Scaling up child psychosocial stimulation programmes for young children
Authors: Frances E Aboud, Aisha K Yousafzai
Journal: The Lancet Global Health (2019)

Psychosocial stimulation has been shown to be crucial for the cognitive and language development of children younger than 3 years. In low-income and middle-income countries, 43% of children younger than 5 years are not reaching their potential mental development.1Black MM Walker SP Fernald LC et al.Early childhood development coming of age: science through the life course.Lancet. 2017; 389: 77-90Summary Full Text Full Text PDF PubMed Scopus (1101) Google Scholar It is recognised that children need nutrition, psychosocial stimulation, and security to thrive. How should these programmes be implemented at larger scales, and what delivery model should be used to maximise access to services, equity, and cost-effectiveness? The cluster-randomised controlled trial in Bangladesh by Jena Hamadani and colleagues2Hamadani JD Mehrin SF Tofail F et al.Integrating an early childhood development programme into Bangladeshi primary health-care services: an open-label, cluster-randomised controlled trial.Lancet Glob Health. 2019; 7: e366-e375Summary Full Text Full Text PDF PubMed Scopus (50) Google Scholar attempts to show how governments can increase access to parenting programmes while maintaining their effectiveness. The researchers invited 859 mothers to attend their local community clinic with their children aged 6–24 months for 25 sessions of a stimulation and nutrition programme that was delivered by trained primary health-care workers. The cognitive and language outcomes for children at the end of the year were significantly improved relative to children in the control group (who received no intervention), with effect sizes of 1·1–1·3 SDs. However, nutrition education did not enhance the children's height or weight, despite all children being moderately to severely underweight. The strengths of the study, as with other studies by this team, include a rigorous design in which clusters of clinics were randomly assigned, health workers were well trained and supervised, a previously used individual curriculum was adapted for delivery to pairs of mother–child dyads, and the Bayley scales were used to assess child outcomes. Only a few features of their study implementation had not been used previously in south Asia. The research team should have included more conventional measures that have been modified for low-income and middle-income countries, such as the HOME Inventory,3Caldwell BM Bradley RH Home observation for measurement of the environment: administration manual. Family & Human Dynamics Research Institute, Arizona State University, Tempe, AZ2003Google Scholar a measure of mothers' generalisable knowledge of child development,4Ertem IO Atay G Dogan DG et al.Mother's knowledge of young child development in a developing country.Child Care Health Dev. 2007; 33: 728-737Crossref PubMed Scopus (62) Google Scholar and programme activities to justify assessment of maternal depression. For governments and organisations that are curating nurturing care programmes with the aim of enhancing children's mental development, some important features remain unknown and other features might need to be examined in less controlled settings. We would like to discuss two key issues: one pertains to the content of this intervention, and the second to its implementation for greater scale and sustainability. First, should the intervention be training children or teaching responsive caregiving? The nature of this intervention puts it into the category of early learning opportunities but not responsive caregiving. The sessions consist of training children how to engage with play materials so that they can master the next set of cognitive, language, and fine motor milestones. Mothers then take the toys and books home to give their child practice. The mothers presumably followed this instruction, thereby scoring higher than control group mothers on the Family Care Indicator of play materials and activities. This type of milestone-focused programme is constrained in that children must attend sessions with children of a similar age who are also ready to learn the next set of skills. Also, many of the skills and play materials resemble the Bayley outcome measure. This type of intervention has been successful in the past, but the intervention's focus on early learning skills restricts group size and the learned skills of children and parents. Another type of intervention is one based on responsive caregiving that guides caregivers to be aware of their child's cues and abilities and to respond in an appropriate way (including answering children's bids for attention, gentle discipline, structure, and stimulation). Although it is often assumed that children learn through instruction, observation, and imitation, language is not learned through imitation but from a parent who verbally responds to them (namely who repeats and extends children's actions and words).5Black MM Aboud FE Responsive feeding is embedded in a theoretical framework of responsive parenting.J Nutr. 2011; 141: 490-494Crossref PubMed Scopus (278) Google Scholar In the future, it will be important to integrate both early learning and responsive caregiving into programmes delivered to parents and health workers. Second, to replicate, expand, and adapt interventions, studies need to provide systematic evidence on how the new intervention is implemented while maintaining and improving existing services.6Yousafzai AK Aboud FE Nores M Kaur R Reporting guidelines for implementation research on nurturing care interventions designed to promote early childhood development.Ann NY Acad Sci. 2018; 1419: 26-37Crossref PubMed Scopus (27) Google Scholar This evidence should include health worker competencies and fidelity in delivering the new intervention, satisfaction (an indicator of acceptance and potential demand), effects on the delivery and quality of existing services, and cost. Implementation information should indicate how this new intervention is compatible with existing human resources (such as the qualifications of service providers and supervisors and time allotted to training), demand for greater access (eg, by increasing group size), and family access to learning materials. For scientific and ethical purposes and reasons relating to health systems, it is also valuable to strengthen existing services in both intervention and comparison sites—for example, by ensuring refresher training for nutrition and providing weighing scales. The next generation of studies on nurturing care need to address interventions at the health system level, including modifications to training, monitoring, and supervising service providers. Financing, advocacy, and communication strategies are required to create an environment that will enable an intervention to be used sustainably within the health system.7Britto PR Singh M Dua T Kaur R Yousafzai AK What implementation evidence matters: scaling-up nurturing interventions that promote early childhood development.Ann NY Acad Sci. 2018; 1419: 5-16Crossref PubMed Scopus (38) Google Scholar Testing a scalable prototype of the intervention that includes the key components identified in previous effectiveness trials could use methods such as rapid learning or so-called plan-do-study-act cycles. Finally, evaluations could use trial designs suitable for scaling up, such as adaptive and stepped-wedge trials. We declare no competing interests. Integrating an early childhood development programme into Bangladeshi primary health-care services: an open-label, cluster-randomised controlled trialThe extent and range of benefits of our intervention are encouraging. Health workers ran most of the sessions effectively and attendance was good, which is promising for scale-up of the intervention model. However, researchers trained and supervised the health workers, and the next step will be to determine whether the Bangladeshi ministry of health can perform these tasks. In future programmes, more attention needs to be paid to the nutrition of the children. Full-Text PDF Open AccessLearning opportunities and responsive caregivingThe Comment by Frances Aboud and Aisha Yousafzai (March 1, p e294–95)1 on our Article (March 1, p e366–75)2 on an early childhood intervention in Bangladesh contains some misunderstandings, which might limit its use by others. Full-Text PDF Open Access