Workforce preparation for delivery of nurturing care in low- and middle-income countries: Expert consensus on critical multisectoral training needs.

BACKGROUND: Services to support nurturing care through early childhood development (ECD) in low- and middle-income countries are hampered by significant workforce challenges. The global early childhood workforce is both diverse and complex, and it supports the delivery of a wide range of services in extremely diverse geographical and social settings. In the context of contemporary global goals for the universal provision of quality early childhood provision, there is an urgent need to build appropriate platforms for strengthening and supporting this workforce. However, the evidence base to support this work is severely limited. METHODS: To contribute to evidence on how to strengthen the ECD workforce in low- and middle-income countries, this study used a Delphi methodology involving three rounds of data collection with 14 global experts, to reach consensus on the most critical training needs of three key early childhood workforce groups: (i) health; (ii) community-based paraprofessionals, and (iii) educational professionals working across ECD programmes. RESULTS: The study identified a comprehensive set of shared, as well as distinct, training needs across the three groups. Shared training needs include the following: (i) nurturing dispositions that facilitate work with children and families in complex settings; (ii) knowledge and skills to support responsive, adaptable delivery of ECD programmes; and (iii) systems for ECD training and professional pathways that prioritise ongoing mentoring and support. CONCLUSIONS: The study's detailed findings help to address a critical gap in the evidence on training needs for ECD workers in low-resource contexts. They provide insights into how to strengthen content, systems, and methods of training to support intersectoral ECD work in resource-constrained contexts.

Early-life family and school impacts on adolescent conduct problems: A path analysis.

Limited research has been conducted to examine the factors during early childhood that may contribute to conduct problems in later stages of life. This study aimed to investigate the relationship between family and school environments during early childhood and conduct problems in adolescence. In Wave 1 (W1), the study recruited 502 participants, aged 5-6 years, from Hong Kong local kindergartens, with 51.4% boys. One of their parents provided information about family socioeconomic status (SES), parent-child recreational activities, and child screen time, whereas the class teacher rated their school readiness using the Chinese version of the Early Development Instrument. Data on the number of special facilities were obtained from the kindergartens. In Wave 2 (W2), the same parents of 395 participants were asked about their involvement in their children's education. Finally, in Wave 3 (W3), the parents of 206 participants completed the Conduct Problem scale of the Strength and Difficulties Questionnaire to evaluate the level of conduct problems in the participants. The results of the path analysis revealed that higher W1 family SES was associated with fewer W3 conduct problems through an increase in W1 and W2 parental involvement in children's learning and play activities. Findings have implications for understanding the impact of early-life family and school environments on adolescent conduct problems. Early childhood interventions that promote family resources and positive parent-child interactions have the potential to reduce adolescent conduct problems.

Family play, reading, and other stimulation and early childhood development in five low-and-middle-income countries.

This paper used longitudinal data from five studies conducted in Bangladesh, Bhutan, Cambodia, Ethiopia, and Rwanda to examine the links between family stimulation and early childhood development outcomes (N = 4904; Mage = 51.5; 49% girls). Results from random-effects and more conservative child-fixed effects models indicate that across these studies, family stimulation, measured by caregivers' engagement in nine activities (e.g., reading, playing, singing), predicted increments in children's early numeracy, literacy, social-emotional, motor, and executive function skills (standardized associations ranged from 0.05 to 0.11 SD). Study-specific models showed variability in the estimates, with null associations in two out of the five studies. These findings indicate the need for additional research on culturally specific ways in which caregivers may support early development and highlight the importance of promoting family stimulation to catalyze positive developmental trajectories in global contexts. RESEARCH HIGHLIGHTS: Research on the links between family stimulation and early childhood development in low-and-middle-income countries (LMICs) is limited. We used longitudinal data from studies conducted in five LMICs to examine the links between family stimulation and early childhood development outcomes. Results suggest that family stimulation predicted increments in children's numeracy, literacy, social-emotional, motor, and executive function skills. We found variability in the observed estimates, with null associations in two out of the five studies, suggesting the need for additional research in LMICs.

Reliability and Validity of the East Asia-Pacific Early Child Development Scales: A Longitudinal Validation Study in China.

This study examined the test-retest reliability and predictive validity of the East Asia-Pacific Early Child Development Scales (EAP-ECDS) Short Form. In China, preschools typically provide children with educational activities in age-segregated classrooms - Kindergarten Level 1 (K1) (3 to 4 years), Kindergarten Level 2 (K2) (4 to 5 years), and Kindergarten Level 3 (K3) (5 to 6 years). A total of 709 children in K2 (Mage = 57.85 months, SD = 4.77) were randomly selected from 29 kindergartens in Shanghai municipality and Guizhou province of China. Children were assessed using the EAP-ECDS in K2 and K3. School readiness was assessed in K3, and literacy and mathematics achievement were assessed in Grade 2. Pearson's correlation coefficient and intraclass correlation coefficient (ICC = 0.73) indicated that the tool had good test-retest reliability across K2 and K3. Regarding predictive validity, K2 EAP-ECDS predicted K3 school readiness (ß = 0.26), Grade 2 language and literacy (ß = 0.18) and mathematics (ß = 0.22) after adjusting for age, gender, socioeconomic status, and region. Findings support using the tool to measure the holistic development of preschool-aged children in China and the region.

Vulnerability and resilience in children during the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic is having a profound impact on the health and development of children worldwide. There is limited evidence on the impact of COVID-19 and its related school closures and disease-containment measures on the psychosocial wellbeing of children; little research has been done on the characteristics of vulnerable groups and factors that promote resilience. METHODS: We conducted a large-scale cross-sectional population study of Hong Kong families with children aged 2-12 years. Parents completed an online survey on family demographics, child psychosocial wellbeing, functioning and lifestyle habits, parent-child interactions, and parental stress during school closures due to COVID-19. We used simple and multiple linear regression analyses to explore factors associated with child psychosocial problems and parental stress during the pandemic. RESULTS: The study included 29,202 individual families; of which 12,163 had children aged 2-5 years and 17,029 had children aged 6-12 years. The risk of child psychosocial problems was higher in children with special educational needs, and/or acute or chronic disease, mothers with mental illness, single-parent families, and low-income families. Delayed bedtime and/or inadequate sleep or exercise duration, extended use of electronic devices were associated with significantly higher parental stress and more psychosocial problems among pre-schoolers. CONCLUSIONS: This study identifies vulnerable groups of children and highlights the importance of strengthening family coherence, adequate sleep and exercise, and responsible use of electronic devices in promoting psychosocial wellbeing during the COVID-19 pandemic.

Parent Technology Use, Parent-Child Interaction, Child Screen Time, and Child Psychosocial Problems among Disadvantaged Families.

OBJECTIVE: To disentangle the pathways of parent technology use, parent-child interactions, child screen time, and child psychosocial difficulties among disadvantaged families in Hong Kong. STUDY DESIGN: Parents of 1254 3-year-old children from the KeySteps@JC project reported on the number of hours their children used electronic devices every day and evaluated their children's psychosocial behaviors using the Strengths and Difficulties Questionnaire. These parents also reported on their own digital device usage patterns and the frequency of parent-child interactions and provided sociodemographic data. Structural models were tested with parent technology use (independent variable), parent technological distractions and parent-child interactions and child screen time (mediators), child psychosocial problems (dependent variable), and children's age and sex and family socioeconomic status index (confounding variables). RESULTS: Parent distraction with technology during parent-child interactions completely mediated the overall association between parent problematic digital technology use and child screen use duration. Parent problematic digital technology use was positively and directly associated with child psychosocial difficulties. In addition, it was indirectly related to child psychosocial difficulties through technological distractions and reductions in parent-child interactions and increased media use by children. CONCLUSION: Higher parent digital technology usage was associated with reduced parent-child interactions and increased child screen time and psychosocial difficulties in disadvantaged families. These results suggest that limiting parents' use of electronic devices in front of their young children could be beneficial for childhood psychosocial development.

Early sleep deprivation and attention-deficit/hyperactivity disorder.

BACKGROUND: This study aims to study prospectively specific sleep patterns and risk of ADHD after adjusting for potential confounders such as obstructive sleep apnoea (OSA) and methylphenidate use. METHODS: A population-representative sample of 514 Chinese preschool children was recruited when in kindergarten (K3). Parents reported on their socioeconomic status and children's sleep duration. The cohort was reassessed 3 years later when the children were in Grade 3 (P3). Parents reported on children's sleep patterns and ADHD symptoms. Information on OSA diagnosis and methylphenidate use was retrieved from health records. RESULTS: Among the 514 parent-child dyads (mean [SD] age, 5.52 [0.33] years), 411 were reassessed (80.0% retention; 9.35 [0.33] years) at follow-up. There were no significant baseline differences between follow-up and drop-out groups. A gradient relationship was observed between probable ADHD in P3 and sleep duration in K3. The risk of probable ADHD was 15.5 per 100 for children with <8 h of sleep in K3, whereas it was 1.1 per 100 for children with 11-12 h of sleep in K3. The adjusted risk ratio was 14.19 (p = 0.02). CONCLUSIONS: Sleep deprivation in early childhood is associated with higher risk of ADHD in middle childhood.

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.

Sleep Duration and School Readiness of Chinese Preschool Children.

OBJECTIVES: To examine the average sleep duration in Chinese preschoolers and to investigate the association between sleep duration and school readiness. STUDY DESIGN: This is a cross-sectional study that included 553 Chinese children (mean age = 5.46 years) from 20 preschools in 2 districts of Hong Kong. Average daily sleep duration in the last week was reported by parents and school readiness as measured by the teacher-rated Chinese Early Development Instrument (CEDI). RESULTS: Most Chinese preschoolers had 9-10 hours of sleep per day. Only 11% of preschoolers had the recommended 11-12 hours of sleep per day. This group was associated with more "very ready" CEDI domains. Sleep deprivation (≤7 hours per day) was associated with a lower CEDI total score, lower scores in the emotional maturity and language/cognitive domain, and prosocial behaviors subdomain but a greater score in the hyperactivity/inattention subdomain. Children with a lower family socioeconomic index, lower maternal education level, infrequent parent-child interactions, and who used electronic devices for more than 3 hours per day had shortened sleep durations. CONCLUSIONS: Optimal sleep duration was associated with better school readiness in preschool children, whereas sleep deprivation was associated with lower school readiness, more hyperactivity and inattention, and less prosocial behavior.

The Power of Research and Stakeholder Collaboration in Enhancing Early Childhood Care and Education in Low- and Middle-Income Countries.

The early years of a child's life are crucial in laying the foundations of learning and development that shape life trajectories [...].

Longitudinal associations between child discipline methods and physical growth patterns across preschool years.

OBJECTIVE: Research has documented the associations of child maltreatment with a range of physical health problems, but little is known about the physical growth patterns of children who experience maltreatment in early childhood. This study aimed to examine the association between various discipline approaches and physical growth in preschool-aged children. METHODS: In the first year of preschool, parents of 661 Chinese preschool-aged children completed a questionnaire with items pertaining to the frequency of using physical maltreatment, psychological aggression, neglect, and nonviolent discipline toward the child. Children's weight and height were assessed annually using direct assessment in the first and two subsequent years. Longitudinal analyses were performed using multiple regression models. RESULTS: More frequent neglect and psychological aggression during the first year of preschool were associated with a higher likelihood of a decreased BMI z score in subsequent years. Conversely, increased experience of physical maltreatment in the first year was associated with an increased likelihood of having overweight or obesity in the third year. CONCLUSIONS: Results indicate that early maltreatment experience can impact physical growth. This highlights the importance of preventing abusive parenting and encouraging healthy habits in young children who have experienced maltreatment to decrease their future risk for weight problems.

Validation study of the Chinese Early Development Instrument (CEDI).

BACKGROUND: The Early Development Instrument (EDI) is a comprehensive instrument used to assess school readiness in preschool children. This study was carried out to evaluate the psychometric properties of the Chinese version of the EDI (CEDI) in Hong Kong. METHODS: One hundred and sixty-seven children were purposefully sampled from kindergartens in two districts with very different socioeconomic statuses. The CEDI was assessed for concurrent validity, internal consistency and test-retest reliability. The developmental vulnerability identified using the CEDI scores was further examined in relation to the socioeconomic status of the district and family. RESULTS: The CEDI displayed adequate internal consistency, with Cronbach's alphas ranging from 0.70 to 0.95 on its five domains. Concurrent validity was supported by moderate and significant correlations (0.25 to 0.49) on the relevant domains between the CEDI and a comparable measure. The level of test-retest reliability was good, with a kappa statistic of 0.89. In general, girls outperformed boys, particularly in the social, emotional and communication/general knowledge domains. After controlling for the uneven distribution of sex, children from socioeconomically disadvantaged districts and families were found to be at greater risk of developmental vulnerability than their more advantaged counterparts. CONCLUSION: The evidence gathered in this study supports the CEDI's use as a valid and reliable instrument in assessing school readiness and identifying developmentally vulnerable children in Chinese populations. Its preliminary findings on the socioeconomic gradients of child development suggest that the CEDI is a promising tool for leveraging evidence-based, context-sensitive policies and practices to foster the development of all children.

Preschool experiences and home learning environments of migrant children in urban China.

Internal migration and urban expansion, hallmarks of rapid urbanization in China, have led to an increasing number of children with diverse backgrounds in cities. Cities now include migrants from rural and urban areas, and children from "urban villages" in addition to "urban locals". Parents of young children who migrate from rural to urban areas leave their children behind in rural areas ("left-behind" children) or take them along with them. In recent years, increasing parental migration from one urban area to another has also led to children being "left-behind" in urban areas. This study examined the preschool experiences and home learning environments of rural-origin migrants, urban-origin migrants, and rural-origin locals in comparison to urban locals, leveraging data from the nationally representative China Family Panel Studies (2012-2018) with 2,446 3- to 5-year-olds residing in urban areas. Regression model results indicated that children living in cities who held a rural household registration certificate (hukou) were less likely to attend publically funded preschools and experienced less stimulating home learning environments than urban local children. After controlling for family characteristics (i) rural-origin locals remained less likely to participate in preschool and experienced fewer home learning activities than urban locals; and (ii) there were no differences in preschool experiences and home learning environments between rural-origin migrants and urban locals. Mediation analyses suggested that the relation between hukou status and the home learning environment was mediated by parental absence. Implications of the findings are discussed.

Associations between parental well-being and early learning at home before and during the COVID-19 pandemic: observations from the China Family Panel Studies.

Background: COVID-19-related lockdowns and preschool closures resulted in many young children spending all their time at home. Some parents had to manage child care while working from home, and increased demands may have led them to experience considerable stress. Evidence indicates that among parents with young children, those who had pre-existing mental and physical conditions adapted less well than other parents. We considered associations between parental well-being and the home learning environment for young children. Method: We leveraged data from the nationally representative China Family Panel Studies. We analyzed longitudinal data collected before (2018) and during (2020) the pandemic. Participants were parents of 1,155 preschoolers (aged 3-5 years in 2020). Moderated mediation models were conducted. Maternal and paternal psychological well-being, depression, physical health, and physical illness in 2018 and 2020 were predictors. The frequency of marital and intergenerational conflicts in 2020 were mediators. Primary caregiver-reported engagement in home learning activities and family educational expenditure and parent-reported time spent on child care in 2020 were outcome variables. The number of COVID-19 cases in each province 3 months before the 2020 assessment was the moderator. Child, parental, and household characteristics and urbanicity were covariates. Results: Controlling for covariates, improvements in parental psychological well-being predicted more home learning activities and increases in paternal depression predicted less time spent by fathers on child care. Negative changes in maternal physical health predicted less family educational expenditure and mothers spending more time on child care. Family conflicts mediated the association between maternal physical illness in 2018 and family educational expenditure. The number of COVID-19 cases in a province (i) was positively associated with mothers spending more time on child care, (ii) moderated the association of improvements in maternal physical health and mothers spending less time on child care, and (iii) moderated the association of family conflicts and more family educational expenditure. Conclusion: The findings indicate that decreased parental psychological and physical well-being foretells reductions in monetary and non-monetary investment in early learning and care at home. Regional pandemic risk undermines maternal investment in early learning and care, especially for those with pre-existing physical conditions.

Promoting Equity in Access to Quality Early Childhood Education in China.

This paper reviews the Chinese government's efforts and progress towards ensuring equitable access to quality early childhood education (ECE). It begins with an overview of the Chinese context and analysing the reasons for a policy focus on ECE in recent decades. Thereafter, from a historical perspective, it critically reviews policies pertaining to enhancing access to and the quality of ECE in China since 2010. Nationally representative data are used to document policy implementation. Our analyses of national policies and representative data suggest that the state considers ECE a public good. This is evident from policy changes, efforts to bridge urban-rural disparities, fiscal allocations to the most economically disadvantaged groups, and strategies to enhance the quality of ECE.A significant focus on policy implementation with improved regulation and monitoring of services provided by both state and non-state actors was found. However, it is evident that gaps persist between urban and rural areas regarding infrastructure and resourcing, gross enrolment rates, and teacher-child ratios. That stated, the momentum that has driven policy change and the dramatic gains demonstrates the priority accorded to ECE.

Digital Technology Use and Adolescent Mental Health Before and During the COVID-19 Pandemic: The Roles of Internet Addiction and Digital Competence.

This study examined whether Internet addiction (IA) and digital competence (DC) mediated the association between digital technology use and mental health problems in adolescents before and during the COVID-19 pandemic, when digital device use increased dramatically. Repeated cross-sectional data from a 3-year cross-cohort study adopting stratified random sampling were analyzed. In 2019, 569 adolescents (female = 312) from 14 secondary schools completed a DC assessment and an online survey on their digital technology use, IA, and mental health. In 2021, 775 adolescents (female = 397) from 11 of those 14 schools completed both instruments. Results showed that adolescents in 2021 spent more time using digital devices, were more digitally competent, and reported more mental health problems than adolescents in 2019. The prevalence of IA was 8 percent in 2019 and 12.4 percent in 2021. In both years, more frequent digital technology use predicted a higher risk of IA, which was associated with more mental health problems (indirect ß = 0.08, p < 0.001 for 2019 and ß = 0.05, p < 0.001 for 2021). In addition, in 2021, DC was positively associated with digital technology use and negatively with IA, which indirectly related to fewer mental health problems (indirect ß = -0.01, p = 0.03). In conclusion, DC is a protective factor alleviating the positive associations of digital technology use and IA with mental health problems in adolescents when the ecological context requires high levels of digital device use.

Role of osteopontin in oral epithelial dysplasia, oral submucous fibrosis and oral squamous cell carcinoma.

Background: Inflammatory cells and cytokines in the chronically injured mucosa promote fibrosis in the oral submucous fibrosis (OSF) fibrotic milieu. Osteopontin (OPN) is a wound-healing mediator that upregulates the inflammatory response and is involved in the malignancy and fibrosis of multiple organ systems. Objectives: We investigated the expression of OPN in oral potentially malignant disorders (OPMDs) and oral squamous cell carcinomas (OSCCs) to determine its role in the malignant transformation and fibrosis of oral tissues. The expression of OPN in OPMDs and OSCCs was compared and correlated, and the role of OPN as a fibrotic mediator in OSF was explained. Study Design: A total of 30 cases of normal mucosa and OPMDs (mild dysplasia, severe dysplasia, OSF and OSCCs) were studied by purposive sampling. In these groups, OPN immunoreactivity was examined and correlated with clinical findings. Results: In mild dysplasia, OPN expression was restricted to the basal cell layer with moderate staining intensity. In severe dysplasia, it was extremely intense and extended throughout the epithelium. In the OSF, OPN expression was moderate in the perinuclear areas of the basal cell layer. The expression of OPN was very strong in OSCC. A flow diagram explaining the profibrotic role of OPN in OSF has been provided. Conclusion: A positive role of OPN in both pathogenesis and malignant transformation of OPMDs and OSCC has been demonstrated.

Trends in the prevalence and social determinants of stunting in India, 2005-2021: findings from three rounds of the National Family Health Survey.

Objectives: To assess social determinants of stunting and the shifts in contributions of socio-demographic factors to national prevalence trends in India between 2005 and 2021. Methods: We leveraged data from three rounds of the National Family Health Survey (NFHS-3: 2005-2006, NFHS-4: 2015-2016, NFHS-5: 2019-2021) for 443 038 children under 5 years. Adjusted logistic regression models and a Kitigawa-Oaxaca-Blinder decomposition were deployed to examine how wealth, residence, belonging to a marginalised social group, maternal education and child sex contributed to changes in stunting prevalence. Results: The decrease in stunting prevalence was notably slower between NFHS-4 and NFHS-5 (annual average rate of reduction (AARR): 1.33%) than between NFHS-3 and NFHS-4 (AARR: 2.20%). The protective effect of high wealth diminished from 2015 onwards but persisted for high maternal education. However, an intersection of higher household wealth and maternal education mitigated stunting to a greater extent than either factor in isolation. Residence only predicted stunting in 2005-2006 with an urban disadvantage (adjusted OR: 1.18; 95% CI: 1.07 to 1.29). Children from marginalised social groups displayed increased likelihoods of stunting, from 6-16% in 2005-2006 to 11-21% in 2015-2016 and 2020-2021. Being male was associated with 6% and 7% increased odds of stunting in 2015-2016 and 2019-2021, respectively. Increased household wealth (45%) and maternal education (14%) contributed to decreased stunting prevalence between 2005 and 2021. Conclusions: Stunting prevalence in India has decreased across social groups. However, social disparities in stunting persist and are exacerbated by intersections of low household wealth, maternal education and being from a marginalised social group. Increased survival must be accompanied by needs-based interventions to support children and mitigate mutually reinforcing sources of inequality.

Hygiene Practices and Early Childhood Development in the East Asia-Pacific Region: A Cross-Sectional Analysis.

Poor hygiene might be a risk factor for early childhood development (ECD). This study investigated the associations of three hygiene practices ('wash hands before a meal,' 'wash hands after going to the toilet,' and 'brush teeth'), separately and combined, with ECD. Six thousand six hundred ninety-seven children (4 [0.8] years) from the East Asia-Pacific Early Child Development Scales validation study were included in this cross-sectional analysis. The hygiene variables were recoded to have comparable values as 'always,' 'sometimes,' and 'never.' These variables were then grouped to create combined categories. The binary outcome variables, poor ECD, were defined as a score < age-specific 25th centile. Modified Poisson regression models were used to analyse the associations. Data collection was performed between 2012 and 2014, and the analyses were conducted in April 2022. Compared with children who 'always' washed their hands before a meal, those who did it 'sometimes' (Prevalence Ratio [PR]: 1.30 [95% CI: 1.16-1.46]) or 'never' (PR: 1.35 [1.18-1.55]) had a higher likelihood of poorer overall development. Comparable results were identified for the other two hygiene practices and the other four domain-specific outcomes (p < 0.05). Compared with children who always followed the three hygiene practices, the likelihood of poor overall ECD increased as the combined hygiene practice decreased among children with poor hygiene practices (PRnever: 1.67 [1.40-2.00]; PRrarely: 1.49 [1.30-1.71]; PRsometimes: 1.30 [1.14-1.49]). Children who did not always follow good hygiene practices had a higher likelihood of poor ECD independently of sociodemographic factors. Considering these findings, future hygiene practice interventions and trials should consider including ECD outcomes.