A cluster randomised controlled trial of an early childhood parenting programme delivered through early childhood education centres in rural Zimbabwe.

BACKGROUND: Early childhood is a critical period for child development. Effective approaches to support families in low-resource settings in the use of responsive and stimulating parenting are needed. AIM: The aim of this study was to examine the effects of the Reach Up early childhood parenting programme on children's development, parenting attitudes and practices, when delivered through early childhood development (ECD) centres in Zimbabwe. METHODS: A cluster randomised controlled trial was conducted in Sanyati, a rural district in Zimbabwe. Twenty-four of 51 available centres were randomised to intervention (n = 12) or control (n = 12) groups. Sixteen mothers with a child aged 12-30 months were recruited from each centre's catchment area (n = 189 intervention; n = 193 control). The intervention comprised two home visits per month delivered by centre teaching assistants over a period of 27 months. Primary outcomes were child Developmental Quotient (DQ), Language, Eye and Hand coordination, Performance and Practical Reasoning subscale scores assessed at follow-up. Secondary outcomes were mothers' attitudes about child development, parenting practices and maternal depressive symptoms all measured at baseline and follow-up. Intention to treat analyses was conducted using mixed-effects regression models with the standard error adjusted for cluster and inverse proportionality weights to adjust for attrition. Significance was set at P < 0.05. RESULTS: A total of 285 (74.6%) of 382 children enrolled were tested, with 97 children lost to follow-up. The intervention improved the children's DQ by 3.55 points (95% CI 0.82 to 6.28), Eye and Hand by 3.58 (95% CI 0.59 to 6.56) and Practical Reasoning by 4.19 (95% CI 0.96 to 7.42). No significant improvements to Performance or Language scores, parenting attitudes, parenting practices and depressive symptoms were identified. CONCLUSIONS: A home visiting intervention delivered by ECD teaching assistants promoted children's development. This suggests that outreach from preschools may be an effective platform for delivery of parenting interventions.

Acceptability and use of waist-worn physical activity monitors in Jamaican adolescents: lessons from the field.

OBJECTIVE: We report our experience with a validated waist-worn activity monitor in Jamaican adolescents attending urban high schools. Seventy-nine adolescents from the Global Diet and Activity Research (GDAR) study, recruited from 5 urban Jamaican high schools (two coeducational (n = 37), two all-female schools (n = 32) and one all-boys school (n = 10)) were asked to wear Actigraph wGT3X-BT accelerometers for 7 days (24-h), removing the device only when bathing or swimming. They also logged wake up and bed times in an activity diary. Accelerometry was considered valid if at least 4 days with ≥ 10-h monitor wear were recorded. Validity was compared by adolescent demographic and school characteristics. We also reviewed the students' written feedback on objective physical activity measurement. RESULTS: Participants, 80.5% female, had a mean age of 15.5 ± 0.8 years with 60% attending schools in low-income communities. Accelerometer return rates were > 98% with 84% providing valid data. Validity did not vary by age group, sex and school setting. While participants were excited about participating in the accelerometer sub-study, commonly reported challenges included monitor discomfort during sleep and maintaining the study diary. Objective measurement of physical activity using 24-h waist-worn accelerometers is feasible and acceptable in Jamaican adolescents.

Association of Perceived Neighbourhood Walkability with Self-Reported Physical Activity and Body Mass Index in South African Adolescents.

Adolescence is a life stage critical to the establishment of healthy behaviours, including physical activity (PA). Factors associated with the built environment have been shown to impact PA across the life course. We examined the sociodemographic differences in, and associations between, perceived neighbourhood walkability, PA, and body mass index (BMI) in South African adolescents. We recruited a convenience sample (n = 143; 13-18 years; 65% female) of students from three high schools (middle/high and low-income areas). Participants completed a PA questionnaire and the Neighbourhood Environment Walkability Scale (NEWS)-Africa and anthropometry measurements. Multivariable linear regression was used to examine various relationships. We found that, compared with adolescents living in middle/high income neighbourhoods, those living in low-income neighbourhoods had lower perceived walkability and PA with higher BMI percentiles. The associations between neighbourhood walkability and PA were inconsistent. In the adjusted models, land use diversity and personal safety were associated with club sports participation, street connectivity was positively associated with school sports PA, and more favourable perceived walkability was negatively associated with active transport. Overall, our findings suggest that the perceived walkability of lower income neighbourhoods is worse in comparison with higher income neighbourhoods, though the association with PA and BMI is unclear.

A Remote Parenting Program and Parent and Staff Perspectives: A Randomized Trial.

OBJECTIVES: To assess impact and implementation of remote delivery of a parenting program following suspension of in-person visits during the coronavirus disease 2019 pandemic. METHODS: Impact of remote delivery of the Reach Up parenting program on parenting practices was evaluated by randomized trial in Jamaica. Mothers with children aged 5 to 24 months who met 1 of 7 at-risk criteria were enrolled at health centers. Participants were randomly assigned to intervention or control using random number tables generated by a statistician. Intervention comprised a manual for parents with illustrated play activities, phone calls, and short message service messages. The control group received usual care. Parent practices were measured using an adapted Family Care Indicators telephone-administered questionnaire by interviewers unaware of group assignment. Qualitative interviews were conducted with staff and parents in Jamaica and Brazil and staff in Ecuador to identify facilitators and barriers to remote delivery of Reach Up. RESULTS: Two hundred forty-seven participants were assessed at endline (control n = 130; intervention n = 117). Intervention increased parent activities that support child development, effect size 0.34 SD (95% confidence interval 0.03-0.53), and use of praise, odds 2 times higher with intervention. There were no benefits to interactive language or play materials. Qualitative results showed parents appreciated program continuation and felt motivated to help their child, and methods were acceptable to staff. Barriers included poor mobile phone access, difficulty contacting parents, and feedback limitations without in-person contact. CONCLUSIONS: Remote delivery methods have potential to contribute to scaling of parenting programs.

The Reach Up Parenting Program, Child Development, and Maternal Depression: A Meta-analysis.

BACKGROUND AND OBJECTIVES: Evidence is needed on effective approaches to build parents' ability to promote child development feasible in low- and middle-income countries. Our objective was to synthesize impact of the Reach Up early childhood parenting program in several low- and middle-income countries and examine moderation by family and implementation characteristics. METHODS: Systematic search using PubMed and Academic Search Elite/EBSCO Host. Randomized controlled trials of the Reach Up program from 1985 to February 2022 were selected. Data were extracted by 2 independent researchers. Primary outcomes were child cognitive, language, and motor development. Secondary outcomes were home stimulation and maternal depressive symptoms. We synthesized pooled effect sizes using random effect inverse-variance weighting and effect modification by testing pooled subgroup effect estimates using the χ2 test for heterogeneity. RESULTS: Average effect size across 18 studies ranged from 0.49 (95% confidence interval [CI] 0.32 to 0.66) for cognition, 0.38 (CI 0.24 to 0.51) for language, 0.27 (CI 0.13 to 0.40) for motor development, 0.37 (CI 0.21 to 0.54) for home stimulation, and -0.09 (CI -0.19 to 0.01) for maternal depressive symptoms. Impacts were larger in studies targeted to undernourished children, with mean enrollment older than age 12 months and intervention duration 6 to 12 months. Quality of evidence assessed with the Cochrane Assessment of Risk of Bias and GRADE system was moderate. Instruments used to assess child development varied. In moderator analyses, some subgroups included few studies. CONCLUSIONS: Reach Up benefits child development and home stimulation and is adaptable across cultures and delivery methods. Child and implementation characteristics modified the effects, with implications for scaling.

Are Benefits From a Parenting Intervention Delivered Through the Health Services Sustainable? Follow-Up of a Randomized Evaluation in Jamaica.

OBJECTIVE: An innovative low-cost parenting intervention, implemented through health services in Jamaica showed benefits to children's cognitive development at 18 months and parent's attitudes concerning childcare. We assessed the impact of the intervention on child and parent outcomes at 6 years of age. METHODS: A cluster randomized trial of 2 parenting interventions was conducted through 20 health centers in Jamaica. Interventions were implemented from age 3 to 18 months and each intervention benefited cognitive development at 18 months (effect size 0.34-0.38 standard deviation). Children were reassessed at 6 years (n = 262, 80.1% of those assessed at 18 months) to determine any benefits to cognition, behavior, and parenting behavior. Loss to follow-up was not significantly different by treatment. Inverse probability weighting and Lee bounds were used to adjust for loss to follow-up, and multilevel regression analyses conducted with random effects at the health center level. RESULTS: There were no significant benefits to any child outcomes at age 6 years or to parenting behavior. Results are robust using the wild cluster bootstrap procedure and using Lee bounds for attrition. The initial trial benefits were reproduced with the current sample and methods. CONCLUSION: Lack of sustained benefits may be related to the initial effect size and low intensity of the intervention that ended very young at age 18 months. It may also be related to lack of initial impact on home environment and fade-out of effects in a country with near universal preschool. The findings have implications for intervention design and targeting.

Adolescent Levers for a Diet and Physical Activity Intervention Across Socioecological Levels in Kenya, South Africa, Cameroon, and Jamaica: Mixed Methods Study Protocol.

BACKGROUND: The increasing burden of noncommunicable diseases that are prevalent in low- and middle-income countries (LMICs) is largely attributed to modifiable behavioral risk factors such as unhealthy diets and insufficient physical activity (PA). The adolescent stage, defined as 10 to 24 years of age, is an important formative phase of life and offers an opportunity to reduce the risk of noncommunicable diseases across the life course and for future generations. OBJECTIVE: The aim of this paper is to describe a protocol for a study using a convergent mixed methods design to explore exposures in the household, neighborhood, school, and the journey from home to school that may influence diet and PA behaviors in adolescents from LMICs. METHODS: Male and female adolescents (n≥150) aged between 13 and 24 years will be recruited from selected high schools or households in project site countries to ensure the socioeconomic diversity of perspectives and experiences at the individual, home, and neighborhood levels. The project will be conducted at 5 sites in 4 countries: Kenya, Cameroon, Jamaica, and South Africa (Cape Town and Johannesburg). Data on anthropometric measures, food intake, and PA knowledge and behavior will be collected using self-report questionnaires. In addition, a small number of learners (n=30-45) from each site will be selected as citizen scientists to capture data (photographs, audio notes, text, and geolocations) on their lived experiences in relation to food and PA in their homes, the journey to and from school, and the school and neighborhood environments using a mobile app, and for objective PA measurements. In-depth interviews will be conducted with the citizen scientists and their caregivers to explore household experiences and determinants of food intake and foodways, as well as the PA of household members. RESULTS: The study described in this protocol paper was primarily funded through a UK National Institute for Health Research grant in 2017 and approved by the relevant institutional ethics review boards in the country sites (South Africa, Cameroun, and Jamaica in 2019, and Kenya in 2020). As of December 23, 2020, we had completed data collection from adolescents (n≥150) in all the country sites, except Kenya, and data collection for the subgroup (n=30-45) is ongoing. Data analysis is ongoing and the output of findings from the study described in this protocol is expected to be published by 2022. CONCLUSIONS: This project protocol contributes to research that focuses on adolescents and the socioecological determinants of food intake and PA in LMIC settings. It includes innovative methodologies to interrogate and map the contexts of these determinants and will generate much-needed data to understand the multilevel system of factors that can be leveraged through upstream and downstream strategies and interventions to improve health outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/26739.

Implementation of Reach Up early childhood parenting program: acceptability, appropriateness, and feasibility in Brazil and Zimbabwe.

Young children need nurturing care, which includes responsive caregiver-child interactions and opportunities to learn. However, there are few extant large-scale programs that build parents' abilities to provide this. We have developed an early childhood parenting training package, called Reach Up, with the aim of providing an evidence-based, adaptable program that is feasible for low-resource settings. Implementation of Reach Up was evaluated in Brazil and Zimbabwe to inform modifications needed and identify challenges that implementers and delivery agents encountered. Interview guides were developed to collect information on the program's appropriateness, acceptability, and feasibility from mothers, home visitors, and supervisors. Information on adaptation was obtained from country program leads and Reach Up team logs, as well as quality of visits from observations conducted by supervisors. The program was well accepted by mothers and visitors, who perceived benefits for the children; training was viewed as appropriate, and visitors felt well-prepared to conduct visits. A need for expansion of supervisor training was identified and the program was feasible to implement, although challenges were identified, including staff turnover; implementation was less feasible for staff with other work commitments (in Brazil). However, most aspects of visit quality were high. We conclude that the Reach Up program can expand capacity for parenting programs in low- and middle-income countries.