Longitudinal causal impacts of preschool teacher training on Ghanaian children’s school readiness: Evidence for persistence and fade‐out

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.

"I-just-wanna-get-by" hurts teachers and their work: Linking preschool teacher identity to work withdrawals in an emerging economy

Motivation deficit in low- and middle-income countries (LMICs) has implications for teacher well-being and education outcomes. This study, utilizing the job demand resource (JD-R) theory, explores the role of teacher identity as a motivational resource that antecedes emotional labor strategies - deep acting and surface acting. We further examined the relationship between emotional labor strategies and teacher work withdrawals - presenteeism and lateness, and the intervening role of teacher emotional exhaustion. We tested our theoretical model using 574 preschool teachers in Ghana. We found that teacher identity relates positively to deep acting but negatively to surface acting. And that deep acting relates to work withdrawals negatively whilst surface acting is associated with them positively. Deep acting diminishes work withdrawals because of its capacity to prevent emotional exhaustion, but the mediation role of emotional exhaustion in surface acting and work withdrawal links was non-significant. Our study presents preliminary evidence from an emerging economy on the central role of teacher identity (motivation component) in emotion management in an attempt to reduce emotional strain, thereby lessening negative work behaviors.

Global tracking of access and quality in early childhood care and education

Investments in early childhood care and education (ECCE) have contributed to a growing demand for internationally comparable data. Yet data on access to quality ECCE are not routinely collected in many countries, leading to limited information on equitable access to ECCE, quality of provision, and the impact on learning and wellbeing outcomes. This paper outlines the current status of global measurement of access to quality ECCE and identifies issues with definitions, availability, and accuracy of ECCE data across countries and outlines paths forward. We argue that estimates of access to ECCE should be based on children's participation in quality ECCE across multiple program types, rather than enrollment or attendance alone, given the critical importance of dosage and participation for ensuring positive benefits from ECCE. Governments, international organizations, and researchers all have roles to play in setting standards to define and monitor ECCE, generating workable tools for measuring nationally, and globally investing in national monitoring systems and routine household surveys to obtain accurate estimates of access to quality ECCE.

Medium-term protective effects of quality early childhood education during the COVID-19 pandemic in Ghana

The COVID‐19 pandemic led to extended school closures globally. Access to remote learning opportunities during this time was vastly unequal within and across countries. Higher‐quality early childhood education (ECE) can improve later academic outcomes, but longer‐term effects during crises are unknown. This study provides the first experimental evidence of how previously attending a higher‐quality ECE program affected child engagement in remote learning and academic scores during pandemic‐related school closures in Ghana. Children (N = 1668; 50.1% male; M_age = 10.1 years; all Ghanaian nationals) who attended higher‐quality ECE at age 4 or 5 years had greater engagement in remote learning (d = .14) in October 2020, but not better language and literacy and math scores. Previous exposure to higher‐quality ECE may support educational engagement during crises.

Strengthening Executive Function and Self-Regulation Through Teacher-Student Interaction in Preschool and Primary School Children: A Systematic Review

Executive functions (EF) and self-regulation (SR) are fundamental for children's learning, school functioning and academic achievement. EF/SR fail to develop to its full potential if contextual stimulation is not adequately presented. This is evident in the training programmes directly and exclusively targeting EF/SR stimulation, which lack durable and transferable effects. Therefore, recent research has shifted the attention towards malleable environmental factors; more specifically, to the role of school and classroom environment as an important developmental context for promoting children's EF/SR skills and, in turn, their cognition and behaviour. Numerous observational studies have shown a correlation between the quality of teacher-student relationship (TSR) at the dyadic level or teacher-student interaction (TSI) at the classroom level and children's EF/SR skills. To explore the direction of this association, the objective of this systematic literature review was to examine the causal effect of experiments and interventions that aim to improve children's EF/SR by manipulating the TSI. Overall, the results from 18 included studies indicated that children in treatment groups show higher gains, albeit small-sized, in EF/SR performance compared to controls. Furthermore, TSI manipulation seemed to affect children's SR skills more strongly than children's EF skills. More importantly, the findings revealed the largest effects of these manipulations in children considered vulnerable or disadvantaged, suggesting that the cognitive deficits can be minimised if these children are supported appropriately. Given high study heterogeneity, this review highlights the need for more research (and interventions) explicitly investigating TSI and TSR and their potential impact on EF and SR in children. This study aims to provide information as to which specific aspects need to be examined more closely, instructing further development and implementation of efficient and effective interventions in education.

A Complex Systems Network Approach to Quantifying Peer Effects: Evidence From Ghanaian Preprimary Classrooms

Research on classroom peer effects has focused nearly exclusively on high-income countries and on academic skills. Little is known about peer effects in low-income countries and whether effects differ under different educational environments (e.g., teacher-directed versus child-centered, conditions of concentrated advantage or disadvantage). Based on a data set of Ghanaian preprimary classrooms in the Greater Accra Region collected in the 2015-2016 school year, we use complex system networks with multilevel modeling to study the presence and magnitude of peer effects. Results corroborated small statistically significant effects on academic and nonacademic skills (d = .06-.10). Peer effects on literacy were larger for children in public schools, who are relatively more disadvantaged than their private school counterparts. Teacher-directivity intensity did not moderate peer effects.

Household food insecurity and early childhood development: Longitudinal evidence from Ghana

The burden of food insecurity is large in Sub-Saharan Africa, yet the evidence-base on the relation between household food insecurity and early child development is extremely limited. Furthermore, available research mostly relies on cross-sectional data, limiting the quality of existing evidence. We use longitudinal data on preschool-aged children and their households in Ghana to investigate how being in a food insecure household was associated with early child development outcomes across three years. Household food insecurity was measured over three years using the Household Hunger Score. Households were first classified as "ever food insecure" if they were food insecure at any round. We also assessed persistence of household food insecurity by classifying households into three categories: (i) never food insecure; (ii) transitory food insecurity, if the household was food insecure only in one wave; and (iii) persistent food insecurity, if the household was food insecure in two or all waves. Child development was assessed across literacy, numeracy, social-emotional, short-term memory, and self-regulation domains. Controlling for baseline values of each respective outcome and child and household characteristics, children from ever food insecure households had lower literacy, numeracy and short-term memory. When we distinguished between transitory and persistent food insecurity, transitory spells of food insecurity predicted decreased numeracy (β = -0.176, 95% CI: -0.317; -0.035), short-term memory (β = -0.237, 95% CI: -0.382; -0.092), and self-regulation (β = -0.154, 95% CI: -0.326; 0.017) compared with children from never food insecure households. By contrast, children residing in persistently food insecure households had lower literacy scores (β = -0.243, 95% CI: -0.496; 0.009). No gender differences were detected. Results were broadly robust to the inclusion of additional controls. This novel evidence from a Sub-Saharan African country highlights the need for multi-sectoral approaches including social protection and nutrition to support early child development.