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Testing means to scale early childhood development interventions in rural Kenya: the Msingi Bora cluster randomized controlled trial study design and protocol.
Luoto, JE, Lopez Garcia, I, Aboud, FE, Fernald, LCH, Singla, DR
BMC public health. 2019;(1):259
Abstract
BACKGROUND Forty-three percent of children under five in low and middle-income countries (LMICs) experience compromised cognitive and psychosocial development. Early childhood development (ECD) interventions that promote parent-child psychosocial stimulation and nutrition activities can help remediate early disadvantages in child development and health outcomes, but are difficult to scale. Key questions are: 1) how to maximize the reach and cost-effectiveness of ECD interventions; 2) what pathways connect interventions to parental behavioral changes and child outcomes; and 3) how to sustain impacts long-term. METHODS Msingi Bora ("good foundation" in Swahili) is a multi-arm cluster randomized controlled trial across 60 villages and 1200 households in rural Western Kenya that tests different, potentially cost-effective and scalable models to deliver an ECD intervention in biweekly sessions lasting 7 months. The curriculum integrates child psychosocial stimulation with hygiene and nutrition education. The multi-arm study will test the cost-effectiveness of two models of delivery: a group-based model versus a mixed model combining group sessions with personalized home visits. Households in a third study arm will serve as a control group. Each arm will have 20 villages and 400 households with a child aged 6-24 months at baseline. Primary outcomes are child cognitive and socioemotional development and home stimulation practices. In a 2 × 2 design among the 40 treatment villages, we will also test the role of including fathers in the intervention. We will estimate intention-to-treat and local average treatment effects, and examine mediating pathways using Mediation Analysis. One treatment arm will receive quarterly booster visits for 6 months following the end of the sessions. A follow-up survey 2 years after the end of the main intervention period will examine sustainability of outcomes and any spillover impacts onto younger siblings. Study protocols have been approved by the Maseno Ethics Review Committee (MUERC) in Kenya (00539/18) and by RAND's institutional review board. This study is funded by the National Institute for Child Health and Human Development (R01HD090045). DISCUSSION Results can provide policymakers with rigorous evidence of how best to design ECD interventions in low-resource rural settings. TRIAL REGISTRATION Clinical Trial NCT03548558 registered June 7, 2018 at clinicaltrials.gov; AEA-RCT registry AEARCTR-0002913.
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Early Caregiver-Child Interaction and Children's Development: Lessons from the St. Petersburg-USA Orphanage Intervention Research Project.
McCall, RB, Groark, CJ, Hawk, BN, Julian, MM, Merz, EC, Rosas, JM, Muhamedrahimov, RJ, Palmov, OI, Nikiforova, NV
Clinical child and family psychology review. 2019;(2):208-224
Abstract
We review a series of interrelated studies on the development of children residing in institutions (i.e., orphanages) in the Russian Federation or placed with families in the USA and the Russian Federation. These studies rely on a single population, and many potential parameters that typically vary in the literature are similar across studies. The conceptual focus is on the role of early caregiver-child interactions and environmental factors that influence those interactions in children's development. Generally, children residing in institutions that provided minimal caregiver-child interactions displayed delayed physical, cognitive, and social-emotional development. Children and adolescents adopted from such institutions at 18 months of age or older had higher rates of behavioral and executive function problems, even many years after adoption. An intervention that improved the institutional environment by increasing the quality of caregiver-child interactions-without changes in nutrition, medical care, sanitation, and safety-led to substantial increases in the physical, cognitive, and social-emotional development of resident children with and without disabilities. Follow-up studies of children in this intervention who were subsequently placed with USA and Russian families revealed some longer-term benefits of the intervention. Implications are discussed for theoretical understanding of the role of early caregiver-child interactions in development as well as for practice and policy.
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Nutrition-Related Practices of Family Child Care Providers and Differences by Ethnicity.
Gans, KM, Tovar, A, Jiang, Q, Mello, J, Dionne, L, Kang, A, Mena, NZ, Palomo, V, Risica, PM
Childhood obesity (Print). 2019;(3):167-184
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BACKGROUND Child care settings play an important role in shaping children's eating behaviors; yet few studies have included family child care homes (FCCHs). We examined provider-reported nutrition-related practices in FCCHs and observed adherence to nutrition guidelines from the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC), exploring differences by provider ethnicity. METHODS We assessed baseline data from a cluster-randomized trial, including surveys with FCCH providers and observational data collected at the FCCH. We examined provider-reported nutrition-related practices and if providers met NAP SACC guidelines using observational data. Differences by ethnicity were assessed using chi-square and multivariate log-linear analysis adjusting for education. RESULTS Providers completed a telephone survey (n = 166, 100% female and 72% Hispanic) and participated in 2 full-day observations (n = 119). Many providers reported engaging in positive nutrition-related practices. Significant differences by ethnicity included the following: Hispanic providers less likely to report feeding practices that were responsive to children's self-regulation, but also less likely to report eating and drinking unhealthy foods/beverages in front of children and having screens on during meals and more likely to report seeking nutrition trainings. Using observational data, only 10 of 26 NAP SACC practices were met by >60% of providers. Few ethnic differences in meeting guidelines were found (7 of 26 practices). CONCLUSIONS While providers engage in some positive nutrition practices, improvement is needed to ensure that all providers actually meet evidence-based guidelines. Ethnic differences in certain practices underscore the need for culturally relevant trainings. TRIAL REGISTRATION NUMBER NCT02452645.
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Physical activity in early childhood education and care settings in a low-income, rural South African community: an observational study.
Tomaz, SA, Jones, RA, Hinkley, T, Twine, R, Kahn, K, Norris, SA, Draper, CE
Rural and remote health. 2019;(4):5249
Abstract
INTRODUCTION Research has not been conducted on physical activity in early child education and care (ECEC) settings in low-income, rural communities in South Africa. This study aimed to describe the physical activity environment of these settings and identify child and contextual factors associated with physical activity in these settings. By understanding physical activity in this environment, it will be possible to identify context-specific opportunities, including with teachers, to overcome potential challenges and maximise physical activity in a low- and middle-income country setting. METHODS The study was conducted in rural Bushbuckridge, Mpumalanga in 2014. Preschool-aged children (n=55) were recruited from five ECEC settings, including three preschools and two primary schools, where preschool-aged children are in their reception year, grade R. Preschool environment characteristics were assessed using an observational tool adapted from existing tools. Children's physical activity was assessed using the Observational System for Recording Physical Activity in Children - Preschool Version. Differences between preschool and grade R settings were assessed using χ2 analyses, and multinomial logistic regression analysis was used to determine factors associated with physical activity in the ECEC settings. RESULTS The physical activity environment differed between preschool and grade R ECEC settings in terms of space (preschoolpgrade R, p<0.001). On average, children spent 28.7% of their day in the ECEC settings engaged in physical activity, of which 22.3% was moderate- to vigorous-intensity physical activity (MVPA). Children spent the greatest proportion of the day in sedentary activities (69.9%) and this differed significantly between preschool (63.2%) and grade R children (81.3%, p<0.001). Preschool children were significantly more active than grade R children, and spent greater proportions of time in light-intensity physical activity (8.6% v 2.7%, p<0.001) and MVPA (25.4% v 15.3%, p<0.001). Irrespective of ECEC setting, children were significantly more likely to participate in MVPA if they were outdoors (p=0.001), and significantly less likely to do MVPA if they were overweight/obese (p=0.006). CONCLUSION These findings provide insight into child-level and contextual factors associated with preschool-aged children's physical activity within ECEC settings in a low-income, rural community in South Africa. Particularly, the physical and social features of ECEC settings are important in the promotion of physical activity. Findings from this study suggest that it is necessary to upskill and encourage teachers in ECEC settings to maximise opportunities for physical activity in rural low-income communities in South Africa.
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What Can Be Learned from Existing Investigations of Weight-Related Practices and Policies with the Potential to Impact Disparities in US Child-Care Settings? A Narrative Review and Call for Surveillance and Evaluation Efforts.
Larson, N, Ayers Looby, A, Frost, N, Nanney, MS, Story, M
Journal of the Academy of Nutrition and Dietetics. 2017;(10):1554-1577
Abstract
Child-care settings and the combination of policies and regulations under which they operate may reduce or perpetuate disparities in weight-related health, depending on the environmental supports they provide for healthy eating and activity. The objectives of this review are to summarize research on state and local policies germane to weight-related health equity among young children in the United States and on how federal policies and regulations may provide supports for child-care providers serving families with the most limited resources. In addition, a third objective is to comprehensively review studies of whether there are differences in practices and policies within US child-care facilities according to the location or demographics of providers and children. The review found there is growing evidence addressing disparities in the social and physical child-care environments provided for young children, but scientific gaps are present in the current understanding of how resources should best be allocated and policies designed to promote health equity. Additional research is needed to address limitations of prior studies relating to the measurement of supports for weight-related health; complexities of categorizing socioeconomic position, ethnicity/race, and urban and rural areas; exclusion of legally nonlicensed care settings from most research; and the cross-sectional nature of most study designs. There is a particularly great need for the development of strong surveillance systems to allow for better monitoring and evaluation of state policies that may impact weight-related aspects of child-care environments, implementation at the program level, and needed implementation supports.
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A Healthy Weight for Toddlers? Two-Year Follow-up of a Randomized Controlled Trial of Group Well-Child Care.
Shah, NB, Fenick, AM, Rosenthal, MS
Clinical pediatrics. 2016;(14):1354-1357
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"GET-UP" study rationale and protocol: a cluster randomised controlled trial to evaluate the effects of reduced sitting on toddlers' cognitive development.
Santos, R, Cliff, DP, Howard, SJ, Veldman, SL, Wright, IM, Sousa-Sá, E, Pereira, JR, Okely, AD
BMC pediatrics. 2016;(1):182
Abstract
BACKGROUND The educational and cognitive differences associated with low socioeconomic status begin early in life and tend to persist throughout life. Coupled with the finding that levels of sedentary time are negatively associated with cognitive development, and time spent active tends to be lower in disadvantaged circumstances, this highlights the need for interventions that reduce the amount of time children spend sitting and sedentary during childcare. The proposed study aims to assess the effects of reducing sitting time during Early Childhood Education and Care (ECEC) services on cognitive development in toddlers from low socio-economic families. METHODS/DESIGN We will implement a 12-months 2-arm parallel group cluster randomised controlled trial (RCT) with Australian toddlers, aged 12 to 26 months at baseline. Educators from the ECEC services allocated to the intervention group will receive professional development on how to reduce sitting time while children attend ECEC. Participants' cognitive development will be assessed as a primary outcome, at baseline and post-intervention, using the cognitive sub-test from the Bayley Scales of Infant and Toddler Development. DISCUSSION This trial has the potential to inform programs and policies designed to optimize developmental and health outcomes in toddlers, specifically in those from disadvantaged backgrounds. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry: ACTRN12616000471482 , 11/04/2016, retrospectively registered.
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The association between childcare and risk of childhood overweight and obesity in children aged 5 years and under: a systematic review.
Alberdi, G, McNamara, AE, Lindsay, KL, Scully, HA, Horan, MH, Gibney, ER, McAuliffe, FM
European journal of pediatrics. 2016;(10):1277-94
Abstract
UNLABELLED The aim of this paper was to systematically review the published evidence on the relationship between the type of childcare and risk of childhood overweight or obesity. The databases PubMed, MEDLINE, Cochrane Library and EMBASE were searched using combinations of the various search terms to identify eligible observational studies published between 2000 and May 2016 in English. Fifteen publications from 7 countries matched the inclusion criteria. The most commonly reported childcare arrangements were centre-based (e.g. crèche) and informal care (e.g. relatives, neighbours, friends). Informal care was most frequently associated with an increased risk of childhood overweight and obesity. Associations were also found for other lifestyle variables such as low maternal education, high birth-weight, maternal employment, ethnicity, maternal overweight/obesity and father's Body Mass Index (BMI). CONCLUSION The relationship between childcare and childhood overweight/obesity is multi-faceted with many aspects linked to childhood adiposity, in particular the age of initiation to care, type of care (i.e. informal care) and shorter breastfeeding duration were related with infant adiposity. WHAT IS KNOWN • Lifestyle factors during early years affect health outcomes in adulthood, particularly in children with low birth weight. • Pre-school stage influences children's body composition and growth. What is new: • This is the first systematic review of observational studies examining the association between childcare and childhood overweight and obesity in preschool children. • 'Informal' care is linked to early introduction to solid foods, less physical activity and obesity.
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A transactional approach to preventing early childhood neglect: The Family Check-Up as a public health strategy.
Dishion, TJ, Mun, CJ, Drake, EC, Tein, JY, Shaw, DS, Wilson, M
Development and psychopathology. 2015;(4 Pt 2):1647-60
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This study examined the hypothesis that a brief, strengths-based home visiting strategy can promote positive engagement between caregiver and child and thereby reduce various forms of early childhood neglect. A total of 731 low-income families receiving services through the Women, Infants, and Children nutritional supplement program were randomized to the Women, Infants, and Children as usual or the Family Check-Up intervention. Assessments and intervention services were delivered in the home environment at ages 2, 3, 4, and 5. During the assessments, staff videotaped caregiver-child interactions and rated various features of the home environment, including the physical appropriateness of the home setting for children. Trained observers later coded the videotapes, unaware of the family's intervention condition. Specific caregiver-child interaction patterns were coded and macroratings were made of the caregiver's affection, monitoring, and involvement with the child. An intention to treat design revealed that randomization to the Family Check-Up increased duration of positive engagement between caregivers and children by age 3, which in turn was prognostic of less neglect of the child at age 4, controlling for family adversity. It was also found that family adversity moderated the impact of the intervention, such that the families with the most adverse circumstances were highly responsive to the intervention. Families with the highest levels of adversity exhibited the strongest mediation between positive engagement and reduction of neglect. Findings are discussed with respect to developmental theory and their potential implications for a public health approach to the prevention of early childhood maltreatment.
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Modeling the Cost Effectiveness of Child Care Policy Changes in the U.S.
Wright, DR, Kenney, EL, Giles, CM, Long, MW, Ward, ZJ, Resch, SC, Moodie, ML, Carter, RC, Wang, YC, Sacks, G, et al
American journal of preventive medicine. 2015;(1):135-47
Abstract
INTRODUCTION Child care facilities influence diet and physical activity, making them ideal obesity prevention settings. The purpose of this study is to quantify the health and economic impacts of a multi-component regulatory obesity policy intervention in licensed U.S. child care facilities. METHODS Two-year costs and BMI changes resulting from changes in beverage, physical activity, and screen time regulations affecting a cohort of up to 6.5 million preschool-aged children attending child care facilities were estimated in 2014 using published data. A Markov cohort model simulated the intervention's impact on changes in the U.S. population from 2015 to 2025, including short-term BMI effects and 10-year healthcare expenditures. Future outcomes were discounted at 3% annually. Probabilistic sensitivity analyses simulated 95% uncertainty intervals (UIs) around outcomes. RESULTS Regulatory changes would lead children to watch less TV, get more minutes of moderate and vigorous physical activity, and consume fewer sugar-sweetened beverages. Within the 6.5 million eligible population, national implementation could reach 3.69 million children, cost $4.82 million in the first year, and result in 0.0186 fewer BMI units (95% UI=0.00592 kg/m(2), 0.0434 kg/m(2)) per eligible child at a cost of $57.80 per BMI unit avoided. Over 10 years, these effects would result in net healthcare cost savings of $51.6 (95% UI=$14.2, $134) million. The intervention is 94.7% likely to be cost saving by 2025. CONCLUSIONS Changing child care regulations could have a small but meaningful impact on short-term BMI at low cost. If effects are maintained for 10 years, obesity-related healthcare cost savings are likely.