Every Child's Potential
Posted June 06, 2013
One hundred and sixty five million children in low- and middle-income countries never reach their full developmental, educational, and economic potential as a result of exposure to poverty, malnutrition, poor health, and unstimulating home environments. Interventions that promote good nutrition make a difference: studies show nutritional interventions can improve both growth and child development. Psychosocial-stimulation interventions can also improve child development. Integrating nutritional interventions into child-development programs could thus be an effective way to promote both, but there is little information on integrated interventions. On April 3–4, 2013, researchers from around the world met at the New York Academy of Sciences for Every Child's Potential: Integrating Nutrition, Health, and Psychosocial Interventions to Promote Early Childhood Development, a conference presented by the Sackler Institute for Nutrition Science in partnership with the Global Child Development Group. The meeting focused on how to integrate nutritional and other types of interventions into programs for early childhood development.
Use the tabs above to find a meeting report and multimedia from this event.
Presentations available from:
Harold Alderman, PhD (International Food Policy Research Institute)
Margaret E. Bentley, PhD (University of North Carolina)
Maureen M. Black, PhD (University of Maryland)
Pia Rebello Britto, PhD (Yale Child Study Center)
Ann DiGirolamo, PhD, MPH (CARE International)
Edward A. Frongillo, PhD (University of South Carolina)
Sally Grantham-McGregor, MBBS, MD, DPH (University College London, UK)
Kirsten M. Hurley, PhD (Johns Hopkins School of Public Health)
David Pelletier, PhD (Cornell University)
Oliver Petrovic, MD, MPH (UNICEF)
Atif Rahman, MD, PhD (University of Liverpool, UK)
Rebecca J. Stoltzfus, PhD (Cornell University)
Mark Tomlinson, PhD (Stellenbosch University, South Africa)
Theodore D. Wachs, PhD (Purdue University)
Aisha K. Yousafzai, PhD (Aga Khan University, Pakistan)
Early Childhood Development Resources
Integrated interventions for optimal growth and development
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Combining child development with nutritional or health interventions
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Implementation Processes to Deliver Integrated Programs
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Measures and indicators for assessing impact
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Formative research methods
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Leveraging families' strengths, paraprofessional, and bundled services
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Integrating water, sanitation, and hygiene (WASH)
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Integration of a scalable maternal psychosocial well-being component
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Cross-national analyses of governance
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Advantages and disadvantages of integration
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Integrating ECD and health and nutrition services in Bangladesh
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Aboud FE, Moore AC, Akhter S. Effectiveness of a community-based responsive feeding programme in rural Bangladesh: a cluster randomized field trial. Matern Child Nutr. 2008;4:275-86.
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Capacity building for interventions in the health sector
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Advancing the nutrition and ECD policy agenda
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Maureen M. Black, PhD
Maureen M. Black is the John A. Scholl MD and Mary Louise Scholl MD Endowed Professor in the Department of Pediatrics and the Department of Epidemiology and Public Health at the University of Maryland School of Medicine. She is an adjunct professor in the Center for Human Nutrition at the Johns Hopkins Bloomberg School of Public Health and the Department of Psychology at the University of Maryland Baltimore County. She directs the Growth and Nutrition Clinic, an interdisciplinary clinic for children with growth and/or feeding problems. Black is a pediatric psychologist researching how nutrition policies, food insecurity, maternal mental health, and feeding practices relate to children's growth and development. She is currently conducting an integrated child development/micronutrient fortification trial in India (Project Grow Smart) and an integrated parenting/obesity prevention trial in Baltimore.
Kathryn G. Dewey, PhD
Kathryn G. Dewey is a distinguished professor in the Department of Nutrition and director of the Program in International and Community Nutrition at the University of California, Davis. She holds a PhD in biological sciences from the University of Michigan. She has conducted research on maternal and child nutrition in the U.S., Mexico, Costa Rica, Honduras, Guatemala, Peru, Ghana, Malawi, and Bangladesh. Her professional service includes extensive consultation for the WHO, UNICEF, the NIH, and the March of Dimes, and terms as president of the Society for International Nutrition Research and of the International Society for Research on Human Milk and Lactation.
Lia Fernald, PhD, MBA
Lia Fernald is an associate professor in community health and human development at the School of Public Health at the University of California, Berkeley. Her work focuses on how inequalities in socio-economic position contribute to growth and developmental outcomes in mothers, infants, and children, and on how interventions can address socio-economic and health disparities. Much of her work focuses on the effects of interventions on child development and maternal mental health, particularly in low- and middle-income countries. She recently worked with a team of authors to write a review for the Lancet about strategies to address poor development among infants and children in low- and middle-income countries. She is an NIH Study Section reviewer for the Social Science and Population Studies Panel and a reviewer for the National Science Foundation. She was selected as a member of the Canadian Institute for Advanced Research, Experience-Based Brain and Biological Development Program.
Sally Grantham-McGregor, MBBS, MD, DPH
Sally Grantham-McGregor is emeritus professor of international child health at University College London. She trained as a physician and then worked at the University of the West Indies in Jamaica, where she founded a research group to examine the development of disadvantaged children. In London, she has assisted in developing a research group in child development at the International Center for Diarrheal Disease Research, Bangladesh, as well as continuing to collaborate with the Jamaican group. Topics include zinc, iodine, and iron deficiency; stunting; severe clinical malnutrition; malaria; arsenic exposure; short-term hunger and home stimulation and their effect on child development; early-childhood measurements; interventions with nutritional supplementation; and early-childhood stimulation. She is collaborating with the Institute of Fiscal studies London on ECD interventions in Colombia and is advising the Peruvian government on a large ECD program.
Theodore D. Wachs, PhD
Theodore D. Wachs is a professor of psychological sciences at Purdue University. He received his doctorate in psychology from George Peabody College. He held positions as the Golestan Fellow at the Netherlands Institute for Advanced Studies and as a Fulbright Distinguished Scholar at the Centre for International Child Health at the University of London. He is a member of the editorial boards of the International Journal of Behavioral Development and the Journal of Applied Developmental Psychology. His research focuses on the role of chaotic family environments on child development and parenting, temperament in infancy and early childhood, and the impact of micronutrient deficiencies on infant social-emotional development. He has authored, co-authored, or co-edited 11 books.
Susan Walker, PhD
Susan Walker is a professor of nutrition, director of the Tropical Medicine Research Institute, and head of the Child Development Research Group at the University of the West Indies, Jamaica. The working group is developing low-cost approaches to promote children's development. Its rigorous evaluations have been critical in driving global attention to early stimulation for children under three years old and have influenced commitment in this area by the Inter-American Development Bank, the World Bank, and others. With the support of the Inter-American Development Bank, Walker and her team are evaluating approaches to deliver parenting programs at scale in three Caribbean countries. This research will have important implications for early child development policy. Walker was lead author in papers in the Lancet series (2007, 2011) on child development. She is a founding member of the Global Child Development Group.
Aisha K. Yousafzai, PhD
Aisha K. Yousafzai is an assistant professor in Early Childhood Development and Disability at Aga Khan University, Pakistan. Yousafzai holds a PhD in International Child Health from the Institute of Child Health at University College London. Her main research interests are strengthening early child development programming in health and nutrition services and the inclusion of children with disabilities in health programs in developing countries. Her other focus area is training and capacity development for early child development programs and research to generate and disseminate local evidence and experience more widely. She has ten years of experience in community-based programs in south Asia and East Africa. She was the co-principal investigator of the Pakistan Early Child Development Scale Up (PEDS) trial, which investigates the integration of stimulation, care for development, and nutrition in a government community health program in Pakistan. She is currently funded by the Saving Brains Program, Grand Challenges Canada to study the impact in later life of early intervention delivered in the first 1000 days of life.
Mandana Arabi, MD, PhD
The Sackler Institute for Nutrition Science
Mandana Arabi holds a PhD in nutrition from Cornell University and an MD from Tehran University of Medical Sciences. She has worked as a nutrition adviser with the Ministry of Health and the World Bank in Iran, and has served as an infant and young child nutrition adviser with UNICEF Headquarters in New York for more than four years. She is an expert in international nutrition and has facilitated nutrition programming in more than fifteen countries with a high burden of malnutrition. Arabi's research has addressed infant and child nutrition, within the context of globalization and broader social and economic factors affecting nutrition. She is the founding director of the Sackler Institute for Nutrition Science at the New York Academy of Sciences. In this role, Arabi is leading a global initiative to develop and implement a prioritized agenda for nutrition science research and is building partnerships to activate and implement the research agenda.
Harold Alderman, PhD
Margaret E. Bentley, PhD
Maureen M. Black, PhD
Florencia Lopez Boo, PhD
Pia Rebello Britto, PhD
Kathryn G. Dewey, PhD
Ann DiGirolamo, PhD, MPH
Edward A. Frongillo, PhD
Saima Gowani, PHD
Sally Grantham-McGregor, MBBS, MD, DPH
Jena Derakhshani Hamadani, PhD
Kirsten M. Hurley, PhD
Raghu Lingam, PhD, MBChb
David Pelletier, PhD
Oliver Petrovic, MD, MPH
John Phuka, MBBS
Atif Rahman, MD, PhD
Rebecca J. Stoltzfus, PhD
Mark Tomlinson, PhD
Theodore D. Wachs, PhD
Susan Walker, PhD
Aisha K. Yousafzai, PhD
Alla Katsnelson is a freelance science writer and editor living in Astoria, Queens, specializing in health, biomedical research, and policy. She has a doctorate in developmental neuroscience from Oxford University and a certificate in science communication from the University of California, Santa Cruz, and writes regularly for scientists and non-scientists alike.
Maureen M. Black, University of Maryland
According to the World Health Organization, 24% of children under the age of five—165 million children—do not reach their full developmental potential as a result of chronic undernutrition, a lack of developmental and educational opportunities, and high social and environmental risks. Maureen M. Black from the University of Maryland opened the meeting by comparing the normal trajectory of child development to stunting and discussed interventions that target nutrition and early childhood development (ECD).
Stunting has a huge economic cost, not just for individuals but also for countries. Recent estimates suggest that over 10% of gross national product is lost in developing countries as a result of poor nutrition. Child development involves an orderly progression of skills; the first 1000 days of a child's life, from conception to age two, are crucial for normal neurological development (such as myelination and synaptogenesis) and functional development (such as language skills and sensory development). Some disparities that cause stunting are already present at birth, so the first 1000 days are especially important for interventions.
Association studies have demonstrated that extreme wasting and stunting are both linked with poor development outcomes, but randomized controlled trials show a less clear relationship. Long-term follow-up suggests that positive outcomes often fade over time, but some studies have found evidence for synergistic benefits when nutritional interventions are combined with interventions that involve cognitive and emotional stimulation.
There are many open questions. What is the optimal time to intervene? Can late interventions correct cognitive and other effects of early stunting? How do social factors such as poverty, institutionalization, and lack of caregiver responsiveness affect early brain development? Do nurturing parents provide a buffer against prenatal and early postnatal stressors? Black posited that answering these questions will require models that are complex enough to include a broad array of possibilities from different disciplines.
Studies suggest that interventions should start early to prepare children for school and continue though childhood. Children with low cognitive skills need earlier interventions, while those doing well benefit from later investment. Disparities present at age five persist through age 18, and there are large disparities in preschool availability for low-income children. Government investment in child development varies dramatically across the world.
Nutritional and ECD interventions have overlapping goals and are targeted to the same period in development, so delivery through a shared infrastructure could improve efficiency and streamline messaging to families. However, integrating across health and education sectors can be difficult, and too much information provided at one time can be overwhelming for service providers and caregivers. At this meeting, researchers delved into issues such as the optimal timing, duration, and intensity of interventions; the training health workers need to deliver two types of interventions at once; how to measure outcomes; the effectiveness of government policies; and the sustainability and scale of ECD programs.
Theodore D. Wachs, Purdue University
Sally Grantham-McGregor, University College London, UK
Aisha K. Yousafzai, Aga Khan University, Pakistan
- Nutritional interventions are most effective in early in childhood or prenatally, but other interventions can be targeted to later ages.
- There is an urgent need to evaluate the efficacy of intervention programs at scale and to determine how to measure child-development outcomes.
- Intervention programs must improve reporting on the implementation process so that researchers can understand which elements are effective.
Timing early interventions
What is the best time to intervene to influence development? Theodore D. Wachs from Purdue University reviewed evidence from nutrition science, neuroscience, and developmental psychology that points to particularly sensitive time windows when interventions are most successful.
Data suggest that interventions targeting nutrition are effective at early ages; for example, children are at the highest risk for iron deficiencies before they reach age two. But non-nutritional factors such as hormonal growth factors, stress, and maternal health status are also at play at this time. Stress at low levels can facilitate development, but high-intensity, cumulative "toxic" stress can lead to aberrant brain architecture and physiological changes.
Brain development continues well past age two, and evidence suggests that aspects such as memory, cognition, peer socialization, and self-regulation continue to evolve in adolescence and young adulthood. Studies show that later interventions can improve cognitive, academic, and emotional development, which appear to have a wider window for intervention, extending past early childhood into school age. Thus, the critical question for these other interventions is not necessarily when to start, but which functions to target, Wachs concluded.
Combining child-development interventions with nutritional or health interventions
Children at risk for poor health and nutrition are generally also at risk for underdevelopment. Sally Grantham-McGregor from University College London reviewed trials that measured the efficacy of different interventions in low- and middle-income countries in order to determine whether targeting multiple elements at once produces synergistic effects. Out of 1659 studies in the literature, she and her colleagues identified just 14 efficacy trials and eight program evaluations for health, nutrition, and stimulation interventions that met their criteria.
Of the 14 efficacy trials, six were randomized controlled trials (RCTs), and in these, stimulation—alone and combined with nutritional or health interventions—consistently improved development. Nutritional supplementation improved development in half the studies and improved growth in most. There was little evidence of synergistic effects, although the data were limited. In the non-RCT efficacy trials, stimulation improved development but results for growth and nutrition were mixed.
The eight program evaluations found no robust evidence to support integrating child-development programs into health services at scale. Some programs were beneficial, but others were found to be harmful, and there was no evidence of sustained effects. Thus, the claim that any kind of intervention is better than none is inaccurate.
Grantham-McGregor said there is, therefore, an urgent need for long-term studies to evaluate program efficacy. It is crucial for nutrition scientists to think more about how to measure child development at scale and about why the nutritional components of the programs are not working. Searching for alternative models to deliver services, beyond simply using existing structures in the health care system, is also important.
Integrating nutritional interventions and psychosocial stimulation
Researchers have a poor understanding of how implementation processes affect the outcome of an intervention. Aisha K. Yousafzai from Aga Khan University emphasized that evaluations should consider program fidelity: how well a program conformed to its stated plan, which features made it more or less successful, and how intensive it had to be to produce long-term results.
In a review of the literature, Yousafzai and her co-author identified 26 studies in the Ovid database that described interventions combining nutrition and psychosocial stimulation in children up to five years old in low- and middle-income countries. The review evaluated the interventions based on their context, intensity, and content; the background and training of personnel delivering the interventions; and the supervision these individuals received. But it revealed little about what determines program success and there were scant details about the training and supervision service providers received.
Yousafzai recommended that time and resources be dedicated to evaluation, and said more studies should look at the association between the implementation process and child development and growth.
Audience members and speakers noted the disparity between intervention-efficacy studies and what is actually feasible on the ground. A study might find that spending 30 to 60 minutes with a client is beneficial, but this may not be possible. Some commented that the integrity of an intervention might depend on whether the community takes ownership of its delivery, but others noted that the effectiveness of local efforts is sometimes questionable.
Another theme of the discussion was the rationale for targeting interventions to the first 1000 days of life (prenatal to age two). While all agreed that this early period is extremely important, many noted that cognitive or behavioral outcomes—and even some nutritional ones, such as obesity—would be more appropriately addressed in later years. Studies are needed to examine how factors such as children's nutritional status and mothers' education level affect the impact of interventions.
Harold Alderman, International Food Policy Research Institute
Edward A. Frongillo, University of South Carolina
Margaret E. Bentley, University of North Carolina
- More research is needed to evaluate the cost of changing behavior.
- More research is needed to validate measures of child development.
- There is a lack of guidelines on conducting formative research.
The optimal timing for nutritional intervention is relatively well documented: it should occur before the child is two years old. But the timing for delivery of other types of developmental stimulation might be later, and it is not clear how to integrate such interventions into nutritional programs or how to determine the economic benefits of doing so, said Harold Alderman from the International Food Policy Research Institute.
Providing developmental stimulation to malnourished children can partially close the cognitive gap, but no known set of interventions works preventatively at scale. The few existing effective programs are extremely resource-intensive, both for service providers and for the mother or caregiver, and are therefore difficult to scale up.
Alderman noted that even if the timing of different interventions is not simultaneous, it is possible to create continuity—what he called "programmatic synergy"—by building upon an early bond created between the service provider and the target household. The positive effect of nutritional interventions on cognitive capacity is well known, as is the link between better schooling and improved wages. He advocated tracking this chain of events more closely and documenting the financial cost of changing behavior.
Assessing impact: nutritional and ECD interventions
Edward A. Frongillo from the University of South Carolina identified four domains that interventions might affect—food and nutrition, family care, health, and child development—and emphasized that studies evaluating interventions should assess impacts in a consistent manner. He and his colleagues reviewed commonly-used measures and indicators to assess the validity, sensitivity, and feasibility of these studies in different contexts.
The researchers identified multiple measures and scales that could assess interventions, such as the Household Food Insecurity Access Scale. But few measures of child development have been validated—even those that are widely used. Frongillo said that the field must address this deficit with further research. Other measures are difficult to use. The Bayley Scales of Infant Development, a common measure, requires special training, and many field researchers have expressed a desire for a less-technical alternative.
Designing culturally appropriate integrated interventions
Formative research should be conducted to inform project design before an intervention is launched, but papers that describe integrated interventions often give little to no information about this research, or whether the project implemented a novel intervention or adapted a pre-existing one to a specific environment or cultural context, said Margaret E. Bentley from the University of North Carolina.
Formative research can include one-on-one interviews assessing individual-level knowledge, attitudes, and beliefs; direct observation, which should ideally be video recorded; and focus-group interviews assessing cultural and social norms that affect target behavior. Specific questions about feeding, development, and household and community roles can inform project design. Bentley stressed the importance of considering children's age and gender, maternal education and autonomy, food availability, and the inclusion of other caregivers (father, grandmother) and community leaders in the study.
Bentley described a case study of formative research for an integrated feeding and care intervention in rural India. The team identified opportunities for behavioral change, developed the intervention messages, and defined measures to assess efficacy. She noted that they found a significant lack of guidelines on formative research, particularly in the field of child development.
The discussion focused on study design, such as which measures of child development could realistically be used at scale, and how to evaluate efficacy. Feedback from caregivers is often unreliable; for example, mothers' answers can be biased by preconceptions about the correct response to a question.
The timing of interventions is important. In studies that follow children through development, it is not always clear when to measure progress. Another concern, noted throughout the meeting, was whether some programs deliver too many messages at once, overwhelming caregivers' ability to receive information and health care workers' ability to deliver it.
Mark Tomlinson, Stellenbosch University, South Africa
Raghu Lingam, London School of Health and Tropical Medicine, UK
Rebecca J. Stoltzfus, Cornell University
Atif Rahman, University of Liverpool, UK
Pia Rebello Britto, Yale Child Study Center
- Nutritional and child-development interventions must be extended to the poorest families, which are often left out of such services.
- Researchers must understand local beliefs, customs, and practices in order to design effective interventions.
- Hygiene and sanitation play an important role in ECD, but interventions in this domain are not as well developed or well tested as interventions in nutrition, stimulation, or social protection.
- Health workers delivering child health, nutritional, and developmental interventions could also be trained to address basic aspects of maternal-psychosocial and mental health.
- The most local level of government could serve as an entry point for efforts to improve child-development services.
Leveraging families' strengths, paraprofessionals, and bundled services
Interventions are not distributed equally, according to Mark Tomlinson from Stellenbosch University. Although mortality in children under age five has dropped globally since 1990, it has increased in 13 countries, and newborn deaths have increased in 26 countries. Extending existing child-development interventions to the poorest children, who are often left out, is essential.
There are many barriers to participation in interventions, including dispersed families and migration; family beliefs; resistance from fathers and grandmothers, who can act as gatekeepers to mothers' participation; maternal health problems, such as depression or HIV status; and cost, lack of transportation, and poor infrastructure. Overcoming these barriers requires tailoring interventions to particular communities. For example, targeting interventions solely to mothers is ineffective in areas where children are left with their grandmothers for extended periods. Tomlinson described a study in which his team used motivational interviewing to convince HIV-positive mothers to breastfeed and then talked through barriers that might prevent them from implementing their decision.
Increasing participation in interventions will involve a combination of center-based and home-based programs, and the frequency and quality of contact between community health workers and participants may need to be improved. Integrating interventions and increasing coverage will also be crucial; an inoculation model in which only a single intervention is delivered will not work.
Understanding care and feeding practices: building blocks for a sustainable intervention
Raghu Lingam from London School of Health and Tropical Medicine described his team's formative research for a package of interventions in rural India and Pakistan called SPRING. The interventions, delivered through community-based agents, aimed to maximize child development, growth, and survival and improve maternal psychosocial well-being.
The research aimed to determine how local beliefs and practices would influence the success of these interventions and to identify ways to integrate them into existing activities and scale-up, if effective. Over a year, the researchers interviewed family members and directly observed mothers interacting with children. They identified parental aspirations for their children and practices relating to feeding, weaning, and play as important.
They explored who would receive the interventions, which behaviors would be targeted (for example, exclusive breastfeeding from age 0–6 months old), what the potential benefits would be, which barriers might prevent participation, and how interventions would be delivered.
Integrating water, sanitation, and hygiene with a nutritional intervention
The extent to which diarrhea affects child growth is controversial, but one longitudinal study in Peru reported that 40% of the height deficit at age two could be explained by sanitation conditions in the child's household. Rebecca J. Stoltzfus from Cornell University described her team's work to determine whether preventing a subclinical small-intestine condition called environmental enteropathy (EE) would reduce stunting. They developed an intervention in rural Zimbabwe that aimed to prevent babies under 18 months old from ingesting animal and human feces.
While conducting formative research, the group found that children most frequently develop EE after ingesting dirt and chicken feces, which contains 10 million E. coli cells per "serving," while playing on the kitchen floor. They initially proposed to create a protective play space for babies, but found that this is culturally unacceptable because it contradicts a belief that exploration is integral to healthy development. The team is still exploring this possibility, but is also testing a hygiene intervention that encourages infant hand washing and other sanitation efforts.
Many early-childhood programs provide nutrition, stimulation, and social protection, but hygiene programs are less common and not as well understood. Stoltzfus's group is comparing their hygiene intervention with an infant-feeding and education intervention to measure the independent and combined effects of multiple interventions on stunting and anemia in children under 18 months old.
Integrating maternal psychosocial well-being into child-development interventions
Early-childhood interventions tend to be delivered through the mother. Atif Rahman from the University of Liverpool discussed the SPRING interventions in India and Pakistan described by Raghu Lingam, focusing on a component that aims to support maternal well-being. Up to 25% of women in the developing world suffer from depression, which studies suggest is associated with poor outcomes for children.
Four years ago, Rahman's group trained SPRING lady health workers (LHWs) in rural Pakistan to address mothers' mental health. They taught the LHWs how to integrate new elements into a nutritional/ECD intervention, including family support, empathetic listening, challenging beliefs using pictures, encouraging mothers to take small steps toward improvements (behavioral activation), and encouraging problem solving. Pilot evaluations of the enhanced intervention observed the work and collected feedback from the LHWs and mothers.
Health workers had to adapt to spending more time listening to mothers than delivering instructions. In most cases, both parties found the interaction more satisfying: health workers were able to engage more family members, and mothers felt better supported. The team is planning further research to assess this approach and is working with local partners to ensure that it is scalable.
Audience members asked whether the psychosocial intervention Rahman described could more directly address domestic violence and women's empowerment. Rahman said his team did not do so because that would likely raise intense resistance. Instead, he said, the intervention addressed these issues indirectly by encouraging family dynamics to change. He also said that the group plans to assess the sustainability of the intervention and suggested that researchers should work with local stakeholders to plan how to scale up interventions from the outset.
Another challenge that was raised is researchers' ability to look past their assumptions and recognize their limited knowledge of local culture. Lingham and Stoltzfus noted that formative research could help identify problems with a planned intervention in advance. They also said that understanding culture is an iterative process that should continue throughout each project.
Understanding how to scale up early-childhood interventions in the context of governance
Early-childhood services are not often implemented through a designated government system, but through a patchwork of local and national institutions (such as the health and education sectors) and non-governmental organizations. Pia Rebello Britto from Yale Child Study Center reported that these services are becoming more popular. Her team examined how local, regional, and global governance impacts how ECD programs are run and scaled up.
The research examined the policy infrastructure for early-childhood programs in two countries in East Asia, two in east and southern Africa, and two in Latin America. Within each country, they interviewed individuals at different levels of the government hierarchy and in different geographical areas—the capital (generally the wealthiest district), a median-performing region, and a particularly poor region. People at different levels of government had very different ideas about what a "quality" program is, Britto said.
The research also looked at the policy architecture in each country—the documents that guide early-childhood interventions. A key aspect of implementing integrated nutritional and ECD interventions is establishing collaboration between the health ministry and the education ministry; in Laos, for example, the former is very hierarchical while the latter is not, and the discrepancy makes integration more difficult.
In each country, local governments were most concerned about effective service delivery. This level of government could therefore serve as an entry point for improving access to services and scaling up interventions.
Ann DiGirolamo, CARE International
Jena Derakhshani Hamadani, International Center for Diarrheal Diseases, Bangladesh
Aisha K. Yousafzai, Aga Khan University, Pakistan
John Phuka, University of Malawi, Malawi
- Integrating nutrition and ECD services has many benefits, but there are also challenges.
- In Bangladesh, ECD programs need to be better integrated into existing health services and need more stringent evaluation.
- To increase the capacity of ECD service providers, health workers should be trained to support behavioral change.
- Malawi must strengthen its infrastructure to achieve its policy goal to expand ECD services.
Advantages and disadvantages of integration
Researchers recognize the benefits of early interventions to address children's nutritional and developmental needs, but resources are limited. Ann DiGirolamo from CARE International emphasized that it is important to consider both the opportunities and the challenges posed by integrating nutritional and ECD services.
Integration can be cost-effective and may simplify service delivery for both health workers and caregivers; for example, coordinated messaging may be easier to grasp and can provide a framework for more holistic services. However, integrated services may also increase the workload for health workers and require more supervision and monitoring by program supervisors. In addition, integration relies on collaboration between two disparate fields, as well as between sectors and ministries of government that do not interact with each other often.
Addressing these challenges requires creating multifaceted resources—from incentives and job descriptions for health workers to simpler, integrated measurement tools—and continued research. DiGirolamo suggested that emergencies and conflict situations can provide opportunities to introduce integrated nutrition and ECD programming, particularly if agencies on the ground in such situations value integration
Integrating ECD programs into health and nutrition services in Bangladesh
More than 300 non-governmental organizations are implementing ECD programs in Bangladesh, but few include nutrition programs. Jena Derakhshani Hamadani from the International Center for Diarrheal Diseases in Bangladesh reviewed data from four program evaluations and seven efficacy trials for integrated interventions.
ECD programs are supported by the government, but have not been conducted regularly, Hamadani said. A network of community clinics established about ten years ago that ceased operations during a change in government has now restarted. But most programs target preschool-age children and few offer parenting guidance, provide intervention for children under age three, or integrate nutrition and ECD. Efficacy trials examined interventions for children under age three and reported benefits in several measures. Hamadani and her colleagues followed up on a trial they published in 2006, which provided psychosocial stimulation to malnourished children aged 6–24 months, and found that by ages 9 to 11 the benefits of the original intervention had largely faded.
Now that the government has prioritized ECD, such programs must be integrated into existing health and nutrition infrastructure. Hamadani noted that very few programs are based on research findings and even fewer have been evaluated.
Capacity building for improving child development and nutrition in the health sector
Health workers are usually adept at providing injections, pills, and micronutrients, but not at promoting and supporting behavioral changes, said Aisha K. Yousafzai. She recommended training providers to take ownership of programs so that they can respond to the needs clients identify, rather than relying on a scripted visit schedule. The goal of this training should be to impart knowledge that can be used in real-life settings. Knowledge mobilization must also occur at the policy level.
Through its 13-week training program for managers, field staff, researchers, teachers, doctors, and nurses, the Aga Khan Development Network has increased awareness of ECD and plans to develop short courses for a wider audience, such as health education agencies. The course uses an international version of a five-module online resource developed by researchers at the University of Toronto called the Science of Early Child Development. Yousafzai suggested that ECD training should be provided to graduating doctors and nurses and offered through professional organizations. She also described other training schemes that could help build capacity for ECD, such as the World Health Organization's Care for Child Development and Integrated Management of Childhood Illness programs.
A job analysis of community health workers providing integrated services
The Malawian government plans to expand access to child-development services from 30% to 62% of children under age five. John Phuka from the University of Malawi and his colleagues studied the role community health workers could play in integrating services for child nutrition, health, and psychosocial development.
Health workers receive up to 12 weeks of training funded by the government, plus refresher courses. The curriculum currently contains no ECD, but health workers expressed interest in including it. Each health worker serves 1000 to 5000 people, and although most reported feeling overworked, they also indicated they could take on additional projects. Child protection workers are less numerous (there is one per 6000 to 25 000 people) and not as widely recognized in communities, but they also expressed interest in integrating ECD into their projects. Among caregivers, there was little sense of ownership of the services these health workers provide. According to Phuka, although Malawi has a policy goal to expand ECD programs, scaling up services will be challenging because of a lack of resources.
The discussion focused on the difficulties of making integrated programs operational. DiGirolamo said that rather than focusing on technical expertise in distinct modalities, such as nutrition or education, we should consider how different sectors affect one another. Phuka suggested that researchers should step back from overspecialization and think about interventions more broadly, from a public health point of view. The discussion also touched on the conflicting agendas that different stakeholders can have for health workers delivering a range of interventions.
Gaps in the science of implementation were also addressed. One participant asked whether trial designs other than randomized controlled trials would be helpful for evaluating different components of intervention programs. Yousafzai noted that although programs exist in South Asia many are not implemented effectively. Grantham-McGregor concluded the discussion by pointing out that no evaluation data exist for scaling up interventions. Furthermore, researchers have not agreed upon good measures of ECD that could be submitted to ministries of finance to gauge a program's success and request continued funding.
Saima Gowani, Columbia University
Kirsten M. Hurley, Johns Hopkins School of Public Health
Florencia Lopez Boo, Inter-American Development Bank
- Integrating responsive stimulation into a rural health program in Pakistan is cost-effective, according to an analysis of 1500 children.
- Studying the impact of integrating a micronutrient intervention with a play and communication intervention is a time-intensive, multiphase process.
- A nutritional supplementation program in Nicaragua is cost-effective, but does not improve child-development outcomes.
Cost effectiveness of responsive stimulation and nutrition intervention in rural Pakistan
Research on the cost effectiveness of interventions in children under three years old is scarce. Saima Gowani from Columbia University presented an economic analysis of the Pakistan Early Childhood Development Scale Up (PEDS) trial, a randomized comparison of child-development outcomes after an enhanced nutritional intervention, a responsive-stimulation intervention, and an intervention combining the two. Services were delivered by LHWs in monthly home or group visits to 1500 children age 0–2 years old, and participants were followed for two years.
The researchers first calculated the cost of each intervention and found that responsive stimulation was the most expensive, at $4 per child per month. The integrated group had the best outcomes for cognitive, motor, and language development. The integrated intervention was the most cost-effective in the first year of the study, but responsive stimulation alone was most cost-effective in the second year.
Calculating the cost per month in local currency for a one-point gain on the Bayley scales might provide data to convince policy makers to fund the service. Gowani suggested that the long-term effects of interventions on factors such as school performance or wages could yield convincing cost–benefit data.
Rationale, design, methodology, and sample characteristics for an integrated program in rural India
Kirstin M. Hurley from Johns Hopkins School of Public Health described a randomized study that evaluated the impact of an integrated program combining a micronutrient intervention with a play and communication intervention. For infants in the study (6–24 months old), health workers delivered one of four interventions including play/communication and micronutrient supplementation in biweekly home visits.
Preparing the study was a time-intensive, multi-phase process. In a preliminary phase, the researchers obtained approvals from government and local oversight bodies and developed the interventions; a preparatory phase involved formative research; a formative phase involved a pilot test of a micronutrient sachet and a feasibility assessment of the play and communication intervention; and a final phase involved training health workers in data collection.
Developing the micronutrient sachet was especially challenging, Hurley said. It had to be deemed acceptable in terms of smell, color, and taste. Caregivers were taught how to mix it into food and advised not to share it with other children in the household. Mothers expressed concern about where to store the sachets, so the researchers also developed special storage bags. For the play and communication intervention, health workers showed mothers cards with pictures demonstrating a behavior, such as playing peekaboo. The study required continuous monitoring and supervision of health workers delivering the intervention.
The cost and benefit of micronutrient supplementation in Nicaragua
In Nicaragua 22% of children under age five suffer from chronic malnutrition and 30% of children under age three suffer from anemia. Florencia Lopez Boo from the Inter-American Development Bank presented data from a government program that provides micronutrient supplements within an integrated ECD intervention. The program showed a very small benefit for language and cognitive development, but did decrease anemia among participants, so she conducted a cost–benefit analysis to determine the monetary value of this impact.
The program, called PAININ, is delivered at government-sponsored day care centers (mostly urban) or at community centers run by volunteer mothers in their homes (mostly rural). Lopez Boo reported that it cost only $72 per child per year (or $42 when excluding food), which is extremely low by Latin American standards. For children under three years old, she calculated that receiving the nutritional intervention led to 0.22 more years of education and about seven months less delay in starting school. That translates to approximately 12% higher wages per year, she said, and for every dollar spent on this program, the potential gain for these children is $3–$6. Integrating micronutrient supplementation with an ECD program thus seems to be a cost-effective option.
David Pelletier, Cornell University
Oliver Petrovic, UNICEF
Susan Walker, University of the West Indies, Jamaica
Maureen M. Black, University of Maryland
- UNICEF's MICS4 survey provides powerful data for understanding ECD at the population level and for identifying priorities for interventions.
- The World Bank's SABER database allows users to compare details of national-policy frameworks to identify how policies could be strengthened to improve ECD.
Advancing the nutrition and ECD agenda: indicators and guidance
Despite the known benefits of ECD and governments' interest in providing it, program outcomes are poor, indicating problems in the policy sector, said David Pelletier from Cornell University. He described a World Bank initiative to map national-policy measures relating to ECD for countries around the world. This is part of a larger project called SABER (Systems Approach for Better Education Results), which has already collected multisectoral data for 20 countries and will eventually be compiled in a public website that will compare national-policy frameworks.
The database evaluates three policy goals: establishing an environment that promotes ECD (or another sector), implementing programs widely, and monitoring and assuring quality. It will be able to identify areas of progress and areas that need improvement. To illustrate, Pelletier presented data from Colombia, the Kyrgyz Republic, and Tanzania—which have ECD programs SABER classifies as "established," "latent," and "emerging," respectively—that points to specific challenges for ECD policy. He then discussed data from another World Bank-funded project, the Mainstreaming Nutrition Initiative, which helped identify how countries might strengthen strategic capacity for ECD programs.
Panel discussion: scaling-up integrated interventions
In a panel discussion moderated by Susan Walker from the University of the West Indies, Pelletier said that the key initial step for successful scale-up is achieving cohesion within the policy community. Policy makers must find an "optimal level of precision or ambiguity around which they could agree." This probably excludes the specifics of resource allocation. One concern voiced by a participant was that it is not clear which elements of intervention programs are most effective, and thus the high-impact pieces might not be not scaled up—resulting in a program that has little or no impact.
Yousafzai noted that there is little data on which factors influence program effectiveness. Another concern is cost: the monitoring component of a program is likely to be cut when it is scaled up, but intervention programs require a lot of monitoring to ensure they are implemented well and that efficacy is not lost. Finances can scuttle success even before a program is ready for scale-up: projects are typically 3 to 5 years long, which means that, because of the typical length of grants, funding ends just as results being to appear. Current measures of success are also inadequate: scales like Bayley developmental scores are unlikely to convince governments to fund ECD projects. Participants proposed possible alternative—such as relating ECD to school performance—that could be linked to incentives like wasted school budgets or lost wages.
New evidence on ECD in developing countries
For 15 years UNICEF has run a periodical global index of child and maternal health called the Multiple Indicator Cluster Survey (MICS). The current fourth round of surveys (MICS4) is collecting data on 110 indicators of health, nutrition, child protection, education, and ECD in developing countries. Oliver Petrovic from UNICEF provided a glimpse of these new data.
The purpose of the index is not to rank countries, Petrovic said, but to view child development at the population level, look at how different types of investments are interrelated, and identify priorities for interventions. Because the data are disaggregated by multiple factors such as location, gender, education level, age, and income level, MICS is a powerful tool for monitoring disparities.
The data show, for example, that wealth-based disparities in access to ECD services are decreasing in countries like Mongolia, but remaining steady in other countries such as Sierra Leone. Well-designed measurement tools test hypotheses about the effects of adversity, Petrovic said. For example, in one data set, 12.5% of stunted children aged 3 to 5 years old were on track for literacy and numeracy while 33% of non-stunted children had these skills, providing evidence that could be used for advocacy.
Panel discussion: conclusions
Maureen M. Black, who moderated the final panel, began by asking panelists to offer advice to someone designing a program that is rigorous, acceptable to the local community, and addresses specific issues.
DiGirolamo stressed the need to start with a very strong analysis phase and to incorporate a reliable set of indicators, simple enough to be applied in different contexts. Rahman said it is crucial to work closely with local stakeholders to ensure that the program targets a problem that is important to the community. He said maternal mental health is a proxy indicator for many factors that can affect the success of an intervention, such as self-esteem and sense of empowerment in the community, and it can be addressed through many avenues, including child development.
Lingam noted that since many interventions are achieving little impact on the ground, assessing failures is as important as reporting successes. Frongillo pointed out the importance of resource realism—considering limitations on time and funding—and the need to indentify interventions that are feasible. He suggested that organizations should not pursue interventions that research has shown cannot be scaled.
Black noted that none of the interventions discussed at the meeting were truly integrated. Wachs said that conceiving of interventions in components like nutrition and psychosocial development does not lend itself to integration. Lingam suggested taking ECD out of the context of integration with nutrition and thinking of it instead as a part of child survival.
The terminology of the field may also need to be changed, said one audience member. The phrase chronic undernutrition implies that people should receive more calories, but the situation is much better reflected by the word stunting. Similarly, stimulation sounds like something a machine does; a better phrase might be reaching the child's potential.
At what ages are particular child-development interventions best targeted?
Do some types of interventions have synergistic effects when combined?
Can later interventions reverse the effects of early deprivation?
What measures should be used to evaluate the efficacy of ECD and nutritional intervention programs?
How can researchers best identify which elements of an intervention program are successful?
What are the economic costs of ECD interventions and how much return do they bring?
How should the delivery of multiple health- and development-related messages be balanced with the need to avoid overwhelming caregivers with information?
How can nutritional and ECD interventions be extended to the poorest families, which are often left out of such services?
How can interventions geared towards children also take into account maternal well-being?
How can government policy be optimized to improve child nutrition and welfare?
What kinds of training and supervision best support health workers delivering child nutrition and ECD interventions?