Investment in early childhood development has been recognized as an effective strategy to improve long-term educational, health, and economic outcomes in children across the world.1,2 As such, research supporting the design of evidence-based sustainable early childhood development programs and public policies is critical. In this issue of Pediatrics, Grantham-McGregor et al3 report on a cluster randomized control trial in which the effectiveness of an early childhood development intervention in Odisha, India, was examined. Following a protocol previously adapted from the Reach Up and Learn program,4 the study authors aimed to compare 2 models for delivering the intervention: mother-child group sessions (GS) and home visiting (HV).
In the intervention, researchers sought to support positive parent-child interactions through play. In addition, because of the high prevalence of poor nutrition in this community,4 nutritional education (NE) focused on the child’s diet, and family hygiene practices were also included within the study arms. In this study, 192 villages in Odisha were randomly assigned to 1 of 4 groups: (1) control (not receiving any intervention), (2) NE (40-minute individual home visits), (3) NE + HV (60-minute individual home visits), and (4) NE + GS (90-minute mother-child GS). For 24 months, trained facilitators from the community conducted weekly NE, HV, and GS. Sessions consisted of demonstrations of play and interaction strategies by using homemade toys and books, which mothers could use at home and exchange in the next session. NE included cooking demonstrations. Of 1449 mothers with children 7 to 16 months old who were enrolled, ∼1300 provided data on child cognitive and physical health indicators at baseline and in follow-up assessments conducted 12 and 24 months after the programs started.
Intention-to-treat analyses from this study revealed that children in the NE + HV and in the NE + GS groups had higher scores in cognition and language in the first year of the intervention compared with those in the NE and control groups, with benefits sustained into the second year. There were no detectable differences between the HV and GS groups.
There are 3 important implications of this study for the sustainability of community early childhood development interventions in low- and middle-income countries. First, comparable results were found for the HV and GS groups. This is important because each model has its own strengths and challenges. In GS, parents have the opportunity to learn play and reading strategies by observing and sharing experiences with other families, which may be particularly important in contexts in which families may experience social isolation.5,6 However, GS require significant coordination across families related to time and location. Alternatively, HV addresses challenges related to coordination and comfort and may provide an opportunity to tailor the intervention on the basis of the child and the family’s characteristics,4,7,8 but it usually demands more personnel and time.
Second, comparable effects for GS and HV were observed despite significantly lower attendance in GS. Lack of attendance in parenting programs is a recognized barrier, especially in low-income communities.9,10 One approach to addressing this barrier is situating programs in platforms in which families are already present (eg, health care and child educational settings).11–18 For example, a cluster randomized control trial of a community-based group model in educational child care centers in Brazil demonstrated good attendance with positive impacts on cognitive stimulation and child development.18,19
Third, GS delivered comparable results despite costs that were one-quarter that of HV (GS = $29 versus HV = $123 per child per year). Previous research has indicated that groups can cost significantly less than individualized approaches,20 primarily because one facilitator can deliver the intervention to many families in one session. Even so, consistent with other research in low- and middle-income countries,18,21 both approaches resulted in relatively low costs by using community personnel and resources as well as processes for exchange of play materials as an alternative to purchasing.
Another finding was that the provision of NE alone had no benefit for child cognitive development or physical growth. This is consistent with other studies revealing that NE or supplements may not result in improved cognitive development, whereas interventions focused on cognitive stimulation have consistently revealed developmental benefits.22,23 The authors note that nutrition supplementation might be needed in addition to education to address growth and that broader improvements within the community (eg, sanitation) may also be required.22,24–26
Coronavirus disease 2019 has added new challenges for delivering early childhood development prevention programs. In higher income countries, there have been significant efforts to address these challenges through remote adaptations, including in health care (eg, Reach Out and Read,27 Video Interaction Project,28 HealthySteps29 ) and through HV30 (eg, Nurse-Family Partnership,31 Family Connects,32 Parents as Teachers33 ). Although low- and middle-income countries may have barriers to remote delivery related to access to devices and data,34 studies suggest potential for positive impacts.35–39 Adaptation of early childhood development prevention programs for remote delivery in lower middle-income countries represents an urgent need given the high likelihood of developmental morbidity resulting from the pandemic.40–48
In summary, this study contributes significantly to the evidence base regarding early childhood development program implementation, optimization, and sustainability in low- and middle-income countries.2,49 Findings suggest that both GS and HV models can be used to effectively deliver early childhood development interventions, suggesting that there is a range of effective approaches to choose from. Although HV may present fewer barriers to attendance and/or engagement, GS may result in comparable impact at lower costs. Communities can therefore make decisions regarding platforms for implementation of early childhood development programs on the basis of their individual resources and needs.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-002725.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.