Testing means to scale early childhood development interventions in rural Kenya: the Msingi Bora cluster randomized controlled trial study design and protocol.

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.

Introduction of iodised salt benefits infants' mental development in a community-based cluster-randomised effectiveness trial in Ethiopia.

The effectiveness of salt iodisation in improving the mental development of young children has not been assessed. We implemented a community-based cluster-randomised effectiveness trial in sixty randomly selected districts in the Amhara region of Ethiopia. We randomly allocated each district to treatment and randomly selected one of its villages. In parallel to national salt iodisation efforts, iodised salt was brought early into the markets of the thirty intervention villages before it became widely available in the thirty control villages 4-6 months later. The primary outcome was children's mental development scores on the Bayley Scales. This was an intention-to-treat analysis using mixed linear models adjusted for covariates and clusters. The trial was registered at ClinicalTrials.gov, NCT013496. We assessed 1835 infants aged 5-11 months at baseline. The same children (85 % of the sample) were re-assessed at 20-29 months when all villages had iodised salt. At endline, urinary iodine concentration was higher in children in the intervention group compared with those in the control group (median 228·0 v. 155·1 µg/l, P=0·001). The intervention group had higher scores compared with the control group on the Bayley composite score (raw scores:130·60 v. 128·51; standardised scores: 27·8 v. 26·9; d=0·13; 95 % CI 0·02, 0·23) and three of the four subscales: cognitive (53·27 v. 52·54, d=0·13; 95 % CI 0·03, 0·23), receptive language (20·71 v. 20·18, d=0·13; 95 % CI 0·03, 0·24) and fine motor (35·45 v. 34·94, d=0·15; 95 % CI 0·04, 0·25). The introduction of iodised salt contributes to children's higher urinary iodine concentration and mental development.

Evaluation of the effects of iodized salt on the mental development of preschool-aged children: a cluster randomized trial in northern Ethiopia.

A cluster randomized effectiveness trial was used to examine the effects on mental development of introducing iodized salt to children 4 to 6 years of age in Ethiopia, where there were reportedly high levels of iodine deficiency. Sixty district clusters were randomized to receive iodized salt early at their markets with assistance from regular salt distributors or later as introduced by market forces. At pre- and post-iodization, 1602 children were given cognitive/language tests (namely School Readiness, WPPSI verbal reasoning, WPPSI Matrix reasoning), and mothers were interviewed concerning demographics, nutrition and health. Children's weight, height, urine and a blood sample were taken. Analyses of covariance, adjusting for clustering and baseline levels were conducted. Urinary iodine concentrations were significantly higher at endline in the intervention children than controls though both medians were above threshold. Overall, less than 5% were anemic. There were no significant main effect differences between groups on the cognitive/language tests, but there were effect modifiers, namely mother's education, child's sex and diet. For example, the intervention group performed better on the school readiness test than controls if their mothers had attended school, but not otherwise. In conclusion, the data are consistent with negative findings from studies where children 6 to 12 years were supplemented with an iodine capsule, indicating that the benefits of iodine, in salt or capsule form, for brain development may be restricted to children under 3 years. Yet, benefits may be tied to those with more educational resources or may compensate for conditions of disadvantage.

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 children's brain functions that underlie language and cognition and are affected by nutrition and stimulation.

A 22-element micronutrient powder benefits language but not cognition in Bangladeshi full-term low-birth-weight children.

BACKGROUND: Low-birth-weight children are known to be at risk of both anemia and cognitive/language deficits in their early years. OBJECTIVE: The aim of the current study was to examine the effects of a 22-element multiple micronutrient powder (MNP) on the cognitive and language development of full-term low-birth-weight (LBW-T) children in Bangladesh. METHODS: The current study was a follow-up of children who were enrolled in a randomized cluster trial at 7-12 mo of age. Children in 12 intervention clusters (communities) were administered a daily 22-element MNP sachet with their food for 5 mo, and both intervention and control groups (also 12 clusters) received nutrition, health, and hygiene education. The current study involved the assessment of children at 16-22 mo of age (22-element MNP group: n = 96; control group: n = 82) on 3 subtests of the Bayley Scales of Infant and Toddler Development III test to measure cognitive, receptive language, and expressive language development. RESULTS: There was a significant effect of the 22-element MNP on children's expressive language scores (d = 0.39), and stunting moderated the effect on receptive language scores; there was no effect on cognitive development (d = 0.08). CONCLUSION: An MNP may thus offer one feasible solution to improve language development of LBW-T children in low-resource community settings. This trial was registered at clinicaltrials.gov as NCT01455636.

Father involvement and early child development in a low-resource setting.

Evidence on the role of father involvement in children's development from low-resource settings is very limited and historically has only relied on maternal reports of father's direct engagement activities such as reading to the child. However, fathers can also potentially influence their children's development via greater positive involvement with the mother, such as by offering interpersonal support or sharing decision-making duties. Such positive intrahousehold interactions can benefit maternal mental health and wellbeing, and ultimately children's development. We use data collected from mothers, fathers and children in the context of the cluster randomized controlled trial evaluation of Msingi Bora, a responsive parenting intervention implemented across 60 villages in rural western Kenya, to explore the various pathways through which fathers may influence their children's outcomes. In an endline survey in Fall 2019 among a sample of 681 two-parent households with children aged 16-34 months, fathers reported on measures of their behaviors towards children and with mothers, mothers reported on their wellbeing and behaviors, and interviewers assessed child cognitive and language development with the Bayley Scales. In adjusted multivariate regression analyses we found that greater father interpersonal support to mothers and greater participation in shared household decision-making were positively associated with children's development. These associations were partially mediated through maternal wellbeing and behaviors. We found no association between fathers' direct engagement in stimulation activities with children and children's outcomes. Inviting fathers to the program had no impact on their involvement or on any maternal or child outcomes, and fathers attended sessions at low rates. Overall, our results show the potential promises and challenges of involving fathers in a parenting intervention in a rural low-resource setting. Our findings do highlight the importance of considering intrahousehold pathways of influence in the design of parenting interventions involving fathers.

Responsive feeding is embedded in a theoretical framework of responsive parenting.

Children throughout the world are confronted with growth problems ranging from underweight and stunting to overweight and obesity. The development of healthy eating behaviors depends on both healthy food and responsive parenting behaviors. With origins from anthropology, psychology, and nutrition, responsive parenting reflects reciprocity between child and caregiver, conceptualized as a 4-step mutually responsive process: 1) the caregiver creates a routine, structure, expectations, and emotional context that promote interaction; 2) the child responds and signals to the caregiver; 3) the caregiver responds promptly in a manner that is emotionally supportive, contingent, and developmentally appropriate; and 4) the child experiences predictable responses. This paper examines evidence for the practice and developmental benefits of responsive parenting with a view to providing a theoretical basis for responsive feeding. Recommendations are made that future efforts to promote healthy growth and to prevent underweight and overweight among young children incorporate and evaluate responsive feeding.

An Implementation Evaluation of A Group-Based Parenting Intervention to Promote Early Childhood Development in Rural Kenya.

Early childhood development (ECD) parenting interventions can improve child developmental outcomes in low-resource settings, but information about their implementation lags far behind evidence of their effectiveness, hindering their generalizability. This study presents results from an implementation evaluation of Msingi Bora ("Good Foundation" in Swahili), a group-based responsive stimulation and nutrition education intervention recently tested in a cluster randomized controlled trial across 60 villages in rural western Kenya. Msingi Bora successfully improved child cognitive, receptive language, and socioemotional outcomes, as well as parenting practices. We conducted a mixed methods implementation evaluation of the Msingi Bora trial between April 2018 and November 2019 following the Consolidated Advice for Reporting ECD implementation research (CARE) guidelines. We collected qualitative and quantitative data on program inputs, outputs, and outcomes, with a view to examining how aspects of the program's implementation, such as program acceptance and delivery fidelity, related to observed program impacts on parents and children. We found that study areas had initially very low levels of familiarity or knowledge of ECD among parents, community delivery agents, and even supervisory staff from our partner non-governmental organization (NGO). We increased training and supervision in response, and provided a structured manual to enable local delivery agents to successfully lead the sessions. There was a high level of parental compliance, with median attendance of 13 out of 16 fortnightly sessions over 8 months. For delivery agents, all measures of delivery performance and fidelity increased with program experience. Older, more knowledable delivery agents were associated with larger impacts on parental stimulation and child outcomes, and delivery agents with higher fidelity scores were also related to improved parenting practices. We conclude that a group-based parenting intervention delivered by local delivery agents can improve multiple child and parent outcomes. An upfront investment in training local trainers and delivery agents, and regular supervision of delivery of a manualized program, appear key to our documented success. Our results represent a promising avenue for scaling similar interventions in low-resource rural settings to serve families in need of ECD programming. This trial is registered at ClinicalTrials.gov, NCT03548558, June 7, 2018. https://clinicaltrials.gov/ct2/show/NCT03548558.

Group-based parenting interventions to promote child development in rural Kenya: a multi-arm, cluster-randomised community effectiveness trial.

BACKGROUND: Early childhood development (ECD) programmes can help address early disadvantages for the 43% of children younger than 5 years in low-income and middle-income countries who have compromised development. We aimed to test the effectiveness of two group-based delivery models for an integrated ECD responsive stimulation and nutrition education intervention using Kenya's network of community health volunteers. METHODS: We implemented a multi-arm, cluster-randomised community effectiveness trial in three rural subcounties across 60 villages (clusters) in western Kenya. Eligible participants were mothers or female primary caregivers aged 15 years or older with children aged 6-24 months at enrolment. If married or in established relationships, fathers or male caregivers aged 18 years or older were also eligible. Villages were randomly assigned (1:1:1) to one of three groups: group-only delivery with 16 fortnightly sessions; mixed delivery combining 12 group sessions with four home visits; and a comparison group. Villages in the intervention groups were randomly assigned (1:1) to invite or not invite fathers and male caregivers to participate. Households were surveyed at baseline and immediately post-intervention. Assessors were masked. Primary outcomes were child cognitive and language development (score on the Bayley Scales of Infant Development third edition), socioemotional development (score on the Wolke scale), and parental stimulation (Home Observation for Measurement of the Environment inventory). Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, NCT03548558. FINDINGS: Between Oct 1 and Nov 12, 2018, 1152 mother-child dyads were enrolled and randomly assigned (n=376 group-only intervention, n=400 mixed-delivery intervention, n=376 comparison group). At the 11-month endline survey (Aug 5-Oct 31, 2019), 1070 households were assessed for the primary outcomes (n=346 group only, n=373 mixed delivery, n=351 comparison). Children in group-only villages had higher cognitive (effect size 0·52 SD [95% CI 0·21-0·83]), receptive language (0·42 SD [0·08-0·77]), and socioemotional scores (0·23 SD [0·03-0·44]) than children in comparison villages at endline. Children in mixed-delivery villages had higher cognitive (0·34 SD [0·05-0·62]) and socioemotional scores (0·22 SD [0·05-0·38]) than children in comparison villages; there was no difference in language scores. Parental stimulation also improved for group-only (0·80 SD [0·49-1·11]) and mixed-delivery villages (0·77 SD [0·49-1·05]) compared with the villages in the comparison group. Including fathers in the intervention had no measurable effect on any of the primary outcomes. INTERPRETATION: Parenting interventions delivered by trained community health volunteers in mother-child groups can effectively promote child development in low-resource settings and have great potential for scalability. FUNDING: Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health.

A responsive feeding intervention increases children's self-feeding and maternal responsiveness but not weight gain.

Responsive complementary feeding, whereby the mother feeds her child in response to child cues and psychomotor abilities, is low in some countries and likely contributes to malnutrition. Interventions are needed to evaluate whether promoting responsive feeding would add any benefit. Using a cluster-randomized field trial, we evaluated a 6-session educational program that emphasized the practice of child self-feeding and maternal responsiveness. A total of 108 mothers and their 8- to 20-mo-old children in 19 clusters were randomly assigned to the intervention group and 95 in 18 clusters were assigned to the informational control group. Outcomes were assessed at pretest, postintervention, and follow-up. Research assistants, who were unaware of group assignment, observed and coded mother and child midday meal behaviors. At follow-up, the percent of self-fed mouthfuls was 47.8 +/- 42.4 (mean +/- SD) in the responsive feeding group children compared with 32.2 +/- 41.0 in the controls (P = 0.01); likewise, the number of responsive verbalizations was 6.55 +/- 5.9 in the responsive feeding mothers and 4.62 +/- 4.5 in controls (P = 0.01). Intervention mothers recalled more messages. Mouthfuls of food eaten by children and weight were equivalent in the 2 groups. Lack of change in foods eaten and small quantities may explain the similarly low levels of weight gain. These results provide evidence that self-feeding and maternal verbal responsiveness, two developmentally important behaviors, can be increased by targeting specific behaviors with appropriate behavior change strategies of modeling and coached practice. Weight gain may require more nutritional input, especially in areas of high food insecurity.

Effectiveness of a community-based responsive feeding programme in rural Bangladesh: a cluster randomized field trial.

Responsive complementary feeding, whereby the mother feeds her child in response to child cues of hunger state and psychomotor abilities, is a problem in some countries, and likely contributes to malnutrition. Interventions are needed to evaluate whether promoting responsive feeding would add any benefit. Using a cluster randomized field trial, we evaluated a six-session educational programme that emphasized practice of two key behaviours, namely child self-feeding and maternal responsiveness. One hundred mothers and their 12- to 24-month-olds attended the sessions as part of village clusters randomly assigned to the intervention group. A similar number of controls received sessions on foods to feed and nutritional disorders. Outcomes assessed at pre-test, 2-week post-intervention and again 5-months post-intervention included weight, mouthfuls of food taken, self-feeding and maternal responsiveness. Research assistants, blind to group assignment, observed and coded mother and child behaviours during the midday meal. Secondary measures included foods fed and feeding messages recalled. Analysis was based on intention to treat and accounted for clustering. Only 10% of each group was lost to follow-up. Weight (d = 0.28), weight gain (d = 0.48) and child self-feeding (d = 0.30) were significantly higher in the responsive feeding group. Mouthfuls of food eaten and maternal responsiveness were not significantly increased by the intervention. Mothers in the intervention gave their children more vegetables, and spontaneously recalled more feeding messages at the 5-month follow-up. These results provide evidence that self-feeding and weight gain can improve by targeting specific behaviours, while maternal responsiveness may require more intensive strategies.

Measuring the implementation of early childhood development programs.

In this paper we describe ways to measure variables of interest when evaluating the implementation of a program to improve early childhood development (ECD). The variables apply to programs delivered to parents in group sessions and home or clinic visits, as well as in early group care for children. Measurements for four categories of variables are included: training and assessment of delivery agents and supervisors; program features such as quality of delivery, reach, and dosage; recipients' acceptance and enactment; and stakeholders' engagement. Quantitative and qualitative methods are described, along with when measures might be taken throughout the processes of planning, preparing, and implementing. A few standard measures are available, along with others that researchers can select and modify according to their goals. Descriptions of measures include who might collect the information, from whom, and when, along with how information might be analyzed and findings used. By converging on a set of common methods to measure implementation variables, investigators can work toward improving programs, identifying gaps that impede the scalability and sustainability of programs, and, over time, ascertain program features that lead to successful outcomes.

State of the science on implementation research in early child development and future directions.

We summarize the state of the field of implementation research and practice for early child development and propose recommendations. First, conclusions are drawn regarding what is generally known about the implementation of early childhood development programs, based on papers and discussions leading to a published series on the topic. Second, recommendations for short-term activities emphasize the use of newly published guidelines for reporting data collection methods and results for implementation processes; knowledge of the guidelines and a menu of measures allows for planning ahead. Additional recommendations include careful documentation of early-stage implementation, such as adapting a program to a different context and assessing feasibility, as well as the process of sustaining and scaling up a program. Using existing implementation information by building on and improving past programs and translating them into policy are recommended. Longer term goals are to identify implementation characteristics of effective programs and determinants of these characteristics.

Child development in rural Ghana: Associations between cognitive/language milestones and indicators of nutrition and stimulation of children under two years of age.

OBJECTIVES: Two studies aimed to assess the provision of nutrition and psychosocial stimulation in the home and to examine associations between mental development and nutrition and stimulation using a validated measure of development milestones. METHODS: The first study consisted of secondary analyses on health and nutrition data from 1081 mother-child pairs (the children aged 0-12 months) and their households in Ghana's Eastern Region. For the second study, the Ghana Milestones Measure, consisting of items assessing cognitive and language development, was used to assess child development in a subsample (N = 330) of Study 1 participants one year later (children 10-24 months of age). This measure was mother-reported and had been validated in a separate community in Ghana. Correlation and linear regression analyses were used to analyze the data. RESULTS: Family assets and maternal education were identified as key factors of the family context. Both variables were positively associated with preventive health practices (r = 0.08 to 0.13, p < 0.0001 to 0.01), and dietary diversity (r = 0.15, p = 0.0001 to 0.0006), and negatively associated with maternal depressive symptoms (r = -0.19 to -0.12, p < 0.0001). Taller children had higher receptive (standardized beta = 0.16; p = 0.04) and expressive (0.21; 0.003) language, but not cognitive (0.15; 0.07) milestone scores, and psychosocial stimulation was positively associated with all three milestones (receptive = 0.13, p = 0.01; expressive = 0.21, p < 0.0001; and cognitive = 0.24, p < 0.0001). CONCLUSION: Our study provides the first validated measure of children's language and cognitive development in Ghana, finding associations with nutrition and stimulation. The Ghana Milestones Measure can be used to assess and help promote children's mental development.

Reporting guidelines for implementation research on nurturing care interventions designed to promote early childhood development.

Meta-analyses of interventions such as parenting, stimulation, and early childhood education have reported consistent medium-to-high effect sizes on early childhood development (ECD) and early learning outcomes. However, few effective interventions promoting ECD have achieved scale. In order to increase the access to effective or high-quality services, greater focus on implementation research of interventions promoting ECD is necessary. In this paper, we describe the development of reporting guidelines for implementation research of nurturing care interventions designed to promote ECD following an expert consensus-building process. The goal of these guidelines is to support a transparent and standard reporting of implementation evidence on nurturing care interventions designed to promote early childhood development.

Evaluation of an early childhood parenting programme in rural Bangladesh.

To promote physical and mental development of children, parenting education programmes in developing countries focus on specific practices such as age-appropriate responsive stimulation and feeding. A programme delivered to groups of poor mothers of children, aged less than three years, in rural Bangladesh was evaluated using an intervention-control post-test design. Mothers (n=170) who had attended a year of educational sessions and their children were compared with those (n=159) from neighbouring villages who did not have access to such a programme. After covariates were controlled, the parenting mothers obtained higher scores on a test of child-rearing knowledge and on the Home Observation for Measurement of the Environment (HOME) inventory of stimulation. The parenting mothers did not communicate differently with their children while doing a picture-talking task, and children did not show benefits in nutritional status or language comprehension. Parenting sessions offered by peer educators were informative and participatory, yet they need to include more practice, problem-solving, and peer-support if information is to be translated into behaviour.

Interrupting pathways to sepsis: Effectiveness of an intervention to reduce delays in timely care for sick children in rural Bangladesh.

RATIONALE: The time it takes for a child with suspected sepsis to receive care is critical. OBJECTIVE: We evaluated care-seeking practices for sick children under 5 years in rural Bangladesh, following interpersonal communication to inform households of newly introduced supports for quality care. Based on the Delays Framework, we assessed length and source of care-seeking delays, use of formal providers, and autonomous decision-making among mothers. METHOD: Using two cross-sectional rounds before and after the 3-year intervention (August 2012 and August 2015), we surveyed 400 mothers of recently sick children in 26 randomly sampled villages from 2 intervention and 2 control subdistricts, using structured questions about delays. Six to ten times during the 18-month intervention period, local workers communicated four key messages to most intervention households in 292 villages: serious symptoms of suspected sepsis in children, a call-in center number for referral advice, a reliable transport hub, and upgrades to the local hospital. RESULTS: Compared to baseline, endline results demonstrated a significant difference in the total delay between the onset of child's illness and seeking external care, with intervention families having shorter delays. Over 90% of mothers informed someone in the family, mainly the husband, about the sick child before acting to seek care. Delays due to transportation and receiving provider care were short and not different. Using a benchmark of seeking external care within 24 h of onset, only 14.14% of intervention households and 13.40% of control households were "timely" in seeking care. Approximately 78% of parents, similar for the two groups, sought care from a non-formal practitioner (the village doctor). CONCLUSION: The results demonstrate that the delay in deciding to seek external care is most serious, and that communication strategies at the community level are necessary to increase the uptake of improved health services.

Responsive complementary feeding in rural Bangladesh.

It is now widely recognized that malnutrition can partly be attributed to caregiver-child interaction during feeding episodes. Current conceptual frameworks emphasize the importance of responsiveness (including active and social behaviour), psychomotor abilities of the child to self-feed, and a non-distracting feeding environment. The present observational study had three main objectives: (1) to define operationally key terms such as responsive and active feeding and observe their frequency in a rural Bangladesh sample; (2) to examine whether self-feeding, responsive and active behaviours of the mother and child varied with child's age and amounts eaten; and (3) to determine associations between mother and child behaviours. Fifty-four mother-child pairs were observed during one feeding episode and behaviours were coded for 5 categories, namely self-feeding, responsive, active, social and distracting behaviours. Children were between 8 and 24 months of age. Results indicated that the five behaviours could be observed and reliably coded. Two-thirds of mothers had an active feeding style but only a third were responsive; the two styles did not overlap. With older children, mothers encouraged more eating and more self-feeding, but children did not feed themselves more; instead older children were more negatively responsive (refusing offered food). Positively responsive mothers tended to have active children who explicitly signaled their desire for food or water, and who ate more mouthfuls of food. Positively active mothers adopted different strategies to encourage eating, such as verbally directing the child to eat, focusing, and temporarily diverting. These mothers tended to have children who were negatively responsive and refused food. Children accepted on average 5.31 mouthfuls of food and rejected 2.13. Mothers who used intrusively active strategies (e.g. force feeding) tended to have children who were both positively and negatively responsive, thus partially reinforcing her forceful behaviour. Thus, the responsive feeding framework, once operationalized, has the potential to identify specific behaviours that support or impede mother-child interaction during complementary feeding.

An impact evaluation of Plan Indonesia's early childhood program.

OBJECTIVES: High-quality preschools are known to prepare children for success in primary school. Over half of Indonesia's children now pass through preschools whose quality and effectiveness are unknown. Our goal was to evaluate two government preschool models, namely kindergarten (TK) and the less formal health-post (PAUD), with and without capacity-building efforts of a non-governmental organization (NGO-Plan), on children's language and math skills. METHODS: Thirteen TK and 17 PAUD Plan-supported and the same number of government-supported preschools were randomly selected from East Nusa Tenggara, Indonesia. Five children from each (n = 292) and five who had graduated from each and were now in first grade (n = 241) were randomly selected and tested on language and math measures. The Plan-supported preschools were assessed for quality. Mothers reported on their family's socio-demographic situation and their child's preventive health practices, illnesses and diet over the previous two weeks. RESULTS: Analyses of covariance adjusting for clusters indicated that children attending Plan-supported preschools performed better overall, and especially those in TK preschools. Plan-supported TKs were observed to have higher quality than Plan-supported PAUDs. First graders who graduated from Plan-supported preschools, both TK and PAUD, achieved higher scores on language and math tests than government-supported graduates. Preventive health practices were better in the Plan group, though diet and height-for-age were poor overall. CONCLUSIONS: Upgrades to the government preschool program are needed to raise its quality and effectiveness, specifically by introducing a mix of instructional and indoor free-choice play, resources and teacher training to support children's learning.

Airflow and autonomic responses to stress and relaxation in asthma: the impact of stressor type.

The impact of stress on respiratory airflow in asthmatics is unclear. Part of the uncertainty may spring from the different physiological effects of different stressors. Given their potential to elicit increases in parasympathetic vagal activity, stressful situations that present few opportunities for coping (passive coping stressors) may be particularly problematic for people with asthma. Thirty-one adult asthmatics participated in a protocol including a widely used passive coping stressor (the cold pressor test), an active coping stressor (mental arithmetic), an interview about an upsetting asthma-related incident (viewed as a potential passive coping stressor given the exposure to unpleasant memories), and progressive muscle relaxation. Repeated measurements of airflow (via peak expiratory flow), vagal tone (via heart rate variability), and other variables were obtained. The cold pressor test, asthma interview and progressive muscle relaxation produced significant decreases in airflow compared to the baseline period. The cold pressor test and progressive muscle relaxation produced significant, complementary increases in vagal tone. These results suggest that passive coping stressors and other stimuli (e.g., certain forms of relaxation) that elicit increased vagal tone may be associated with poorer asthma control, a view consistent with a significant negative correlation between the participant's mean vagal tone response to the tasks and score on a measure of asthma self-efficacy.