Aisha K. Yousafzai

Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries

This report is the second in a Series on early child development in low-income and middle-income countries and assesses the effectiveness of early child development interventions, such as parenting support and preschool enrolment. The evidence reviewed suggests that early child development can be improved through these interventions, with effects greater for programmes of higher quality and for the most vulnerable children. Other promising interventions for the promotion of early child development include childrens educational media, interventions with children at high risk, and combining the promotion of early child development with conditional cash transfer programmes. Effective investments in early child development have the potential to reduce inequalities perpetuated by poverty, poor nutrition, and restricted learning opportunities. A simulation model of the potential long-term economic effects of increasing preschool enrolment to 25% or 50% in every low-income and middle-income country showed a benefit-to-cost ratio ranging from 6·4 to 17·6, depending on preschool enrolment rate and discount rate.

Nurturing care: promoting early childhood development.

The UN Sustainable Development Goals provide a historic opportunity to implement interventions, at scale, to promote early childhood development. Although the evidence base for the importance of early childhood development has grown, the research is distributed across sectors, populations, and settings, with diversity noted in both scope and focus. We provide a comprehensive updated analysis of early childhood development interventions across the five sectors of health, nutrition, education, child protection, and social protection. Our review concludes that to make interventions successful, smart, and sustainable, they need to be implemented as multi-sectoral intervention packages anchored in nurturing care. The recommendations emphasise that intervention packages should be applied at developmentally appropriate times during the life course, target multiple risks, and build on existing delivery platforms for feasibility of scale-up. While interventions will continue to improve with the growth of developmental science, the evidence now strongly suggests that parents, caregivers, and families need to be supported in providing nurturing care and protection in order for young children to achieve their developmental potential.

Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial

BACKGROUND Stimulation and nutrition delivered through health programmes at a large scale could potentially benefit more than 200 million young children worldwide who are not meeting their developmental potential. We investigated the feasibility and effectiveness of the integration of interventions to enhance child development and growth outcomes in the Lady Health Worker (LHW) programme in Sindh, Pakistan. METHODS We implemented a community-based cluster-randomised effectiveness trial through the LHW programme in rural Sindh, Pakistan, with a 2 × 2 factorial design. We randomly allocated 80 clusters (LHW catchments) of children to receive routine health and nutrition services (controls; n=368), nutrition education and multiple micronutrient powders (enhanced nutrition; n=364), responsive stimulation (responsive stimulation; n=383), or a combination of both enriched interventions (n=374). The allocation ratio was 1:20 (ie, 20 clusters per intervention group). The data collection team were masked to the allocated intervention. All children born in the study area between April, 2009, and March, 2010, were eligible for enrolment if they were up to 2·5 months old without signs of severe impairments. Interventions were delivered by LHWs to families with children up to 24 months of age in routine monthly group sessions and home visits. The primary endpoints were child development at 12 and 24 months of age (assessed with the Bayley Scales of Infant and Toddler Development, Third Edition) and growth at 24 months of age. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT007159636. FINDINGS 1489 mother-infant dyads were enrolled into the study, of whom 1411 (93%) were followed up until the children were 24 months old. Children who received responsive stimulation had significantly higher development scores on the cognitive, language, and motor scales at 12 and 24 months of age, and on the social-emotional scale at 12 months of age, than did those who did not receive the intervention. Children who received enhanced nutrition had significantly higher development scores on the cognitive, language, and social-emotional scales at 12 months of age than those who did not receive this intervention, but at 24 months of age only the language scores remained significantly higher. We did not record any additive benefits when responsive stimulation was combined with nutrition interventions. Responsive stimulation effect sizes (Cohens d) were 0·6 for cognition, 0·7 for language, and 0·5 for motor development at 24 months of age; these effect sizes were slightly smaller for the combined intervention group and were low to moderate for the enhanced nutrition intervention alone. Children exposed to enhanced nutrition had significantly better height-for-age Z scores at 6 months (p<0·0001) and 18 months (p=0·02) than did children not exposed to enhanced nutrition. Longitudinal analysis showed a small benefit to linear growth from enrolment to 24 months (p=0·026) in the children who received the enhanced nutrition intervention. INTERPRETATION The responsive stimulation intervention can be delivered effectively by LHWs and positively affects development outcomes. The absence of a major effect of the enhanced nutrition intervention on growth shows the need for further analysis of mediating variables (eg, household food security status) that will help to optimise future nutrition implementation design. FUNDING UNICEF.

Global Health and Development in Early Childhood

Health and nutritional risks co-occur in the lives of children under the age of 2 years who live in developing countries. We review evidence showing how these risks, in addition to inadequate psychosocial stimulation, prevent children from developing expected cognitive and language abilities. A systematic review and meta-analysis of 21 interventions aimed at enhancing stimulation and 18 interventions that provided better nutrition--all conducted since 2000--revealed that stimulation had a medium effect size of 0.42 and 0.47 on cognitive and language development, respectively, whereas nutrition by itself had a small effect size of 0.09. The implementation processes of these interventions are described and compared. A number of unresolved issues are outlined and discussed, including ways to maximize parental health behavior change, assess mediators that account for intervention effects, and expand the assessment of young childrens brain functions that underlie language and cognition and are affected by nutrition and stimulation.

HIV/AIDS and disability: Differences in HIV/AIDS knowledge between deaf and hearing people in Nigeria

Purpose. Studies both in North America and Europe have found that deaf individuals lack access to AIDS information, due to problems in communication, low literacy and tightly woven social networks within the deaf community. However few comparable studies are available from countries in the Developing World. The present study was undertaken in Nigeria where there is an estimated adult HIV prevalence rate of 5.4%. We sought to compare HIV knowledge among deaf and hearing individuals in order to identify how effectively deaf members of the community are being reached by HIV/AIDS messages. Methods. A survey comparing knowledge about HIV/AIDS among deaf and hard of hearing adolescents (n = 50) and young adults (n = 50) was undertaken. Results. Significant differences (p < 0.05) in levels of understanding about certain aspects of how AIDS is spread were identified as well as differences in available resources for access to accurate information among deaf members of the population. Conclusion. These findings from Nigeria speak strongly to the need for the development of interventions that include people with disabilities in public health and HIV/AIDS strategies and that address their specific vulnerabilities. Evaluating the adaptation of education material and the inclusion of the deaf population in HIV awareness programmes is an urgent ‘next step.’

Knowledge, personal risk and experiences of HIV/AIDS among people with disabilities in Swaziland

Although there has been research focused on the disabling consequences of HIV/AIDS, there has been very little documented information about HIV/AIDS for individuals with disability prior to infection. There is evidence to suggest that people with disabilities face inequalities in accessing health information and services. The aim of this study was to explore whether disabled and non-disabled young adults in Swaziland perceive HIV/AIDS similarly. A qualitative study using focus-group discussions was conducted. Four focus groups were conducted with a total of 56 non-disabled adults (aged 16–29 years) and four focus groups were conducted with a total of 32 adults with either a physical or hearing disability (aged 18–32 years). The focus-group schedule explored knowledge about HIV/AIDS, personal risk and experiences of health-seeking practices. Information and awareness about HIV/AIDS was good in both rural and urban areas among the non-disabled participants, who obtained their information from a wide range of sources. In contrast, participants with disability, who obtained information about HIV/AIDS from a limited range of sources, lacked knowledge about HIV/AIDS and were misinformed about modes of transmission. Women with disabilities described experiences of sexual exploitation and abuse, which was perceived to be higher among disabled women than their non-disabled peers; they felt this was because disabled women were perceived to be ‘free’ from the HIV virus by non-disabled men. Further research is necessary to enable HIV/AIDS programmes to address the specific needs of people with disabilities.

Review of implementation processes for integrated nutrition and psychosocial stimulation interventions

This article reviews the implementation processes for interventions that integrate nutrition and psychosocial stimulation for children under 5 years of age in low‐ and middle‐income countries. We examine the content of these programs, the delivery strategy, intensity and duration, personnel training and supervision, compliance, and fidelity. A systematic search of the Global Health Ovid database yielded 1020 articles, of which 29 fit the criteria, and two further studies recently completed were reported by author communication. Some of these articles describe efficacy or effectiveness studies where nutritional supplements or education along with psychosocial stimulation experiences or education were delivered directly to children or their caregivers. Other papers describe large‐scale programs, such as conditional cash transfers in Latin America, Integrated Child Development Services preschools in India, and World Bank collaborations with national governments in Africa. A summary table of the implementation processes of the 31 programs is included. We conclude with a set of recommendations summarizing what we know so far regarding best practices for integrative programs.

HIV/AIDS information and services: The situation experienced by adolescents with disabilities in Rwanda and Uganda

Purpose. The study had 2 aims: (1) To explore whether knowledge about HIV and AIDS was similar among adolescents with disabilities compared with their non-disabled peers; and (2) To determine factors which may increase vulnerability of disabled adolescents to HIV infection and/or inappropriate access to HIV related services. Method. A qualitative study using focus group discussions and semi-structured interviews was conducted with purposefully selected participants in Rwanda and Uganda. The participants included disabled adolescents, non-disabled adolescents, parents, teachers, members of disabled peoples organisations and representatives of HIV/AIDS organisations. Interviews explored issues of HIV/AIDS knowledge, access to HIV/AIDS services and perceptions of personal risk. Results. Barriers preventing adequate access to information about HIV and AIDS experienced by adolescents with disabilities depended on the nature and severity of the impairment. For example, parents and health workers were unable to communicate with deaf adolescents using sign language, adolescents with physical impairments were often unable to access community meetings about HIV and print material was not adapted for those with visual impairments. Further, assumptions by health workers and community members that people with disabilities were not sexually active lead to the marginalisation of disabled people from HIV services. Adolescents with disability described low self esteem and issues of self efficacy affecting control of safer sexual relationships. A high level of targeted abuse, rape and exploitation was reported leading to vulnerability among this population. Conclusion. The impact of the HIV epidemic among people with disabilities is a neglected area. This study supports the need to develop strategies in HIV prevention programmes that include people with disabilities.

Feeding difficulties in disabled children leads to malnutrition: experience in an Indian slum

The aim of the present study was to explore the nature, extent and probable causes of nutritional deficiencies among children with disabilities living in Dharavi, a slum in Mumbai, India. A cross-sectional study was conducted to investigate whether the nutritional status of children with disabilities, aged 2-6 years (n 141), was worse than that of non-disabled sibling controls (n 122) and neighbour controls (n 162). Data on food patterns, anthropometry, micronutrient status and feeding difficulties reported by parents were collected. The mean weight for age of the children with disabilities (-2.44 (SD 1.39) Z scores; n 120) was significantly lower (P<0.05) compared with the sibling (-1.70 (SD 1.20) Z scores; n 109) and neighbour (-1.83 (SD 1.290) Z scores; n 162) control groups. The children with disabilities had significantly lower (P<0.05) mean haemoglobin levels (92 (SD 23) g/l; n 134) compared with siblings (102 (SD 18) g/l; n 103) and neighbours (99 (SD 18) g/l; n 153). Relative risk (RR) analysis indicated that the disabled children with feeding difficulties were significantly more likely (P<0.05) to be malnourished, by the indicator of weight for age (RR 1.1; 95 % CI 1.08, 1.20) compared with the disabled children without a feeding difficulty. They were also significantly more likely to be malnourished using the indicators of height for age (RR 1.3; 95 % CI 1.19, 1.43) and weight for height (RR 2.4; 95 % CI 1.78, 3.23) compared with the disabled children without a feeding difficulty. Feeding difficulties were identified as a risk factor for vulnerability to inadequate nutritional status among children with disabilities.

Moving beyond prevalence studies: screening and interventions for children with disabilities in low-income and middle-income countries

Research understanding the lives of children with disabilities in low-income and middle-income countries has predominantly focused on prevalence studies with little progress on evidence-based service development. At the same time, global attention in child health has shifted from child survival strategies to those that bring child survival and development together. This review examines whether intervention research can be better aligned with current theoretical constructs of disability and international guidelines that advocate for the realisation of rights for children with disabilities and inclusive early childhood development.