to improve nurturing care for young children under 5 years of age in LMICs. Three authors independently extracted data using a structured form. Forty-four articles, representing 33 intervention evaluations, were included. The most common type of intervention targeted fathers along with their female partners and primarily to address child nutrition and health. Across interventions, maternal outcomes were the most evaluated outcomes (82%), followed by paternal (58%), couple's relationship (48%) and child-level outcomes (45%). Overall, father-inclusive interventions had positive impacts on maternal, paternal and couples' relationship outcomes. Although there was greater variation in the degree of supportive evidence for child outcomes compared to maternal, paternal, and couples outcomes, findings suggested mostly positive effects across all outcomes. Limitations included relatively weak study designs and heterogeneity across interventions, outcome types, and measurement tools. Interventions that include fathers and other male caregivers have potential to improve maternal and paternal caregiving, couple's relationships dynamics, and early child outcomes in LMICs. More evaluation studies, using rigorous methods and robust measurement frameworks, is needed to bolster this evidence-base about the effect of fathers' engagement for young children, caregivers, and families in LMICs.

Home stimulation, development, and nutritional status of children under 2 years of age in the highlands of Madagascar

BACKGROUND

The Vakinankaratra region of Madagascar has a high burden of child undernutrition which, in addition to poor psychosocial stimulation, is a strong risk factor of poor child development. However, there are limited studies evaluating the relations between developmental deficits, child nutrition outcomes, and home stimulation in the region. The purpose of this study was to assess the development of children aged 11-13 months in relation to their nutritional status and to examine parental home stimulation attitudes and practices in the Vakinankaratra region.

METHODS

Cognitive (n = 36), language (n = 36), motor (n = 36), and socioemotional (n = 76) development were assessed using the Bayley Scales of Infant and Toddler Development III. Household stimulation environment was evaluated using the family care indicators survey. Stunting (length-for-age z-score < - 2) and underweight (weight-for-age z-score < - 2) were determined using the 2006 WHO growth standards. Perceptions of and barriers to greater home stimulation for children were collected using focus group discussions among parents and in-depth interviews with community nutrition agents.

RESULTS

Almost all mothers reported that parent-child interaction with talk and play was very important. Alarmingly high stunting rates (> 69%) were observed in this subsample. Limited time and tiredness were the major barriers to home stimulation mentioned by parents and confirmed by key informants. Children had a very limited variety of play materials, and most of the mothers used household objects (75%) and materials from outside the house (71%) as children's toys. Composite cognitive [mean (SD): 60 (10.3)], motor [61.9 (13.4)], language [62 (13.2)], and socioemotional [85.1 (17.9]) scores were low. Fine motor, cognitive, and receptive and expressive language scores were correlated [0.4 < r < 0.7, p < 0.05].

CONCLUSIONS

The very high stunting rates and very low performance on cognitive, motor, language, and socioemotional development assessments of children in the Vakinankaratra region require urgent attention.

The Reach Up Parenting Program, Child Development, and Maternal Depression: A Meta-analysis

BACKGROUND AND OBJECTIVES

Evidence is needed on effective approaches to build parents' ability to promote child development feasible in low- and middle-income countries. Our objective was to synthesize impact of the Reach Up early childhood parenting program in several low- and middle-income countries and examine moderation by family and implementation characteristics.

METHODS

Systematic search using PubMed and Academic Search Elite/EBSCO Host. Randomized controlled trials of the Reach Up program from 1985 to February 2022 were selected. Data were extracted by 2 independent researchers. Primary outcomes were child cognitive, language, and motor development. Secondary outcomes were home stimulation and maternal depressive symptoms. We synthesized pooled effect sizes using random effect inverse-variance weighting and effect modification by testing pooled subgroup effect estimates using the χ2 test for heterogeneity.

RESULTS

Average effect size across 18 studies ranged from 0.49 (95% confidence interval [CI] 0.32 to 0.66) for cognition, 0.38 (CI 0.24 to 0.51) for language, 0.27 (CI 0.13 to 0.40) for motor development, 0.37 (CI 0.21 to 0.54) for home stimulation, and -0.09 (CI -0.19 to 0.01) for maternal depressive symptoms. Impacts were larger in studies targeted to undernourished children, with mean enrollment older than age 12 months and intervention duration 6 to 12 months. Quality of evidence assessed with the Cochrane Assessment of Risk of Bias and GRADE system was moderate. Instruments used to assess child development varied. In moderator analyses, some subgroups included few studies.

CONCLUSIONS

Reach Up benefits child development and home stimulation and is adaptable across cultures and delivery methods. Child and implementation characteristics modified the effects, with implications for scaling.

Structured, multicomponent, community-based programme for women's health and infant health and development in rural Vietnam: a parallel-group cluster randomised controlled trial

BACKGROUND

Interventions to improve early childhood development have previously addressed only one or a few risk factors. Learning Clubs is a structured, facilitated, multicomponent programme designed to address eight potentially modifiable risk factors, and offered from mid-pregnancy to 12 months post partum; we aimed to establish whether this programme could improve the cognitive development of children at 2 years of age.

METHODS

For this parallel-group cluster-randomised controlled trial, 84 of 116 communes (the clustering unit) in HaNam Province in rural Vietnam were randomly selected and randomly assigned to receive the Learning Clubs intervention (n=42) or usual care (n=42). Women aged at least 18 years who were pregnant (gestational age <20 weeks) were eligible for inclusion. Data sources were standardised, and study-specific questionnaires assessing risks and outcomes were completed in interviews in mid-pregnancy (baseline), late pregnancy (after 32 weeks of gestation), at 6-12 months post partum, and at the end of the study period when children were 2 years of age. Mixed-effects models were used to estimate trial effects, adjusting for clustering. The primary outcome was the cognitive development of children at 2 years of age, assessed by the Bayley Scales of Infant and Toddler Development Third Edition (Bayley-III) cognitive score. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12617000442303).

FINDINGS

Between April 28, 2018, and May 30, 2018, 1380 women were screened and 1245 were randomly assigned (669 to the intervention group and 576 to the control group). Data collection was completed on Jan 17, 2021. Data at the end of the study period were contributed by 616 (92%) of 669 women and their children in the intervention group, and by 544 (94%) of 576 women and their children in the control group. Children aged 2 years in the intervention group had significantly higher mean Bayley-III cognitive scores than those in the control group (99·6 [SD 9·7] vs 95·6 [9·4]; mean difference 4·00 [95% CI 2·56-5·43]; p<0·0001). At 2 years of age, 19 (3%) children in the intervention group had Bayley-III scores less than 1 SD, compared with 32 (6%) children in the control group, but this difference was not significant (odds ratio 0·55 [95% CI 0·26-1·17]; p=0·12). There were no significant differences between groups in maternal, fetal, newborn, or child deaths.

INTERPRETATION

A facilitated, structured, community-based, multicomponent group programme improved early childhood development to the standardised mean in rural Vietnam and could be implemented in other similarly resource-constrained settings.

FUNDING

Australian National Health and Medical Research Council and Grand Challenges Canada Saving Brains Initiative.

TRANSLATION

For the Vietnamese translation of the abstract see Supplementary Materials section.

An Integrated Mother-Child Intervention on Child Development and Maternal Mental Health

OBJECTIVES

To evaluate an integrated, low-cost, facility-based group intervention designed to promote child care, boost maternal mental-wellbeing, reduce harsh discipline, and improve children's health, nutrition, and early development.

METHODS

In Dhaka, 30 neighborhood clusters of a low-income urban community were randomized to intervention or control groups. Mothers with children between 6 and 24 months (n = 300) who self-reported negative discipline were identified and enrolled. A 1-year group intervention included integration of responsive caregiving, nutritional supplementation, caregivers' mental health, child protection, and health advice. Child outcomes were cognition (primary) and language, motor and behavioral development, growth, and hemoglobin and iron status (secondary). Maternal outcomes were depressive symptoms, self-esteem, negative discipline, and child care knowledge and practices.

RESULTS

Overall, 222 (74%) mother-child dyads participated in the 1-year follow-up. Intervention and control groups differed on wealth, with no other significant differences. The intervention resulted in a 0.75 SD effect on cognition, 0.77 SD on language, 0.41 SD on motor, and 0.43 to 0.66 SDs on behavior during testing (emotion, cooperation, and vocalization) in the intervention arm. Mothers in the intervention group had fewer depressive symptoms (effect size: -0.72 SD), higher self-esteem (0.62 SD), better child care knowledge (2.02 SD), fewer harsh discipline practices (0.25 SD), and better home stimulation (0.73 SD). The intervention showed no effect on child growth or hemoglobin, but significantly improved serum iron status (-0.36 SD).

CONCLUSIONS

A comprehensive intervention, delivered through group sessions in health facilities, was effective in promoting child development and reducing maternal depressive symptoms among mothers who reported using negative or harsh discipline.

Effect of early childhood development interventions delivered by healthcare providers to improve cognitive outcomes in children at 0-36 months: a systematic review and meta-analysis

OBJECTIVE

To determine the effect of early childhood development interventions delivered by healthcare providers (HCP-ECD) on child cognition and maternal mental health.

DESIGN

Systematic review, meta-analysis.

SETTING

Healthcare setting or home.

PARTICIPANTS

Infants under 1 month of age.

INTERVENTIONS

HCP-ECD interventions that supported responsive caregiving, early learning and motor stimulation. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, Database of Abstracts of Reviews of Effects and Cochrane Database of Systematic Reviews were searched until 15 November 2021. Studies reporting prespecified outcomes were pooled using standard meta-analytical methods.

MAIN OUTCOME MEASURES

Cognitive development in children at 0-36 months.

RESULTS

Forty-two randomised controlled trials with 15 557 infants were included in the narrative synthesis. Twenty-seven trials were included in the meta-analyses. Pooled data from 13 trials suggest that HCP-ECD interventions may improve cognitive outcomes in children between 0 and 36 months (Bayley Scales of Infant Development version IIII (BSID-III) mean difference (MD) 2.65; 95% CI 0.61 to 4.70; 2482 participants; low certainty of evidence). Pooled data from nine trials suggest improvements in motor development (BSID-III MD 4.01; 95% CI 1.54 to 6.48; 1437 participants; low certainty of evidence). There was no evidence of improvement in maternal mental health (standardised MD -0.13; 95% CI -0.28 to 0.03; 2806 participants; 11 trials; low certainty of evidence).

CONCLUSIONS

We report promising evidence, particularly for cognitive and motor outcomes, of the effect of HCP-ECD interventions. However, effect sizes were small, and the certainty of evidence ranged from very low to moderate. Additional high-quality research is required.

PROSPERO REGISTRATION NUMBER

CRD42019122021.

Effects of engaging fathers and bundling nutrition and parenting interventions on household gender equality and women's empowerment in rural Tanzania: Results from EFFECTS, a five-arm cluster-randomized controlled trial

Advancing gender equality and women's empowerment (GE/WE) may contribute to better child nutrition and development in low-resource settings. However, few empirical studies have generated evidence on GE/WE and examined the potential of engaging men to transform gender norms and power relations in the context of nutrition and parenting programs. We tested the independent and combined effects of engaging couples and bundling nutrition and parenting interventions on GE/WE in Mara, Tanzania. EFFECTS (ClinicalTrials.gov, NCT03759821) was a cluster-randomized 2 × 2 factorial trial plus control. Eighty village clusters were randomly assigned to one of five intervention conditions: standard of care, mothers nutrition, couples nutrition, mothers bundled nutrition and parenting, or couples bundled nutrition and parenting. Between October 2018-May 2019, 960 households were enrolled with children under 18 months of age residing with their mother and father. Community health workers (CHWs) delivered a bi-weekly 24-session hybrid peer group/home visit gender-transformative behavior change program to either mothers or couples. GE/WE outcomes were analyzed as intention-to-treat and included time use, gender attitudes, social support, couples' communication frequency and quality, decision-making power, intimate partner violence (IPV), and women's dietary diversity (WDD). Data were collected from 957 to 815 mothers and 913 and 733 fathers at baseline and endline, respectively. Engaging couples compared to mothers only significantly increased paternal and maternal gender-equitable attitudes, paternal time spent on domestic chores, and maternal decision-making power. Bundling increased maternal leisure time, decreased maternal exposure to any IPV, and increased WDD over 7 days. A combination of engaging couples and bundling was most effective for paternal gender attitudes, couples communication frequency, and WDD over 24 h and 7 days. Our findings generate novel evidence that CHWs can deliver bundled nutrition and parenting interventions to couples in low-resource community settings that advance GE/WE more than nutrition interventions targeting only women.

Differentiation Governance of Rural Human Settlement Environments in China: Knowledge Mapping and Visualization

To further promote the effective governance of rural human settlements in China, it is necessary to summarize and organize the research on rural human settlements that has been undertaken in the last decade. This paper analyzes the current status of rural human settlements research from the perspectives of Chinese literature and English literature. It takes the core documents included in WOS (Web of Science) and CNKI (Chinese National Knowledge Infrastructure) as samples, and produces a visual analysis of the authors, institutions, disciplines, and research hotspots for rural human settlements research with the help of CiteSpace V and other measurement software, focus on identifying the similarities and differences between CNKI and WOS in the study of rural human settlements. The results show that the number of papers is increasing; cooperation between Chinese researchers and institutions needs to be further strengthened; the existing research has achieved interdisciplinary integration; the research hotspots are converging, but China pays more attention to the study of the hard environment, such as the macro level of rural human settlements and the natural ecological environments of residence, and lacks insight into the soft environment, such as the main body of residences, social relations, and individual needs in the urban fringe. This study is conducive to promoting the integrated development of urban and rural areas in China, promoting the revitalization and development of rural areas in China, and achieving social equity.

The relationship between home environment and early childhood development of left-behind children under 3 years in rural China

BACKGROUND

Home environment provides stimulation and learning opportunities required for children's early development. However, few studies have focused on the effects of home environment on left-behind children's development in rural China. The study aimed to investigate the relationship between home environment and early childhood development of left-behind children under 3 years old in rural China.

METHODS

Information about sociodemographic characteristics, caregivers' mental health, home environment and children's development was collected. Infant/Toddler Home Observation for Measurement of the Environment Inventory (IT-HOME) was used to assess home environment. Child's development was evaluated with the Chinese version of the Ages & Stages Questionnaire - third edition.

RESULTS

Elevated caregivers' depressive symptoms were associated with a higher risk of total suspected development delay. An increase of one score in the IT-HOME resulted in a 7% decrease in total suspected development delay. Higher scores in the dimensions of involvement and variety were associated with a lower risk of suspected development delay adjusting for covariates.

CONCLUSIONS

Our results have implications for home-based intervention aiming at promoting nurturing care as well as caregivers' mental health, which is required for early development of young left-behind children in rural areas of China.

The Effect of Parenting Peer Education Interventions for Young Mothers on the Growth and Development of Children under Five

One of the contributing factors in the growth and development of children under five is the mother's ability to provide childcare, but young mothers do not have enough parenting skills. The goal of the current study was to examine the effect of the parenting peer education (PPE) programme on young mothers' parenting self-efficacy and behaviour, and the growth and development of children under five. There were two groups, which were a control group (without intervention) and an intervention group, in which there were 15 participants in each group. Analysis covariance with the pre-test scores as covariates was used in this study. The results showed that, compared with the control group, the intervention group reported significantly better parenting self-efficacy, parenting behaviour, children's growth, and children's development, including cognitive, language, and motoric aspects. The PPE programme can exchange the young mothers' experiences on how their children grow and develop, and the mothers will also receive psychological support. In conclusion, the PPE programme affected the young mothers' parenting self-efficacy and parenting behaviour and the children's growth and development.

Implementation characteristics of father-inclusive interventions in low- and middle-income countries: A systematic review

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

Effect of the mHealth-supported Healthy Future programme delivered by community health workers on maternal and child health in rural China: study protocol for a cluster randomised controlled trial

INTRODUCTION

Millions of young rural children in China still suffer from poor health and malnutrition, partly due to a lack of knowledge about optimal perinatal and child care among rural mothers and caregivers. Meanwhile, there is an urgent need to improve maternal mental health in rural communities. Comprehensive home visiting programmes delivered by community health workers (CHWs) can bridge the caregiver knowledge gap and improve child health and maternal well-being in low-resource settings, but the effectiveness of this approach is unknown in rural China. Additionally, grandmothers play important roles in child care and family decision-making in rural China, suggesting the importance of engaging multiple caregivers in interventions. The Healthy Future programme seeks to improve child health and maternal well-being by developing a staged-based curriculum that CHWs deliver to mothers and caregivers of young children through home visits with the assistance of a tablet-based mHealth system. This protocol describes the design and evaluation plan for this programme.

METHODS AND ANALYSIS

We designed a cluster-randomised controlled trial among 119 rural townships in four nationally designated poverty counties in Southwestern China. We will compare the outcomes between three arms: one standard arm with only primary caregivers participating in the intervention, one encouragement arm engaging primary and secondary caregivers and one control arm with no intervention. Families with pregnant women or infants under 6 months of age are invited to enrol in the 12-month study. Primary outcomes include children's haemoglobin levels, exclusive breastfeeding rates and dietary diversity in complementary feeding. Secondary outcomes include a combination of health, behavioural and intermediate outcomes.

ETHICS AND DISSEMINATION

Ethical approval has been provided by Stanford University, Sichuan University and the University of Nevada, Reno. Trial findings will be disseminated through national and international peer-reviewed publications and conferences.

TRIAL REGISTRATION NUMBER

ISRCTN16800789.

Effectiveness of an integrated multilevel early child development intervention on caregiver knowledge and behavior: a quasi-experimental evaluation of the Malezi program in Tanzania

BACKGROUND

The quality of caregiving and the parent-child relationship is critical for early child development (ECD) and has been shown to be modifiable. This study evaluated an ECD project in Tanzania, assessing the effectiveness of radio messaging (RM) alone and a combined radio messaging/video job aids/ECD (RMV-ECD) intervention.

METHODS

This two-arm pre-post evaluation study enrolled a cohort of caregivers of children 0-24 months in four districts of Tabora region, following them for 9 months. ECD radio messages were broadcast on popular stations at least 10 times/day reaching all study districts. In two districts, community health workers (CHW), trained in UNICEF's Care for Child Development package, used ECD videos in home- and facility-based sessions with caregivers. We used McNemar's testing (pre-post pairs) within intervention group to describe how the intervention was associated with change in five outcomes: ECD knowledge, early stimulation, father engagement, responsive care, and environment safety. Logistic regression was used to describe the relative benefits of the combined intervention package (RMV-ECD) compared to radio messaging (RM).

RESULTS

In the RMV-ECD arm, all outcomes at endline except environment safety significantly improved after the intervention with the largest change seen in ECD knowledge (35.8% increase, p < .0001) and the smallest in father engagement (6.7%, p = .015). In the RM arm, ECD knowledge (5.7%, p = .031) and environment safety (18.1%, p = <.0001) improved. High measures of parenting stress were associated with lower likelihood of having good ECD knowledge (AOR 0.50, 95%CI: 0.35, 0.71), father engagement (AOR 0.72, 95%CI: 0.52, 0.99) and responsive care (AOR 0.31, 95%CI: 0.18, 0.54).

CONCLUSIONS

An intervention that includes mass media, educational video content and CHWs who counsel caregivers in their homes and health facilities was associated with significant improvements in ECD parenting knowledge and behaviors but a relationship with responsive care could not be established. The less costly mass media-only intervention was associated with improved parenting knowledge and household environment safety. Parenting interventions targeting young children could be improved by incorporating more messaging and caregiver coaching in managing parental stress.

TRIAL REGISTRATION

NCT05244161 (17/02/2022); retrospectively registered with the US National Institutes of Health ClinicalTrials.gov.

Exploring the feasibility of integrating health, nutrition and stimulation interventions for children under three years in Nepal's health system: A qualitative study

Community-based primary care settings are a potential entry point for delivering Early Childhood Development (ECD) interventions in Nepal. Past studies have suggested that integrating stimulation with nutrition interventions is an effective way to deliver multiple benefits for children, but there is limited knowledge of how to do this in Nepal. We conducted a qualitative study in Nepal's Dhanusha district to explore how stimulation interventions for early learning could be integrated into existing health and nutrition programmes within the public health system. Between March and April 2021, we completed semi-structured interviews with caregivers (n = 18), health service providers (n = 4), district (n = 1) and national stakeholders (n = 4), as well as policymakers (n = 3). We also carried out focus group discussions with Female Community Health Volunteers (FCHVs) (n = 2) and health facility operation and management committee members (n = 2). We analysed data using the framework method. Respondents were positive about introducing stimulation interventions into maternal and child health and nutrition services. They thought that using health system structures would help in the implementation of integrated interventions. Respondents also highlighted that local governments play a lead role in decision-making but must be supported by provincial and national governments and external agencies. Key factors impeding the integration of stimulation into national programmes included a lack of intersectoral collaboration, poor health worker competency, increased workload for FCHVs, financial constraints, a lack of prioritisation of ECD and inadequate capacity in local governments. Key barriers influencing the uptake of intervention by community members included lack of knowledge about stimulation, caregivers' limited time, lack of paternal engagement, poverty, religious or caste discrimination, and social restrictions for newlywed women and young mothers. There is an urgent need for an effective coordination mechanism between ministries and within all three tiers of government to support the integration and implementation of scalable ECD interventions in rural Nepal.

Supporting parenting among Syrian refugees in Lebanon: a randomized controlled trial of the caregiver support intervention

BACKGROUND

Parenting interventions in humanitarian settings have prioritized the acquisition of parenting knowledge and skills, while overlooking the adverse effects of stress and distress on parenting-a key mediator of refugee children's mental health. We evaluated the effectiveness of the Caregiver Support Intervention (CSI), which emphasizes caregiver wellbeing together with training in positive parenting.

METHODS

We conducted a two-arm randomized controlled trial of the CSI with Syrian refugees in Lebanon, with an intent-to-treat design, from September 2019-December 2020. A total of 480 caregivers from 240 families were randomized to the CSI or a waitlist control group (1:1). Retention from baseline to endline was 93%. Data on parenting and caregiver psychological wellbeing were collected at baseline, endline, and three-month follow-up. Prospective trial registration: ISRCTN22321773.

RESULTS

We did not find a significant change on overall parenting skills at endline (primary outcome endpoint) (d = .11, p = .126) or at follow-up (Cohen's d = .15, p = .054). We did find a significant effect on overall parenting skills among participants receiving the full intervention-the sub-sample not interrupted by (COVID-19) (d = 0.25, p < .05). The CSI showed beneficial effects in the full sample at endline and follow-up on harsh parenting (d = -.17, p < .05; d = .19, p < .05), parenting knowledge (d = .63, p < .001; d = .50, p < .001), and caregiver distress (d = -.33, p < .001; d = .23, p < .01). We found no effects on parental warmth and responsiveness, psychosocial wellbeing, stress, or stress management. Changes in caregiver wellbeing partially mediated the impact of the CSI on harsh parenting, accounting for 37% of the reduction in harsh parenting.

CONCLUSIONS

The CSI reduced harsh parenting and caregiver distress, and demonstrated the value of addressing caregiver wellbeing as a pathway to strengthening parenting in adversity. These effects were achieved despite a pandemic-related lockdown that impacted implementation, a severe economic crisis, and widespread social unrest. Replication under less extreme conditions may more accurately demonstrate the intervention's full potential.

Effect of parenting intervention through "Care for Child Development Guideline" on early child development and behaviors: a randomized controlled trial

BACKGROUND

Several studies showed that parenting intervention programs play a core component in early child development. Considering the limited healthcare resources in developing countries, group-session intervention based on care for child development (CCD) guideline might be cost-effective.

METHODS

This randomized controlled trial was conducted at an outpatient public Pediatrics clinic in Isfahan, Iran. We included 210 pregnant women aged 18-45 years in their third trimester and followed their children for 18 months. The intervention group underwent 5 educational group sessions, each lasting for almost 45 minutes. The main outcomes were the children's development and socio-emotional behavior problems based on Bayley Scales of Infant and Toddler Development-III (BSID-III) at 12 months and the Children Behavior Checklist (CBCL) at 18 months.

RESULTS

Overall, data of 181 children were included in the current study, including 80 in the intervention group and 101 controls. The adjusted median/mean differences between intervention and control groups using median/linear regression were not significant for all BSID-III domains except for median differences for cognitive score based on BSID-III (β (SE): - 4.98(2.31), p:0.032) and mean differences for anxiety/depression score based on CBCL (β (SE): - 2.54(1.27), p:0.046).

CONCLUSION

In this study, parenting interventions through CCD group sessions were significantly effective on just one subscale of children's socio-emotional behavior domains based on CBCL and one domain of children's development based on BSID-III. There might be a ceiling or floor effects for the BSID-III and CBCL assessment, respectively, leaving little room for improvement as almost all children have achieved their full developmental potential in our study.

TRIAL REGISTRATION

IRCT20190128042533N2, Date of registration: 16/01/2020, www.irct.ir.

The effect of ECD program on the caregiver's parenting knowledge, attitudes, and practices: based on a cluster-randomized controlled trial in economically vulnerable areas of China

BACKGROUND

The first three years of life are the critical and sensitive periods for the formation of individual abilities. However, existing data indicates that early childhood development (ECD) in economically vulnerable areas of China is lagging, which is closely related to the lack of parenting knowledge and poor parenting practices.

METHODS

We conducted a non-masked cluster-randomized controlled trial in a former nationally designated poverty county of China. All 6-36-month-old children and their caregivers living in 18 communities/clusters (10 towns and 8 districts of the county seat) were enrolled in a 9-month parenting training program. In the treatment-group communities, ECD centers were installed where community workers provided parenting training sessions. If caregivers were unable to visit the center, home-based parenting training was offered. No intervention was provided to the control group. Furthermore, we assigned half of the treatment group to receive monthly developmental feedback in addition to the parenting training. Based on the baseline and follow-up data, we investigated the treatment effects on parenting knowledge, attitudes, and practices through Intention-to-Treat (ITT) and Treatment-on-the-Treated (TOT) analyses.

RESULTS

We found no effects on the parenting knowledge and attitudes of the caregivers but significant effects on the parenting practices. The effects were heterogeneous among families with different characteristics. Specifically, on average, the program had the largest effect on internally oriented caregivers, mothers with higher education, and mothers who are primary caregivers. We want to emphasize that, although the ITT effect on parenting practices (the average treatment effect) were stronger for mothers with higher education, the TOT effect on parenting practices (the local average treatment effect, LATE) were stronger for mothers with less education. That is, even though on average the program helped mothers with higher education, but among complier families, the program benefited mothers with less education.

CONCLUSION

The findings indicate that, at least in the short run, the program can directly change caregivers' parenting practices without changing their knowledge and attitudes. Future studies are needed to investigate whether parenting knowledge and attitudes can change in the long run.

Effectiveness and implementation outcomes for peer-delivered mental health interventions in low- and middle-income countries: a mixed-methods systematic review

PURPOSE

This review aimed to evaluate interventions led by peer counselors (PCs) for adults with common mental disorders in low- and middle-income countries (LMICs) along indices of overall effectiveness and key implementation outcomes (acceptability, feasibility, cost, fidelity, sustainability).

METHODS

This review followed a mixed-methods systematic review design. MEDLINE/PubMed, Embase, PsycINFO, and Global Health databases were searched for PC-led interventions for adults in LMICs targeting depressive and/or anxiety disorders or PTSD. Quantitative data was narratively synthesized, and qualitative data was thematically synthesized separately. The results from the qualitative and quantitative syntheses were then combined in a cross-study synthesis.

RESULTS

Twenty-four papers describing thirteen PC-led interventions were included for review. Narrative synthesis results indicated mixed effectiveness of PC-led interventions in reducing depressive, anxiety, PTSD symptoms and high PC competency. Thematic synthesis revealed five descriptive themes: (1) Preferred PC characteristics; (2) Incentives and motivation for PCs; (3) Barriers to PC-led intervention implementation; (4) Helpful supervision/training practices; and (5) Overall high acceptability of PC-led interventions. Cross-study synthesis revealed high acceptability, feasibility, and fidelity, but cost and sustainability outcomes were underreported in included papers.

CONCLUSION

PC-led interventions seem to show initial promise in terms of effectiveness, acceptability, feasibility, cost, fidelity, and sustainability. Future research should focus on standardizing measurements of implementation outcomes to facilitate cross-study analysis. Additional empirical attention should be paid to underrepresented implementation outcomes (e.g., cost, sustainability). Finally, researchers should adopt a participatory approach that elevates the perspectives of PCs throughout all stages of the implementation process.

Early Stimulation and Nutrition: The Impacts of a Scalable Intervention

Early childhood development is becoming the focus of policy worldwide. However, the evidence on the effectiveness of scalable models is scant, particularly when it comes to infants in developing countries. In this paper, we describe and evaluate with a cluster-Randomized Controlled Trial an intervention designed to improve the quality of child stimulation within the context of an existing parenting program in Colombia, known as FAMI. The intervention improved children's development by 0.16 of a standard deviation (SD) and children's nutritional status, as reflected in a reduction of 5.8 percentage points of children whose height-for-age is below -1 SD.

Communication about distress and well-being: Epistemic and ethical considerations

Communication about well-being and distress involves multiple stakeholders, including experts by experience (EBE), researchers, clinical practitioners, interpreters, and translators. Communication can involve a variety of discourses and languages and each of the stakeholders may employ diverging epistemologies to understand and explain experiences. These epistemologies may link to different sources of authority and be articulated using particular linguistic resources. Epistemic injustice can occur when stakeholders, intentionally or unintentionally, fail to recognise the validity of other stakeholders' ways of conceptualising and verbalising their experience of well-being and distress. Language lies at the heart of the risk of epistemic injustice involved in the process of expressing well-being and distress as seen in: 1) the interface between divergent discourses on well-being and distress (e.g., biomedical vs. spiritual); and 2) communications involving multiple linguistic resources, which can be subdivided into multi-language communications involving a) translation of assessment measures, and b) interpreted interactions. Some of the challenges of multi-language communication can be addressed by translators or interpreters who strive for conceptual equivalence. We argue, however, that all stakeholders have an important role as "epistemic brokers" in the languaging of possible epistemological differences. Effective epistemic brokering requires that all stakeholders are reflexively and critically aware of the risks of epistemic injustice inherent in multi-language communication. The article concludes with a set of prompts to help raise stakeholder awareness and reflexivity when engaging in communication about well-being and distress.

Effectiveness of family-centered program for enhancing competencies of responsive parenting among caregivers for early childhood development in rural India

BACKGROUND

Responsive parenting constitutes an essential part of the context in which children live and has shown a positive effect on child development in the early years of life.

AIMS

This study aimed to assess the effectiveness of family parenting programs for enhancing competencies of responsive parenting among caregivers.

STUDY DESIGN

Cluster-RCT in 50 Anganwadi center areas. Twenty-five intervention clusters received responsive parenting intervention. Anganwadi workers delivered sessions after support and training.

SUBJECTS

We enrolled 530 mother-child dyads; 264 (49.9 %) from the intervention arm and 266 (50.1 %) from the control arm.

OUTCOME MEASURES

We assessed caregivers' knowledge and skills about child development using a parenting quiz. We evaluated the effect of an intervention on the home environment, mother-child interaction, and development outcomes at the endpoint.

RESULTS

We conducted 200 parenting sessions in 25 intervention clusters. Caregivers attended, on average, five sessions out of the nine scheduled. Caregivers with improved knowledge and skills about nutrition, shelter & care, play & stimulation for responsive parenting were significantly more in the intervention than in the control arm (p < 0.05). Mean difference in scores of home environment (1.24; SE-0.75 & ICC-0.088) and mother to child interaction (2.36; SE-0.87 & ICC-0.023) motor development (1.71; SE-0.61 & ICC-0.002), language development (2.97; SE-0.85 & ICC-0.002) and socioemotional development (1.45; SE-0.56 & ICC-0.066) between intervention and control arm was statistically significant (p < 0.05).

CONCLUSIONS

A locally adapted, family parenting curriculum was a practical approach for enhancing parents' competencies and confidence to promote early child development.

Integrating a Group-Based, Early Childhood Parenting Intervention Into Primary Health Care Services in Rural Bangladesh: A Cluster-Randomized Controlled Trial

Background

Over 250 million children globally do not reach their developmental potential. We tested whether integrating a group-based, early childhood parenting program into government healthcare clinics improved children's development, growth, and behavior.

Methods

We conducted a cluster-randomized controlled trial in 40 community clinics in the Kishorganj district of Bangladesh. We randomly assigned clinics (1:1) to deliver a group-based parenting interventions or to a comparison group that received no intervention. Participants were children aged 5-24 months, with weight-for-age z-score of ≤ -1.5 SDs of the WHO standards, living within a thirty-minute walking distance from the clinic (n = 419 intervention, 366 control). Government health staff facilitated parenting sessions in the clinic with groups of four mother/child dyads fortnightly for one year as part of their routine duties. Primary outcomes measured at baseline and endline were child development assessed using the Bayley scales, child behaviors during the test by tester ratings, and child growth. The trial is registered at ClinicalTrials.gov, NCT02208531.

Findings

91% of children were tested at endline (396 intervention, 319 control). Multilevel analyses showed significant benefits of intervention to child cognition (effect size 0.85 SDs, 95% CI: 0.59, 1.11), language (0.69 SDs, 0.43, 0.94), and motor development (0.52 SDs, 0.31, 0.73), and to child behaviors during the test (ranging from 0.36 SDs, 0.14, 0.58, to 0.53 SDs, 0.35, 0.71). There were no significant effects on growth.

Conclusion

A scalable parenting intervention, integrated into existing government health services and implemented by government health staff, led to significant benefits to child development and behavior.