The Irie Classroom Toolbox, a universal violence-prevention teacher-training programme, in Jamaican preschools: a single-blind, cluster-randomised controlled trial.

BACKGROUND: Violence is a leading global public health problem, and interventions in early childhood are important in the primary prevention of violence. We tested whether the Irie Classroom Toolbox, a violence-prevention teacher-training programme reduced violence against children by teachers and reduced class-wide child aggression in Jamaican preschools (catering to children aged 3-6 years). METHODS: We did a single-blind, cluster-randomised controlled trial in 76 preschools in Kingston and St Andrew, randomly selected, using simple randomisation, from 120 eligible preschools. Inclusion criteria were two to four classes of children; at least ten children per class; and located in an urban area. We randomly assigned preschools (1:1) to either the Irie Classroom Toolbox intervention or waiting-list control that received no intervention, using a computer-generated randomisation sequence by an independent statistician masked to school identity. The Toolbox involved training teachers in classroom behaviour management and promoting child social-emotional competence. All assessors were masked to group assignment. All teachers and classrooms in the selected schools participated in the study. Within each school, we used simple randomisation to randomly select up to 12 children aged 4 years for evaluation of child outcomes. The Toolbox intervention was implemented from August to April the following year. Teacher and classroom measures were done at baseline (the summer school term; ie, May to June), post-intervention (after 8 months of intervention; ie, May to June of the following year), and 1-year follow-up (ie, May to June 2 years later). The primary outcomes were observations of violence against children (including physical violence and psychological aggression) by teachers occurring across one full school day, and class-wide child aggression occurring over five 20-min intervals on another school day, all measured at post-intervention and 1-year follow-up and analysed by intention to treat. This trial is registered with ISRCTN, number ISRCTN11968472. FINDINGS: Between June 22, 2015, and April 29, 2016, (after baseline measurements were completed), we assigned 38 preschools (with 119 teachers) to the Toolbox intervention and 38 preschools (with 110 teachers) to control. 441 children in the intervention schools and 424 in the control schools were included in the evaluation. All schools were included in the post-intervention and follow-up analyses. There were fewer counts of violence against children by teachers in the intervention schools compared with control schools at post-intervention (median counts 3 [IQR 0-11] vs 15 [3-35]; effect size -67·12%, 95% CI -80·71 to -53·52, p<0·0001) and 1-year follow-up (median counts 3 [IQR 0-9] vs 6 [1-16]; effect size -53·86, 95% CI -71·08 to -36·65, p<0·0001). No differences between groups were found for class-wide child aggression at post-intervention (effect size 0·07, 95% CI -0·16 to 0·29, p=0·72) or 1-year follow-up (-0·14, -0·42 to 0·16, p=0·72). INTERPRETATION: In Jamaican preschools, the Irie Classroom Toolbox effectively reduced violence against children by teachers. The Toolbox was designed for use with undertrained teachers working in low-resource settings and should be effective with early childhood practitioners in other LMICs. Additional research is needed to further develop the Toolbox to reduce class-wide child aggression. FUNDING: Medical Research Council, Wellcome Trust, UK Aid, and the National Institute of Health Research.

The effects of the transition from home-based childcare to childcare centers on children's health and development in Colombia.

Colombia's national early childhood strategy launched in 2011 aimed at improving the quality of childcare services offered to socio-economically vulnerable children, and included the possibility that children and their childcare providers could transfer from non-parental family daycare units to large childcare centers in urban areas. This study seeks to understand whether the offer to transfer and the actual transfer from one program to the other had an impact on child cognitive and socioemotional development, and nutrition, using a cluster-randomized control trial with a sample of 2767 children between the ages of 6 and 60 months located in 14 cities in Colombia. The results indicate a negative effect of this initiative on cognitive development, a positive effect on nutrition, and no statistically significant effect of the intervention on socioemotional development. We also explored the extent to which these impacts might be explained by differences in the quality of both services during the transition, and report that quality indicators are low in both programs but are significantly worse in centers compared to community nurseries.

Irie Classroom Toolbox: a study protocol for a cluster-randomised trial of a universal violence prevention programme in Jamaican preschools.

INTRODUCTION: We aim to determine the effectiveness of a school-based violence prevention programme implemented in Jamaican preschools, on reducing the levels of aggression among children at school, and violence against children by teachers. METHODS AND ANALYSIS: This is a 2-arm, single-blind, cluster-randomised controlled trial with parallel assignment. Clusters are 76 preschools in Kingston, and all teachers and classrooms in the selected schools are included in the study. In addition, a random sample of up to 12 children in the 4-year-old classes have been selected for evaluation of child-level outcomes. The intervention involves training teachers in classroom behaviour management and in strategies to promote children's social-emotional competence. Training is delivered through five full-day workshops, monthly in-class coaching over 2 school terms, and weekly text messages. The primary outcome measures are: (1) observed levels of child aggression and (2) observed violence against children by teachers. Secondary outcomes include observations of the levels of children's prosocial behaviour and the quality of the classroom environment, teachers' reports of their mental health, teacher-reported child mental health, direct tests of children's self-regulation and child attendance. ETHICS AND DISSEMINATION: If this intervention were effective at improving the caregiving environment of young children in school, this would have significant implications for the prevention of child mental health problems, and prevention of violence against children in low and middle-income countries where services are often limited. The intervention is integrated into the school system and involves training existing staff, and thus, represents an appropriate strategy for large-scale implementation and benefits at the population level. Ethical consent for the study was given by the School of Psychology Ethics and Research Committee, Bangor University (ref: 2014-14167), and by the University of the West Indies Ethics Committee (ref: ECP 50,14/15). TRIAL REGISTRATION NUMBER: ISRCTN11968472; Pre-results.

Integrating a Parenting Intervention With Routine Primary Health Care: A Cluster Randomized Trial.

OBJECTIVE: More than 200 million children globally do not attain their developmental potential. We hypothesized that a parent training program could be integrated into primary health center visits and benefit child development. METHODS: We conducted a cluster randomized trial in the Caribbean (Jamaica, Antigua, and St Lucia). Fifteen centers were randomly assigned to the control (n = 250 mother-child pairs) and 14 to the intervention (n = 251 mother-child pairs) groups. Participants were recruited at the 6- to 8-week child health visit. The intervention used group delivery at 5 routine visits from age 3 to 18 months and comprised short films of child development messages, which were shown in the waiting area; discussion and demonstration led by community health workers; and mothers' practice of activities. Nurses distributed message cards and a few play materials. Primary outcomes were child cognition, language, and hand-eye coordination and secondary outcomes were caregiver knowledge, practices, maternal depression, and child growth, measured after the 18-month visit. RESULTS: Eight-five percent of enrolled children were tested (control = 210, intervention = 216). Loss did not differ by group. Multilevel analyses showed significant benefits for cognitive development (3.09 points; 95% confidence interval: 1.31 to 4.87 points; effect size: 0.3 SDs). There were no other child benefits. There was a significant benefit to parenting knowledge (treatment effect: 1.59; 95% confidence interval: 1.01 to 2.17; effect size: 0.4). CONCLUSIONS: An innovative parenting intervention, requiring no additional clinic staff or mothers' time, was integrated into health services, with benefits to child cognitive development and parent knowledge. This is a promising strategy that merits further evaluation at scale.

Exploiting subjective information to understand impoverished children's use of health care.

Understanding what drives households to seek medical services is challenging because the factors affecting the perceived benefits and costs of professional health care can be the same. In this paper, we disentangle the channels through which different factors affect the use of medical services, whether through perceived benefits and/or costs. We do this by exploiting data on why individuals have not visited a health care professional. Amongst a sample of impoverished Colombian households, we find that health knowledge reduces the use of medical services through decreasing mothers' perceived benefits of seeking professional care for ill children; birth parity, distance to health facilities and violent shocks all decrease medical care use due to increasing the perceived costs; and education decreases both the perceived benefits and costs, with no overall effect on use. We propose two specification tests, both of which our model passes, as well as a series of robustness checks.

Risk Protection, Service Use, and Health Outcomes under Colombia's Health Insurance Program for the Poor.

Unexpected medical care spending imposes considerable financial risk on developing country households. Based on managed care models of health insurance in wealthy countries, Colombia's Régimen Subsidiado is a publicly financed insurance program targeted to the poor, aiming both to provide risk protection and to promote allocative efficiency in the use of medical care. Using a "fuzzy" regression discontinuity design, we find that the program has shielded the poor from some financial risk while increasing the use of traditionally under-utilized preventive services - with measurable health gains.

Early childhood stimulation benefits adult competence and reduces violent behavior.

OBJECTIVE: An estimated 178 million children younger than 5 years in developing countries experience linear growth retardation and are unlikely to attain their developmental potential. We aimed to evaluate adult benefits from early childhood stimulation and/or nutritional supplementation in growth-retarded children. METHODS: In Kingston, Jamaica, 129 growth-retarded children aged 9 to 24 months took part in a 2-year trial of nutritional supplementation (1 kg milk-based formula per week) and/or psychosocial stimulation (weekly play sessions to improve mother-child interaction). We assessed IQ, educational attainment, and behavior at 22 years old in 105 participants. We used multivariate regressions, weighted to adjust for loss to follow-up, to determine treatment benefits. RESULTS: We found no significant benefits from supplementation. Participants who received stimulation reported less involvement in fights (odds ratio: 0.36 [95% confidence interval (CI) 0.12-1.06]) and in serious violent behavior (odds ratio: 0.33 [95% CI: 0.11-0.93]) than did participants with no stimulation. They also had higher adult IQ (coefficient: 6.3 [95% CI: 2.2-10.4]), higher educational attainment (achievement, grade level attained, and secondary examinations), better general knowledge, and fewer symptoms of depression and social inhibition. CONCLUSIONS: Early psychosocial intervention had wide-ranging benefits in adulthood that are likely to facilitate functioning in everyday life. The reductions in violent behavior are extremely important given the high levels of violence in many developing countries. The study provides critical evidence that early intervention can lead to gains in adult functioning.

Child health in rural Colombia: determinants and policy interventions.

We study the determinants of child anthropometrics on a sample of poor Colombian children living in small municipalities. We focus on the influence of household consumption, and public infrastructure, taking into account the endogeneity of household consumption using two different sets of instruments: household assets and municipality average wage. We find that both household consumption and public infrastructure are important determinants of child health. We have also found that the coverage of the piped water network positively influenced child health if the parents have some education.