Estimates of a multidimensional index of nurturing care in the next 1000 days of life for children in low-income and middle-income countries: a modelling study.

BACKGROUND: Nurturing care is crucial for children's ongoing development during the pre-primary education period, or the next 1000 days of life. We generated nationally representative prevalence estimates of access to ten basic indicators of nurturing care among children aged 3-4 years in low-income and middle-income countries (LMICs). METHODS: We applied multiple imputation and predictive modelling to data on children living in LMICs. Individual-level data on ten indicators were from UNICEF's Multiple Indicator Cluster Surveys and the Demographic Health Surveys Program, and we included data on all children aged 36 to 59 months for whom the surveys asked relevant questions on parenting and child development. We defined minimally adequate care as receiving at least one of two indicators in each of five dimensions of nurturing care: responsive caregiving, early learning, safety and security, nutrition, and health. We used a two-step multi-level multiple imputation procedure to address missing data across individuals, indicators, and countries. Using imputed datasets, we generated a set of expected-a-posteriori estimates of the percentage and overall number of children receiving each indicator of nurturing care, as well as overall minimally adequate care, for each country, country income grouping, and region, and across all LMICs. For the 54 countries with individual-level data on all indicators, we also produced subgroup estimates of nurturing care on the basis of household wealth, child sex, and urbanicity. FINDINGS: We included individual-level data collected between 2005 and 2019 on 426 349 children aged 3-4 years in 104 LMICs. Across the 137 LMICs considered in our modelling, we estimated that 62·0 million (90% credible interval [CrI] 51·6-71·7) children aged 3-4 years, equivalent to 25·4% (90% CrI 21·2-29·4) of that age group in LMICs, were receiving minimally adequate nurturing care at the time of assessment, leaving 181·9 million (172·2-192·3) without adequate care. Access to care was highest for nutrition (86·2% [84·2-88·2], or 210·3 million [205·4-215·1], with healthy weight), and lowest for early learning (29·3% [21·5-39·6], or 71·5 million [52·5-96·6], in early childhood care and education), responsive caregiving (29·7% [25·6-34·9], or 72·4 million [62·4-85·0], experiencing adequate stimulation from non-maternal caregivers), and safety and security (32·3% [28·3-36·7], or 78·7 million [68·9-89·5], living without physical punishment). Gaps were evident in the estimates, with 50·8% (38·3-60·7) of children from upper middle-income countries receiving minimally adequate care compared with 5·6% (4·8-6·4) in low-income countries. Within 54 countries with complete child-level data, 10·7% (10·4-10·9) of children from households in the lowest wealth quintile had access to minimally adequate care compared with 41·2% (40·7-41·7) in the highest quintile. Inequalities were also large by urbanicity (17·7% [17·5-18.0] rural vs 32·2% [31·8-32.6] urban) but smaller by child sex (23·9% [23·6-24·2] girls vs 22·1% [21·9-22·4] boys). INTERPRETATION: Most children in LMICs are not receiving minimally adequate nurturing care during the next 1000-day period. Further investments in indicator measurement and resources for preschool-age children are needed, particularly for low-income populations and in the domains of responsive caregiving, early learning, and safety and security. FUNDING: None.

Measuring and forecasting progress in education: what about early childhood?

A recent Nature article modelled within-country inequalities in primary, secondary, and tertiary education and forecast progress towards Sustainable Development Goal (SDG) targets related to education (SDG 4). However, their paper entirely overlooks inequalities in achieving Target 4.2, which aims to achieve universal access to quality early childhood development, care and preschool education by 2030. This is an important omission because of the substantial brain, cognitive and socioemotional developments that occur in early life and because of increasing evidence of early-life learning's large impacts on subsequent education and lifetime wellbeing. We provide an overview of this evidence and use new analyses to illustrate medium- and long-term implications of early learning, first by presenting associations between pre-primary programme participation and adolescent mathematics and science test scores in 73 countries and secondly, by estimating the costs of inaction (not making pre-primary programmes universal) in terms of forgone lifetime earnings in 134 countries. We find considerable losses, comparable to or greater than current governmental expenditures on all education (as percentages of GDP), particularly in low- and lower-middle-income countries. In addition to improving primary, secondary and tertiary schooling, we conclude that to attain SDG 4 and reduce inequalities in a post-COVID era, it is essential to prioritize quality early childhood care and education, including adopting policies that support families to promote early learning and their children's education.

Physical punishment as a predictor of early cognitive development: Evidence from econometric approaches.

This study estimates the effect of physical punishment on the cognitive development of 1,167 low-income Colombian children (Mage = 17.8 months old) using 3 analytic strategies: lagged-dependent variables, a difference-in-differences-like approach (DD), and a novel strategy combining matching with a DD-like approach. Across approaches, physical punishment at ages 9-26 months predicted reductions in children's cognitive development of 0.08-0.21 SD at ages 27-46 months. These results, plus null results of falsification tests, strengthen the argument that physical punishment leads to slower cognitive growth and illustrate the utility of alternative statistical methods to reduce problems of selection bias in developmental research. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Maternal, paternal, and other caregivers' stimulation in low- and- middle-income countries.

BACKGROUND AND OBJECTIVES: Globally, studies have shown associations between maternal stimulation and early child development. Yet, little is known about the prevalence of paternal and other caregivers' stimulation practices, particularly in low- and- middle-income countries (LMICs). METHODS: Data from the Multiple Indicators Cluster Survey (MICS) and the Demographic and Health Survey (DHS) were combined across 62 LMICs (2010-2018). The sample included 205,150 mothers of children aged 3 and 4 years. High levels of stimulation were defined as caregiver engagement in at least 4 out of 6 possible activities with the child. The proportion of mothers, fathers, and other caregivers providing high levels of stimulation was calculated by country, region, and for the whole sample. Socioeconomic disparities within and between countries were estimated. RESULTS: On average, 39.8% (95% CI 37.4 to 42.2) of mothers, 11.9% (95% CI 10.1 to 13.8) of fathers, and 20.7% (95% CI 18.4 to 23.0) of other adult caregivers provided high levels of stimulation. Stimulation varied by region, country income group, and Human Development Index (HDI), with higher levels of maternal and paternal-but not other caregivers'-stimulation in high-income and high-HDI countries. Within countries, stimulation levels were, on average, lower in the poorest relative to the richest households, and some but not all countries exhibited differences by child sex (i.e., boys vs. girls) or area (i.e., urban vs. rural). CONCLUSIONS: Results suggest a need for intervention efforts that focus on increasing caregiver stimulation in LMICs, particularly for fathers and in low-income contexts.

Contextual and socioeconomic variation in early motor and language development.

OBJECTIVE: To compare early motor and language development of children <3 years of age growing up in high-income and low-income contexts. DESIGN: Cross-sectional study. SETTING: We analysed differences in motor and language skills across study sites in Cambodia, Chile, Ghana, Guatemala, Lebanon, Pakistan, the Philippines and the USA. MAIN OUTCOME MEASURE: Cognitive and language development assessed with the Caregiver Reported Early Development Instruments (CREDI) tool. RESULTS: 4649 children aged 0-35 months (mean age=18 months) were analysed. On average, children in sites with a low Human Development Index (HDI) had 0.54 SD (95% CI -0.63 to -0.44) lower CREDI motor scores and 0.73 SD (95% CI -0.82 to -0.64) lower language scores than children growing up in high HDI sites. On average, each unit increase in national log income per capita was associated with a 0.77-month (95% CI -0.93 to 0.60) reduction in the age of motor milestone attainment and a reduction in the age of language milestone attainment of 0.55 months (95% CI -0.79 to -0.30). These observed developmental differences were not universal: no developmental differences across sites with highly heterogeneous socioeconomic contexts were found among children growing up in households with highly educated caregivers providing stimulating early environments. CONCLUSION: Developmental gaps in settings with low HDI are substantial on average, but appear to be largely attributable to differences in family-level socioeconomic status and caregiving practices. Programmes targeting the most vulnerable subpopulations will be essential to reduce early life disparities and improve long-run outcomes.

Lifetime economic impact of the burden of childhood stunting attributable to maternal psychosocial risk factors in 137 low/middle-income countries.

INTRODUCTION: The first 1000 days of life is a period of great potential and vulnerability. In particular, physical growth of children can be affected by the lack of access to basic needs as well as psychosocial factors, such as maternal depression. The objectives of the present study are to: (1) quantify the burden of childhood stunting in low/middle-income countries attributable to psychosocial risk factors; and (2) estimate the related lifetime economic costs. METHODS: A comparative risk assessment analysis was performed with data from 137 low/middle-income countries throughout Asia, Latin America and the Caribbean, North Africa and the Middle East, and sub-Saharan Africa. The proportion of stunting prevalence, defined as <-2 SDs from the median height for age according to the WHO Child Growth Standards, and the number of cases attributable to low maternal education, intimate partner violence (IPV), maternal depression and orphanhood were calculated. The joint effect of psychosocial risk factors on stunting was estimated. The economic impact, as reflected in the total future income losses per birth cohort, was examined. RESULTS: Approximately 7.2 million cases of stunting in low/middle-income countries were attributable to psychosocial factors. The leading risk factor was maternal depression with 3.2 million cases attributable. Maternal depression also demonstrated the greatest economic cost at $14.5 billion, followed by low maternal education ($10.0 billion) and IPV ($8.5 billion). The joint cost of these risk factors was $29.3 billion per birth cohort. CONCLUSION: The cost of neglecting these psychosocial risk factors is significant. Improving access to formal secondary school education for girls may offset the risk of maternal depression, IPV and orphanhood. Focusing on maternal depression may play a key role in reducing the burden of stunting. Overall, addressing psychosocial factors among perinatal women can have a significant impact on child growth and well-being in the developing world.

Household Socioeconomic Status and Parental Investments: Direct and Indirect Relations With School Readiness in Ghana.

This study examines how parent socioeconomic status (SES) directly and indirectly predicts children's school readiness through pathways of parental investment. Data come from direct assessments with preschool children and surveys with their primary caregivers in Ghana at the start of the 2015-2016 school year (N = 2,137; Mage  = 5.2 years). Results revealed SES-related gaps in all parental investment characteristics and child school readiness skills. Preschool involvement served as the primary mediating mechanism in the path from SES to most school readiness skills, though it did not predict executive function. The number of books in the household was marginally positively predictive of early literacy, whereas at-home stimulation was negatively related to motor, literacy, and numeracy skills.

Risk Factors for Childhood Stunting in 137 Developing Countries: A Comparative Risk Assessment Analysis at Global, Regional, and Country Levels.

BACKGROUND: Stunting affects one-third of children under 5 y old in developing countries, and 14% of childhood deaths are attributable to it. A large number of risk factors for stunting have been identified in epidemiological studies. However, the relative contribution of these risk factors to stunting has not been examined across countries. We estimated the number of stunting cases among children aged 24-35 mo (i.e., at the end of the 1,000 days' period of vulnerability) that are attributable to 18 risk factors in 137 developing countries. METHODS AND FINDINGS: We classified risk factors into five clusters: maternal nutrition and infection, teenage motherhood and short birth intervals, fetal growth restriction (FGR) and preterm birth, child nutrition and infection, and environmental factors. We combined published estimates and individual-level data from population-based surveys to derive risk factor prevalence in each country in 2010 and identified the most recent meta-analysis or conducted de novo reviews to derive effect sizes. We estimated the prevalence of stunting and the number of stunting cases that were attributable to each risk factor and cluster of risk factors by country and region. The leading risk worldwide was FGR, defined as being term and small for gestational age, and 10.8 million cases (95% CI 9.1 million-12.6 million) of stunting (out of 44.1 million) were attributable to it, followed by unimproved sanitation, with 7.2 million (95% CI 6.3 million-8.2 million), and diarrhea with 5.8 million (95% CI 2.4 million-9.2 million). FGR and preterm birth was the leading risk factor cluster in all regions. Environmental risks had the second largest estimated impact on stunting globally and in the South Asia, sub-Saharan Africa, and East Asia and Pacific regions, whereas child nutrition and infection was the second leading cluster of risk factors in other regions. Although extensive, our analysis is limited to risk factors for which effect sizes and country-level exposure data were available. The global nature of the study required approximations (e.g., using exposures estimated among women of reproductive age as a proxy for maternal exposures, or estimating the impact of risk factors on stunting through a mediator rather than directly on stunting). Finally, as is standard in global risk factor analyses, we used the effect size of risk factors on stunting from meta-analyses of epidemiological studies and assumed that proportional effects were fairly similar across countries. CONCLUSIONS: FGR and unimproved sanitation are the leading risk factors for stunting in developing countries. Reducing the burden of stunting requires a paradigm shift from interventions focusing solely on children and infants to those that reach mothers and families and improve their living environment and nutrition.

Schooling and wage income losses due to early-childhood growth faltering in developing countries: national, regional, and global estimates.

BACKGROUND: The growth of >300 million children <5 y old was mildly, moderately, or severely stunted worldwide in 2010. However, national estimates of the human capital and financial losses due to growth faltering in early childhood are not available. OBJECTIVE: We quantified the economic cost of growth faltering in developing countries. DESIGN: We combined the most recent country-level estimates of linear growth delays from the Nutrition Impact Model Study with estimates of returns to education in developing countries to estimate the impact of early-life growth faltering on educational attainment and future incomes. Primary outcomes were total years of educational attainment lost as well as the net present value of future wage earnings lost per child and birth cohort due to growth faltering in 137 developing countries. Bootstrapped standard errors were computed to account for uncertainty in modeling inputs. RESULTS: Our estimates suggest that early-life growth faltering in developing countries caused a total loss of 69.4 million y of educational attainment (95% CI: 41.7 million, 92.6 million y) per birth cohort. Educational attainment losses were largest in South Asia (27.6 million y; 95% CI: 20.0 million, 35.8 million y) as well as in Eastern (10.3 million y; 95% CI: 7.2 million, 12.9 million y) and Western sub-Saharan Africa (8.8 million y; 95% CI: 6.4 million, 11.5 million y). Globally, growth faltering in developing countries caused a total economic cost of $176.8 billion (95% CI: $100.9 billion, $262.6 billion)/birth cohort at nominal exchange rates, and $616.5 billion (95% CI: $365.3 billion, $898.9 billion) at purchasing power parity-adjusted exchange rates. At the regional level, economic costs were largest in South Asia ($46.6 billion; 95% CI: $33.3 billion, $61.1 billion), followed by Latin America ($44.7 billion; 95% CI: $19.2 billion, $74.6 billion) and sub-Saharan Africa ($34.2 billion; 95% CI: $24.4 billion, $45.3 billion). CONCLUSIONS: Our results indicate that the annual cost of early-childhood growth faltering is substantial. Further investment in scaling up effective interventions in this area is urgently needed and likely to yield long run benefits of $3 for every $1 invested.

Early Childhood Developmental Status in Low- and Middle-Income Countries: National, Regional, and Global Prevalence Estimates Using Predictive Modeling.

BACKGROUND: The development of cognitive and socioemotional skills early in life influences later health and well-being. Existing estimates of unmet developmental potential in low- and middle-income countries (LMICs) are based on either measures of physical growth or proxy measures such as poverty. In this paper we aim to directly estimate the number of children in LMICs who would be reported by their caregivers to show low cognitive and/or socioemotional development. METHODS AND FINDINGS: The present paper uses Early Childhood Development Index (ECDI) data collected between 2005 and 2015 from 99,222 3- and 4-y-old children living in 35 LMICs as part of the Multiple Indicator Cluster Survey (MICS) and Demographic and Health Surveys (DHS) programs. First, we estimate the prevalence of low cognitive and/or socioemotional ECDI scores within our MICS/DHS sample. Next, we test a series of ordinary least squares regression models predicting low ECDI scores across our MICS/DHS sample countries based on country-level data from the Human Development Index (HDI) and the Nutrition Impact Model Study. We use cross-validation to select the model with the best predictive validity. We then apply this model to all LMICs to generate country-level estimates of the prevalence of low ECDI scores globally, as well as confidence intervals around these estimates. In the pooled MICS and DHS sample, 14.6% of children had low ECDI scores in the cognitive domain, 26.2% had low socioemotional scores, and 36.8% performed poorly in either or both domains. Country-level prevalence of low cognitive and/or socioemotional scores on the ECDI was best represented by a model using the HDI as a predictor. Applying this model to all LMICs, we estimate that 80.8 million children ages 3 and 4 y (95% CI 48.1 million, 113.6 million) in LMICs experienced low cognitive and/or socioemotional development in 2010, with the largest number of affected children in sub-Saharan Africa (29.4.1 million; 43.8% of children ages 3 and 4 y), followed by South Asia (27.7 million; 37.7%) and the East Asia and Pacific region (15.1 million; 25.9%). Positive associations were found between low development scores and stunting, poverty, male sex, rural residence, and lack of cognitive stimulation. Additional research using more detailed developmental assessments across a larger number of LMICs is needed to address the limitations of the present study. CONCLUSIONS: The number of children globally failing to reach their developmental potential remains large. Additional research is needed to identify the specific causes of poor developmental outcomes in diverse settings, as well as potential context-specific interventions that might promote children's early cognitive and socioemotional well-being.

Neighborhood Economic Disadvantage and Children's Cognitive and Social-Emotional Development: Exploring Head Start Classroom Quality as a Mediating Mechanism.

Past research has shown robust relationships between neighborhood socioeconomic disadvantage and children's school achievement and social-emotional outcomes, yet the mechanisms for explaining these relationships are poorly understood. The present study uses data from 1,904 Head Start participants enrolled in the Head Start Impact Study to examine the role that classroom structural and relational quality play in explaining the association between neighborhood poverty and children's developmental gains over the preschool year. Results suggest that neighborhood poverty is directly related to lower levels of classroom quality, and lower gains in early literacy and math scores. Indirect relationships were also found between neighborhood poverty and children's social-emotional outcomes (i.e., approaches to learning and behavior problems) via differences in the physical resources and negative student-teacher relationships within classrooms. These findings highlight the need for policy initiatives to consider community characteristics as potential predictors of disparities in classroom quality and children's cognitive and social-emotional development in Head Start.

Poverty, physical stature, and cognitive skills: Mechanisms underlying children's school enrollment in Zambia.

Past research suggests robust positive associations between household socioeconomic status and children's early cognitive development in Western countries. Relatively little is known about these relations in low-income country settings characterized by economic adversity, high prevalence of malnutrition and infectious disease, and relatively lower school enrollment. The present study develops and empirically evaluates an adapted model of early childhood development using a sample of 2,711 Zambian 6-year-olds. Early learning in and out of the home was found to explain much of the relation between socioeconomic status and children's cognitive skills, including language, nonverbal reasoning, and executive function. Child height-for-age (a proxy for overall nutritional status and health) was also predictive of children's cognitive skills and both early and on-time school enrollment. Implications for global child development, intervention, and future work are discussed.

Predicting individual differences in low-income children's executive control from early to middle childhood.

The present longitudinal study tested the roles of early childhood executive control (EC) as well as exposure to poverty-related adversity at family and school levels as key predictors of low-income children's EC in elementary school (n = 391). Findings suggest that children's EC difficulties in preschool and lower family income from early to middle childhood are robust predictors of later EC difficulties as rated by teachers in 2nd and 3rd grades. Findings also suggest enrollment in unsafe elementary schools is significantly predictive of higher levels of teacher-rated EC difficulty, but only for those children who showed initially elevated levels of EC difficulty in early childhood. Implications for scientific models of cognitive development and poverty-related adversity are discussed.