Nurturing care practices for children with developmental disabilities in sub-Saharan Africa: A scoping review protocol.

BACKGROUND: The majority of children with neurodevelopmental disorders (NDDs) reside in low- and middle-income countries (LMICs). NDDs are a public health concern in countries in sub-Saharan Africa (SSA). Nurturing care has been recommended as a pathway for addressing the developmental needs and unlocking the full potential of children, including those with NDDs. However, little information exists on the strategies to support children with NDDs using the Nurturing Care Framework in many countries in SSA. This review aims to synthesize information on nurturing care practices for children with NDDs in SSA. The review will also determine gaps in the provision of nurturing care for children with NDDs. Further, the review will highlight the drivers of care as well as the experiences of the caregivers. METHODS: The review will be implemented in six steps: specification of the research question, identification of relevant studies, selection of studies to be included, extracting, mapping, and charting the data, collating, summarizing, and reporting the results, and stakeholder consultation. We propose a database search followed by a manual search for the literature synthesis. We will search the following electronic databases: PubMed, ScienceDirect, Scopus, Open Grey and African Journals Online (AJOL). All studies published after May 2018 to May 2023 that include relevant terms will be identified and included. The research team will develop a data extraction form for use in capturing relevant information from each of the included studies. A patterning chart that will summarize and analyze the key findings of each article will be created. DISCUSSION: We anticipate that the study will provide evidence on the existing nurturing care practices and unearth gaps in the provision of nurturing care for children with NDDs. Key determinants of care and the experiences of the parents/caregivers of children will also be identified. The study will provide key recommendations on interventions to improve the quality of care for children with NDDs. Through this study, awareness of the unmet nurturing care needs of these children will be increased. The evidence generated may assist policymakers and stakeholders in addressing the needs of children with NDDs.

Parental stress and child stimulation practices: examining associations with child developmental outcomes over time in Kenya and Zambia.

BACKGROUND: Parental stress often arises when parenting demands exceed the expected and actual resources available for parents to succeed in the parenting role. Parental stress is an important contributor to parent-child relationships. This, in turn, affects opportunities to engage their children in stimulating activities which could improve their development outcomes. However, limited evidence exists from sub-Saharan Africa (SSA) on the association between parental stress, caregiving practices, and child developmental outcomes. METHODS: The findings reported in this paper were derived from data collected through previous longitudinal work on nurturing care evaluation studies in Kisumu and Nairobi Counties in Kenya, and Chisamba District in Zambia. A total of 341 caregivers and their children who participated in the three rounds of data collection were included in this study. The children's mean age was 9.3 (SD = 8.2) months pre-intervention, 25.5 (SD = 8.6) months in mid-intervention, and 36 (SD = 10.0) months post-intervention. The Ages and Stages Questionnaire (ASQ), Parental Stress Scale (PSS), and caregiving tools were used to assess children's developmental outcomes, parental stress, and stimulation practices, respectively. A Random Intercept Cross-Lagged Panel model (RI-CLPM) was used to determine the association between caregivers' parenting stress, child stimulation practices, and child developmental outcomes. RESULTS: The findings showed that caregiver stimulation practices were positively associated with developmental outcomes. Findings on the associations between parental stress and caregivers' stimulation practices and children's developmental outcomes were not universally supported. CONCLUSION: The findings show that improved caregiver stimulation practices are likely to improve children's developmental outcomes. The policy implications of the findings from this study focus on improving parenting practices by addressing the predictors of parental stress. This includes subsidising childcare services to reduce costs. TRIAL REGISTRATION: Pan African Clinical Trials Registry ( https://pactr.samrc.ac.za/ ) database (ID number: PACTR20180774832663 Date: 26/July/2018.

Maternal stimulation and early child development in sub-saharan Africa: evidence from Kenya and Zambia.

BACKGROUND: Despite major improvements in child survival over the past decade, many children in low and middle-income countries (LMICs) remain at risk of not reaching their developmental potential due to malnutrition, poor health, and a lack of stimulation. Maternal engagement and stimulation have been identified as some of the most critical inputs for healthy development of children. However, relatively little evidence exists on the links between maternal stimulation and child development exists in sub-Saharan Africa (SSA). This current paper aims to identify the associations between maternal stimulation and child development in Kenya and Zambia, as well as the activities that are most predictive of developmental outcomes in these settings. METHODS: We conducted a descriptive study using data from a prospective study in Kenya and Zambia. The study included three rounds of data collection. Children were on average 10 months old in round one, 25 months old in round two, and 36 months old in round three. The primary exposure variable of interest was maternal stimulation activities, which we grouped into cognitive, language, motor, and socio-emotional activities. The outcome of interest was child development measured through the Third Edition of the Ages and Stages Questionnaire (ASQ-3). Linear regression models were used to estimate the associations between overall maternal stimulation and domain-specific maternal stimulation and child development across the three rounds of the survey. RESULTS: Higher maternal stimulation scores were associated with higher ASQ scores (effect size = 0.25; 95% CI: 0.19, 0.31) after adjusting for other confounders. For domain specific and child development (ASQ scores), the largest effect size (ES) was found for language stimulation (ES = 0.15) while weakest associations were found for socio-emotional domain activities (ES= -0.05). Overall maternal stimulation was most strongly associated with gross motor development (ES = 0.21) and the least associated with problem-solving (ES = 0.16). CONCLUSION: Our study findings suggest a strong positive link between maternal stimulation activities and children's developmental outcomes among communities in poor rural settings. TRIAL REGISTRATION: NA (not a clinical trial).

Predictors of quality of childcare centers in low-income settings: findings from a cross-sectional study in two Nairobi slums.

Background: Rapid urbanization and increased women's involvement in paid work have contributed to the upsurge of informal childcare centers, especially in low-income settings where quality is a major issue. However, there are limited data on the factors associated with the quality of childcare centers in informal settlements in Africa. Methods: We conducted a quantitative observation and questionnaire survey of 66 childcare centers to identify the factors associated with the quality of childcare services in two informal settlements (Korogocho and Viwandani) in Nairobi. The quality of the centers (outcome variable) was assessed using a locally developed tool. Data on center characteristics including type, size, location, length of operation, charges, and number of staff were collected. Center providers' knowledge, attitude, and practices (KAP) in childcare were assessed through a questionnaire, focusing on nurturing care and business management. Data were described using means and standard deviation or frequencies and percentages. Associations between quality center score (outcome variable) and other variables were examined using multivariable linear regression to identify potential predictors of the quality of the center environment. Findings: A total of 129 childcare centers were identified and categorized as home-based (n = 45), center-based (n = 14), school-based (n = 61), and church-based (n = 9). The number of home-based centers was particularly high in Viwandani (n = 40; 52%). Only 9% of home-based centers reported any external support and 20% had any training on early childhood development. Of the 129 centers, 66 had complete detailed assessment of predictors of quality reported here. Unadjusted linear regressions revealed associations between quality of childcare center and center providers' education level, type of center, support received, caregiver-child ratio, number of children in the center, and center providers' KAP score (p < 0.05). However, in the multivariable regression, only higher levels of center provider KAP (ß = 0.51; 95% CI: 0.18, 0.84; p = 0.003) and center type (ß = 8.68; 95% CI: 2.32, 15.04; p = 0.008) were significantly associated with center quality score. Implication: Our results show that center providers' knowledge and practices are a major driver of the quality of childcare centers in informal settlements in Nairobi. Interventions for improving the quality of childcare services in such settings should invest in equipping center providers with the necessary knowledge and skills through training and supportive supervision.

Perceptions of the influence of a mobile phone-based messaging platform on caregiver ECD knowledge, attitudes and practices: a qualitative exploration in an informal settlement in Nairobi.

BACKGROUND: Programs supporting initiatives for children younger than three years are inadequate and not accessible to many families, particularly in resource-limited settings. Many primary caregivers have little knowledge on how to monitor the development of their children or the importance of engaging children in stimulative activities during the course of early development. Health system limitations make it difficult for health workers to educate and demonstrate stimulative engagement to caregivers. The massive use of technology can be used to facilitate access to growth and development programs for children. We developed and implemented a mobile phone technology to help caregivers monitor and stimulate their children's development in real-time. This study explored the influence that this intervention had on the caregivers' early child development (ECD) knowledge, attitudes and practices. METHODS: In this qualitative cross-sectional study, we conducted interviews through eight (8) focus group discussions, three (3) key informant interviews and 9 indepth interviews among a total of 111 participants including primary caregivers (n = 87), community health volunteers (CHVs) (n = 21) health managers and workers (n = 3) to determine their attitudes and experience with the intervention with regards to improving their KAP. Interviews were audio-recorded, transcribed, and analyzed thematically. RESULTS: Caregivers and CHVs reported that the intervention had provided them with new knowledge that positively influenced their ECD caregiving attitudes and practices. CHVs and health workers and managers reported that the intervention had provided caregivers with confidence in caring for their children while increasing their knowledge on how to monitor and stimulate their children's development. CONCLUSION: Mobile phone technology can be effectively used to enhance caregivers' knowledge of ECD and enable them to monitor and support their children's development in real-time. TRIAL REGISTRATION: The trial was registered with the Pan African Clinical Trial Registry ( www.pactr.org ) database (ID number: PACTR201905787868050 Date: 6/05/2019.

Developing an intervention to improve the quality of childcare centers in resource-poor urban settings: a mixed methods study in Nairobi, Kenya.

Background: Globally, 350 million under-5s do not have adequate childcare. This may damage their health and development and undermine societal and economic development. Rapid urbanization is changing patterns of work, social structures, and gender norms. Parents, mainly mothers, work long hours for insecure daily wages. To respond to increasing demand, childcare centers have sprung up in informal settlements. However, there is currently little or no support to ensure they provide safe, nurturing care accessible to low-income families. Here, we present the process of co-designing an intervention, delivered by local government community health teams to improve the quality of childcare centers and ultimately the health and development of under-5 children in informal settlements in Kenya. Methods: This mixed methods study started with a rapid mapping of the location and basic characteristics of all childcare centers in two informal settlements in Nairobi. Qualitative interviews were conducted with parents and grandparents (n = 44), childcare providers, and community health teams (n = 44). A series of 7 co-design workshops with representatives from government and non-governmental organizations (NGOs), community health teams, and childcare providers were held to design the intervention. Questionnaires to assess the knowledge, attitudes, and practices of community health volunteers (n = 22) and childcare center providers (n = 66) were conducted. Results: In total, 129 childcare centers were identified -55 in Korogocho and 77 in Viwandani. School-based providers dominated in Korogocho (73%) while home-based centers were prevalent in Viwandani (53%). All centers reported minimal support from any organization (19% supported) and this was particularly low among home-based (9%) and center-based (14%) providers. Home-based center providers were the least likely to be trained in early childhood development (20%), hence the co-designed intervention focused on supporting these centers. All co-design stakeholders agreed that with further training, community health volunteers were well placed to support these informal centers. Findings showed that given the context of informal settlements, support for strengthening management within the centers in addition to the core domains of WHO's Nurturing Care Framework was required as a key component of the intervention. Conclusion: Implementing a co-design process embedded within existing community health systems and drawing on the lived experiences of childcare providers and parents in informal settlements facilitated the development of an intervention with the potential for scalability and sustainability. Such interventions are urgently needed as the number of home-based and small center-based informal childcare centers is growing rapidly to meet the demand; yet, they receive little support to improve quality and are largely unregulated. Childcare providers, and government and community health teams were able to co-design an intervention delivered within current public community health structures to support centers in improving nurturing care. Further research on the effectiveness and sustainability of support to private and informal childcare centers in the context of low-income urban neighborhoods is needed.

The feasibility, acceptability, cost and benefits of a "communities of practice" model for improving the quality of childcare centres: a mixed-methods study in the informal settlements in Nairobi.

Background: Informal childcare centres have mushroomed in the informal settlements of Nairobi, Kenya to meet the increasing demand. However, centre providers are untrained and the facilities are below standard putting children at risk of poor health and development. We aimed to co-design and test the feasibility, acceptability, cost and potential benefits of a communities of practice (CoP) model where trained community health volunteers (CHVs) provide group training sessions to build skills and improve practices in informal childcare centres. Methods: A CoP model was co-designed with sub-county health teams, centre providers and parents with inputs from Kidogo, government nutritionists and ECD experts and implemented in 68 childcare centres by trained CHVs. Its feasibility and potential benefits were measured quantitatively and qualitatively. Centre provider (n = 68) and CHV (n = 20) knowledge and practice scores before and after the intervention were assessed and compared. Intervention benefits were examined using linear regressions adjusting for potential confounding factors. We conducted in-depth interviews with 10 parents, 10 CHVs, 10 centre providers and 20 local government officials, and two focus groups with CHVs and centre providers. Qualitative data were analysed, focusing on feasibility, acceptability, potential benefits, challenges and ideas for improvement. Cost for delivering and accessing the intervention were examined. Results: The intervention was acceptable and feasible to deliver within existing government community health systems; 16 CHVs successfully facilitated CoP sessions to 58 centre providers grouped into 13 groups each with 5-6 centre providers, each group receiving four sessions representing the four modules. There were significant improvements in provider knowledge and practice (effect size = 0.40; p < 0.05) and quality of centre environment (effect size = 0.56; p < 0.01) following the intervention. CHVs' scores showed no significant changes due to pre-existing high knowledge levels. Qualitative interviews also reported improvements in knowledge and practices and the desire among the different participants for the support to be continued. The total explicit costs were USD 22,598 and the total opportunity costs were USD 3,632 (IQR; USD 3,570, USD 4,049). Conclusion: A simple model delivered by CHVs was feasible and has potential to improve the quality of informal childcare centres. Leveraging these teams and integration of the intervention into the health system is likely to enable scale-up and sustainability in Kenya and similar contexts.

Parental experiences of the impacts of Covid-19 on the care of young children; qualitative interview findings from the Nairobi Early Childcare in Slums (NECS) project.

INTRODUCTION: The Covid-19 pandemic, and societal attempts to control it, have touched almost every aspect of people's lives around the world, albeit in unequal ways. In particular, there is considerable concern about the way that stringent 'lockdowns', as implemented in Kenya and many other countries, affected young children, especially those living in informal settlements. However, to date, there has been little research attempting to unpack and understand how the pandemic has impacted on the care of young children. METHODS: In-depth telephone interviews were conducted with 21 parents/carers of children aged under five years living in three Nairobi slums between May and September 2021 exploring the ways in which Covid-19, and policies to control the pandemic, impacted on their household and the care of their child/children. RESULTS: The impacts of Covid-19 control measures on the care of children have been widely felt, deep and multiple. The impact of economic hardship has been significant, reportedly undermining food security and access to services including healthcare and childcare. Respondents reported an associated increase in domestic and community violence. Many people relied on help from others; this was most commonly reported to be in the form of variable levels of flexibility from landlords and help from other community members. No direct harms from Covid-19 disease were reported by respondents. CONCLUSION: The impacts of Covid-19 control measures on the care of young children in informal settlements have been indirect but dramatic. Given the breadth and depth of these reported impacts, and the particular vulnerability of young children, deeper consideration ought to inform decisions about approaches to implementation of stringent disease control measures in future. In addition, these findings imply a need for both short- and long-term policy responses to ameliorate the impacts described.

Parental experiences of childcare in an informal urban settlement: qualitative interview findings from the Nairobi Early Childcare in Slums (NECS) project.

OBJECTIVES: To gain an in-depth understanding of parent/carers' perspectives on, and decision-making about, early childhood care in general, and paid childcare specifically, in informal settlements in Nairobi. DESIGN: In-depth telephone interviews, conducted using a topic guide, were analysed through a combination of deductive and inductive thematic analysis and regular reflexivity meetings. We explored parents' childcare needs and experiences over time, and their perspectives on the provision of paid childcare in the slums. SETTING: Three informal settlements or slums in Nairobi: Kibera; Kawangware; and Mukuru-Viwandani. PARTICIPANTS: A purposively selected sample of 21 parental and non-parental carers of children aged under 5 years who were currently living in three Nairobi slums, including men and women, and users and non-users of paid childcare. RESULTS: Childcare is complex, with a plurality of approaches being used. Common strategies include family member provided care (often but not exclusively by mothers, at home or at a place of work), paid childcare and informal or ad hoc arrangements with neighbours. Childcare decision-making in these settings is constrained by economics and the broader context of living in the slum. Paid childcare is frequently used, but is widely understood to be lacking in quality, especially for the poorest. Quality of childcare is understood to comprise a combination of structural factors, such as the physical space, play and learning resources and processes such as interactions between the care provider and children or parents. CONCLUSIONS: These findings suggest a need, and opportunity, to improve early childhood care in slums. Understanding parental perspectives on both the deficiencies and valued features of childcare is likely to be vital to informing efforts to improve childcare in these settings.

Improving early childhood development in the context of the nurturing care framework in Kenya: A policy review and qualitative exploration of emerging issues with policy makers.

Introduction: The Nurturing Care Framework (NCF) describes "nurturing care" as the ability of nations and communities to support caregivers and provide an environment that ensures children's good health and nutrition, protects them from threats, and provides opportunities for early learning through responsive and emotionally supportive interaction. We assessed the extent to which Kenyan government policies address the components of the NCF and explored policy/decision makers' views on policy gaps and emerging issues. Methods: A search strategy was formulated to identify policy documents focusing on early childhood development (ECD), health and nutrition, responsive caregiving, opportunities for early learning and security and safety, which are key components of the NCF. We limited the search to policy documents published since 2010 when the Kenya constitution was promulgated and ECD functions devolved to county governments. Policy/decision-maker interviews were also conducted to clarify emerging gaps from policy data. Data was extracted, coded and analyzed based on the components of the NCF. Framework analysis was used for interview data with NCF being the main framework of analysis. The Jaccard's similarity coefficient was used to assess similarities between the themes being compared to further understand the challenges, successes and future plans of policy and implementation under each of the NCF domains. Results: 127 policy documents were retrieved from government e-repository and county websites. Of these, n = 91 were assessed against the inclusion criteria, and n = 66 were included in final analysis. The 66 documents included 47 County Integrated Development Plans (CIDPs) and 19 national policy documents. Twenty policy/decision-maker interviews were conducted. Analysis of both policy and interview data reveal that, while areas of health and nutrition have been considered in policies and county level plans (coefficients >0.5), the domains of early learning, responsive caregiving and safety and security face significant policy and implementation gaps (coefficients ≤ 0.5), particularly for the 0-3 year age group. Inconsistencies were noted between county level implementation plans and national policies in areas such as support for children with disabilities and allocation of budget to early learning and nutrition domains. Conclusion: Findings indicate a strong focus on nutrition and health with limited coverage of responsive caregiving and opportunities for early learning domains. Therefore, if nurturing care goals are to be achieved in Kenya, policies are needed to support current gaps identified with urgent need for policies of minimum standards that provide support for improvements across all Nurturing Care Framework domains.

Evaluating the effectiveness of the Kidogo model in empowering women and strengthening their capacities to engage in paid labor opportunities through the provision of quality childcare: a study protocol for an exploratory study in Nakuru County, Kenya.

Worldwide, there is a wide gap between what women can contribute to the economy and what they actually contribute. One of the main barriers to women's engagement in the labor market and productivity at work is the societal expectation that they should take care of their children in addition to meeting the demands of employment. Furthermore, those in informal employment face difficulties due to long working hours and environments that are not appropriate for childcare. To address this, Kidogo runs an innovative "Hub & Spoke" model for low-income communities. Here, we present a study protocol aimed at evaluating whether the provision of quality childcare opportunities for working women through the Kidogo model is feasible and acceptable and whether it contributes to improvements in their incomes and productivity at work. The study reported in this protocol which is currently ongoing, employed a quasi-experimental design with two study arms: primary caregivers who use childcare services were recruited into the intervention (n = 170) and comparison groups (n = 170). Both groups are being followed up for one year. We are using a mixed-methods approach. Appropriate statistical methods including a difference-in-differences (DID) estimator will be used to analyze the effects of the intervention. We expect that the intervention will improve the quality of childcare services which in turn will improve the incomes of the center providers. We expect that providing improved childcare services will enhance women's economic empowerment. Trial registration: PACTR202107762759962.

Parent and implementer attitudes on gender-equal caregiving in theory and practice: perspectives on the impact of a community-led parenting empowerment program in rural Kenya and Zambia.

BACKGROUND: Fathers are often perceived to be mainly responsible for the provision of the family's economic needs. However, past studies have demonstrated that fathers' involvement in parenting has great significance for the child's holistic growth and development. Few studies have investigated fathers' roles in the nurturing care of young children, particularly responsive care and stimulation, in sub-Saharan Africa. The study reported here was carried out as part of a larger study that sought to evaluate the effectiveness of the Moments That Matter (MTM) program in improving the nurturing care of young children in rural communities in Zambia and Kenya. The MTM program uses a parenting empowerment approach to promote bonding and interactions between caregivers and their children within the home, focusing on responsive care, early learning, and security and safety so that children reach their full developmental potential. Trained volunteers facilitated monthly primary caregiver support and learning groups and ECD home visits. Fathers were encouraged to participate in the home visits and to attend some of the group meetings on specific topics. The study reported in this paper aimed to establish the impact of the parenting empowerment program in promoting more gender-equal attitudes and practices on parenting among fathers (who were not the primary caregivers). METHODS: Qualitative data were collected at three time points (pre-intervention before the implementation began; mid-intervention after 6 months of implementation; and post-intervention, after 24 months). We conducted focused group discussions with primary caregivers (n = 72) and fathers (n = 24) with children below 3 years. In-depth interviews were conducted with ECD Promoters (n = 43) and faith leaders (= 20). We also conducted key informant interviews with the MTM program implementers (n = 8) and government officials (n = 5) involved in the program implementation. We employed thematic analysis to analyse the qualitative data. RESULTS: The findings showed that the MTM program resulted in improved gender-equal parenting attitudes and practices among mothers/other primary caregivers and fathers. Study participants reported that most fathers spent more time playing and interacting with their children and were more involved in household chores due to their participation in the MTM program. CONCLUSION: The study findings provide evidence for policy formulation and a guide for implementation of policies that can influence changes in perceived gender roles in parenting.

Associations between exclusive breastfeeding duration and children's developmental outcomes: Evidence from Siaya county, Kenya.

BACKGROUND: Exclusive breastfeeding (EBF) during the first 6 months of life is widely promoted as a key strategy to enhance child health, growth, and development. Even though a high proportion of children in Kenya are currently breastfed exclusively, there is little evidence regarding the developmental benefits during the first year of life. This paper aims to fill this gap by establishing an association between EBF and early childhood developmental outcomes among children below the age of 6 months in Kenya. METHODS: We used data collected as part of a cluster-randomized controlled trial conducted in Bondo sub-county in the western part of Kenya to assess the associations between EBF and development in the first year of life. The primary exposure variable was EBF, and the outcome variable was child development as measured by the Ages and Stages Questionnaire-Third Edition (ASQ-3). RESULTS: We analyzed data from 570 children aged below 6 months at the time of the interview. Breastfeeding children exclusively between 3 and 6 months was associated with 0.61 standard deviation (SD) higher ASQ-3 scores in the adjusted model. When specific domains were considered, in the adjusted models, EBF in the 3-6 months period was associated with 0.44 SD, 0.34 SD and 0.36 SD higher ASQ-3 scores in communication, gross motor, and problem solving domains, respectively. There were weak associations in the fine motor and social-emotional domains. CONCLUSION: EBF in the 3- to 6-month age range has significant positive associations with child development, especially for communication, gross motor, and problem-solving. Programs encouraging mothers to continue EBF in this period may have substantial benefits for children.

Development and feasibility testing of a mobile phone application to track children's developmental progression.

Given that mobile phone usage has increased rapidly throughout the world, one possibility to increase parental involvement in monitoring their children's progression is to train parents or primary caregivers on the use of mobile phone technology to track their children's developmental milestones. The current paper aimed to describe the development of a mobile phone application for use among primary caregivers and establish the feasibility and preliminary impact of caregivers using a mobile phone application to track the progression of their children's development in a context where there is a paucity of similar studies. This study is a substudy that focusses on the intervention group only of a recently completed two-armed quasi-experimental study in an informal settlement in Nairobi. The mobile phone application which consisted of questions on children's developmental progression, as well as stimulation messages, was developed through a step-wise approach. The questions covered five child developmental domains: communication; fine motor; gross motor; personal-social; and, problem-solving. Depending on the response received, the child would be classified as having 'achieved a milestone' or 'milestone not achieved.' If a child had achieved the milestone for a specific age, a caregiver would receive an SMS on how to stimulate the child to achieve the next milestone. Where the milestone was not achieved, the caregiver would get a message to enhance development in the area of delay. Caregivers with children aged between six months and two years were recruited into the study and received questions and messages regarding their children's development (age-specific) on a monthly basis for 12 months. Caregiver adherence to the intervention was above 90% in the first three months of implementation. Thereafter, the response rate fluctuated between 76% and 86% across the subsequent months of the intervention. The high level and fairly stable caregivers' rate of response to the 12 rounds of messaging indicated feasibility of the mobile technology. Further, in the first three months of intervention implementation, the majority of caregivers were able to keep track of how their children attained their developmental milestones. The intervention seems to be scalable, practical and potentially low-cost because of the wide coverage of phones.

Who actually cares for children in slums? Why we need to think, and do, more about paid childcare in urbanizing sub-Saharan Africa.

The early years are critical and inform the developmental trajectory of children. This is justifiably attracting growing policy attention. Much of this attention is focused on interventions and policies directed at parents, especially mothers. Yet emerging evidence suggests that increasing numbers of children in rapidly urbanizing low- and middle-income countries are now spending much of their day with other formal and informal childcare providers, including largely unregulated paid childcare providers. This paper summarizes the limited literature about the use of such paid childcare in low- and middle-income countries in sub-Saharan Africa, before considering possible reasons behind the lack of research evidence. Finally, key research gaps and their implications for public health practice are explored, with reference to the ongoing British Academy funded Nairobi Early Childcare in Slums research programme in Nairobi, Kenya. We argue that improving childcare may be an under-explored strategy to help some of the world's most disadvantaged children in the most important period of their lives, and that interventions in this largely informal market should be built on a rigorous research base. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

Nairobi Early Childcare in Slums (NECS) Study Protocol: a mixed-methods exploration of paid early childcare in Mukuru slum, Nairobi.

INTRODUCTION: The early years are critical. Early nurturing care can lay the foundation for human capital accumulation with lifelong benefits. Conversely, early adversity undermines brain development, learning and future earning.Slums are among the most challenging places to spend those early years and are difficult places to care for a child. Shifting family and work structures mean that paid, largely informal, childcare seems to be becoming the 'new normal' for many preschool children growing up in rapidly urbanising Africa. However, little is known about the quality of this childcare. AIMS: To build a rigorous understanding what childcare strategies are used and why in a typical Nairobi slum, with a particular focus on provision and quality of paid childcare. Through this, to inform evaluation of quality and design and implementation of interventions with the potential to reach some of the most vulnerable children at the most critical time in the life course. METHODS AND ANALYSIS: Mixed methods will be employed. Qualitative research (in-depth interviews and focus group discussions) with parents/carers will explore need for and decision-making about childcare. A household survey (of 480 households) will estimate the use of different childcare strategies by parents/carers and associated parent/carer characteristics. Subsequently, childcare providers will be mapped and surveyed to document and assess quality of current paid childcare. Semistructured observations will augment self-reported quality with observable characteristics/practices. Finally, in-depth interviews and focus group discussions with childcare providers will explore their behaviours and motivations. Qualitative data will be analysed through thematic analysis and triangulation across methods. Quantitative and spatial data will be analysed through epidemiological methods (random effects regression modelling and spatial statistics). ETHICS AND DISSEMINATION: Ethical approval has been granted in the UK and Kenya. Findings will be disseminated through journal publications, community and government stakeholder workshops, policy briefs and social media content.

Measurement of expressive vocabulary in school-age children: Development and application of the Kilifi Naming Test (KNT).

The dearth of locally developed measures of language makes it difficult to detect language and communication problems among school-age children in sub-Saharan African settings. We sought to describe variability in vocabulary acquisition as an important element of global cognitive functioning. Our primary aims were to establish the psychometric properties of an expressive vocabulary measure, examine sources of variability, and investigate the measure's associations with non-verbal reasoning and educational achievement. The study included 308 boys and girls living in a predominantly rural district in Kenya. The developed measure, the Kilifi Naming Test (KNT), had excellent reliability and acceptable convergent validity. However, concurrent validity was not adequately demonstrated. In the final regression model, significant effects of schooling and area of residence were recorded. Contextual factors should be taken into account in the interpretation of test scores. There is need for future studies to explore the concurrent validity of the KNT further.

Effect of provision of an integrated neonatal survival kit and early cognitive stimulation package by community health workers on developmental outcomes of infants in Kwale County, Kenya: study protocol for a cluster randomized trial.

BACKGROUND: Each year, more than 200 million children under the age of 5 years, almost all in low- and middle-income countries (LMICs), fail to achieve their developmental potential. Risk factors for compromised development often coexist and include inadequate cognitive stimulation, poverty, nutritional deficiencies, infection and complications of being born low birthweight and/or premature. Moreover, many of these risk factors are closely associated with newborn morbidity and mortality. As compromised development has significant implications on human capital, inexpensive and scalable interventions are urgently needed to promote neurodevelopment and reduce risk factors for impaired development. METHOD/DESIGN: This cluster randomized trial aims at evaluating the impact of volunteer community health workers delivering either an integrated neonatal survival kit, an early stimulation package, or a combination of both interventions, to pregnant women during their third trimester of pregnancy, compared to the current standard of care in Kwale County, Kenya. The neonatal survival kit comprises a clean delivery kit (sterile blade, cord clamp, clean plastic sheet, surgical gloves and hand soap), sunflower oil emollient, chlorhexidine, ThermoSpot(TM), Mylar infant sleeve, and a reusable instant heater. Community health workers are also equipped with a portable hand-held electric scale. The early cognitive stimulation package focuses on enhancing caregiver practices by teaching caregivers three key messages that comprise combining a gentle touch with making eye contact and talking to children, responsive feeding and caregiving, and singing. The primary outcome measure is child development at 12 months of age assessed with the Protocol for Child Monitoring (Infant and Toddler version). The main secondary outcome is newborn mortality. DISCUSSION: This study will provide evidence on effectiveness of delivering an innovative neonatal survival kit and/or early stimulation package to pregnant women in Kwale County, Kenya. Study findings will help inform policy on the most appropriate interventions for promoting healthy brain development and reduction of newborn morbidity and mortality in Kenya and other similar settings. TRIAL REGISTRATION: ClinicalTrial.gov NCT02208960 (August 1, 2014).