Effect of a Center-Based Early Childhood Care and Education Program on Child Nutritional Status: A Secondary Analysis of a Stepped-Wedge Cluster Randomized Controlled Trial in Rural Sindh, Pakistan.

BACKGROUND: High-quality early childhood care and education (ECCE) programs can positively impact children's development. However, as an unintended consequence, ECCE attendance may also affect children's nutritional status. OBJECTIVE: We evaluated the effect of a center-based ECCE intervention on child nutritional outcomes in rural Pakistan. METHODS: This study utilized data from a stepped-wedge cluster randomized controlled trial of a center-based ECCE program that trained female youth to run high-quality preschools for children aged 3.5-5.5 y (Youth Leaders for Early Childhood Assuring Children are Prepared for School (LEAPS) program) in rural Sindh, Pakistan. The program did not include any school meals. A total of 99 village clusters were randomized to receive the LEAPS intervention in 3 steps, and repeated cross-sectional surveys were conducted to assess the impact on children (age: 4.5-5.5 y) at 4- time points. ITT analyses with multilevel mixed-effect models were used to estimate the effect of the intervention on child anthropometric outcomes. RESULTS: The analysis included 3858 children with anthropometric data from 4 cross-sectional survey rounds. The LEAPS intervention was found to have a positive effect on child height-for-age z score (mean difference: 0.13 z-scores; 95% confidence interval [CI]: 0.02, 0.24). However, there was a negative effect on weight-based anthropometric indicators, -0.29 weight-for-height z score (WHZ) (95% CI: -0.42, -0.15), -0.13 BMI z score (BMIZ) (95% CI: -0.23, -0.03), and -0.16 mid-upper arm circumference-for-age z score MUACZ (95% CI: -0.25, -0.05). An exploratory analysis suggested that the magnitude of the negative effect of LEAPS on WHZ, BMIZ, and weight-for-age z score (WAZ) was greater in the survey round during the COVID-19 lockdown. DISCUSSION: The LEAPS intervention positively affected child linear growth but had negative effects on multiple weight-based anthropometric measures. ECCE programs in low- and middle-income country settings should evaluate the integration of nutrition-specific interventions (eg school lunch, counseling on healthy diets) and infection control strategies to promote children's healthy growth and development. CLINICAL TRIAL REGISTRY: clinicaltrials.gov, NCT03764436, https://clinicaltrials.gov/ct2/show/NCT03764436.

Effects of engaging fathers and bundling parenting and nutrition interventions on early child development and maternal and paternal parenting in Mara, Tanzania: a factorial cluster-randomized controlled trial.

BACKGROUND: Multicomponent interventions are needed to address the various co-occurring risks that compromise early child nutrition and development. We compared the independent and combined effects of engaging fathers and bundling parenting components into a nutrition intervention on early child development (ECD) and parenting outcomes. METHODS: We conducted a 2×2 factorial cluster-randomized controlled trial across 80 villages in Mara Region, Tanzania, also known as EFFECTS (Engaging Fathers for Effective Child Nutrition and Development in Tanzania; ClinicalTrials.gov, NCT03759821). Households with children under 18 months of age residing with their mother and father were enrolled. Villages were randomly assigned to one of five groups: a nutrition intervention for mothers, a nutrition intervention for couples, a bundled nutrition and parenting intervention for mothers, a bundled intervention for couples, and a standard-of-care control. Interventions were delivered by trained community health workers through peer groups and home visits over 12 months. Mothers, fathers, and children were assessed at baseline, midline, and endline or postintervention. We used a difference-in-difference approach with intention-to-treat analysis to estimate intervention effects on ECD (Bayley Scales of Infant and Toddler Development, third edition) and maternal and paternal parenting and psychosocial well-being. RESULTS: Between October 29, 2018, and May 24, 2019, 960 households were enrolled (n = 192 per arm). Compared to nutrition interventions, bundled interventions improved children's cognitive (ß = .18 [95% CI: 0.01, 0.36]) and receptive language development (ß = .23 [0.04, 0.41]). There were no differences between interventions for other ECD domains. Compared to nutrition interventions, bundled interventions achieved additional benefits on maternal stimulation (ß = .21 [0.04, 0.38]) and availability of home learning materials (ß = .25 [0.07-0.43]) and reduced paternal parenting distress (ß = -.34 [-0.55, -0.12]). Compared to interventions with mothers only, interventions that engaged fathers improved paternal stimulation (ß = .45 [0.27, 0.63]). CONCLUSIONS: Jointly bundling parenting components into nutrition interventions while also engaging both mothers and fathers is most effective for improving maternal and paternal parenting and ECD outcomes.

A qualitative study of maternal and paternal parenting knowledge and practices in rural Mozambique.

BACKGROUND: Providing nurturing care for young children is essential for promoting early child development (ECD). However, there is limited knowledge about how mothers and fathers across diverse contexts in sub-Saharan Africa care for their children and from whom they receive guidance and support in their caregiving roles. We aimed to examine caregivers' nurturing care practices and sources of parenting knowledge in rural Mozambique. METHODS: This is a secondary analysis using data from a qualitative evaluation of a pilot intervention to improve nurturing care for early child health and development within existing health systems. The evaluation was conducted across three primary care health facilities and their catchment areas in Nampula province, Mozambique. For this study, we analyzed data from in-depth interviews conducted with 36 caregivers (32 mothers and 4 fathers) to investigate mothers' and fathers' daily caregiving experiences. Data were analyzed using thematic content analysis. RESULTS: Caregivers described various caregiving roles relating to general caregiving of young children (e.g., feeding, bathing, caring for child's health) and stimulation (e.g., play and communication) activities. Mothers more commonly engaged in general caregiving activities than fathers, whereas both mothers and fathers engaged in stimulation activities. Other family members, including siblings, grandparents, and aunts/uncles, were also actively engaged in general caregiving activities. With respect to sources of parenting knowledge, caregivers received parenting guidance and support primarily from their own mothers/parents and facility-based health providers. CONCLUSIONS: These findings highlight the importance of adopting a holistic approach involving caregivers and their context and reveal potential strategies to promote caregiving and ECD in rural Mozambique and similar contexts.

Evaluation of a community health worker home visit intervention to improve child development in South Africa: A cluster-randomized controlled trial.

BACKGROUND: Effective integration of home visit interventions focused on early childhood development into existing service platforms is important for expanding access in low- and middle-income countries (LMICs). We designed and evaluated a home visit intervention integrated into community health worker (CHW) operations in South Africa. METHODS AND FINDINGS: We conducted a cluster-randomized controlled trial in Limpopo Province, South Africa. CHWs operating in ward-based outreach teams (WBOTs; clusters) and caregiver-child dyads they served were randomized to the intervention or control group. Group assignment was masked from all data collectors. Dyads were eligible if they resided within a participating CHW catchment area, the caregiver was at least 18 years old, and the child was born after December 15, 2017. Intervention CHWs were trained on a job aid that included content on child health, nutrition, developmental milestones, and encouragement to engage in developmentally appropriate play-based activities, for use during regular monthly home visits with caregivers of children under 2 years of age. Control CHWs provided the local standard of care. Household surveys were administered to the full study sample at baseline and endline. Data were collected on household demographics and assets; caregiver engagement; and child diet, anthropometry, and development scores. In a subsample of children, electroencephalography (EEG) and eye-tracking measures of neural function were assessed at a lab concurrent with endline and at 2 interim time points. Primary outcomes were as follows: height-for-age z-scores (HAZs) and stunting; child development scores measured using the Malawi Developmental Assessment Tool (MDAT); EEG absolute gamma and total power; relative EEG gamma power; and saccadic reaction time (SRT)-an eye-tracking measure of visual processing speed. In the main analysis, unadjusted and adjusted impacts were estimated using intention-to-treat analysis. Adjusted models included a set of demographic covariates measured at baseline. On September 1, 2017, we randomly assigned 51 clusters to intervention (26 clusters, 607 caregiver-child dyads) or control (25 clusters, 488 caregiver-child dyads). At endline (last assessment June 11, 2021), 432 dyads (71%) in 26 clusters remained in the intervention group, and 332 dyads (68%) in 25 clusters remained in the control group. In total, 316 dyads attended the first lab visit, 316 dyads the second lab visit, and 284 dyads the third lab visit. In adjusted models, the intervention had no significant impact on HAZ (adjusted mean difference (aMD) 0.11 [95% confidence interval (CI): -0.07, 0.30]; p = 0.220) or stunting (adjusted odds ratio (aOR) 0.63 [0.32, 1.25]; p = 0.184), nor did the intervention significantly impact gross motor skills (aMD 0.04 [-0.15, 0.24]; p = 0.656), fine motor skills (aMD -0.04 [-0.19, 0.11]; p = 0.610), language skills (aMD -0.02 [-0.18, 0.14]; p = 0.820), or social-emotional skills (aMD -0.02 [-0.20, 0.16]; p = 0.816). In the lab subsample, the intervention had a significant impact on SRT (aMD -7.13 [-12.69, -1.58]; p = 0.012), absolute EEG gamma power (aMD -0.14 [-0.24, -0.04]; p = 0.005), and total EEG power (aMD -0.15 [-0.23, -0.08]; p < 0.001), and no significant impact on relative gamma power (aMD 0.02 [-0.78, 0.83]; p = 0.959). While the effect on SRT was observed at the first 2 lab visits, it was no longer present at the third visit, which coincided with the overall endline assessment. At the end of the first year of the intervention period, 43% of CHWs adhered to monthly home visits. Due to the COVID-19 pandemic, we were not able to assess outcomes until 1 year after the end of the intervention period. CONCLUSIONS: While the home visit intervention did not significantly impact linear growth or skills, we found significant improvement in SRT. This study contributes to a growing literature documenting the positive effects of home visit interventions on child development in LMICs. This study also demonstrates the feasibility of collecting markers of neural function like EEG power and SRT in low-resource settings. TRIAL REGISTRATION: PACTR 201710002683810; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=2683; South African Clinical Trials Registry, SANCTR 4407.

Improving health and social systems for all children in LMICs: structural innovations to deliver high-quality services.

Despite health gains over the past 30 years, children and adolescents are not reaching their health potential in many low-income and middle-income countries (LMICs). In addition to health systems, social systems, such as schools, communities, families, and digital platforms, can be used to promote health. We did a targeted literature review of how well health and social systems are meeting the needs of children in LMICs using the framework of The Lancet Global Health Commission on high-quality health systems and we reviewed evidence for structural reforms in health and social sectors. We found that quality of services for children is substandard across both health and social systems. Health systems have deficits in care competence (eg, diagnosis and management), system competence (eg, timeliness, continuity, and referral), user experience (eg, respect and usability), service provision for common and serious conditions (eg, cancer, trauma, and mental health), and service offerings for adolescents. Education and social services for child health are limited by low funding and poor coordination with other sectors. Structural reforms are more likely to improve service quality substantially and at scale than are micro-level efforts. Promising approaches include governing for quality (eg, leadership, expert management, and learning systems), redesigning service delivery to maximise outcomes, and empowering families to better care for children and to demand quality care from health and social systems. Additional research is needed on health needs across the life course, health system performance for children and families, and large-scale evaluation of promising health and social programmes.

Gender and Violence in the Daily Routine of Community Health Workers in Fortaleza, Brazil.

Community Health Workers (CHWs) are the link between the Brazilian primary health care system and the community. Since CHWs live in the same neighborhoods they work, they are involved in what happens in the community, including observants and or potential targets of violence. However, it is not known if female and male CHWs perceive and suffer violence similarly. This study aimed to investigate the violence to which CHWs are exposed and if female CHWs experience and or perceive violence the same way as male CHWs. A structured questionnaire was used to collect information from CHWs. Two periods (2019 [n=1402] and 2021 [n=364]) were compared. The data show that more than 80% of CHWs were exposed to violence, either as victims or witnesses within the community they served. In general, while the occurrence of violence towards CHWs decreased, their perception of community violence increased. Over time, the perception of urban/community violence remained constant among male CHWs, but increased among female CHWs, as shown by the significant rise between 2019 and 2021 in the percentage of female CHWs reporting witnessing or hearing about manifestations of violence (e.g., physical aggression; assault; stabbing; lethal gunshot; non-lethal gunshot; and gang violence). Among male CHWs, perception only increased with regard to the item assault. Given the complexity of violence and its repercussions on the daily routines of CHWs, intersectoral and interdisciplinary partnerships between health workers and other stakeholders are needed to create strategies capable of dealing with expressions of violence in the territories served.

Interventions to promote development in the next 1000 days: A mapping review.

The next 1000 days - the period from 2 to 5 years of age - has been highlighted as a key developmental stage in the life-course. A mapping review was conducted to categorize existing literature on interventions in the next 1000 days that promote key developmental outcomes, including publications between 1990 and July 2020. A total of 805 intervention studies were included for data extraction in the review. The number of intervention studies has increased substantially from 2010. Most interventions were from high-income countries, with few (5%) from low- and lower-middle-income countries. Interventions including typically developing children (n = 593, 74%) were mostly (80%) implemented in early childhood care and education (ECCE) settings, with 15% taking place in the home or with families and 5% in community or healthcare settings. Children's literacy and language outcomes were the target of 27% of these interventions, while 25% of interventions targeted early childhood development more holistically or targeted multiple developmental domains. Social-emotional development and social skills were the target of 15% of interventions, motor development 13%, numeracy 8% and cognitive development 8%. For children with any developmental delay, disability, disease or exposure (n = 212), interventions frequently targeted Autism Spectrum Disorder (24%), language or literacy delays (21%), developmental delays or disability more generally (20%); 16% targeted behavioral (or conduct) problems; and 5% targeted attention deficit hyperactivity disorder. Almost half (49%) took place in ECCE settings; 24% occurred in the home or with families, or in community (13%) and/or healthcare (14%) settings. This review highlights the need for more intervention research in low- and middle-income countries and for interventions supporting development in the next 1000 days. While the evidence base for interventions to promote development in this age group continues to expand, the most vulnerable children are not benefiting from this evidence.

The unique relevance of executive functions and self-regulation behaviors for understanding early childhood experiences and preschoolers' outcomes in rural Pakistan.

Performance-based measures of children's executive functions (EFs) do not capture children's application of these skills during everyday emotionally-laden and socially-mediated interactions. The current study demonstrates the value of using assessor report of self-regulation behaviors (inhibitory control and positive affect/engagement) in addition to EF tasks when studying early childhood experiences and development in a rural lower-middle-income country setting. In a sample of 1302 disadvantaged 4-year-olds living in rural Pakistan, we found that directly assessed EFs were significantly related to assessor observations of children's inhibitory control and positive affect/engagement during a structured assessment protocol. However, EFs and two types of self-regulation behaviors demonstrated unique associations with children's (1) contextual experiences, as indexed by family socio-economic resources, participation in parenting interventions, and children's physical growth; and (2) age-salient developmental outcomes, as indexed by direct assessment of pre-academic skills and maternal report of prosocial behaviors and behavior problems. First, family wealth uniquely predicted only observed positive affect/engagement, whereas maternal education uniquely predicted only EFs. Second, children's antecedent linear growth was a significant predictor of both EFs and positive affect/engagement, but exposure to an enhanced nutrition intervention during the first 2 years of life and preschoolers' hair cortisol concentration were associated only with observed self-regulation behaviors. Finally, both EFs and observed positive affect/engagement uniquely predicted children's pre-academic skills. In contrast, only assessors' ratings of positive affect/engagement uniquely predicted maternal report of prosocial behaviors and only assessors' ratings of inhibitory control uniquely predicted maternal report of behavioral problems.

Child diet and mother-child interactions mediate intervention effects on child growth and development.

This study examined whether child diet and mother-child interactions mediated the effects of a responsive stimulation and nutrition intervention delivered from 2009 to 2012 to 1324 children aged 0-24 months living in rural Pakistan. Results showed that the intervention improved children's cognitive, language and motor development through child diet and mother-child interactions. Although the intervention did not improve child growth or socio-emotional development, we observed positive indirect effects on child growth via child diet and on socio-emotional development via both child diet and mother-child interactions. In addition, child diet emerged as a shared mechanism to improve both child growth and development, whereas mother-child interactions emerged as a distinct mechanism to improve child development. Nevertheless, our results suggest the two mechanisms were mutually reinforcing and that interventions leveraging both mechanisms are likely to be more effective at improving child outcomes than interventions leveraging only one of these mechanisms.

Associations between women's empowerment and child development, growth, and nurturing care practices in sub-Saharan Africa: A cross-sectional analysis of demographic and health survey data.

BACKGROUND: Approximately 40% of children 3 to 4 years of age in low- and middle-income countries have suboptimal development and growth. Women's empowerment may help provide inputs of nurturing care for early development and growth by building caregiver capacity and family support. We examined the associations between women's empowerment and child development, growth, early learning, and nutrition in sub-Saharan Africa (SSA). METHODS AND FINDINGS: We pooled data on married women (15 to 49 years) and their children (36 to 59 months) from Demographic and Health Surveys that collected data on child development (2011 to 2018) in 9 SSA countries (N = 21,434): Benin, Burundi, Cameroon, Chad, Congo, Rwanda, Senegal, Togo, and Uganda. We constructed a women's empowerment score using factor analysis and assigned women to country-specific quintile categories. The child outcomes included cognitive, socioemotional, literacy-numeracy, and physical development (Early Childhood Development Index), linear growth (height-for-age Z-score (HAZ) and stunting (HAZ <-2). Early learning outcomes were number of parental stimulation activities (range 0 to 6) and learning resources (range 0 to 4). The nutrition outcome was child dietary diversity score (DDS, range 0 to 7). We assessed the relationship between women's empowerment and child development, growth, early learning, and nutrition using multivariate generalized linear models. On average, households in our sample were large (8.5 ± 5.7 members) and primarily living in rural areas (71%). Women were 31 ± 6.6 years on average, 54% had no education, and 31% had completed primary education. Children were 47 ± 7 months old and 49% were female. About 23% of children had suboptimal cognitive development, 31% had suboptimal socioemotional development, and 90% had suboptimal literacy-numeracy development. Only 9% of children had suboptimal physical development, but 35% were stunted. Approximately 14% of mothers and 3% of fathers provided ≥4 stimulation activities. Relative to the lowest quintile category, children of women in the highest empowerment quintile category were less likely to have suboptimal cognitive development (relative risk (RR) 0.89; 95% confidence interval (CI) 0.80, 0.99), had higher HAZ (mean difference (MD) 0.09; 95% CI 0.02, 0.16), lower risk of stunting (RR 0.93; 95% CI 0.87, 1.00), higher DDS (MD 0.17; 95% CI 0.06, 0.29), had 0.07 (95% CI 0.01, 0.13) additional learning resources, and received 0.16 (95% CI 0.06, 0.25) additional stimulation activities from their mothers and 0.23 (95% CI 0.17 to 0.29) additional activities from their fathers. We found no evidence that women's empowerment was associated with socioemotional, literacy-numeracy, or physical development. Study limitations include the possibility of reverse causality and suboptimal assessments of the outcomes and exposure. CONCLUSIONS: Women's empowerment was positively associated with early child cognitive development, child growth, early learning, and nutrition outcomes in SSA. Efforts to improve child development and growth should consider women's empowerment as a potential strategy.

Parenting interventions to promote early child development in the first three years of life: A global systematic review and meta-analysis.

BACKGROUND: Parents are the primary caregivers of young children. Responsive parent-child relationships and parental support for learning during the earliest years of life are crucial for promoting early child development (ECD). We conducted a global systematic review and meta-analysis to evaluate the effectiveness of parenting interventions on ECD and parenting outcomes. METHODS AND FINDINGS: We searched MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, and Global Health Library for peer-reviewed, published articles from database inception until November 15, 2020. We included randomized controlled trials (RCTs) of parenting interventions delivered during the first 3 years of life that evaluated at least 1 ECD outcome. At least 2 reviewers independently screened, extracted data, and assessed study quality from eligible studies. ECD outcomes included cognitive, language, motor, and socioemotional development, behavior problems, and attachment. Parenting outcomes included parenting knowledge, parenting practices, parent-child interactions, and parental depressive symptoms. We calculated intervention effect sizes as the standardized mean difference (SMD) and estimated pooled effect sizes for each outcome separately using robust variance estimation meta-analytic approaches. We used random-effects meta-regression models to assess potential effect modification by country-income level, child age, intervention content, duration, delivery, setting, and study quality. This review was registered with PROSPERO (CRD42018092458 and CRD42018092461). Of the 11,920 articles identified, we included 111 articles representing 102 unique RCTs. Pooled effect sizes indicated positive benefits of parenting interventions on child cognitive development (SMD = 0.32, 95% CI [confidence interval]: 0.23, 0.40, P < 0.001), language development (SMD = 0.28, 95% CI: 0.18 to 0.37, P < 0.001), motor development (SMD = 0.24, 95% CI: 0.15 to 0.32, P < 0.001), socioemotional development (SMD = 0.19, 95% CI: 0.10 to 0.28, P < 0.001), and attachment (SMD = 0.29, 95% CI: 0.18 to 0.40, P < 0.001) and reductions in behavior problems (SMD = -0.13, 95% CI: -0.18 to -0.08, P < 0.001). Positive benefits were also found on parenting knowledge (SMD = 0.56, 95% CI: 0.33 to 0.79, P < 0.001), parenting practices (SMD = 0.33, 95% CI: 0.22 to 0.44, P < 0.001), and parent-child interactions (SMD = 0.39, 95% CI: 0.24 to 0.53, P < 0.001). However, there was no significant reduction in parental depressive symptoms (SMD = -0.07, 95% CI: -0.16 to 0.02, P = 0.08). Subgroup analyses revealed significantly greater effects on child cognitive, language, and motor development, and parenting practices in low- and middle-income countries compared to high-income countries; and significantly greater effects on child cognitive development, parenting knowledge, parenting practices, and parent-child interactions for programs that focused on responsive caregiving compared to those that did not. On the other hand, there was no clear evidence of effect modification by child age, intervention duration, delivery, setting, or study risk of bias. Study limitations include considerable unexplained heterogeneity, inadequate reporting of intervention content and implementation, and varying quality of evidence in terms of the conduct of trials and robustness of outcome measures used across studies. CONCLUSIONS: Parenting interventions for children during the first 3 years of life are effective for improving ECD outcomes and enhancing parenting outcomes across low-, middle-, and high-income countries. Increasing implementation of effective and high-quality parenting interventions is needed globally and at scale in order to support parents and enable young children to achieve their full developmental potential.

Depression and Viral Suppression Among Adults Living with HIV in Tanzania.

Limited information is available on the association between depression and viral suppression among people living with HIV (PLH) in sub-Saharan Africa. We conducted a prospective cohort study of 3996 adults initiating antiretroviral therapy (ART) in Dar es Salaam, Tanzania. Log-binomial models were used to assess the association between depression and the risk of an unsuppressed viral load (> 400 copies/mL) after 6 months of ART. Women who had depression at both initiation and after 6 months of treatment had 1.94 times (95% CI 1.22, 3.09; z = 2.78, p < 0.01) the risk of an unsuppressed viral load after 6 months of treatment as compared to women who did not have depression at either time point. Men with the top tertile of depressive symptoms after 6 months of treatment had 1.58 times the risk of an unsuppressed viral load (95% CI 1.04, 2.38; z = 2.15, p = 0.03) as compared to the lowest tertile. Research should be pursued on interventions to prevent and address depression among adults initiating ART to potentially support achievement of viral suppression.

Promoting parent-child relationships and preventing violence via home-visiting: a pre-post cluster randomised trial among Rwandan families linked to social protection programmes.

BACKGROUND: Sugira Muryango is a father-engaged early child development and violence-prevention home-visiting programme delivered by trained lay workers. This cluster-randomised trial evaluates whether families living in extreme poverty (Ubudehe 1, the poorest category in the Government of Rwanda's wealth ranking) who receive Sugira Muryango in combination with a government-provided social protection programme demonstrate greater responsive, positive caregiving, nutrition, care seeking, hygiene, and father involvement compared with control families receiving usual care (UC). METHODS: Using detailed maps, we grouped closely spaced villages into 284 geographic clusters stratified by the type of social protection programmes operating in the village clusters; 198 clusters met all enrolment criteria. Sugira Muryango was delivered to n = 541 families in 100 treatment clusters with children aged 6-36 months living in extreme poverty. We assessed changes in outcomes in intervention and n = 508 UC control families using structured surveys and observation. Analyses were intent to treat using mixed models to accommodate clustering. RESULTS: Families receiving Sugira Muryango improved on core outcomes of parent-child relationships assessed using the Home Observation for Measurement of the Environment (Cohen's d = 0.87, 95% CI: 0.74, 0.99) and the Observation of Mother-Child Interaction (Cohen's d = 0.29, 95% CI: 0.17, 0.41). We also saw reductions in harsh discipline on items from the UNICEF MICS (OR = 0.30: 95% CI: 0.19, 0.47) and in violent victimisation of female caregivers by their partners (OR = 0.49, 95% CI: 0.24, 1.00) compared with UC. Moreover, children in families receiving SM had a 0.45 higher increase in food groups consumed in the past 24 h (Cohen's d = 0.35, 95% CI: 0.22, 0.47), increased care seeking for diarrhoea (OR = 4.43, 95% CI: 1.95, 10.10) and fever (OR = 3.28, 95% CI: 1.82, 5.89), and improved hygiene behaviours such as proper treatment of water (OR = 3.39, 95% CI: 2.16, 5.30) compared with UC. Finally, Sugira Muryango was associated with decreased caregiver depression and anxiety (OR = 0.58, 95% CI: 0.38, 0.88). CONCLUSIONS: Sugira Muryango led to improvements in caregiver behaviours linked to child development and health as well as reductions in violence. TRIAL REGISTRATION: ClinicalTrials.gov number NCT02510313.

Biological sensitivity to context in Pakistani preschoolers: Hair cortisol and family wealth are interactively associated with girls' cognitive skills.

Many young children in low- and middle-income countries (LMICs) face heightened risk for experiencing environmental adversity, which is linked with poorer developmental outcomes. Children's stress physiology can shed light on why children are differentially susceptible to adversity. However, no known studies have examined whether links between adversity and children's development are moderated by children's stress physiology in LMICs. The present study revealed significant interactive effects of hair cortisol concentrations, an index of chronic physiological stress regulation, and family wealth on preschoolers' cognitive skills in rural Pakistan. In a sample of 535 4-year-old children (n = 342 girls), we found significant associations between family wealth and direct assessments of verbal intelligence, pre-academic skills, and executive functions only in girls with lower hair cortisol concentrations. Specifically, girls with lower cortisol concentrations displayed greater cognitive skills if they came from relatively wealthier families, but lower cognitive skills if they came from very poor families. There were no significant associations among boys. Results provide evidence of biological sensitivity to context among young girls in a LMIC, perhaps reflecting, in part, sex differences in daily experiences of environmental adversity.

Early executive functioning in a global context: Developmental continuity and family protective factors.

This study extends the methodological and theoretical understanding of executive functions (EFs) in preschoolers from low- and middle-income countries (LMIC). First, the authors describe a rigorous process of adapting and evaluating six EF tasks to produce a culturally and developmentally appropriate measure of emerging EFs in a large sample of at-risk children in rural Pakistan. Next, the authors identify critical developmental and family factors that relate to preschoolers' EFs over the first 4 years of life. Direct assessment of children's general cognitive skills at age two showed developmental continuity with EFs at age four, and these early cognitive skills mediated the effect of an antecedent parenting intervention on EFs as well as associations of targeted individual and family factors with EFs. Furthermore, directly assessed maternal cognitive capacities and observed maternal scaffolding uniquely predicted EFs in preschoolers. This study is also the first to demonstrate a significant overlap between direct assessments of IQ and EFs in young children from LMIC. Children's general intelligence mediated the associations of EFs with antecedent physical growth and cognitive skills as well as concurrent family factors (maternal verbal intelligence, maternal scaffolding, and home stimulation). After controlling for shared variance between preschoolers' general intelligence and EFs, three factors emerged as unique predictors of EFs: exposure to an early parenting intervention, physical growth status at age two, and number of older siblings. The findings have important implications for the design of interventions that aim to improve EFs in young children in LMIC. A video abstract of this article can be viewed at https://vimeo.com/316329544/5abde94cd7.

Effect of a community health worker delivered health, nutrition and responsive stimulation package and conditional cash transfers on child development and growth in rural Tanzania: protocol for a cluster-randomized trial.

BACKGROUND: Child health, nutrition, and responsive stimulation interventions have been developed to improve child survival, growth and development outcomes in low- and middle-income countries. Nevertheless, research on integrated implementation approaches to deliver and promote uptake of these interventions is needed, particularly in sub-Saharan Africa. METHODS/DESIGN: We will conduct a cluster-randomized controlled trial of a supply-side community health worker (CHW) delivered child health, nutrition, and responsive stimulation intervention alone and in combination with a demand-side conditional cash transfer (CCT) intervention to promote antenatal care and child growth monitoring attendance in rural Morogoro region, Tanzania. Twelve village clusters will be randomly assigned to one of the three trial arms: (1) CHW, (2) CHW + CCT, or (3) Control. Mothers (or another primary caregiver) residing in study villages are eligible for trial enrollment if they are currently pregnant or have a child < 1 year of age at the time of enrollment. For the duration of the trial, CHWs will visit households once every 4-6 weeks to deliver the intervention package and CCTs will be provided for documented antenatal care and routine child health and growth monitoring clinic visits. Participants will be followed-up at 9 months (midline) and 18 months (endline) post-randomization. The primary outcomes of the trial are child development assessed by the Bayley Scales of Infant and Toddler Development (BSID-III) and child height-for-age z-score. Secondary outcomes include a range of maternal, child and household outcomes. DISCUSSION: This trial will provide evidence on the effect of CHWs and conditional cash transfers on child growth and development. The results of the trial may be generalizable to similar settings in sub-Saharan Africa. TRIAL REGISTRATION: ISRCTN10323949 , Retrospectively registered on October 3, 2017.

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.

Correction to: "His mind will work better with both of us": a qualitative study on fathers' roles and coparenting of young children in rural Pakistan.

After publication of the original article [1], the authors wanted to make an amendment in the Acknowledgments section as Muneera Rasheed requested to be removed. This correction article shows the original and revised version of the "Acknowledgments". The original article was not updated.

"His mind will work better with both of us": a qualitative study on fathers' roles and coparenting of young children in rural Pakistan.

BACKGROUND: Parents are the primary providers of nurturing care for young children's healthy early development. However, the literature on parenting in early childhood, especially in low- and middle-income countries, has primarily focused on mothers. In this study, we investigate how parents make meaning of fathers' parenting roles with regards to their young children's early health and development in rural Pakistan. METHODS: Data were collected between January and March 2017 through in-depth interviews with fathers (N = 33) and their partners (N = 32); as well as separate focus group discussions with fathers (N = 7) and mothers (N = 7). Data were analyzed using thematic content analysis. RESULTS: Parents described a distinct division of roles between fathers and mothers; and also several shared caregiving roles of fathers and mothers. Specifically, parents highlighted aspects of fathers' coparenting and several common ways by which fathers supported their partners. We found that these gendered divisions in parenting roles were strongly embedded within a complex network of interacting factors across the individual, family, and sociocultural contexts of the study community. CONCLUSIONS: Our findings suggest a more family-centered conceptualization of fatherhood during early childhood that encompasses both fathers' direct engagement with their young children and their indirect contributions through coparenting, while recognizing a variety of contextual systems that shape paternal parenting. Future parenting interventions that reflect the lived experiences of both fathers and mothers as parents and partners may further enhance the nurturing care environments that are critical for promoting healthy early child development.

A meta-analysis of nutrition interventions on mental development of children under-two in low- and middle-income countries.

Interventions to improve nutritional status of young children in low- and middle-income countries (LMIC) may have the added benefit of improving their mental and motor development. This meta-analysis updates and goes beyond previous ones by answering two important questions: (1) do prenatal and postnatal nutritional inputs improve mental development, and (2) are effects on mental development associated with two theoretically interesting mediators namely physical growth and motor development? The meta-analysis of articles on Medline, PsycINFO, Global Health and Embase was limited to randomized trials in LMICs, with mental development of children from birth to age two years as an outcome. The initial yield of 2689 studies was reduced to 33; 12 received a global quality rating of strong. Of the 10 prenatal and 23 postnatal nutrition interventions, the majority used zinc, iron/folic acid, vitamin A or multiple micronutrients, with a few evaluating macronutrients. The weighted mean effect size, Cohen's d (95% CI) for prenatal and postnatal nutrition interventions on mental development was 0.042 (-0.0084, 0.092) and 0.076 (0.019, 0.13), respectively. Postnatal supplements consisting of macronutrients yielded an effect size d (95% CI) of 0.14 (0.0067, 0.27), multiple micronutrients 0.082 (-0.012, 0.18) and single micronutrients 0.058 (-0.0015, 0.12). Motor development, but not growth status, effect sizes were significantly associated with mental development in postnatal interventions. In summary, nutrition interventions had small effects on mental development. Future studies might have greater effect if they addressed macronutrient deficiencies combined with child stimulation and hygiene and sanitation interventions.