Global research priorities to accelerate early child development in the sustainable development era
Authors: Tarun Dua, Mark Tomlinson, Elizabeth Tablante, Pia Britto, Aisha Yousfzai, Bernadette Daelmans, Gary L Darmstadt
Journal: The Lancet Global Health (2016)

Between 1990 and 2015, the under-5 mortality rate declined by 53%, resulting in approximately 48 million more children reaching their fifth birthday than would have occurred had 1990 mortality rates continued.1UNICEFFor every child, a fair chance: the promise of equity. UNICEF, New York2015Google Scholar Many of these children, however, continue to live in conditions of adversity—marked by extreme poverty, undernutrition, conflict, and insecurity—and are not afforded the level of care required to ensure that they meet their developmental potential.2Grantham-McGregor S Cheung YB Cueto S et al.Developmental potential in the first 5 years for children in developing countries.Lancet. 2007; 369: 60-70Summary Full Text Full Text PDF PubMed Scopus (1953) Google Scholar Neuroscience research in the past two decades is unequivocal that the period from conception through early childhood (ie, at least the first 3 years) is foundational in terms of brain development. There is increasing evidence (mostly from high-income countries) that delivering quality interventions in the early years is cost-effective,3Heckman JJ Skill formation and the economics of investing in disadvantaged children.Science. 2006; 312: 1900-1902Crossref PubMed Scopus (1865) Google Scholar reduces health inequities,4Marmot M Friel S Bell R Houweling TA Taylor S Closing the gap in a generation: health equity through action on the social determinants of health.Lancet. 2008; 372: 1661-1669Summary Full Text Full Text PDF PubMed Scopus (2116) Google Scholar improves learning and academic attainment,5Reynolds AJ Temple JA Robertson DL Mann EA Long-term effects of an early childhood intervention on educational achievement and juvenile arrest: a 15-year follow-up of low-income children in public schools.JAMA. 2001; 285: 2339-2346Crossref PubMed Scopus (559) Google Scholar lowers crime and violence,5Reynolds AJ Temple JA Robertson DL Mann EA Long-term effects of an early childhood intervention on educational achievement and juvenile arrest: a 15-year follow-up of low-income children in public schools.JAMA. 2001; 285: 2339-2346Crossref PubMed Scopus (559) Google Scholar and can substantially improve adult health and economic productivity.6Campbell F Conti G Heckman JJ et al.Early childhood investments substantially boost adult health.Science. 2014; 343: 1478-1485Crossref PubMed Scopus (587) Google Scholar For the first time, the foremost global development framework—the new Sustainable Development Goals (SDGs)—includes child development, under target 4.2.7United NationsTransforming our world: the 2030 Agenda for Sustainable Development.http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=EGoogle Scholar This is also reflected in the new Global Strategy for Women's, Children's and Adolescents' Health (2016–2030),8Every Woman Every ChildThe Global Strategy for Women's, Children's and Adolescent's Health (2016-2030). United Nations, New York2015Google Scholar within which one of the core objectives is to ensure that all women, children, and adolescents have an equal chance to thrive (and not simply survive). Thus, any research agenda that aims to give young children the chance to both survive and thrive must ensure that early child development (ECD) is prioritised in order to inform policy and programmatic implementation and achieve the SDG target. Although the scientific evidence is clear, donor and policy neglect of ECD has been striking. Recently however, high-level support for ECD has been emerging,9Chan M Linking child survival and child development for health, equity, and sustainable development.Lancet. 2013; 381: 1514-1515Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 10Lake A Chan M Putting science into practice for early child development.Lancet. 2014; 385: 1816-1817Summary Full Text Full Text PDF PubMed Scopus (33) Google Scholar including in the recent Lancet series.11Black MM Walker SP Fernald LC et al.for the Lancet Early Childhood Development Series Steering CommitteeEarly childhood development coming of age: science through the life course.Lancet. 2016; (published online Oct 4.)http://doi.org/10.1016/S0140-6736(16)31389-7Google Scholar, 12Britto PR Lyes S Proulx K et al.with the Early Childhood Development Interventions Review Groupfor the Lancet Early Childhood Development Series Steering CommitteeNurturing care: promoting early childhood development.Lancet. 2016; (published online Oct 4.)http://doi.org/10.1016/S0140-6736(16)31390-3Google Scholar, 13Richter LM Daelmans B Lombardi J et al.with the Paper 3 Working Groupfor the Lancet Early Childhood Development Series Steering CommitteeInvesting in the foundation of sustainable development: pathways to scale up for early childhood development.Lancet. 2016; (published online Oct 4.)http://doi.org/10.1016/S0140-6736(16)31698-1Google Scholar To optimise the impact of this new momentum, ECD research prioritisation is required. Between February and November, 2015, we conducted a priority-setting exercise to set research priorities for ECD to 2025. This is part of WHO's larger initiative to set priorities for maternal, newborn, child, and adolescent health. We used the Child Health and Nutrition Research Initiative (CHNRI) methodology for setting priorities in health research investments because: (a) it is a carefully developed and documented conceptual framework available in the public domain; (b) it has demonstrated usefulness in several previous exercises; and (c) it is increasingly being used by policy makers, large donors, and international organisations.14Rudan I Kapiriri L Tomlinson M Balliet M Cohen B Chopra M Evidence-based priority setting for health care and research: tools to support policy in maternal, neonatal, and child health in Africa.PLoS Med. 2010; 7: e1000308Crossref PubMed Scopus (73) Google Scholar, 15Rudan I Chopra M Kapiriri L et al.Setting priorities in global child health research investments: universal challenges and conceptual framework.Croat Med J. 2008; 49: 307-317Crossref PubMed Scopus (77) Google Scholar We adapted a set of five criteria from the CHNRI methodology—answerability, effectiveness, feasibility, impact, and effect on equity—against which an expert group scored research investment priorities. Library searches and snowball sampling were used to identify 348 experts (both researchers and programme experts) who were then approached by email to provide their three to five top research questions. 74 participants responded, generating 406 research questions, which we then collated into a composite set of questions by eliminating redundancies and overlaps, excluding irrelevant questions, and identifying thematic areas. This process yielded 54 questions that were then scored by 69 of the original experts against the five criteria outlined above. Composite scores ranging from 0 to 100% were calculated for each research question. The experts who completed scoring were geographically diverse, with 7% from WHO African Region, 34% from the Americas, 5% from Eastern Mediterranean Region, 18% from European Region, 11% from South-East Asian Region, and 8% from Western Pacific Region; 18% considered themselves international (WHO or UNICEF or international non-governmental organisations or agencies). The research questions were organised by six thematic goals. The table presents the goals and the top three research questions for each of the goals, including their ranking. Research priority scores among the top 10 priorities ranged from 82% to 87%. All of the top-ranked priorities were related to the impact of implementation of interventions, whether by community health workers or through increased support to parents and families. Three of the top 10 ranked priorities related to integration, such as integrating ECD services within maternal, newborn, and child health services or the additive costs of integrating health or nutrition interventions into early childhood education programmes. There were no questions in the top 10 about epidemiology, basic science, or discovery, although questions arose about interactions between nutrition and physical and cognitive development.TableTop three priority research questions in each thematic goalRankingImprove awareness and promotionWhat are cost-effective ways to promote an understanding of child development at the community level?25What is the impact of demand-side strategies designed to reduce access barriers for poor and vulnerable groups on pre-primary enrolment?27What is the impact of social mobilisation campaigns on use of positive discipline?40Advance identification of risk factors, and better understanding of the burdenWhat factors contribute to growth and development recovery following early nutritional deficiencies?14What is the strength of association between stunting and cognitive development?28What are the most appropriate tools for population-level assessment of development in children <8 years in resource limited settings at scale?29Improve impact of interventionsCan early child development packages focusing on nurturing care and parent support improve child cognitive development in rural low-income settings?1What approaches to improve quality of early childhood care and education programmes result in improved developmental outcomes for young children?2What is the impact and sustainability of nutritional supplementation to improve the physical and cognitive health of children?5Enhance implementation of interventionsCan community health workers/paraprofessionals be trained to deliver ECD interventions effectively?3Can group-based parenting support programmes in the postnatal period increase self-efficacy of new mothers?8Are group-based interventions more effective than home visiting to deliver ECD interventions?10Expand integration and coordinationWould the integration of an ECD counselling model within an integrated maternal, newborn, and child health strategy lead to better child development outcomes?4Can ECD programmes be taken to scale and maintain the degree of integrity/fidelity necessary to assure effectiveness?11Can ECD programmes be integrated with existing routine health care visits?12Increase understanding of health economics and social protection strategiesWhat are the additive costs of integrating health/nutrition interventions into early childhood education programmes?6What is the impact of unconditional cash transfer programmes in pregnancy on child development?17What are the most cost-effective parenting interventions to promote ECD?21ECD=early child development. Open table in a new tab ECD=early child development. The results of this process clearly indicate that the crucial priorities for future research relate to the need for services and support to parents to provide nurturing care and the training of health workers and non-specialists. What is most striking about the top-ranked priorities is the emphasis on creating enabling environments to support families in providing nurturing care for young children, which is a key message of The Lancet series on Early Child Development.11Black MM Walker SP Fernald LC et al.for the Lancet Early Childhood Development Series Steering CommitteeEarly childhood development coming of age: science through the life course.Lancet. 2016; (published online Oct 4.)http://doi.org/10.1016/S0140-6736(16)31389-7Google Scholar, 12Britto PR Lyes S Proulx K et al.with the Early Childhood Development Interventions Review Groupfor the Lancet Early Childhood Development Series Steering CommitteeNurturing care: promoting early childhood development.Lancet. 2016; (published online Oct 4.)http://doi.org/10.1016/S0140-6736(16)31390-3Google Scholar, 13Richter LM Daelmans B Lombardi J et al.with the Paper 3 Working Groupfor the Lancet Early Childhood Development Series Steering CommitteeInvesting in the foundation of sustainable development: pathways to scale up for early childhood development.Lancet. 2016; (published online Oct 4.)http://doi.org/10.1016/S0140-6736(16)31698-1Google Scholar In addition, the emphasis on integration is important—also emphasised in The Lancet series—as it speaks to the importance of implementing programmes using existing delivery platforms such as maternal and child health and nutrition services.13Richter LM Daelmans B Lombardi J et al.with the Paper 3 Working Groupfor the Lancet Early Childhood Development Series Steering CommitteeInvesting in the foundation of sustainable development: pathways to scale up for early childhood development.Lancet. 2016; (published online Oct 4.)http://doi.org/10.1016/S0140-6736(16)31698-1Google Scholar Given the current global focus on quality of care, the high priority given to questions of maintaining impact when going to scale is important as well as improving the policy environment, improving quality of interventions, and increasing effectiveness and improving demand. Currently, research funding for the "thrive" component of the Global Strategy is lower than for the survival agenda for children. The SDG agenda places ECD in the centre of global efforts to improve human capital. We encourage international organisations, national governments, research institutes, and donors to consider the findings of this exercise in order to address key gaps in our knowledge and enhance the ECD agenda and the achievement of the SDGs. This work was funded by Grand Challenges Canada. We declare no competing interests.